Social Cost of Pathological Gambling Robert Ladouceur
Jean-Marie Boisvert Michel P~pin Michel Loranger Caroline Sylvain Universitg Laval, Qugbec
Pathological gambling creates enormous problems for the afflicted individuals, their families, employers, and society, and has n u m e r o u s disastrous financial consequences. T h e present study evaluates the financial burdens of pathological gambling by questioning pathological gamblers in treatment in G a m b l e r s A n o n y m o u s (n = 60; 56 males, 4 females; mean age = 40 years old) about personal debts, loss of productivity at work, illegal activities, medical costs and the presence of other dependencies. Results show that important debts, loss of productivity at work and legal problems are associated with pathological gambling. Discussion is formulated in terms of the social cost of adopting a liberal attitude toward the legalization of various gambling activities.
Gambling is a widespread cultural phenomenon. This activity has become a prime leisure industry in the United States with numerous participants (Abt, Smith, & Christiansen, 1985). Rates of gambling and the sums invested have increased over the years through North America. In 1974, 61% of Americans gambled and $17.4 billion was spent on gambling in the U.S. (Kallick, Suits, Dielman & Hybels,
This study was completed with the financial support of the FCAR, CQRS and Loto-Quebec grants. Authors wish to thank Lisa Kelley for her helpful comments on an earlier version of the manuscript. All correspondence should be addressed to Robert Ladouceur, Ph.D., Ecole de Psychologie, Universit6 Laval, Quebec, Canada, G1K 7P4.
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1979). By 1992 the amount had reached $329.9 billion, an increase of 1,900% in eighteen years (Christiansen, 1993). A similar trend was found in Quebec; from 1974 to 1992, money spent on lotteries grew from 51 million to $1.2 billion per year, an increase of 2,000% (LotoQuebec, 1993). Today, 48 American states have legalized at least one form of gambling, with a trend toward increasing diversity (Lesieur, 1992). In Canada, many forms of legal gambling are available in all provinces. Video lottery terminals and casinos are present in more than half of the provinces. If one excludes horse racing, revenues from gambling are increasing. This liberal attitude concerning the legalization of gambling activities is typical of most Western countries and, rarely seems to be questioned. The accessibility of these games, both legal and illegal, encourages gambling involvement and exposes more vulnerable individuals to the risks of becoming excessive or pathological gamblers. Frequent gambling presents a danger of dependency, similar to frequent alcohol or drug consumption (Eadington, 1989; Harris, 1988; Lesieur, 1992; Volberg, 1994). While some authors are unwilling to suggest a causal relationship between the accessibility of gambling and the n u m b e r of pathological gamblers, others believe that the incidence of pathological gambling is higher in jurisdictions that offer legalized games (Eadington, 1989; Lesieur, 1992; Volberg, 1994). It seems reasonable to assume that access to games will increase the n u m b e r of gamblers and the frequency of gambling. In fact, several prevalence studies demonstrate that there are more problem gamblers where gambling is legal. For example, a 1974 survey reported fewer than 1% of the total U.S. population were recognized as "probable compulsive" gamblers, compared to 2.5% in the state of Nevada, where casino gambling was legal at the time. Other studies indicate that in 1989, there were 1.4%, 1.4% and 1.5% pathological gamblers in New York, New Jersey and Maryland respectively. In each of these states, at least 2.4% of the population had gaming habits that were problematic without meeting all the criteria for pathological gambling (Volberg & Steadman, 1989). In Quebec, although casinos were not legal until October 1993, there are significant numbers of lottery players, horse race bettors and bingo players, as well as players of some illegal games like VLTs, with substantial gambling-related problems. A 1991 survey of 1,000 individuals over 18 years of age found that 1.2 % could be classified as pathological gamblers. An additional 2.6%
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could be classified as having somewhat less severe gambling problems. O n the basis of these figures, it was estimated that between 61,000 and 136,000 individuals in Quebec have moderate to severe gambling problems. These individuals are mostly male (75.9%) and are either less than 30 years old or between 40 and 49 years of age (Ladouceur, 1991). Not all gamblers are adults, as shown by two surveys of adolescents; 1.7 %, and 2.8 % of adolescents in the Quebec City region report gambling problems (Ladouceur, DubS, & Bujold, 1994; Ladouceur & Mireault, 1988). The American Psychiatric Association officially recognized pathological gambling dependency as a pathology in 1980; pathological gambling is defined as a chronic and progressive failure to resist impulses to gamble. These impulses become so intense and powerful that the gambler can no longer control them, despite the serious negative consequences arising from gambling (Custer & Milt, 1985; Lesieur & Rosenthal, 1991). Pathological gambling gradually destroys many aspects of an individual's life. The gambler typically incurs considerable debts, commits illegal acts to get money, develops workrelated problems (absenteeism and lower productivity), and jeopardizes physical and psychological health because of gambling (Gambino, Shaffer, & Cummings, 1992; Overman, 1990; Nelson, 1992; Lesieur, 1984). As Lesieur (1992) suggests, gambling creates a redistribution of resources from the losers to the winners. The biggest winners are the operators of these gambling activities; in m a n y cases, the operator is an agency of the state. Regular gamblers, including pathological gamblers, account for a large share of the state profits from gambling. Much of this money comes out of paychecks and personal savings, and is very difficult to quantify. Since losses typically outweigh winnings in long run, compulsive gamblers must often resort to borrowing from banks and other financial institutions to cover their losses. Limited data, make it impossible to estimate the total annual debt and bankruptcies arising from pathological gambling in the U.S. However, Lesieur (1992) estimates that in New Jersey, debts totaling $514 million are accrued each year by pathological gamblers. Even this total does not reflect the further costs of bankruptcy proceedings and other civil actions related to indebtedness. Considering the recent increase in legalized games, it is imperative to establish the potential impact of legalization, particularly on that proportion of the population susceptible to gambling dependency.
