Gambling with America’s Health? The public health costs of legal gambling

Publicly, Scott Stevens, a chief operating officer of a company in Steubenville, Ohio, was a well-regarded member of his community. A married father of three, he was active in his local Catholic church, involved with high school sports teams, and helped develop parks in the area. Privately, Stevens was addicted to gambling. First exposed to slot machines at a trade show in Las Vegas in 2007, Stevens became a regular slot player at the Mountaineer Casino, Racetrack, & Resort, about 30 minutes away in Chester, West Virginia. By 2010, he had embezzled $7 million from his employer to gamble, and when they found out, he lost his job. Stevens continued to gamble secretly for the next 10 months, going to Mountaineer nearly every day, drawing money from his family’s savings, his 401(k), and his children’s college fund.

On August 13, 2012, that money ran out. In a suicide note to his wife, he wrote: “I know you don’t believe it, but I love you so much. I have hurt you so much. Our family only has a chance if I’m not around to bring us down any further.” That evening, Stevens asked his 13-year-old daughter to bring him his hunting bag from the attic. He drove to a local park he had helped develop and called 9-1-1. When the sheriffs arrived, he shot himself.

“If it can happen to a guy as smart as he was, then it can happen to anybody,” said Indianapolis attorney Terry Noffsinger in a talk last November at Harvard Law School. Noffsinger, with other attorneys, is representing Stevens’ widow Stacy in a lawsuit filed last month against Mountaineer Casino, its parent company MTR Gaming Group, and slot machine maker International Game Technology, alleging they are liable for her husband’s suicide. The suit accuses both the casino and the slot designer of using predatory and deceptive tactics to profit from people with gambling problems, like Scott Stevens.

“Mountaineer Casino knew, or should have known, that the condition of disordered gambling, especially slot machine addiction, is associated with severe adverse health and other consequences for individuals and their families. Not only are gambling addicts like Scott Stevens liable to literally gamble away everything they own and end up in crippling debt, but also to become suicidal at far higher rates than the general population and even the population of persons addicted to substances such as illegal drugs and alcohol,” the suit states.

Although the suit’s success is not assured—the few other cases in this area have not succeeded—it is part of a growing movement of activists, academics, lawyers, and former gambling addicts who are trying to spotlight the health, economic, and social costs of legal gambling. This group believes the gambling industry preys upon vulnerable people, including low-income individuals, youth, and problem gamblers and that gambling availability is linked to larger societal problems like crime and economic inequality.

For its part, the gambling industry points to a record of funding research into gambling addiction and efforts to educate the public about problem gambling. They maintain that they offer a fun activity that most people can do without serious consequences.

The opening of new gambling venues shows no signs of slowing down, despite the planned closing of four casinos in Atlantic City and financial problems for casinos in other states. Last fall, New Yorkers approved the building of up to seven casinos. Many other states are in various stages of building casinos. Some in the gambling industry are trying to legalize online gambling, which is currently allowed in only three states, Nevada, New Jersey, and Delaware.

A debate over the social and health costs of legal gambling has largely been sidelined even as availability has expanded dramatically in the last 25 years. This is not because of a lack of merit, say experts and activists, but because of the political power of the gambling industry. They allege that the industry has employed tactics in the same spirit as those of tobacco companies, which for many years misled consumers about the addictive properties of cigarettes and advertised to young people and other vulnerable consumers.

According to Les Bernal, the national director of Stop Predatory Gambling, a Washington, D.C.-based non-profit, “This is one of the biggest public health issues in America today that no one has been paying attention to.”

A few experts predict that as stories of gambling addiction become more common, suits like that of Stacy Stevens will increase and could even succeed, as tobacco lawsuits did. “Ultimately gambling will be linked to the increase in social costs, gambling will be linked to the problems it creates, just like smoking was ultimately linked to cancer,” says Dr. Earl Grinols, a professor of economics at Baylor University. “It can take a while.”

