3
Pathological and Problem Gamblers in the United States

The perception of increased pathological and problem gambling is currently driving interest and concern among policymakers, treatment professionals, industry officials, gambling researchers, and the public. Data describing the extent of pathological and problem gambling are useful for many purposes, including planning public health services and medical services. This chapter discusses the prevalence of pathological and problem gamblers among the general U.S. population and specific subpopulations. As limited by the available data, the discussion is often framed in terms of the proportion of pathological and problem gamblers reported in studies of U.S. residents. Of particular concern is determining prevalence among reportedly vulnerable demographic groups, such as men, adolescents, the poor, the elderly, and minorities (including American Indians). We also attempt to examine trends in relation to the increased availability of legal gambling opportunities in the last decade. This chapter also makes comparisons with the prevalence rates of alcohol and drug abusers, to help put the magnitude of excessive gambling and related problems into perspective.

The committee thanks Matthew N. Hall and Joni Vander Bilt for their assistance in providing literature and data for this chapter.



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--> 3 Pathological and Problem Gamblers in the United States The perception of increased pathological and problem gambling is currently driving interest and concern among policymakers, treatment professionals, industry officials, gambling researchers, and the public. Data describing the extent of pathological and problem gambling are useful for many purposes, including planning public health services and medical services. This chapter discusses the prevalence of pathological and problem gamblers among the general U.S. population and specific subpopulations. As limited by the available data, the discussion is often framed in terms of the proportion of pathological and problem gamblers reported in studies of U.S. residents. Of particular concern is determining prevalence among reportedly vulnerable demographic groups, such as men, adolescents, the poor, the elderly, and minorities (including American Indians). We also attempt to examine trends in relation to the increased availability of legal gambling opportunities in the last decade. This chapter also makes comparisons with the prevalence rates of alcohol and drug abusers, to help put the magnitude of excessive gambling and related problems into perspective. The committee thanks Matthew N. Hall and Joni Vander Bilt for their assistance in providing literature and data for this chapter.

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--> Limitations of Prevalence Research In Chapter 2 we described the difficulties involved in defining and measuring pathological gambling using various assessment instruments. Here it is important to note that comparing and interpreting prevalence findings is problematic when different studies use different screening and/or diagnostic instruments or criterion levels to measure differing levels of intemperate gambling and associated problems. Unfortunately, such differences are common in the research literature on pathological and problem gambling (Volberg, 1998b), which creates problems in estimating prevalence rates in the United States. Another important limitation of the available prevalence research pertains to the different facets of the concept of prevalence. A prevalence estimate requires specification of the population or geographical area represented and the time frame over which prevalence is defined (Walker and Dickerson, 1996). Most of the prevalence research on pathological and problem gambling is specific about the population or area represented, but the time frames within which gambling behavior is assessed vary widely. This variation is troublesome because the information of greatest policy relevance is generally the prevalence of current pathological or problem gambling, that is, estimates over a relatively recent but behaviorally representative time frame (e.g., the past year). The time frame most common in available research, however, is lifetime. Thus, many of those who are counted in prevalence research as being pathological or problem gamblers may have met screening or diagnostic criteria at some point during their lives, but did not manifest gambling problems at the time of the study. Measuring pathological and problem gambling also requires distinguishing incidence from prevalence: incidence is the number of new cases arising in a given time period, and prevalence is the average total number of cases during a given time period, factoring in new cases and deleting cases representing cures deaths. Incidence is especially pertinent to policy questions involving the effects of increased gambling opportunities and changes in technology, industry practices, and regulation. There is almost no research that examines the incidence of pathological or problem gambling cases over a representative, recent time