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There is good evidence that gambling dependency can cause multiple problems for gamblers, ranging from financial to family-related, from professional to emotional (Lorenz & Yaffee, 1986, 1988). But what are the real costs? What are the effects on society of such a dependency? Few studies have explored this important aspect of pathological gambling. Unfortunately, the pioneering work of Politzer, Morrow and Leavey (1985), which demonstrated the financial benefit of treatment, has not been pursued. Lorenz and Politzer (1990) and Lesieur (1992) reviewed researches evaluating the social cost of pathological gambling. They showed that enormous direct and indirect costs result from this pathology. For example, the average indebtedness of the pathological gambler undergoing treatment or seeking help at G.A. was $71,853 and $83,336 respectively (Lorenz & Politzer, 1990). As part of a prevalence study of problem and pathological gambling in the province of Alberta, 30 gamblers (10 frequent, 10 problem and 10 pathological gamblers) were interviewed in order to estimate the social and financial costs of problem gambling (Wynne, Smith & Volberg, 1994). Results showed that in many aspects, probable pathological gamblers differed from the two others groups on negative social impacts. Among the most striking results, we find the following characteristics. If no frequent gamblers indicated that their gambling affected their family finances, the majority of the pathological gamblers reported that their family lives quite stressful and their uncontrolled gambling increased the pressure they were under. None of the frequent gamblers had been approached by a significant other to be more circumspect about their gambling, whereas 50% of the pathological gamblers had been counselled by a friend or a relative. Concerning the workplace, several pathological gamblers reported having left work early to gamble, took extended breaks or were absent from work to gamble. Such behaviors were not reported by the frequent gamblers. On the financial aspect, the range of the pathological gamblers' losses varied from 4,500 to $50,000. It may not be surprising that they have experienced more physical ailments such as ulcers, colitis and migraines than the other groups. If these data are preliminary and tentative, they nevertheless provide a trend of what could be expected in an extensive study of the social impacts of pathological gambling. In the similar perspective, Volberg (1993, July) estimated the cost of pathological gambling in Connecticut at half a billion dollars. These figures were based on the social cost of addictive disorders model presented by Rice et al. (1991) and on a prevalence survey conducted
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in that jurisdiction. The present study will explore the social cost of pathological gambling in the Canadian province of Quebec. These preliminary data provide a basis for further exploration of this research avenue and may also be generalized to other Canadian provinces and American states. Prevalence estimates represent the first step in studying the impact of problem gambling on society, and these estimates then allow the direct and indirect economic costs of this illness to be evaluated (Rice, Kelman, & Miller, 1991). As indicated by Volberg (1993), the question of the social costs of gambling arises at two critical junctures: (1) during the political debate about legalizing a new type of gambling and (2) during the development of prevention and treatment programs for problem gamblers. As there are no existing procedures for the evaluation of the social cost of gambling, the approach used by Rice et al. (1991) to assess economic cost of alcohol abuse provides a valuable model. The cost of illness is divided into two major categories: (1) core costs that result directly from the illness, such as services, and treatment and (2) related costs, which stem from nonhealth aspects of the illness, including reduced productivity and premature death. For this study, information about both cost categories were collected in order to provide a gross estimate of the total social cost of pathological gambling.
METHOD
Subjects Pathological gamblers attending Gamblers Anonymous meetings in the regions of Quebec City, Montreal, Trois-Rivieres and Chicoutimi or engaged in therapy sessions at the Center for the Treatment of Pathological Gamblers at Laval University were invited to participate in the study. Sixty individuals completed and returned the questionnaire. As in similar studies, this sample is probably not representative of all pathological gamblers in Quebec but is based on the assumption that pathological gamblers not in treatment are similar to those in treatment (Lorenz & Yaffee, 1986, 1988; Lesieur, 1992; Volberg, 1993). The gamblers in the present sample are predominantly male (93%), with a high school level education, and with a mean age of 40 years. These characteristics are strikingly similar to
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those found in the pathological gamblers identified in a provincial survey in Quebec (Ladouceur, 1991).
Measures A 31 item questionnairC was developed evaluating the impact of pathological gambling on employment-related behaviors, debts, money spend on gambling, illegal acts, frequency of alcohol and drug use, and psychosomatic complaints.
RESULTS
As frequently stated by legislators, approval of gambling is based on the premise that the social benefits of legal gambling outweigh the social costs(see Wayne, Smith & Volberg, 1994). But no systematic analysis of the full social and financial impacts of legal gambling have been published in any jurisdictions. The present results bring preliminary and descriptive data on the social consequences of pathological gambling.
Spending and Gambling Debts Analyses of questionnaire responses show that 33% 2 of respondents spent between $1,000 and $2,000 a month on gambling, and 23 % spent between $2,000 and $5,000 a month on gambling. Considering that in Quebec, 1.2 % of the adult population or 50,000 individuals are pathological gamblers (Ladouceur, 1991) 3, a conservative estimate would suggest that pathological gamblers in the province spend a m i n i m u m of three quarters of a billion dollars on gambling
~Copy of the questionnaire is available upon request to corresponding author. 2For purpose of clarity decimals of percentages were dropped. 3The issue concerning current or lifetime prevalence rates is most important in evaluating the social cost of pathological gambling. Volberg (1993) suggested that since on average, prevalence studies have shown that 60% of lifetime pathological gamblers score as current probable pathological gamblers, lifetime rate should be corrected by .6. In the present report, we think that this correction would underestimate the figures of the social cost of pathological gambling, because the 1.2 % lifetime prevalance rate of probable pathological gamblers was obtained in 1989 three years before the legislation of three new gaming activities in Quebec: Casinos, V L T s and OTB.