ADDICTIVE PROPERTIES

In the world of gambling, the most addictive property is electronic video gambling machines, often slots, which bring in 70 to 85 percent of the revenue for casinos. In some states, electronic video terminals are even available in other venues, like restaurants and bars. The machines do not typically have warning labels or cut offs for heavy users. Casinos aggressively market to frequent patrons, giving them complimentary flights, hotels, and other perks. Meanwhile, the success of state voluntary exclusion programs where problem gamblers sign up to ban themselves from casinos is unclear.

Today’s slots are not the old lever-operated “one-armed bandits” but video game-like terminals that keep users playing by deliberate design, according to Dr. Natasha Dow Schüll, an associate professor in the program of science, technology, and society at the Massachusetts Institute of Technology and the author of Addiction by Design: Machine Gambling in Las Vegas. “The particular addictiveness of modern slots has to do with the solitary, continuous, rapid wagering they enable. It is possible to complete a game every three to four seconds, with no delay between one game and the next. Some machine gamblers become so caught up in the rhythm of play that it dampens their awareness of space, time and monetary value,” writes Schüll in a New York Timescommentary.

“A lot of people think it’s a tax on the stupid,” recovering gambling addict Kitty Martz told the Oregonian. “Really, we’re behaving exactly the way the machines want us to.”

The idea that gambling lends itself to addiction like drugs or alcohol has taken some time to be acknowledged. Until the 2013 publication of the fifth edition of the Diagnostic Statistics Manual, or DSM-5, problem gambling was classified as an “impulse control disorder” in the same category as pyromania and kleptomania, even though most clinicians who treated problem gamblers recognized it as an addiction, says Dr. Silvia Martins, an associate professor of epidemiology at the Columbia University Mailman School of Public Health.

These gamblers exhibit many of the same problems as other addicts. “Everything you see with substance abuse you can make an analogy to gambling problems,” Martins says, citing family strife, financial hardship, and struggles with depression or anxiety.

“GIVE YOUR DREAMS A CHANCE”

To gamble legally 40 years ago, one had to travel to Nevada, go to a racetrack, or live in one of the handful of states that offered lotteries. In most towns, the closest one came to a betting game was playing charitable Bingo at church. Video slot machines had not yet come to market.

For most Americans today, a casino is just a car ride away. There are about 1,400 of them in 39 states, and 43 states sponsor lotteries with games that are recognizable even to non-gamblers, like Mega Millions, Powerball, Pick 10, and instant scratch off tickets. In advertising to citizens, states use slogans like, “Hey you never know,” “Give your dreams a chance,” and “Believe in something bigger.” Hawaii and Utah are the only states that offer no forms of legal gambling.

Casinos represent a substantial part of the nation’s economy and enjoy support from members of both political parties. In 2012, the industry took in $37 billion in gross revenue, employed 332,075 people, paid $13 billion in wages, and contributed $8.6 billion in taxes,according to the American Gaming Association. Many casinos are not just places to play blackjack and slots but to eat or take in live music and comedy acts.

In this environment, gambling addiction is often considered a small cost, one brought upon by the individual unwise gambler. “They think that it’s an easy, painless way to raise revenue but they don’t see the other side of it,” says Arnie Wexler. Wexler quit gambling over 45 years ago after a nearly three-decade addiction and has since served as executive director of New Jersey’s Council on Compulsive Gambling. He also runs counseling services for compulsive gamblers with his wife, Sheila.

According to a conservative interpretation of the available research bythe National Center for Problem Gambling, 1.1 percent or 3.4 million Americans have a pathological gambling disorder and two percent or 6.2 million engage in problem gambling, a less severe form of gambling addiction. (The term problem gambling is often used to refer to both problem and pathological gambling.) Internationally, prevalence is as low as 0.5 percent of the population in Denmark and the Netherlands, and as high as 7.6 percent in Hong Kong, according to a 2012 review for the province of Ontario. Though problem gamblers are a minority of visitors to casinos, their spending accounts for anywhere from 35 to 50 percent of the revenues, according to several studies summed up in a paper by the Institute for American Values, a non-partisan think tank that focuses on family and social issues.