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--> period.1 Nor are there longitudinal studies that provide trend data for population cohorts or that track the progression of individuals into or out of the states of pathological or problem gambling. Finally, literature on pathological and problem gambling rarely distinguishes, in an epidemiological sense, the difference between rates of pathological and problem gambling and proportions of pathological and problem gamblers. This distinction is made throughout the chapter to the extent allowed by the data available to the committee. Determining National Prevalence Perhaps the most serious limitation of existing prevalence research is that the volume and scope of studies are not sufficient to provide solid estimates for the national and regional prevalence of pathological and problem gamblers, or to provide estimates of changes in prevalence associated with expanded gambling opportunities and other recent secular trends. Only three studies have attempted to measure the prevalence of pathological or problem gambling in the United States for more than one or a few states. A national study was undertaken by the University of Michigan Survey Research Center in 1975 (Commission on the Review of the National Policy Toward Gambling, 1976; Kallick et al., 1979). At that time, illegal gambling was believed to be widespread, and the nation was facing the prospect of increased legalization of gambling. Accordingly, the survey concentrated on assessing American gambling practices and attitudes toward gambling. The scale that attempted to measure "compulsive gambling" was only one small component of the larger gambling survey (Commission on the Review of the National Policy Toward Gambling, 1976). From the responses of 1,736 adults about behaviors over their lifetimes, "it was estimated that 0.77 percent of the national sample could be classified as 'probable' compulsive gamblers, 1   The one notable exception is the Epidemiologic Catchment Area (ECA) Study (see Cunningham et al., 1996; Cunningham-Williams et al., 1998).

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--> with another 2.33 percent identified as 'potential' compulsive gamblers" (Commission on the Review of the National Policy Toward Gambling, 1976). A combined total of 3.10 percent of the population was therefore estimated to be probable or potential compulsive gamblers sometime during their lives. Although the findings of the survey were considered important, the researchers advised caution in interpreting the results because it was not clear that their measures could distinguish compulsive (i.e., pathological) gambling from other possible disorders (Commission on the Review of the National Policy Toward Gambling, 1976). A second attempt to estimate the prevalence of pathological or problem gambling in the United States and Canada was the recent meta-analysis by Shaffer and colleagues (Shaffer et al., 1997) under a grant received from the National Center for Responsible Gaming. As opposed to original research, which involves collection of new data, meta-analytic research empirically integrates the findings of previously conducted independent studies. On the basis of predetermined criteria, Shaffer et al. selected 120 studies of gambling prevalence in various states and provinces of the United States and Canada for inclusion in the meta-analysis. These studies represented adults and youth in the general population, college students, adults and youth in treatment or prison settings, and a variety of other special populations. To standardize the different terms used in the studies analyzed, Shaffer et al. (1997) defined four levels of gambling: Level 0 referred to nongamblers; Level 1 described social or recreational gamblers who did not experience gambling problems; Level 2 represented gamblers with less serious levels of gambling problems (problem gambling); and Level 3 represented pathological gambling. This meta-analysis concluded that combined pathological and problem gambling—what they termed disordered gambling—was a robust phenomenon, although the majority of Americans and Canadians gamble with little or no adverse consequences. The study found that lifetime prevalence rates among adults in the general population for both nations together were estimated at 1.60 percent for Level 3 gamblers and 5.45 percent for Levels 2