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each year. Although these figures are based on lifetime prevalence rate, the fact that gambling is more available now in Quebec than in 1989 when this survey was conducted, these figures are probably not inflated particularly since the legalization of video lottery terminals (VLTs), casinos and the opening of off-track betting (OTB) in the province. The great majority of respondents (90 %) use their paycheck or their family savings to gamble, and 83 % had to borrow money during the past year in order to gamble. Sixty-two percent of respondents had borrowed money from relatives or friends in order to avoid serious problems with creditors, with more than half of them (35 %) receiving amounts ranging from $3,000 to $5,000. Twenty percent of the respondents borrowed money from loan sharks. As a result of their gambling debts, 28 % of the respondents have filed for bankruptcy and 30% reported debts ranging from $75,000 to $150,000.
Workplace Impacts Both lateness and absence from work are very frequent among pathological gamblers in this study. Among the respondents, 66% report having missed work (or left early) to gamble, with half of these individuals doing so more than 5 times a month. Three-fifths (61%) of the respondents have been late for work because they were gambling, and half of this group did so more than 5 times a month. Each of these instances represents an average of 1 to 3 hours lateness. For 11% of respondents, late arrivals can extend to half a day, while 14% say that they have missed up to an entire day of work in order to gamble. If 50 % of the pathological gamblers are late by an average of 5 hours a month, and the average wage is $30,000 a year or $15 an hour, then the overall loss to employers amounts to a minimum of $45 million per year. Preoccupation with gambling debts, recent losses or future gambling may cause gamblers to lack concentration, thereby affecting productivity. In this study, 59% of respondents report that they are very often irritable at work and frequently have difficulty concentrating, due to the pervasive nature of thoughts about gambling. Nearly half (43 %) of respondents have asked for an advance on their paycheck and 37% have stolen money from their employer in order to gamble. Close to 50% of these individuals report having stolen from their employer more than once, in amounts ranging from $2,000 to more
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than $5,000. Finally, half of the respondents almost lost their jobs, and 36 % had already lost their jobs because of gambling problems. More than half of these respondents earned a salary ranging from $35,000 to more than $50,000.
Other Dependencies Systematic studies reveal rates of alcohol and other substance abuse among pathological gamblers to range from 47% to 52% (Lesieur, 1992). In this study, it appears other dependencies add to gambling problems for many pathological gamblers. Over half of these respondents regularly consume alcohol and drugs with one fifth of these respondents consuming alcohol 6 to 10 times a week. Also, 13% of the sample reported consuming nonprescription drugs between 1 and 10 times a week. These proportions are considerably higher than the 5 % of the general population in Quebec that report a dependency on alcohol. The social costs associated with pathological gambling are especially high when combined with the costs related to other dependencies. Pathological gamblers with alcohol and drug dependency are at greater risk of incarceration, and they have a higher rate of stress-related illnesses and serious psychiatric problems, including attempted suicide.
Illegal Activities to Finance Gambling Pathological gambling often leads to criminal behavior. Studies conducted to date reveal a variety of illegal behaviors among pathological gamblers; these include fraud, theft, fencing stolen goods, embezzlement, tax fraud, tax evasion, forgery and selling drugs. A very high proportion of pathological gamblers admit engaging in these illegal activities as a last resort to finance their gambling or pay substantial gambling-related debts. Lesieur reported that approximately twothirds of non-incarcerated and 97 % of incarcerated gamblers reported engaging in illegal activities to finance gambling (Lesieur, 1992). In this study, 68 % of respondents report having engaged in illegal acts to finance their gambling. Lorenz and Politzer (1990) also reported that 61% of pathological gamblers in Maryland engaged in illegal acts; thus data on illegal activities by pathological gamblers appear to be consistent across Canada and the United States. Detailed analysis of our data shows that 10 % of respondents admit having falsified documents
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or forged signatures, 23% engaged in embezzlement, 33% signed checks without sufficient funds, 18% filed false income tax returns or neglected to pay income tax, and 3 % made false statements to insurance companies. A significantly higher rate of insurance fraud was reported in United States (Lesieur & Puig, 1987): the reason for a discrepancy with the Canadian data is not clear. One reason may be that no specific questions were asked to elicit different forms of insurance fraud in this study. In addition, 37 % of the respondents stole money from an employer, 17% committed a non-violent theft, 3% committed a violent theft, 17 % shoplifted and 7 % fenced stolen goods. Finally, 17 % of respondents have already appeared in court for an offense and 8 % were sentenced to jail. As in other studies, the majority of offenses committed by pathological gamblers in Quebec are non-violent. It is difficult to calculate precisely the social cost of illegal acts and crimes committed by gamblers to obtain money for gambling or pay gambling-related debts. Estimate of such costs involves far more than simply the amounts of money taken by theft or fraud; in some cases, the cost of judicial procedures, including arrest and incarceration could entail considerable expenses for society. Medical Costs
Pathological gambling has been shown to have negative effects on the gambler's physical and emotional health (Lesieur, 1992). Our study confirms that pathological gambling has serious negative consequences for the individual's health. Over two thirds of respondents indicated that due to gambling they experience depressive moods, insomnia, headaches or stomach aches, at least once a week, while an additional one quarter experience these symptoms occasionally. The cost of treating these stress-related problems, as well as other physical illnesses requiring frequent medical consultations and hospitalization, could prove to be a significant additional expense for society. DISCUSSION AND CONCLUSIONS The results of this study indicate that the cost of pathological gambling is a critical, and often underestimated burden on society. It is difficult to assess all the costs related to this dependency, when the use of health services and the judicial system must be taken into account, as well as the problems and losses experienced by employers. There is also the issue of the more subtle consequences of pathological gambling,
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such as the emotional problems of family members, loss of trust in families, separations, divorces, and suicide attempts. These additional costs are difficult to quantify, but our results make it clear that they should be further explored (see Rice et al., 1991). The cost estimates depend on a set of assumptions which may or may not be true. That is, the Gamblers Anonymous members surveyed are similar to other Gamblers Anonymous members not surveyed. Secondly, that Gamblers Anonymous members are similar to compulsive gamblers found in the general population surveys. Regardless of that fact, the costs of pathological gambling are probably high and should not be underestimated. This study on the social costs of gambling underlines the importance of taking measures to stop or lessen the effects of this dependency, especially as the rapidly expanding availability of legal gambling leads increasing numbers of individuals to gamble. Considering the consequences of pathological gambling to society, it is important that both private industries and public agencies become more involved in the prevention and treatment of pathological gambling. At this point, we strongly endorse the suggest made by Lesieur (1992) that no new forms of gambling be legalized without first providing treatment facilities for current problem gamblers. Furthermore, the present data support the recommendations of the National Council on Problem Gambling (1993) that (1) the severity of pathological gambling should be recognized by the adoption of a national policy about problem gambling, (2) the treatment of pathological gambling should be included in provincial or national health care plans and (3) groups providing public education or treatment interventions should be funded. Finally, as with other disorders, clinicians and researchers should focus on prevention programs as well as treatment. In light of the mounting costs to society of excessive gambling, it is surprising that, to date, there is only one published study addressing the prevention of this pathology (Gaboury & Ladouceur, 1993). REFERENCES Abt, V., Smith, J.F., & Christiansen, E.M. (1985). The business of risk: Commercial gambling in mainstream America. Lawrence, Kansas: University of Kansas Press. Christiansen, E.M. (1993). Income 1992 gross annual wager of the U.S. Part 1: Handle. Gaming and Wagering Business, 14, no 7, 12-35. Custer, R.L., & Milt, H. (1985). When luck runs out. New York: Facts on File Publications.