BETTING ON SCIENCE

Neuroscientists have found commonalities between the brains of gambling and drug addicted people, like increased impulsivity and lower levels of activity in a region of the brain’s reward system, which leads people to seek bigger and potentially dangerous thrills. But it is not clear from this research when or how someone becomes addicted to gambling.

Compared to other nations, there has been relatively little epidemiologic research on rates of problem gambling in the U.S. The existing studies find that problem gambling increases with proximity to casinos. The federal government’s 1999 National Gambling Impact Study found that areas within 50 miles of a casino had twice as high a rate of problem gambling as those within 250 miles. The presence of a casino within 10 miles of a survey respondent’s home was positively related to problem or pathological gambling, according to a 2004 study by the University of Buffalo’s Research Institute on Addictions published in the Journal of Gambling Studies.

“Basically what we’ve learned is that as with many other kinds of environmental exposures, there typically is an increase in the prevalence rate of problem gambling in the wake of major introductions of new forms of gambling, whether it’s lotteries back in the 1980s and 1990s or casinos in the 1990s and 2000s,” says Dr. Rachel Volberg, a research associate professor of epidemiology at University of Massachusetts-Amherst and a researcher for the Massachusetts Gaming Commission. Volberg has found that rates of problem gambling began increasing during the most rapid expansion of gambling opportunities in North America and in Australia.

Yet she says problem gambling rates seem to level off after awhile. A study by the Research Institute on Addictions that has not been published yet found that rates of problem gambling did not continue to rise between 2010-2012 despite greater opportunity to gamble. Principal investigator Dr. John Welte, senior research scientist in psychology at the University of Buffalo, says it is not clear why, but he says it could be a result of the economic crisis.

The National Center for Responsible Gambling, or NCRG, is the charitable arm of the gambling industry’s trade association, called the American Gaming Association. NCRG cites a few studies that it says show problem gambling has not risen since the 1970s. After a casino moves in, problem gambling may become more widespread initially, but after a while, people “adapt”—they become more aware of the risks, seek treatment, or simply lose interest, says Christine Reilly, the senior research director of NCRG. This is called an “adaption effect.”

But prevalence studies do not tell the full story, says Dr. Stephen Q. Shafer, the chairman of the Coalition Against Gambling in New York. “One of the fallacies is that, let’s say you assume that your prevalence statistics are absolutely correct and you show that the prevalence of pathological gambling has not risen. It was, say, five years ago 1.1 percent. Last year it was 1.2 percent. What that forgets is that the prevalence is a pool out of which people move and into which people come, and looking at prevalence compared to time one and time two, you have to account for the people who have recovered, died, moved away.” For instance, a prevalence study conducted in 2008 would have counted Scott Stevens, but one in 2013 would not have.

For this reason, there need to be studies that use more rigorous epidemiologic methods, says Shafer, who is also a retired clinical professor of neurology and epidemiology at Columbia’s College of Physicians & Surgeons and the Mailman School. He has pushed to get New York State to commission such a study, but the state’s health department, the legislature, and the gambling commission have shown no interest.

INDIVIDUAL DISEASE OR PUBLIC HEALTH PROBLEM?

Funding for gambling addiction research in the U.S. is about one-twentieth of funding in Australia and Canada, where gambling availability has also risen significantly in the past several decades,according to Volberg. Within the National Institutes of Health, there is an institute for research on alcohol disorders and an institute forresearch on drug addiction, but no institute for general addiction. Investigators who study problem gambling typically have to propose to look at it in conjunction with drug or alcohol use in order to win grants.

The NCRG is the only private funder of gambling addiction research in the country. According to Reilly, they fund research by top scientists at universities like Caltech, Duke, and Stanford, which are published in peer-reviewed journals. “We are funding some of the best people in the country, people who will lead us and force the issue at a national level,” says Reilly.

The majority of the NCRG’s funding goes to research based on a “disease model”—which investigates what goes on in the brains of individuals addicted to gambling—rather than the public health model, which looks at how availability affects population rates of problem gambling and potential social costs.

Both the disease model and the public health model “have points of truth, and they’re not mutually exclusive,” says Welte. But he adds, “If I were the gambling industry, I would want to fund people who had the disease point-of-view … because [they are] putting the source of problem gambling between the ears of the gambler.”

