Definition of problem gambling
The concept of problem gambling should incorporate the ideas of both behavior and consequences (Delfabbro, 2009). In Australia, it has been agreed at a national level that problem gambling is characterized by difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community (Neal et al., 2005; Delfabbro, 2009). The national definition of problem gambling in Australia is deliberately intended to be more general, aiming for incorporating many different reasons for people’s inability to limit their time and expenditure. This can avoid not only controversial terms such as “compulsive gambling”, “impaired control” but also specific reference to theoretical concepts that is possibly subject to contention (Delfabbro, 2009). In Europe, the definition of problem gambling is subtly different from that in Australia, as the term of problem gambling is to describe gambling that compromises, disrupts or damages family, personal or recreational pursuits (Griffiths 2009). Yet, the assessment methods of problem gambling are quite similar all over the world, including Asia, Australia, Europe and North America, and they will be described in the following section.
Assessment methods of problem gambling
In clinical situations, problem gambling is the gambling behavior meeting the established diagnostic criteria for pathological gambling, such as Diagnostic and Statistics Manual Version IV-TR (DSM IV-TR), e.g., “pathological gambling”, and the gambling behavior with subclinical levels of pathological gambling, e.g., “problem gambling”, “at-risk gambling”, and “in-transition gambling” (Shaffer et al., 1999).
According to DSM IV-TR (American Psychiatric Association, 2000), the clinical definition of pathological gambling is persistent, maladaptive gambling expressed by 5 or more of the followings: The patient needs to put increasing amounts of money into play to get the desired excitement, has repeatedly tried (and failed) to control or stop gambling, feels restless or irritable when trying to control gambling, uses gambling to escape from problems, often tries to recoup losses, lies to cover up the extent of gambling, has stolen to finance gambling, has jeopardized a job or important relationship, has had to rely on others for money to relieve the consequences of gambling, or is preoccupied with gambling. For problem gambling, there is no formal clinical definition in DSM IV-TR, but field study usually defines it by 3 or 4 marks of the aforementioned statements, compared with 5 or more marks in pathological gambling (Welte, Barnes et al. 2004).
DSM IV-TR diagnostic criteria for pathological and problem gambling are essential for clinical practice, especially in psychiatry. In an epidemiological study or questionnaire survey, the presence of pathological and/or problem gambling is usually difficult to ascertain, if not impossible, as psychiatric diagnosis is usually not available. Simple screening or assessment tools are therefore available for classifying the respondents into “non-gambler”, “probable pathological gamblers” and “probable problem gamblers”, such as South Oaks Gambling Screen (SOGS) (Stinchfield, 2002), Problem Gambling Severity Index (PGSI) (Loo et al., 2011), and Canadian Problem Gambling Index (CPGI) (Ferris & Wynne 2001). SOGS is a 20-item questionnaire, with a 3–4 score classified as “probable problem gambler,” and 5 or more score classified as “probable pathological gambler” (Stinchfield, 2002). Short SOGS, a more concise version of SOGS, is a 5-item questionnaire with yes/no answers available for more rapid screening, and a score of 2 or above indicates pathological or problem gambling (Room et al., 1999). PGSI is a 9-item questionnaire, with a 1–2 score as “low level of problems with few or no identified negative consequences”, a 3–7 score as “moderate level of problems leading to some negative consequences” and a 8 score as “problem gambling with negative consequences and a possible loss of control” (Loo et al., 2011). However, in literature, it is observed that there are still some papers using the terms of “pathological gambling” and “probable pathological gambling”, and “problem gambling” and “probable problem gambling” interchangeably in an incorrect manner, especially for those studies not in the areas of clinical or medical sciences (Pearce et al. 2008).
Although there is no formal consensus in the definition of “casino gambling”, according to Merriam-Webster dictionary, the definition of casino is “a building or room used for social amusements; specifically: one used for gambling”, and the definition of gambling is “1a: to play a game for money or property; b: to bet on an uncertain outcome; 2: to stake something on a contingency: take a chance”.
Casino gambling is popular. In a U.S. national survey of 2630 representative adults, casino gambling accounted for the largest extent of gambling involvement in the country (Welte et al., 2002). As a special form of gambling, casino gambling was found to be the form of gambling with strong association with problem gambling (Welte et al., 2009; Afifi et al., 2010). Among American youth, the form of gambling that made the largest contribution to gambling problems per 14 days of play was casino gambling. Incidence risk ratio for casino gambling, negative binomial regression of SOGS symptom count with past-year gambler was 2.52, which was of statistical significance at p <0.01, demonstrating that casino gambling was associated with a large increase in gambling symptoms (Welte et al., 2009). In Canadian women, the top three types of gambling associated with highest odds of problem gambling were all related to casinos, i.e., video lottery terminals outside the casino and inside the casino, and other casino games (Afifi et al., 2010). Problem gambling related to casino gambling is, therefore, becoming a public health concern (Welte et al., 2009; Afifi et al., 2010).