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Eadington, W.R. (1989). Problem gambling and public policy: Alternatives in dealing with problem gamblers and commercial gambling. In H.J. Shaffer, S.A. Stein, B. Gambino, & T.N. Cummings. (Eds.), Compulsive gambling." Theory, research, and practice. Lexington, MA: Lexington Books. Gaboury, A. & Ladouceur, R. (1993). Evaluation of a prevention program for pathological gambling among adolescents. Journal of Primary Prevention, 14, 21-28. Gambino, B., Shaffer, H.J., & Cummings, T.N. (1992, November, December). Compulsive Gambling: An Overlooked Problem. EAP Digest, pp. 32-35, 46-47. Harris, J.L. (1988). A model for treating compulsive gamblings through cognitive-behavioral approaches. Psychotherapy and the Self-Contained Patient, 4, 211-226. Kallick, M., Suits, D., Dielman, T., & Hybels, J. (1979). A survey of American gambling attitudes and behavior. Survey Research Center, Institute for Social Research. The University of Michigan. Ladouceur, R. (1991). Prevalence estimates of pathological gamblers in Quebec, Canada. Canadian Journal of Psychiatry, 36, 732-734. Ladouceur, R., Dubfi, D., & Bujold, A. (1994). Prevalence of pathological gambling and related problems among college students in the Quebec metropolitan area. Canadian Journal of Psychiatry, 39, 289-293. Ladouceur, R., & Mireault, C. (1988). Gambling behaviors among high school students in the Quebec area. Journal of Gambling Behavior, 4, 3-12. Lesieur, H.R. (1992). Compulsive gambling. Society, 29, 43-50. Lesieur, H.R. (1984). The Chase: Career of the compulsive gambler. Cambridge, MA: Schenkman Books. Lesieur, H.R., & Puig, K. (1987). Insurance problems and pathological gambling. Journal of Gambling Behavior, 3, 123-136. Lesieur, H.R., & Rosenthal, R.J. (1991). Pathological gambling: A review of the literature. Journal of Gambhng &udies, 7, 5-40. Lorenz, V.C., & Politzer, R.M. (1990). Final report on the taskforce on gambling addiction in Maryland. Report to the Maryland Department of Health en Mental Hygiene. Baltimore, Maryland. Lorenz, V.C., & Yaffee, R.A. (1988). Pathological gambling: Psychosomatic, emotional and marital difficulties as reported by the spouse. Journal of Gambling Behavior, 4, 13-26. Lorenz, V.C., & Yaffee, R.A. (1986). Pathological gambling: Psychosomatic, emotional and marital difficulties as reported by the gambler. Journal of Gambling Behavior, 2, 40-49. Loto-Qu~bec (1993). Rapport annuel 1992-1993 (Annual Report 1992-1993) Montreal: Author. National Council on Problem Gambling (1993). The need for a national policy on problem and pathological gambling in America. The National Council on Problem Gambling, New York, N.Y. Nelson, K. (1992, November, December). Risky Business: Compulsive Gambling and the Company Bottom Line. LAP Digest, 45, 26-18. Overman, S. (1990, April). Addiction: Odds Are Gamblers Cost Companies. Human Resources Magazine, pp. 50-54. Politzer, R.M., Morrow, J.S., & Leavey, S.B. (1985). Report on the Cost Benefit/effectiveness of treatment at the John Hopkins Center for pathological gambling. Journal of Gambling Behavior, 2, 13 i - 142. Rice, D.P., Kelman, S., & Miller, L.S. (1991). The economic cost of alcohol abuse. AlcoholHealth and Research World, 15, 307-316. Volberg, R.A. (1994). The prevalence and demographics of pathological gamblers: Implications for public health. American Journal of Public Health, 84, 237-241. Volberg, R.A. (1993, July). Assessing the social costs of gambling: An exploration. Paper presented at the Seventh National Conference on Gambling Behavior, New London, Connecticut. Volberg, R.A., & Steadman, H. (1989). Prevalence estimates of pathological gambling in New Jersey and Maryland. American Journal of Psychiatry, 146, 1618-1619. Wynne, H.J., Smith, G.J., & Volberg, R.A. (1994). Gambling and problem gambling in Alberta. Prepared for the Alberta Lotteries and Gaming. Edmondton, Alberta.