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--> and 3 combined. Past-year prevalence rates were estimated at 1.14 percent for Level 3 gamblers and 3.94 percent for Levels 2 and 3 combined. Prevalence rates among youth and other special populations were found to be substantially higher (Shaffer et al., 1997). As part of its review of the pathological gambling literature, the committee undertook an analysis of the Shaffer et al. meta-analysis data for 49 of the original 120 studies that were based on samples of the general population (not clinical or institutional) drawn from U.S. residents.2 Of these 49, 20 were conducted during the past 10 years, all at the state level. Although these 20 surveys do not represent all states and territories within the United States, or any reasonable purposive sampling of them, they nonetheless provide the best recent information about the prevalence of pathological and problem gambling in the United States that is currently available. As described in more detail in the following sections, the median prevalence rates found in those studies were as follows: Lifetime prevalence rates: 1.5 percent for Level 3 gamblers and 5.4 percent for Levels 2 and 3 combined. Past-year prevalence rates: 0.9 percent for Level 3 gamblers and 2.9 percent for Levels 2 and 3 combined. Most recently, a third national prevalence study was commissioned by the National Gambling Impact Study Commission. The study was conducted by the National Opinion Research Center (NORC) of the University of Chicago. Preliminary results, released while this report was in its final stages, estimated the lifetime prevalence rate of Type E (i.e., pathological) adult gamblers to be 0.9 percent. The past-year prevalence rate for Type E adult gamblers was estimated to be 0.6 percent (National Opinion Research Center, 1999). The NORC study estimates are discussed in more detail later in this chapter. 2   A few state and regional surveys have been conducted since publication of the Shaffer et al. meta-analysis in December 1997, but they vary sufficiently in methods and coverage that meaningful comparison is difficult. No attempt, therefore, was made to include them in this analysis.

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--> Pathological and Problem Gamblers in the U.S. Adult Population Table 3-1 identifies the general population studies included in the Shaffer et al. (1997) meta-analysis that furnished gambling prevalence data for U.S. adult samples from 1975 to 1997 (exclusive of persons in treatment, prisoners, and other specialized groups).3 The majority of these surveys were conducted at the state level in the past 10 years, but a few regional studies are also included. Table 3-1 also shows that a variety of survey instruments for identifying pathological and problem gamblers was used in these studies. However, the South Oaks Gambling Screen (SOGS) and its variants have dominated practice so completely that it has been the de facto standard operationalization of pathological and problem gambling for adult populations. As discussed in Chapter 2, the SOGS instrument has been criticized as a measure of pathological or problem gambling in the general population, chiefly because it was originally developed for use in clinical settings (Lesieur and Blume, 1987) and may produce a high rate of false positives (Culleton, 1989). In particular, there is some evidence that the threshold values for pathological and problem gambling generally applied to SOGs scores yield overestimates of prevalence relative to the results of classification using the criteria from the DSM (Shaffer et al., 1997; Volberg, 1998b). Not shown in Table 3-1, but relevant to interpretation of the limited available prevalence research, are the uneven methodological characteristics of the prevalence studies. Response rate, for instance, varied from 36 to 98 percent, with a median of 68 percent. These prevalence studies were also inconsistent in their coverage of the gambling items. Some surveys asked all questions of all respondents, and others asked certain questions only of those who responded affirmatively to a prior question. (For example, if people had never had financial problems from gambling, they might not be asked how much money they lost from gambling.) Finally, the data analysis in these studies consisted chiefly of frequency distributions and simple cross-tabulations, 3   The meta-analysis reference number for each study listed in Table 3-1 is the same used by Shaffer et al. (1997).

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--> with little examination of missing data or other potentially biasing characteristics. One useful approach for integrating information across studies of varying methodological quality is to use meta-analytic techniques to adjust for methodological differences, in an attempt to minimize any distortion in the cross-study mean that stems from those differences. For instance, Shaffer et al. coded nine items related to the quality of study methods and combined them into a composite methodological quality score. They found, however, that there was neither a statistically significant relationship between that score and reported prevalence rates nor meaningful differences between unweighted prevalence means and those weighted by methodological quality. In light of these findings and the relatively small number of recent U.S. studies pertinent to the committee's analysis, no attempt was made to develop adjustments for method differences among studies. With the limitations of coverage and methodological quality in mind, the prevalence findings from the studies listed in Table 3-1 are discussed in the remaining portions of this section. Gambling Activities Rather high proportions of the adult populations in the states surveyed have participated in at least some gambling during their lives. Among the 20 surveys identified in Table 3-1 that were conducted in the past 10 years (i.e., 1988-1997), the percentage of respondents reporting lifetime participation in some form of gambling ranged from 64 to 96 percent, with a median of 87 percent. However, there was great variation across the years in which studies were conducted, across different types of gambling activities, and between states. More indicative of the prevalence of currently active gamblers are the survey data for participation in gambling activities in the past year. Unfortunately, this information was less often collected than lifetime data. Eleven of the studies in Table 3-1 that were conducted in the past 10 years reported gambling during the prior year. The proportion of respondents in those studies who reported any type of gambling in the past year ranged from 49 to 88 percent, with a median of 72 percent. If this is representative,