According to Reilly, the disease model is more practical because it can lead to treatments and that it is less prone to the flaws of survey research. “To me it seems kind of silly to spend time and money on an issue that is extremely difficult to research, because you can’t count on people’s memory,” she says.

But it is not in the gambling industry’s interest to have good research conducted on the social and economic costs of casinos and other forms of gambling, says Grinols. He points out that the federal government’s 1999 National Gambling Impact Study Commission recommended a moratorium on further gambling expansion until more research could be done on the economic and social costs and benefits. “No research of the type and focus hoped for by the Commission has been forthcoming since. That’s because the gambling industry has done what it could to question these studies and has not itself funded such studies,” says Grinols. “The whole conclusion of the Commission has been ignored and in fact thwarted by the failure of money to be available for good research.” Dr. John Warren Kindt, a business administration professor at the University of Illinois whose research looks at the social and economic costs of gambling, calls what NCRG funds “pabulum research designed not to hurt the gambling industry and to misdirect the debate.” In response to such criticisms, Reilly is adamant that the NCRG has a totally independent review board, which she says mimics the structure of the National Institute of Health and does not interfere in the work of its researchers.

As for self-reporting, there are ways to validate responses. Dr. Robert Williams, a professor of addiction counseling at the University of Lethbridge in Alberta, Canada, has compared what respondents report they spend on gambling to actual gambling revenue. He says the more reliable studies are those in which the total of the revenue reported by participants is closer to the total revenue made by the gaming industry. Williams points out that self-reporting may also under-represent problem gamblers, who would be more likely to have their phone disconnected.

GROWING THE ECONOMY OR EXACERBATING INEQUALITY?

Gambling availability has other public health ramifications beyond addiction. It may exacerbate economic inequality, which has a strong relationship to health. It levies regressive taxes which take a larger share of income from lower- than from upper-income Americans. If taxes on gambling revenues substitute tax increases on income—which are progressive—the tax structure in a state becomes even more regressive. And those who spend money on certain forms of gambling are more likely to be low-income.

There is “a strong positive relationship” between state lottery sales and the poverty rates, according to a 2007 study in the American Journal of Economics and Sociology by economists at Cornell University that looked at data over 10 years. The most typical lottery player is a black, male, high school dropout making less than $10,000 a year, according to a 1999 report to the National Gambling Impact Study commission. Problem gambling is significantly worse in economically disadvantaged areas according to two studies from 2013, one by Welte and his colleagues and another by Martins and her colleagues. And the presence of a casino is associated with rises in bankruptcy filings, according to a 2005 study from Creighton University.

While casinos may bring new jobs when they open, most are low-paying service work. The national median wage in the gambling industry is$10.76 per hour. While better than some service jobs, it is less than the$16.87 hourly median wage for all industries, according to 2013 data from the Bureau of Labor Statistics.

And rather than boosting a local economy, casinos often draw business away from other food and entertainment venues. Many casinos are losing patrons to newer competition in neighboring states, straining state budgets and threatening local economies.

When casinos lose money or fail, the repercussions are significant.Delaware is spending hundreds of millions to keep struggling casinos afloat. In Atlantic City, several casinos plan to close by the end of the month, including the Revel, a two-year-old, $2.4 billion casino, entertainment, and conference center that was supposed to buoy the city’s flagging economy. The closures leave thousands of jobless peoplein a city that already has one of the highest unemployment rates in the country at over 15 percent as of April 2014, a violent crime rate six times the rest of New Jersey, and 29 percent of its population in poverty—a seven percent increase since 1974, two years before New Jersey voters legalized gambling.

Although these statistics do not prove that the city’s gambling economy caused its problems, they do call into question claims by politicians and developers that casinos are an engine for economic growth. Nevertheless, some New Jersey politicians and business leaders are now talking about opening a new casino—or four—at the Meadowland Sport Complex in Bergen County, New Jersey.