Jean-Marie Boisvert Michel P~pin Michel Loranger Caroline Sylvain Universitg Laval, Qugbec
Pathological gambling creates enormous problems for the afflicted individuals, their families, employers, and society, and has n u m e r o u s disastrous financial consequences. T h e present study evaluates the financial burdens of pathological gambling by questioning pathological gamblers in treatment in G a m b l e r s A n o n y m o u s (n = 60; 56 males, 4 females; mean age = 40 years old) about personal debts, loss of productivity at work, illegal activities, medical costs and the presence of other dependencies. Results show that important debts, loss of productivity at work and legal problems are associated with pathological gambling. Discussion is formulated in terms of the social cost of adopting a liberal attitude toward the legalization of various gambling activities.
Gambling is a widespread cultural phenomenon. This activity has become a prime leisure industry in the United States with numerous participants (Abt, Smith, & Christiansen, 1985). Rates of gambling and the sums invested have increased over the years through North America. In 1974, 61% of Americans gambled and $17.4 billion was spent on gambling in the U.S. (Kallick, Suits, Dielman & Hybels,
This study was completed with the financial support of the FCAR, CQRS and Loto-Quebec grants. Authors wish to thank Lisa Kelley for her helpful comments on an earlier version of the manuscript. All correspondence should be addressed to Robert Ladouceur, Ph.D., Ecole de Psychologie, Universit6 Laval, Quebec, Canada, G1K 7P4.
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1979). By 1992 the amount had reached $329.9 billion, an increase of 1,900% in eighteen years (Christiansen, 1993). A similar trend was found in Quebec; from 1974 to 1992, money spent on lotteries grew from 51 million to $1.2 billion per year, an increase of 2,000% (LotoQuebec, 1993). Today, 48 American states have legalized at least one form of gambling, with a trend toward increasing diversity (Lesieur, 1992). In Canada, many forms of legal gambling are available in all provinces. Video lottery terminals and casinos are present in more than half of the provinces. If one excludes horse racing, revenues from gambling are increasing. This liberal attitude concerning the legalization of gambling activities is typical of most Western countries and, rarely seems to be questioned. The accessibility of these games, both legal and illegal, encourages gambling involvement and exposes more vulnerable individuals to the risks of becoming excessive or pathological gamblers. Frequent gambling presents a danger of dependency, similar to frequent alcohol or drug consumption (Eadington, 1989; Harris, 1988; Lesieur, 1992; Volberg, 1994). While some authors are unwilling to suggest a causal relationship between the accessibility of gambling and the n u m b e r of pathological gamblers, others believe that the incidence of pathological gambling is higher in jurisdictions that offer legalized games (Eadington, 1989; Lesieur, 1992; Volberg, 1994). It seems reasonable to assume that access to games will increase the n u m b e r of gamblers and the frequency of gambling. In fact, several prevalence studies demonstrate that there are more problem gamblers where gambling is legal. For example, a 1974 survey reported fewer than 1% of the total U.S. population were recognized as "probable compulsive" gamblers, compared to 2.5% in the state of Nevada, where casino gambling was legal at the time. Other studies indicate that in 1989, there were 1.4%, 1.4% and 1.5% pathological gamblers in New York, New Jersey and Maryland respectively. In each of these states, at least 2.4% of the population had gaming habits that were problematic without meeting all the criteria for pathological gambling (Volberg & Steadman, 1989). In Quebec, although casinos were not legal until October 1993, there are significant numbers of lottery players, horse race bettors and bingo players, as well as players of some illegal games like VLTs, with substantial gambling-related problems. A 1991 survey of 1,000 individuals over 18 years of age found that 1.2 % could be classified as pathological gamblers. An additional 2.6%
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could be classified as having somewhat less severe gambling problems. O n the basis of these figures, it was estimated that between 61,000 and 136,000 individuals in Quebec have moderate to severe gambling problems. These individuals are mostly male (75.9%) and are either less than 30 years old or between 40 and 49 years of age (Ladouceur, 1991). Not all gamblers are adults, as shown by two surveys of adolescents; 1.7 %, and 2.8 % of adolescents in the Quebec City region report gambling problems (Ladouceur, DubS, & Bujold, 1994; Ladouceur & Mireault, 1988). The American Psychiatric Association officially recognized pathological gambling dependency as a pathology in 1980; pathological gambling is defined as a chronic and progressive failure to resist impulses to gamble. These impulses become so intense and powerful that the gambler can no longer control them, despite the serious negative consequences arising from gambling (Custer & Milt, 1985; Lesieur & Rosenthal, 1991). Pathological gambling gradually destroys many aspects of an individual's life. The gambler typically incurs considerable debts, commits illegal acts to get money, develops workrelated problems (absenteeism and lower productivity), and jeopardizes physical and psychological health because of gambling (Gambino, Shaffer, & Cummings, 1992; Overman, 1990; Nelson, 1992; Lesieur, 1984). As Lesieur (1992) suggests, gambling creates a redistribution of resources from the losers to the winners. The biggest winners are the operators of these gambling activities; in m a n y cases, the operator is an agency of the state. Regular gamblers, including pathological gamblers, account for a large share of the state profits from gambling. Much of this money comes out of paychecks and personal savings, and is very difficult to quantify. Since losses typically outweigh winnings in long run, compulsive gamblers must often resort to borrowing from banks and other financial institutions to cover their losses. Limited data, make it impossible to estimate the total annual debt and bankruptcies arising from pathological gambling in the U.S. However, Lesieur (1992) estimates that in New Jersey, debts totaling $514 million are accrued each year by pathological gamblers. Even this total does not reflect the further costs of bankruptcy proceedings and other civil actions related to indebtedness. Considering the recent increase in legalized games, it is imperative to establish the potential impact of legalization, particularly on that proportion of the population susceptible to gambling dependency.
