Associations between national gambling policies and disordered gambling prevalence rates within Europe Simon Planzer a,c, ⁎, Heather M. Gray a,b , Howard J. Shaffer a,b a Division on Addiction, Cambridge Health Alliance, a teaching affiliate of Harvard Medical School, Medford, MA, USA b Harvard Medical School, Boston, MA, USA c University of St.Gallen HSG, St.Gallen, Switzerland abstract article info Available online xxxx Keywords: Disordered gambling Gambling policy European Union Internal Market Prevalence rates Advertising Policymakers and other interested stakeholders currently are seeking information about the comparative effec- tiveness of different regulatory approaches to minimising gambling-related harm. This study responds to this re- search gap by exploring associations between gambling policies and disordered gambling prevalence rates. We gathered information about gambling policies for thirty European jurisdictions and past-year prevalence rates for disordered gambling for twelve of these jurisdictions. We present policy trends and prevalence rates and then describe the level of association between policy and prevalence. We observe one statistically significant as- sociation between policy and prevalence: rates of sub-clinical (i.e., Level 2) disordered gambling were higher within environments that mandated less strict regulation of advertising for online gambling. Finally, we discuss the implications of our research in the context of the current process regarding the pan-European regulation of gambling. Our findings do not offer evidence for certain assumptions made in the past by the European judiciary. © 2013 Elsevier Ltd. All rights reserved. 1. Introduction In response to the rapid increase in gambling offers available to citi- zens across Europe, policymakers are currently seeking regulatory ap- proaches to prevent and reduce potential gambling-related harms (European Commission, 2011, 2012; European Committee for Standardization, 2011; Planzer & Wardle, 2011). Research has failed to directly address the comparative effectiveness of different regulatory approaches in terms of minimising gambling-related harm (European Commission, 2011; Planzer & Wardle, 2011). As a result of this void, rather than guided by a scientific evidence base, policymaking in Europe and elsewhere (U.S. Congress, 2010) currently proceeds under conditions of uncertainty. In this research, we began to examine the associations between na- tional gambling policies and population rates of disordered gambling (Shaffer, Hall, & Vander Bilt, 1999). 1 We approached our investigative questions from the standpoint of public health law research (PHLR). Burris et al. (2010) define PHLR as “the scientific study of the relation of law and legal practices to population health,” including both “direct relationships between law and health, and relationships mediated through the effects of law on health behaviors and other processes and structures that affect population health.” Generally, the indepen- dent variable in PHLR is some aspect of the law, which investigators study in relation to some aspect of population morbidity or mortality (i.e., the dependent variable) with an awareness of the potential role of key mediators. Although the terms ‘independent variable’ and ‘dependent variable’ imply a causal relationship between policy and population health, Burris et al. (2010) remind public health law researchers to avoid drawing conclusions about causality on the basis of observed associations and in the absence of specific indicators of cau- sality (Hill, 1965). Public policy as subject of research of PHLR can include law as well as legal practices. In this work, we focused on gam- bling policies as defined in the law (i.e., mainly in statutes), with an aware- ness that the law on the books might deviate from how these laws are applied in a society (legal realism; Frank, 1930; Llewellyn, 1930). The European Internal Market provided the setting for the present research. This market, currently composed of twenty-seven European Union (EU) and three European Free Trade Association (EFTA) Member States, 2 is generally characterised by common pan-European rules (e.g., fundamental freedoms) and a high level of harmonisation of market regulation. However, the gambling sector differs from other economic activities because it is regulated almost exclusively at the International Journal of Law and Psychiatry xxx (2013) xxx–xxx ⁎ Corresponding author at: Planzer Law, PO Box 1924, 8031 Zurich, Switzerland. Tel./ fax: +41 44 559 42 82. E-mail address: simon.planzer@unisg.ch (S. Planzer). 1 Disordered gambling is a term that encompasses the full range of gambling-related problems, from the severe form (‘Level 3’ gambling or ‘pathological gambling’ (clinical) to the less severe form ‘Level 2’ gambling or ‘problem gambling’ (sub-clinical). Researchers using screens that are based on the ten diagnostic criteria of DSM-IV-TR gen- erally apply a threshold score of five or more for Level 3 gambling, and a threshold score of three or four for Level 2 gambling. A fully developed addiction to games of chance is asso- ciated with Level 3 gambling. Level 2 gamblers do not necessarily shift to the more severe form of disordered gambling (Shaffer et al., 1999). 2 Croatia became the 28th Member State of the EU on 1 July 2013, that is, after the time of writing of this article. IJLP-00988; No of Pages 13 0160-2527/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijlp.2013.11.002 Contents lists available at ScienceDirect International Journal of Law and Psychiatry Please cite this article as: Planzer, S., et al., Associations between national gambling policies and disordered gambling prevalence rates within Europe, International Journal of Law and Psychiatry (2013), http://dx.doi.org/10.1016/j.ijlp.2013.11.002