Tribal lands that have casinos have seen improvement in jobs and county-level mortality rates, according to a 2002 study from the National Bureau of Economic Research. Yet these communities still see more bankruptcy, violent crime, and auto thefts and larceny after a casino opens.

Legal gambling is also linked to social problems like rises in crime and risky behavior in youth. Counties where casinos have opened have seen rises in the number of rapes, robberies, aggravated assaults, burglaries, larcenies, and auto thefts, compared with counties without casinos, according to a study by economists Grinols and Dr. David B. Mustard, which looked at county FBI data from 1977 to 1996.

Because children are now growing up in an environment where gambling is so widely advertised and available, they could be especially vulnerable. Youth are at greater risk for problem gambling than adults,according to a 2007 study from Canada. Two percent or about 750,000 teens ages 14 to 21 described gambling with three or more negative consequences in a national survey by Welte and colleagues in 2008. Another 11 percent gambled twice or more per week, which is considered frequent. Teen boys who gamble are more likely to become fathers before age 20, especially those who problem gamble, according to a study by Martins. African-American teens who are problem gamblers are more likely to have sex and get arrested at a younger age than those who don’t gamble. Teens who had depressive symptoms early in adolescence are more likely to have gambling problems later in adolescence, according to another Martins study from 2011.

A PERVASIVE GAMBLING CULTURE

Former U.S. Representative Robert Steele has observed the casino economy at work in southeastern Connecticut, the district he represented from 1970-75, which in the early ’90s became home to both Foxwoods and Mohegan Sun Casinos.

“They became almost instant successes and the two biggest casinos in the world,” says Steele, who has written a novel, The Curse, which is inspired by the story of the two casinos and the tribes behind them. With Atlantic City as their only competition in the Northeast United States, Foxwoods and Mohegan Sun drew about 60 percent of their customers from out of state and created 20,000 jobs.

But soon came problems no one seems to have anticipated. Drunk driving arrests in nearby Norwich more than doubled, and annual calls to the local police department went up fourfold, according to Steele. There was a sharp spike in the number of people who sought treatment for gambling addiction. The rate of embezzlement increased 400 percent, according to a report from the state. Steele’s own tax collector went to prison in 2001 for embezzling money from the town to gamble.

Much of the promised employment was in low-paying service jobs, sometimes part-time and often filled by non-English speaking workers who came from outside the area. This influx put pressure on local housing and social services. The local school system gained 400 children who collectively spoke 31 different primary languages, requiring them to create an “English for speakers of other languages” program. Teachers observed value changes in their students, says Steele. “[They] say, ‘we try to teach the kids the way to succeed in life is through hard work. Then the casino culture comes in and says, ‘you hit it big, you hit the lottery. You hit the payoff.’”

Today, revenue from Connecticut’s casinos is down 35 percent since its high point of 2007. Ultimately, says Steele, who used to have a property abutting Foxwoods, the casinos created a “pervasive gambling culture.” He adds: “The people in southeastern Connecticut were in no way ready for the casinos.”

CITIZEN ACTION

In Massachusetts, citizens are campaigning to repeal a deal that allows for MGM Resorts International to build an $800 million casino in the economically depressed town of Springfield. “We see this as very much a perpetuation of income inequality, and the implications that income inequality has on public health—that people stay in poverty basically, stay under-compensated. It’s the transfer of wealth from people who don’t have money to people who have abundant resources,” says Steven Abdow, a senior staff member of the Episcopal Diocese of Western Massachusetts. “This would be intentionally bring[ing] in a product that destroys lives.”

Abdow is working on a campaign to oppose the MGM casino. Once viewed as a way to revive the city’s dwindled fortunes, the casino’s fate is now in jeopardy. In June, a judge ruled in favor of ballot measure that would allow the citizens of Massachusetts to repeal a 2011 law that authorized casinos in the state.

Tyre, New York, is a town of less than 1,000 people 270 miles northwest of New York City. The town’s website boasts of a community that “strives to maintain its rural flavor,” welcoming visitors to stop by and visit the Montezuma National Wildlife Refuge and the Erie Canal. Last December, residents learned that a Rochester-based real estate company called Wilmorite was bidding to open the Lago Resort and Casino on agricultural land, across from an Amish farm.