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There is good evidence that gambling dependency can cause multiple problems for gamblers, ranging from financial to family-related, from professional to emotional (Lorenz & Yaffee, 1986, 1988). But what are the real costs? What are the effects on society of such a dependency? Few studies have explored this important aspect of pathological gambling. Unfortunately, the pioneering work of Politzer, Morrow and Leavey (1985), which demonstrated the financial benefit of treatment, has not been pursued. Lorenz and Politzer (1990) and Lesieur (1992) reviewed researches evaluating the social cost of pathological gambling. They showed that enormous direct and indirect costs result from this pathology. For example, the average indebtedness of the pathological gambler undergoing treatment or seeking help at G.A. was $71,853 and $83,336 respectively (Lorenz & Politzer, 1990). As part of a prevalence study of problem and pathological gambling in the province of Alberta, 30 gamblers (10 frequent, 10 problem and 10 pathological gamblers) were interviewed in order to estimate the social and financial costs of problem gambling (Wynne, Smith & Volberg, 1994). Results showed that in many aspects, probable pathological gamblers differed from the two others groups on negative social impacts. Among the most striking results, we find the following characteristics. If no frequent gamblers indicated that their gambling affected their family finances, the majority of the pathological gamblers reported that their family lives quite stressful and their uncontrolled gambling increased the pressure they were under. None of the frequent gamblers had been approached by a significant other to be more circumspect about their gambling, whereas 50% of the pathological gamblers had been counselled by a friend or a relative. Concerning the workplace, several pathological gamblers reported having left work early to gamble, took extended breaks or were absent from work to gamble. Such behaviors were not reported by the frequent gamblers. On the financial aspect, the range of the pathological gamblers' losses varied from 4,500 to $50,000. It may not be surprising that they have experienced more physical ailments such as ulcers, colitis and migraines than the other groups. If these data are preliminary and tentative, they nevertheless provide a trend of what could be expected in an extensive study of the social impacts of pathological gambling. In the similar perspective, Volberg (1993, July) estimated the cost of pathological gambling in Connecticut at half a billion dollars. These figures were based on the social cost of addictive disorders model presented by Rice et al. (1991) and on a prevalence survey conducted
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in that jurisdiction. The present study will explore the social cost of pathological gambling in the Canadian province of Quebec. These preliminary data provide a basis for further exploration of this research avenue and may also be generalized to other Canadian provinces and American states. Prevalence estimates represent the first step in studying the impact of problem gambling on society, and these estimates then allow the direct and indirect economic costs of this illness to be evaluated (Rice, Kelman, & Miller, 1991). As indicated by Volberg (1993), the question of the social costs of gambling arises at two critical junctures: (1) during the political debate about legalizing a new type of gambling and (2) during the development of prevention and treatment programs for problem gamblers. As there are no existing procedures for the evaluation of the social cost of gambling, the approach used by Rice et al. (1991) to assess economic cost of alcohol abuse provides a valuable model. The cost of illness is divided into two major categories: (1) core costs that result directly from the illness, such as services, and treatment and (2) related costs, which stem from nonhealth aspects of the illness, including reduced productivity and premature death. For this study, information about both cost categories were collected in order to provide a gross estimate of the total social cost of pathological gambling.
METHOD
Subjects Pathological gamblers attending Gamblers Anonymous meetings in the regions of Quebec City, Montreal, Trois-Rivieres and Chicoutimi or engaged in therapy sessions at the Center for the Treatment of Pathological Gamblers at Laval University were invited to participate in the study. Sixty individuals completed and returned the questionnaire. As in similar studies, this sample is probably not representative of all pathological gamblers in Quebec but is based on the assumption that pathological gamblers not in treatment are similar to those in treatment (Lorenz & Yaffee, 1986, 1988; Lesieur, 1992; Volberg, 1993). The gamblers in the present sample are predominantly male (93%), with a high school level education, and with a mean age of 40 years. These characteristics are strikingly similar to
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those found in the pathological gamblers identified in a provincial survey in Quebec (Ladouceur, 1991).
Measures A 31 item questionnairC was developed evaluating the impact of pathological gambling on employment-related behaviors, debts, money spend on gambling, illegal acts, frequency of alcohol and drug use, and psychosomatic complaints.
RESULTS
As frequently stated by legislators, approval of gambling is based on the premise that the social benefits of legal gambling outweigh the social costs(see Wayne, Smith & Volberg, 1994). But no systematic analysis of the full social and financial impacts of legal gambling have been published in any jurisdictions. The present results bring preliminary and descriptive data on the social consequences of pathological gambling.
Spending and Gambling Debts Analyses of questionnaire responses show that 33% 2 of respondents spent between $1,000 and $2,000 a month on gambling, and 23 % spent between $2,000 and $5,000 a month on gambling. Considering that in Quebec, 1.2 % of the adult population or 50,000 individuals are pathological gamblers (Ladouceur, 1991) 3, a conservative estimate would suggest that pathological gamblers in the province spend a m i n i m u m of three quarters of a billion dollars on gambling
~Copy of the questionnaire is available upon request to corresponding author. 2For purpose of clarity decimals of percentages were dropped. 3The issue concerning current or lifetime prevalence rates is most important in evaluating the social cost of pathological gambling. Volberg (1993) suggested that since on average, prevalence studies have shown that 60% of lifetime pathological gamblers score as current probable pathological gamblers, lifetime rate should be corrected by .6. In the present report, we think that this correction would underestimate the figures of the social cost of pathological gambling, because the 1.2 % lifetime prevalance rate of probable pathological gamblers was obtained in 1989 three years before the legislation of three new gaming activities in Quebec: Casinos, V L T s and OTB.