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--> TABLE 3-1 General Adult Population Surveys of Gambling Conducted in the United States, 1975-1997 Year of Survey State Type of Survey Instrument Sample Size Author Meta-Analysis Ref Numbera 1989 California Telephone SOGS 1,250 Volberg 94 1977 Connecticut Face-to-face 3-item scale 568 Abrahamson 125 1986 Connecticut Telephone DIS 1,224 Laventhol and Horwath 56 1991 Connecticut Telephone SOGS 1,000 Christiansen/Cummings 10 1996 Connecticut Telephone SOGS 992 WEFA Group 154 1994 Georgia Telephone SOGS 1,550 Volberg and Boles 99 1990 Indiana Telephone DSM-IV mod 1,015 Laventhol and Horwath 55 1988 Iowa Telephone SOGS 750 Volberg and Steadman b 94, 105 1995 Iowa Telephone SOGS-R 1,500 Volberg a 95 1995 Louisiana Telephone SOGS-R 1,818 Volberg b 96, 113 1988 Maryland Telephone SOGS 750 Volberg and Steadman a 94, 104 1989 Massachusetts Telephone SOGS 750 Volberg 94 1990 Minnesota Telephone SOGS-M 1,251 Laundergan et al. 54 1994 Minnesota Telephone SOGS-M 1,028 Emerson and Laundergan 23, 24 1996 Mississippi Telephone SOGS 1,014 Volberg b 98 1981 Missouri Face-to-face DIS 2,954 Cunningham et al. 16 1992 Montana Telephone SOGS-R 1,020 Volberg 89

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--> Year of Survey State Type of Survey Instrument Sample Size Author Meta-Analysis Ref Numbera 1975 Nevada Face-to-face ISR 296 Kallick et al. 43 1988 New Jersey Telephone SOGS 1,000 Volberg and Steadman a 94, 104 1996 New Mexico Telephone DSM-IV mod 1,279 University of New Mexico 140 1986 New York Telephone SOGS 1,000 Volberg and Steadman 103 1996 New York Telephone SOGS/DSM-IV 1,829 Volberg a 97 1992 North Dakota Telephone SOGS-R 1,517 Volberg and Silver 102 1985 Ohio Telephone CC/CS 801 Culleton 86 1991 South Dakota Telephone SOGS mod 1,560 Volberg et al. 107 1993 South Dakota Telephone SOGS-R 1,767 Volberg and Stuefen 106 1992 Texas Telephone SOGS 6,308 Wallisch 109 1995 Texas Telephone SOGS 7,015 Wallisch 110 1992 Washington Telephone SOGS 1,502 Volberg 92 1995 Wisconsin Telephone DSM-IV mod 1,000 Thompson 85 1984 Mid-Atlantic Telephone ISR/IGB 534 Culleton 15, 78 1975 National Face-to-face ISR 1,736 Kallick et al. 43 1990 Not reported Not reported 2-item scale 900 Ubell 148 SOGS: South Oaks Gambling Screen SOGS-M: SOGS multifactor method SOGS-R: SOGS modified for adolescents DSM: Diagnostic and Statistical Manual criteria DSM mod: modified DSM criteria DIS: Diagnostic Interview Schedule ISR: Institute of Survey Research "compulsive gambler" items IGB: Inventory of Gambling Behavior CC: Custer criteria CS: Clinical signs a Reference number from source document. SOURCE: Shaffer et al. (1997) database.