“I grew up my whole life in this area. A casino certainly is not what you anticipate showing up on your doorstep,” says Jim Dawley, a resident whose property borders the proposed spot.

Dawley and his wife, who own and run a small manufacturing company, and two friends formed an organization called Casino Free Tyre to oppose Wilmorite’s plans. “When everybody knows everybody, a good portion of the people you know are going to be affected—even if not directly—through broken homes, bankruptcy, the whole gamut,” says Dawley.

Over 200 residents have signed a petition against the casino, but members of the town board are supportive of Wilmorite, which is promising multi-million dollar revenues. The Dawleys are not letting up, even though they are new to activism. “This is so far outside of my normal realm, it’s unbelievable. I have a little manufacturing business out in the woods. I’ve been involved in our church and things like that but as far as any political-rooted opposition, this is our first time.”

FOLLOWING IN THE FOOTSTEPS OF CIGARETTES?

In the court case over the Massachusetts casino deal, an organization called the Public Health Advocacy Institute filed a friend-of-the-court brief that made a public health argument against the gambling industry. “Legalized casino gambling causes devastating effects on the public’s health, including not only the gambler but also their families, neighbors, communities and others with whom they interact,” the brief reads. Electronic gambling machines “are designed to addict their customers in a way that is similar to how the tobacco industry formulates its cigarettes to be addictive by manipulating their nicotine levels and other ingredients.”

“Mirroring the tobacco industry’s strategy of creating scientific doubt where none truly exists, the casino industry has co-opted and corrupted scholarship on the effects of gambling through the use of front groups that funnel money to beholden scientists who are able to sanitize its origin,” the brief continues.

“The commercialization of a dangerous product that threatens both individual and public health has been called an ‘industrial epidemic,’” the brief continues, citing a 2007 paper published in the journal Addictionby Drs. René I. Jahiel and Thomas F. Babor. This is an epidemic “driven at least in part by corporations and their allies who promote a product that is also a disease agent.”

The brief argues that the citizens of Massachusetts have an interest in regulating gambling the way they have regulated cigarettes.

Given the power of the gambling industry and the dependence of states on gambling revenues, winning legal damages and regulating availability may presently seem like a pipe dream in the U.S. However, other countries employ harm reduction strategies in casinos to intervene on potential problem gambling, according to a 2011 report from theCleveland Plain Dealer. In Holland, computers identify anyone who visits a casino more than 15 times a month as having a gambling problem. In the United Kingdom, casinos have to display the odds of winning on slot machines. And in Australia, there are limits on playing speeds and betting amounts.

The underlying principle behind this is articulated by Williams: “If provincial governments are going to make gambling available to their citizens, then concerted efforts are needed to prevent problem gambling, to effectively treat gambling addiction, and to minimize the amount of gambling revenue that comes from problem gamblers.”

LITTLE HELP AVAILABLE

People with gambling problems tend to elicit little sympathy. They are seen typically as exercising bad judgment when it is known that the “house always wins.” They have often hurt people they are closest to, both financially and emotionally.

Former gambling addicts readily admit to their flaws. But, like most people, they typically started gambling because it was available, entertaining, and provided a potential if unlikely monetary reward. However, unlike most people who gamble, they became “hooked.” That’s how Catherine Townsend-Lyon speaks of her gambling addiction. She began playing video lottery terminals at delis and restaurants near her home in Grants Pass, Oregon, sometime after they were introduced in the 1990s. She became obsessed with a game called Flush Fever and soon began playing before and after work and during her lunch hour. She lied to her husband about her whereabouts and started secretly gambling their mortgage payments. She stole from the collection company she worked for and sometimes wore bladder control underwear so she wouldn’t have to get up to use the restroom while playing. When she lost money, she played to win it back, and when she won, she played to win more. In an extreme moment, she skipped the funeral of a close friend to drive 40 miles to an Indian casino so she could win enough money to prevent her home from being foreclosed. Instead, she lost everything. She drove home in tears and slit her wrists.