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each year. Although these figures are based on lifetime prevalence rate, the fact that gambling is more available now in Quebec than in 1989 when this survey was conducted, these figures are probably not inflated particularly since the legalization of video lottery terminals (VLTs), casinos and the opening of off-track betting (OTB) in the province. The great majority of respondents (90 %) use their paycheck or their family savings to gamble, and 83 % had to borrow money during the past year in order to gamble. Sixty-two percent of respondents had borrowed money from relatives or friends in order to avoid serious problems with creditors, with more than half of them (35 %) receiving amounts ranging from $3,000 to $5,000. Twenty percent of the respondents borrowed money from loan sharks. As a result of their gambling debts, 28 % of the respondents have filed for bankruptcy and 30% reported debts ranging from $75,000 to $150,000.
Workplace Impacts Both lateness and absence from work are very frequent among pathological gamblers in this study. Among the respondents, 66% report having missed work (or left early) to gamble, with half of these individuals doing so more than 5 times a month. Three-fifths (61%) of the respondents have been late for work because they were gambling, and half of this group did so more than 5 times a month. Each of these instances represents an average of 1 to 3 hours lateness. For 11% of respondents, late arrivals can extend to half a day, while 14% say that they have missed up to an entire day of work in order to gamble. If 50 % of the pathological gamblers are late by an average of 5 hours a month, and the average wage is $30,000 a year or $15 an hour, then the overall loss to employers amounts to a minimum of $45 million per year. Preoccupation with gambling debts, recent losses or future gambling may cause gamblers to lack concentration, thereby affecting productivity. In this study, 59% of respondents report that they are very often irritable at work and frequently have difficulty concentrating, due to the pervasive nature of thoughts about gambling. Nearly half (43 %) of respondents have asked for an advance on their paycheck and 37% have stolen money from their employer in order to gamble. Close to 50% of these individuals report having stolen from their employer more than once, in amounts ranging from $2,000 to more
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than $5,000. Finally, half of the respondents almost lost their jobs, and 36 % had already lost their jobs because of gambling problems. More than half of these respondents earned a salary ranging from $35,000 to more than $50,000.
Other Dependencies Systematic studies reveal rates of alcohol and other substance abuse among pathological gamblers to range from 47% to 52% (Lesieur, 1992). In this study, it appears other dependencies add to gambling problems for many pathological gamblers. Over half of these respondents regularly consume alcohol and drugs with one fifth of these respondents consuming alcohol 6 to 10 times a week. Also, 13% of the sample reported consuming nonprescription drugs between 1 and 10 times a week. These proportions are considerably higher than the 5 % of the general population in Quebec that report a dependency on alcohol. The social costs associated with pathological gambling are especially high when combined with the costs related to other dependencies. Pathological gamblers with alcohol and drug dependency are at greater risk of incarceration, and they have a higher rate of stress-related illnesses and serious psychiatric problems, including attempted suicide.
Illegal Activities to Finance Gambling Pathological gambling often leads to criminal behavior. Studies conducted to date reveal a variety of illegal behaviors among pathological gamblers; these include fraud, theft, fencing stolen goods, embezzlement, tax fraud, tax evasion, forgery and selling drugs. A very high proportion of pathological gamblers admit engaging in these illegal activities as a last resort to finance their gambling or pay substantial gambling-related debts. Lesieur reported that approximately twothirds of non-incarcerated and 97 % of incarcerated gamblers reported engaging in illegal activities to finance gambling (Lesieur, 1992). In this study, 68 % of respondents report having engaged in illegal acts to finance their gambling. Lorenz and Politzer (1990) also reported that 61% of pathological gamblers in Maryland engaged in illegal acts; thus data on illegal activities by pathological gamblers appear to be consistent across Canada and the United States. Detailed analysis of our data shows that 10 % of respondents admit having falsified documents
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or forged signatures, 23% engaged in embezzlement, 33% signed checks without sufficient funds, 18% filed false income tax returns or neglected to pay income tax, and 3 % made false statements to insurance companies. A significantly higher rate of insurance fraud was reported in United States (Lesieur & Puig, 1987): the reason for a discrepancy with the Canadian data is not clear. One reason may be that no specific questions were asked to elicit different forms of insurance fraud in this study. In addition, 37 % of the respondents stole money from an employer, 17% committed a non-violent theft, 3% committed a violent theft, 17 % shoplifted and 7 % fenced stolen goods. Finally, 17 % of respondents have already appeared in court for an offense and 8 % were sentenced to jail. As in other studies, the majority of offenses committed by pathological gamblers in Quebec are non-violent. It is difficult to calculate precisely the social cost of illegal acts and crimes committed by gamblers to obtain money for gambling or pay gambling-related debts. Estimate of such costs involves far more than simply the amounts of money taken by theft or fraud; in some cases, the cost of judicial procedures, including arrest and incarceration could entail considerable expenses for society. Medical Costs
Pathological gambling has been shown to have negative effects on the gambler's physical and emotional health (Lesieur, 1992). Our study confirms that pathological gambling has serious negative consequences for the individual's health. Over two thirds of respondents indicated that due to gambling they experience depressive moods, insomnia, headaches or stomach aches, at least once a week, while an additional one quarter experience these symptoms occasionally. The cost of treating these stress-related problems, as well as other physical illnesses requiring frequent medical consultations and hospitalization, could prove to be a significant additional expense for society. DISCUSSION AND CONCLUSIONS The results of this study indicate that the cost of pathological gambling is a critical, and often underestimated burden on society. It is difficult to assess all the costs related to this dependency, when the use of health services and the judicial system must be taken into account, as well as the problems and losses experienced by employers. There is also the issue of the more subtle consequences of pathological gambling,
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such as the emotional problems of family members, loss of trust in families, separations, divorces, and suicide attempts. These additional costs are difficult to quantify, but our results make it clear that they should be further explored (see Rice et al., 1991). The cost estimates depend on a set of assumptions which may or may not be true. That is, the Gamblers Anonymous members surveyed are similar to other Gamblers Anonymous members not surveyed. Secondly, that Gamblers Anonymous members are similar to compulsive gamblers found in the general population surveys. Regardless of that fact, the costs of pathological gambling are probably high and should not be underestimated. This study on the social costs of gambling underlines the importance of taking measures to stop or lessen the effects of this dependency, especially as the rapidly expanding availability of legal gambling leads increasing numbers of individuals to gamble. Considering the consequences of pathological gambling to society, it is important that both private industries and public agencies become more involved in the prevention and treatment of pathological gambling. At this point, we strongly endorse the suggest made by Lesieur (1992) that no new forms of gambling be legalized without first providing treatment facilities for current problem gamblers. Furthermore, the present data support the recommendations of the National Council on Problem Gambling (1993) that (1) the severity of pathological gambling should be recognized by the adoption of a national policy about problem gambling, (2) the treatment of pathological gambling should be included in provincial or national health care plans and (3) groups providing public education or treatment interventions should be funded. Finally, as with other disorders, clinicians and researchers should focus on prevention programs as well as treatment. In light of the mounting costs to society of excessive gambling, it is surprising that, to date, there is only one published study addressing the prevention of this pathology (Gaboury & Ladouceur, 1993). REFERENCES Abt, V., Smith, J.F., & Christiansen, E.M. (1985). The business of risk: Commercial gambling in mainstream America. Lawrence, Kansas: University of Kansas Press. Christiansen, E.M. (1993). Income 1992 gross annual wager of the U.S. Part 1: Handle. Gaming and Wagering Business, 14, no 7, 12-35. Custer, R.L., & Milt, H. (1985). When luck runs out. New York: Facts on File Publications.