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--> then approximately three-quarters of the adult population in the United States has participated in some form of gambling in any recent year. Table 3-2 summarizes the information available from studies conducted in the past 10 years regarding the lifetime and past-year participation in various specific forms of gambling. These findings must be interpreted with some caution, since relatively few studies contributed to each category and the coverage and content of the surveys varied considerably. For example, illegal gambling showed the highest percentages of lifetime participation reported for any gambling activity (ranging from 56 percent in Mississippi to 65 percent in New York)—a curious finding given legalized forms of gambling in those states—but was reported in only two studies, both conducted in 1996. As Table 3-2 indicates, lottery gambling and illicit gambling were generally reported as having the highest proportions of respondents who have participated sometime during their lifetime. Following these are charitable games, casino gambling, pari-mutuel betting, sports betting, video lottery, and card games, all with rather similar participation rates. Games of skill and gambling in financial markets (i.e., speculating) had the lowest lifetime participation rates. The more limited information from these surveys on past-year participation in specific types of gambling is similar to that for lifetime participation, but with lower proportions in all categories. Lottery participation was highest, with the lowest proportions found among games of skill, pari-mutuel betting, gambling in financial markets, and charitable games. Pathological and Problem Gamblers Table 3-3 summarizes the prevalence rates of Level 2 (problem) and Level 3 (pathological) gamblers identified in the general population surveys conducted during the past 10 years, virtually all of which were conducted at the state level. The lifetime prevalence of pathological gamblers (Level 3) across the 18 studies reporting that information ranged from 0.1 percent to 3.1 percent, with a median value of 1.5 percent. Estimates of combined lifetime problem and pathological gambler prevalence (Levels 2 and

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--> TABLE 3-2 Percentage of the Adult Population Reporting Lifetime and Past-Year Gambling for Different Types of Gambling (Surveys Conducted 1988-1997)   Lifetime Past Year Type of Gambling No. of Studies Range, % Median, % No. of Studies Range, % Median, % Any gambling 17 64-96 87 11 49-88 72 Lottery 11 28-81 64 10 5-40 24 Video lottery terminal 9 09-54 26 6 6-44 26 Casino 8 19-66 36 7 6-44 27 Charitable 7 13-67 38 3 4-40 04 Pari-mutuel 11 15-37 30 9 4-12 08 Sports 11 20-45 29 9 9-26 17 Cards 9 20-49 26 5 10-20 18 Skill 6 13-25 18 2 11-11 11 Financial markets 9 07-20 12 5 5-7 5 Illicit 2 56-65 60 4 4-39 18   SOURCE: Summarized from the studies identified in Table 3-1 that reported pertinent data and were conducted during the last 10 years (1988-1997).

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--> logical and problem gamblers, the percentages ranged from 20 to 55 percent, with a median of 38 percent. Overall, therefore, men are much more likely to be pathological or problem gamblers than are women. It may be, however, that within this overall trend there are some types of gambling for which women are more likely than men to show problems. Unfortunately, the available research provides too few breakouts of gender by type of gambling to examine this issue. Minorities Eighteen of the studies identified in Table 3-1 provided breakouts of the comparative proportions of at least one ethnic group for gamblers without problems and problem and pathological gamblers.9 Of those, 17 studies included either white or nonwhite as one category. These studies suggest that, in general, minorities who gamble are at risk for developing gambling problems. In every case, the proportion of minorities among the pathological and problem gamblers was greater than the proportion among gamblers without problems. Those percentages ranged from 5 to 63 percent, with a median of 31 percent, of the pathological and problem gamblers being minorities. By comparison, among the gamblers without problems the proportion of minorities ranged from 2 to 36 percent, with a median of 15 percent. These studies clearly indicate that minority groups are overrepresented among pathological and problem gamblers and would appear therefore to be at higher risk. The reasons for this overrepresentation are unknown, because the studies did not generally provide the numbers of minority respondents who gambled so that the rates of pathological or problem gambling within or across groups could be calculated. Less information was available about specific minority groups. Eight studies broke 9   Cunningham et al. (1996); Emerson et al. (1994); Kallick et al. (1979); Laundergan et al. (1990); Reilly and Guida (1990); Volberg (1992, 1993, 1995a, 1996a, 1997); Volberg and Boles (1995); Volberg and Silver (1993); Volberg and Stuefen (1994); Volberg et al. (1991); Wallisch (1993, 1996); New Mexico Department of Health (1996).