“It’s like a battle you have with yourself with the triggers and the urges and the obsessiveness. You don’t even have to be in action or sitting behind a machine because you’re constantly thinking about: When am I going to gamble? When am I going to win or lose? It just compounds. It’s exhausting. It’s never-ending,” says Townsend-Lyon, who, after seeking treatment several times, has managed to stay away from gambling for the last seven-and-a-half years.

Townsend-Lyon says she turned to gambling at a difficult time in her life. With her husband frequently traveling for work, she found herself bored and looking for a way to fill the time. She had undiagnosed bipolar II disorder and had been sexually abused when she was younger but had not been raised to know to seek therapy. “I wasn’t a drug person or an alcoholic or anything like that, although I did drink more when I gambled. And because I was gambling, that was my coping skill. That’s what I was using to escape it, those feelings. I couldn’t stuff them away anymore. I would just use gambling to escape, not feel, zone out, you know what I mean?” she says.

She published a book last year about her former life, called Addicted to Dimes (Confessions of a Liar and a Cheat). What troubles her is how easy it is for people in her position to gamble. She didn’t have to fly to Nevada or even drive to a casino in state. The video poker and slot machines she played, which are sponsored by the Oregon State Lottery, are allowed at bars, restaurants, and delis.

“[I]f these machines weren’t in the bars and delis, then I would not be gambling. It’s that simple for me,” says a 33-year-old man quoted in a recent series on the state lottery by the Oregonian. He estimates he has lost $15,000 over 12 years from gambling. “That may sound like an excuse, but ‘out of sight is out of mind.’”

For people who are trying to recover from gambling addiction, it can be difficult to find help. Calls per month to the National Problem Gambling hotline are over two-and-a-half times what they were 14 years ago, from 9,642 in 2000 to 24,475 in 2013, according to Keith Whyte, executive director of the National Council on Problem Gambling. Yet funding for treatment centers, hotlines, and programs to prevent gambling addiction is minimal, says Martins. Funding for substance abuse treatment is about 281 times greater at $17 billion than public funding for problem gambling, at $60.6 million, although substance use disorders are only 3.6 times more common than gambling disorders, according to a 2013 survey by the Association of Problem Gambling Service Administrators and Problem Gambling Solutions. Just a little over half of the 50 U.S. states have someone whose full-time job is to administer problem gambling services, according to the same survey. By comparison, there are 113 lottery employees in Iowa and approximately 80 in Rhode Island. In several states legislators have cut gambling treatment funding or seen declines as a result of decreases in gambling revenue, which sometimes funds such programs, according to a Wall Street Journalreport from 2011.

Gamblers’ Anonymous, a 12-step program modeled after Alcoholics’ Anonymous, is the most widely available and used treatment in the U.S. Members admit they are powerless over their gambling addiction and embark on changing their character through group meetings and the support of a “sponsor” or older mentor in the group. Little research exists on the efficacy of Gamblers’ Anonymous. A study from 1988found that only 7.5 percent of members had abstained after one-year, and nearly a quarter of members did not go to a second meeting. However, those who regularly attend Gamblers’ Anonymous say they benefit significantly.

As with any kind of addiction, there is no pill for treating problem gambling. Medication and therapy may be used with varying success to treat a related psychiatric illness like depression or bipolar disorder. Moreover, a small number of problem gamblers seek treatment.

For these reasons, a public health approach, which would favor limiting the “exposure” of gambling to prevent addiction from occurring in the first place, is compelling. It is the same as the argument to tighten access to prescription opioids in order to prevent people from becoming hooked.

A DISEASE OF SOCIETY?

At a Gamblers’ Anonymous meeting in New York in August, about 65 people, mostly men, are celebrating one member’s five-year anniversary of abstaining from gambling. He gets to choose the topic for the night, and he picks “starting over.” Other members stand up to say that adhering to the Gamblers’ Anonymous program has fundamentally changed them. They have gone from being selfish and unable to make mature decisions to being better spouses, parents, friends, and members of society. They talk about small triumphs, their families, jobs, illness, and making amends with the people they hurt and stole from during their addiction.