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Eadington, W.R. (1989). Problem gambling and public policy: Alternatives in dealing with problem gamblers and commercial gambling. In H.J. Shaffer, S.A. Stein, B. Gambino, & T.N. Cummings. (Eds.), Compulsive gambling." Theory, research, and practice. Lexington, MA: Lexington Books. Gaboury, A. & Ladouceur, R. (1993). Evaluation of a prevention program for pathological gambling among adolescents. Journal of Primary Prevention, 14, 21-28. Gambino, B., Shaffer, H.J., & Cummings, T.N. (1992, November, December). Compulsive Gambling: An Overlooked Problem. EAP Digest, pp. 32-35, 46-47. Harris, J.L. (1988). A model for treating compulsive gamblings through cognitive-behavioral approaches. Psychotherapy and the Self-Contained Patient, 4, 211-226. Kallick, M., Suits, D., Dielman, T., & Hybels, J. (1979). A survey of American gambling attitudes and behavior. Survey Research Center, Institute for Social Research. The University of Michigan. Ladouceur, R. (1991). Prevalence estimates of pathological gamblers in Quebec, Canada. Canadian Journal of Psychiatry, 36, 732-734. Ladouceur, R., Dubfi, D., & Bujold, A. (1994). Prevalence of pathological gambling and related problems among college students in the Quebec metropolitan area. Canadian Journal of Psychiatry, 39, 289-293. Ladouceur, R., & Mireault, C. (1988). Gambling behaviors among high school students in the Quebec area. Journal of Gambling Behavior, 4, 3-12. Lesieur, H.R. (1992). Compulsive gambling. Society, 29, 43-50. Lesieur, H.R. (1984). The Chase: Career of the compulsive gambler. Cambridge, MA: Schenkman Books. Lesieur, H.R., & Puig, K. (1987). Insurance problems and pathological gambling. Journal of Gambling Behavior, 3, 123-136. Lesieur, H.R., & Rosenthal, R.J. (1991). Pathological gambling: A review of the literature. Journal of Gambhng &udies, 7, 5-40. Lorenz, V.C., & Politzer, R.M. (1990). Final report on the taskforce on gambling addiction in Maryland. Report to the Maryland Department of Health en Mental Hygiene. Baltimore, Maryland. Lorenz, V.C., & Yaffee, R.A. (1988). Pathological gambling: Psychosomatic, emotional and marital difficulties as reported by the spouse. Journal of Gambling Behavior, 4, 13-26. Lorenz, V.C., & Yaffee, R.A. (1986). Pathological gambling: Psychosomatic, emotional and marital difficulties as reported by the gambler. Journal of Gambling Behavior, 2, 40-49. Loto-Qu~bec (1993). Rapport annuel 1992-1993 (Annual Report 1992-1993) Montreal: Author. National Council on Problem Gambling (1993). The need for a national policy on problem and pathological gambling in America. The National Council on Problem Gambling, New York, N.Y. Nelson, K. (1992, November, December). Risky Business: Compulsive Gambling and the Company Bottom Line. LAP Digest, 45, 26-18. Overman, S. (1990, April). Addiction: Odds Are Gamblers Cost Companies. Human Resources Magazine, pp. 50-54. Politzer, R.M., Morrow, J.S., & Leavey, S.B. (1985). Report on the Cost Benefit/effectiveness of treatment at the John Hopkins Center for pathological gambling. Journal of Gambling Behavior, 2, 13 i - 142. Rice, D.P., Kelman, S., & Miller, L.S. (1991). The economic cost of alcohol abuse. AlcoholHealth and Research World, 15, 307-316. Volberg, R.A. (1994). The prevalence and demographics of pathological gamblers: Implications for public health. American Journal of Public Health, 84, 237-241. Volberg, R.A. (1993, July). Assessing the social costs of gambling: An exploration. Paper presented at the Seventh National Conference on Gambling Behavior, New London, Connecticut. Volberg, R.A., & Steadman, H. (1989). Prevalence estimates of pathological gambling in New Jersey and Maryland. American Journal of Psychiatry, 146, 1618-1619. Wynne, H.J., Smith, G.J., & Volberg, R.A. (1994). Gambling and problem gambling in Alberta. Prepared for the Alberta Lotteries and Gaming. Edmondton, Alberta.