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--> out the proportion of African Americans in the nonproblem, problem, and pathological gambling groups. The median values were 18 percent among pathological and problem gamblers and 11 percent among gamblers without problems. The five studies that reported the proportions of Hispanics had a median of 28 percent among pathological and problem gamblers and 22 percent among gamblers without problems. Only three studies reported on the percentage of American Indians among the gambling groups. Across those studies, American Indians were represented among pathological and problem gamblers ranging from 3 to 7 percent, compared with only 1 to 4 percent of the gamblers without problems. These studies are too few in number to allow meaningful comparisons across groups. Income, Employment, and Education Seventeen of the studies in Table 3-1 provided income distributions with two or more brackets for gamblers without problems compared with pathological and problem gamblers.10 The most common breakout was to distinguish household income above and below $25,000 per year. Dividing all the income categories reported by any of the studies into these two broad categories showed some tendency for lower-income persons to be overrepresented among pathological and problem gamblers. In particular, the median percentage of the pathological and problem gamblers with income under $25,000 per year was 33 percent compared with 27 percent of the gamblers without problems. Only seven of the studies in Table 3-1 compared problem and pathological gamblers and gamblers without problems with regard to employment status.11 Employed persons were represented in about equal proportions among the pathological and 10   Emerson et al. (1994); Laundergan et al. (1990); Reilly and Guida (1990); Volberg (1992, 1993, 1995a, 1996a, 1997); Volberg and Boles (1995); Volberg and Silver (1993); Volberg and Stuefen (1994); Volberg et al. (1991); Wallisch, (1993, 1996); New Mexico Department of Health (1996). 11   Emerson et al. (1994); Laundergan et al. (1990); Volberg (1997); Volberg and Boles (1995); Wallisch (1993, 1996); New Mexico Department of Health (1996).

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--> problem gamblers (median = 64 percent) as among the gamblers without problems (median = 61 percent). By contrast, there were larger differentials for persons who were disabled (three studies: median = 6 versus 2 percent), those in school including college (four studies: median = 13 versus 5 percent), and those who were retired (four studies: median = 3 versus 11 percent). Thus disabled persons and those in school were overrepresented among pathological and problem gamblers and retired persons were underrepresented. Eighteen studies provided breakouts of educational background for the groups of gamblers without problems and problem and pathological gamblers.12 These data show that education has a moderately strong relationship to the risk for problem and pathological gambling. Persons who had completed only high school or less were overrepresented among pathological and problem gamblers in these studies. Across 22 comparisons, a median value of 23 percent of the pathological or problem gamblers had a high school education or less compared with a median of 13 percent among gamblers without problems. Conclusions Although a substantial majority of the U.S. population gambles, not everyone does, and of those who do, relatively few experience adverse effects sufficient to qualify them as problem gamblers; fewer still can be considered pathological gamblers. The best current estimates of pathological and problem gambling among the general adult U.S. population and selected subpopulations can be found in the studies included in the meta-analysis conducted by the research team at Harvard Medical School, Division on Addictions (Shaffer et al., 1997). Based on its analysis of the U.S. prevalence studies that had been conducted in the past 10 years, the committee estimates that approximately 0.9 percent 12   Cunningham et al. (1996); Emerson et al. (1994); Laundergan et al. (1990); Reilly and Guida (1990); Volberg (1992, 1993, 1995a, 1996a, 1997); Volberg and Boles (1995); Volberg and Silver (1993); Volberg and Stuefen (1994); Volberg et al. (1991); Wallisch (1993, 1996); New Mexico Department of Health (1996).