Gambling legalization of casino establishments started in Nevada, United States, in 1931, and the booming of casino industry was along with the prosperity experienced by Americans in post-war era (Dunstan, 1997). By 1993, complete spread of the trend within United States was established, as only two states, i.e., Utah and Hawaii, did not have legalized casino gambling (McGowan, 1999). The dissemination of this policy was not limited to United States, since the trend has also been spread to other regions of North America, Europe, and Asia since 1960s, i.e., Bulgaria in 1965, and South Korea in 1967 (Richard, 2010). Since 2007, Macao, a city with a population of 0.5 million in China, overtook Las Vegas with the highest turnover in casino industry (Macao: USD$6.95 billion in 2007 versus Las Vegas: USD $6.50 billion in 2007) (Walsh, 2007). International spread of casino gambling is evident, with casinos established worldwide, and the trend is aggravated by the fact that many governments consider the option of casino gambling legalization in their countries as a strategy to boost stagnant economy (Richard, 2010). Economic development needs, as measured by general unemployment rates, were found to be associated with the casino legalization decisions of national governments, and higher unemployment rates were more likely in the years that nations legalized casino gambling (Richard, 2010). While the positive outcomes are readily quantifiable by monetary amount, its negative impacts are more difficult to measure, except in the form of social capital, i.e., community’s quality of life (Griswold and Nichols 2006). The calculation of social cost resulted from gambling studies remains controversial (Walker, 2003). Socio-cultural, environmental, and psychological impacts of both individuals and society as a whole should be balanced for the decision in gambling legalization. The negative influences of casino gambling, particularly for problem gambling, should not be underestimated.
Casino gambling is not possible if casino accessibility is simply non-existent. Multiple dimensions of casino accessibility have been reported in literature, including opportunities to gamble per venue, number of opportunities to gamble, number of venues, opening hours, conditions of entry, ease of use, initial outlay, social accessibility, and location of venues (Productivity Commission, 1999). Among the nine captioned dimensions, the number and spatial distribution of casinos, i.e., casino proximity, are particularly important (Productivity Commission, 1999), and casino proximity has been viewed as one of the important links between accessibility and gambling behavior (Hing & Nisbet, 2010). Casino proximity is defined as the physical distance or driving distance between respondent’s residing home and nearest casino (Welte, Barnes et al. 2004; Pearce et al., 2008; Sevigny et al., 2008). Casino establishments will definitely increase the casino proximity among local residents, particularly if there are no such casinos in the area beforehand, and this, in turns, leads to a higher exposure of casino among local residents. But the definitions of “high” and “low” casino proximity vary substantially across different studies, probably due to different geographical sizes in the areas of interests. For instances, Pearce et al. (2008) described the distance between casino and respondent’ s home as closest when it is < 0.7 km, and as furthest when it is > 3.0 km, in New Zealand. Welte et al. (Welte, Barnes et al. 2004) utilized the cutoff point of 10 miles between nearest casino and respondent’s home in United States. In contrast, Sevigny et al. (2008) categorized casino proximity into 0–100 km, 100.01-200 km, 200.01-300 km, and 300.01-981 km in the province of Quebec, Canada.
Rationale of this study
Critical analysis from a public health perspective in the influence of gambling on health has been examined (Korn and Shaffer 1999), with further extension on related mental disorders (Shaffer and Korn 2002). However, casino gambling is a special form of gambling, requiring the pre-requisite of casino establishment in the area. It is the responsibility of policy makers to grant the casino licensure within the region. If there are more casino establishments in the area, casino proximity for local residents would be increased accordingly. Inevitably, a public health problem will emerge during the policy decision making process: Will increased casino proximity sharply increase problem gambling in local communities? A more in-depth public health analysis specific to the relationship between casino proximity and problem gambling would be enlightening to many parties involved in the policy formulation process, including policy makers, legislators, public health practitioners, social services providers, medical service providers, non-governmental organizations, and frontline healthcare professionals.
Unfortunately, this important aspect of public health analysis in the potential relationship between casino proximity and problem gambling has not been comprehensively reviewed in literature yet. Geographically speaking, the investigation of public health impacts in casino proximity on problem gambling would be important not only in our residing community, Macao SAR, China, but also in many other areas with casino establishments. Therefore, in this study, we aim to address the research question in the potential relationship between casino proximity and problem gambling by means of a systematic review.