“I think it was known to pretty much everyone in this room that I was an asshole. And I think I have become a decent member of society,” says a man in his early 30s who has been abstinent for 10 years.

Another man echoes this sentiment. “I was anything but a good citizen,” he says. He has been abstinent for over 22 years, but like many others in this room, attends meetings on the Gamblers Anonymous principle that former addicts are always in recovery. “It’s not just starting over, we still have to own our past. We have to settle up with people as best we can.” When his mom passed away, he says he was grateful that he could access his emotions—not something he could have done in his gambling days.

“I can say without a doubt, gambling has ruined my life,” says another member. He has gone to Gamblers’ Anonymous for eight years but has had relapses, and it has been 201 days since he last bet. “Abstinence is for real this time.”

Compulsive gambling is often viewed as an addiction to money, butGamblers’ Anonymous believes it is an emotional rather than financial disease. The addicted person “wants to escape into the dream world of gambling” and “finds he or she is emotionally comfortable only when ‘in action.’” But it doesn’t end up being much comfort, say formerly addicted gamblers who speak of how lonely their life was then.

Dr. Bruce K. Alexander, a psychologist and professor emeritus at Simon Fraser University in British Columbia, believes the loneliness experienced by those with gambling and other addictions has a strong social dimension. In his book, The Globalization of Addiction: A Study of the Poverty of the Spirit, he says: “A free-market society is magnificently productive, but it subjects people to irresistible pressures toward individualism and competition, tearing rich and poor alike from the close social and spiritual ties that normally constitute human life. People adapt to their dislocation by finding the best substitutes for a sustaining social and spiritual life that they can, and addiction serves this function all too well,” he says.

Bernal of Stop Predatory Gambling believes that our nation’s dependence on gambling reveals a deeper civic problem. “What we incentivize as a government shapes the national character,” he says. “We look at the greatest generation, we encouraged people to buy savings bonds, in the Great Depression. After World War II, we had the highest savings rate in modern American history because the government encouraged Americans to save. Today, half of Americans don’t own any assets.”

Terry Noffsinger, the lawyer for Stacy Stevens, admits that it has not been easy to make the legal public health case against gambling. Neither of the two cases he has represented has won in court, and one even provoked the Seventh Circuit Court of Appeals to threaten to sanction him for filing a frivolous claim. But he says the tide is turning. He has a conference call with a group of lawyers across the country about once a month to discuss the issue. Last November a group of Harvard Law students published a white paper making the case for legal action “to protect problem gamblers from the predatory behavior of casinos, including legislative reforms, tort litigation, regulations, and public policies.”

A couple of well-known trial attorneys have joined him on the Stevens suit, including Sharon Eubanks, who was lead counsel on the U.S. casethat ended in a judgment in 2006 that the nation’s big tobacco companies fraudulently covered up the health risks of smoking and marketed to children. The Stevens case also makes product liability claims that the slot machines from which casinos draw so much revenue are intentionally designed, manufactured, and distributed to hurt people. Such claims have never been tried before.

“This is a blockbuster case. There are other cases that are starting to come out of the woodwork. The courts are ready to look more favorably upon addicted gamblers,” says Kindt of the University of Illinois. Kindt published several academic articles in the early 2000s outlining the legal justification for mega-lawsuits against the gambling industry, similar to those which states, individuals, and classes of people filed against Big Tobacco.

In his Harvard talk, Noffsinger said he has had 100 or more people call him for help, many suicidal, nearly all of whom he has had to decline to represent. One of the calls came several years ago from a Boeing employee in Seattle who begged him for legal assistance. She had lost all of her money gambling, sold all of her furniture, and was ready to end it all. When Noffsinger told her he couldn’t represent her, she said she had nothing left to live for. Alarmed, he referred her to a lawyer friend in Seattle who found her counseling. About a year ago, she called Noffsinger and thanked him for saving her life.

“Somebody needs to do something … it may not be me.” Noffsinger told the Harvard students. “It’s going to be an uphill battle, but at the top there’s going to be a great big flag to wave.”

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This post originally appeared on The 2×2 Project as “Gambling With America’s Health?”