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--> of the adults in the United States meet the SOGS criteria as pathological gamblers on the basis of their gambling activities in the past year. For pathological and problem gambling combined, the committee estimates that the prevalence rate for past-year activity was approximately 2.9 percent. Applying these rates to the U.S. census estimates of the number of residents age 18 or older in 1997 (196 million) indicates that currently about 1.8 million adults are pathological gamblers and 5.7 million are either pathological or problem gamblers. In relation to drug and alcohol dependence, the current prevalence of pathological gamblers is equivalent to about one-third the estimated rate of drug-dependent persons under DSM-III-R criteria and one-eighth the estimated rate of alcohol-dependent persons. The few instances of repeated surveys in the same state show either significant increases in the prevalence of pathological and problem gamblers or no significant change, indicating that the national trend over the last decade may be upward. In addition, some of the greatest increases shown in these repeated surveys came over periods of expanded gambling opportunities in the states studied. Although sparse, such evidence is consistent with the view that expansions in the availability of gambling have resulted in increased numbers of pathological and problem gamblers. The most recent gambling surveys also show that the prevalence rates for pathological and problem gamblers vary substantially for different population subgroups in the states studied. The rates are higher for adolescents than for any of the older age groups and higher for men than for women. Prevalence rates were also higher for minorities than for whites and were somewhat higher for lower-income and less-educated people than for their higher-income and more-educated counterparts. Across subpopulations, therefore, we would expect the prevalence rates for pathological and problem gambling to be highest for minority men, especially adolescents, with relatively low levels of income and education. The gambling behavior of adolescents has been more frequently studied than that of other vulnerable populations. On the basis of the available studies, the committee estimates that the current prevalence rate for pathological gambling among adoles-

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--> cents is approximately 6.1 percent and for pathological and problem gamblers combined, about 20 percent. Taken at face value, these figures indicate considerably higher levels of pathological and problem gambling among adolescents than adults. And although the evidence consistently shows higher rates among adolescents, it is difficult to determine how much higher those rates are. Differences between survey instruments, in criteria for classification as a pathological or problem gambler, and in the significance of certain symptoms (e.g., incurring debt) complicate any attempt to directly compare adolescent and adult prevalence rates. Nonetheless, the best available evidence indicates that pathological and problem gambling among adolescents is a significant problem. The proportions of adolescents classified as pathological and problem gamblers in recent studies examining this issue are roughly comparable to the proportions who use alcohol once a month or more or who use illicit drugs. Although we have characterized the findings of the research currently available, it is important to emphasize how inadequate that research base is for drawing confident conclusions about the prevalence of pathological and problem gambling in the U.S. population or in important subpopulations. Only three national prevalence surveys have been conducted since 1977, and each estimated in a way quite different from ways used to operationalize and measure the prevalence of pathological (and problem) gambling in the past 10 years. All consideration of more recent periods must therefore rely on a modest number of state-level surveys. Moreover, the states covered in those surveys do not constitute a representative sample of U.S. states or even a reasonable purposive sample. Further limitations apply to the assessment of trends in pathological and problem gambling during the recent decades of great expansion in the availability of legal gambling opportunities. Prevalence surveys have been conducted at more than one time in only a handful of states, and in some of those cases the same instrument and sampling procedures were not used on both occasions. Further complications are associated with the relatively unstandardized constructs, operational definitions, screening instruments, and criteria that have been used in research on patho-

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--> logical and problem gambling. This variation makes most attempts to compare prevalence rates across states, regions, periods of time, and subpopulations problematic. For purposes of constructing national prevalence estimates for pathological and problem gambling and breaking out important subpopulations, the existing research provides only limited and uncertain information. As a basis for informed policy discussion, therefore, the available prevalence data are incomplete. The findings presented in this chapter are best viewed as rough estimates of the likely orders of magnitude for the prevalence of pathological and problem gamblers, not as definitive estimates. Nevertheless, these finding indicate that pathological and problem gambling is an important enough social issue to warrant a sizeable investment in epidemiological and other studies. It would be useful to undertake a variety of studies that use a common set of instruments, definitions, and design criteria. Studies of high caliber would also distinguish between prevalence and incidence while accounting for conditional risk factors; they would also distinguish between the proportion of pathological and problem gamblers and rates of pathological and problem gambling in both general and subpopulations; and they would be consistent in their use of screening instruments validated for use in general populations to measure pathological and problem gambling longitudinally. References Allen, T.F. 1995 The Incidence of Adolescent Gambling and Drug Involvement. Providence: Rhode Island College School of Social Work. Christiansen/Cummings Associates Inc. 1992 Legal Gambling in Connecticut: Assessment of Current Status and Options for the Future, Volume One. Report to the State of Connecticut Division of Special Revenue. New York: Christiansen/Cummings Associates Inc. Commission on the Review of the National Policy Toward Gambling 1976 Gambling in America: Final Report of the Commission on the Review of the National Policy Toward Gambling. Washington, DC: Commission on the Review of the National Policy Toward Gambling.

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--> Cook, D.R. 1987 Self-identified addictions and emotional disturbances in a sample of college students. Psychology of Addictive Behaviors 1(1):55-61. Cox, S., H.R. Lesieur, R.J. Rosenthal, and R.A. Volberg 1997 Problem and Pathological Gambling in America: The National Picture . Columbia, MD: National Council on Problem Gambling. Culleton, R.P. 1989 The prevalence rates of pathological gambling: A look at methods. Journal of Gambling Behavior 5(1):22-41. Culleton, R.P., and M.H. Lang 1985 The prevalence rate of pathological gambling in the Delaware Valley in 1984. Report to People Acting to Help, Philadelphia PA. Camden, NJ: Forum for Policy Research and Public Service, Rutgers University. Cunningham, R.M., L.B. Cottler, and W.M. Compton 1996 Taking Chances: Problem Gamblers and Mental Health Disorders--Results from the St. Louis Epidemiologic Catchment Area (ECA) Study. St. Louis, MO: Washington University School of Medicine, Department of Psychiatry. Cunningham-Williams, R.M., L.B. Cottler, W.M. Compton, and E.L. Spitznagel 1998 Taking chances: Problem gamblers and mental health disorders-Results from the St. Louis Epidemiological Catchment Area (ECA) Study. American Journal of Public Health 88(7):1093-1096. Devlin, A.S., and D.M. Peppard 1996 Casino use by college students. Psychological Reports (78):899-906. Emerson, M.O., and J.C. Laundergan 1996 Gambling and problem gambling among adult Minnesotans: Changes 1990 to 1994. Journal of Gambling Studies 12(3):291-304. Emerson, M.O., J.C. Laundergan, and J.M. Schaefer 1994 Adult Survey of Minnesota Problem Gambling Behavior; a Needs Assessment: Changes 1990 to 1994. Report to the Minnesota Department of Human Services, Mental Health Division. Duluth: University of Minnesota Center for Addiction Studies. Frank, M.L. 1990 Underage gambling in Atlantic City casinos. Psychological Reports 67:907-912. 1993 Underage gambling in New Jersey. Pp. 387-394 in Gambling Behavior and Problem Gambling, W.R. Eadington and J.A. Cornelius, eds. Reno, NV: Institute for the Study of Gambling and Commercial Gaming. Kallick, M., D. Suits, T. Dielman, and J. Hybels 1979 A Survey of American Gambling Attitudes and Behavior. Research report series, Survey Research Center, Institute for Social Research. Ann Arbor : University of Michigan Press. Kessler, R.C., K.A. McGonagle, S. Zhao, C.B. Nelson, M. Hughes, S. Eshleman, H-U. Wittchen, and K.S. Kendler 1994 Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry 51(1):8-19.

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