Designing a longitudinal cohort study of gambling in Alberta: rationale, methods, and challenges

Making Change: Attempts to Reduce or Stop Gambling in a General Population Sample of People Who Gamble

OBJECTIVE

This study examined past year attempts to reduce or quit gambling among people who gamble generally and those with gambling problems specifically.

METHODS

Regular gamblers recruited from an online panel (N = 10,054) completed a survey of gambling, mental health and substance use comorbidity and attempts to reduce or quit gambling. The sample was weighted to match the gambling and demographic profile for the same subsample (i.e., past month gamblers) in a recent Canadian national survey.

RESULTS

5.7% reported that they tried to cutback or stop gambling in the past year. As predicted, individuals making a change attempt had greater levels of problem gambling severity and were more likely to have a gambling problem. Of individuals with problem gambling, 59.8% made a change attempt. Of those, 90.2% indicated that they did this primarily on their own, and 7.7% accessed formal or informal treatment. Most people attempting self- change indicated that this was a personal preference (55%) but about a third reported feeling too ashamed to seek help. Over a third (31%) reported that their attempt was successful. Of the small group of people accessing treatment, 39% described it as helpful.

CONCLUSIONS

Whereas gambling treatment-seeking rates are low, rates of self-change attempts are high. The public health challenge is to promote self-change efforts among people beginning to experience gambling problems, facilitate success at self-change by providing accessible support for use of successful strategies, and provide seamless bridges to a range of other treatments when desired or required.

Self-reported eating disorder psychopathology prevalence in community-based female and male Albertans: Gender and age group comparisons

OBJECTIVE

We describe and compare eating disorder (ED) psychopathology prevalence in Canadian females and males across five age groups.

METHOD

This secondary data analysis study used the Eating Disorder Examination Questionnaire (EDE-Q) to assess ED psychopathology in 1,316 Alberta community-based female and male participants, aged 15 to 71.

RESULTS

Overall, 15.3% of female and 8.2% of male participants reported clinically-significant ED disturbances. Female participants reported greater global ED psychopathology than male participants, except older men and women aged 65-71, who reported similar, relatively low levels of global ED psychopathology. Women aged 65-71 endorsed less global ED psychopathology than younger females. More females than males reported regular binge eating and self-induced vomiting, whereas other ED behaviors were endorsed at similar rates.

DISCUSSION

This large-scale study, the first involving a Canadian sample, contributes to a small literature on ED psychopathology in community-based samples. The finding that 15% of female and 8% of male Albertans aged 15 to 71 endorsed clinically-significant ED disturbances is concerning; however, women aged 65-71 reported lower ED psychopathology than younger females. Gender and age differences were observed in global ED psychopathology. Routine ED screening of non-clinical adolescents and adults is warranted to permit prevention and early intervention.

Predicting future harm from gambling over a five-year period in a general population sample: a survival analysis

BACKGROUND

There is little longitudinal evidence on the cumulative risk of harm from gambling associated with excess spending and frequency of play. The present study sought to assess the risk of gambling problems over a five-year period in adults who exceed previously derived low-risk gambling limits compared to those who remain within the limits after controlling for other modifiable risk factors.

METHODS

Participants were adults (N = 4212) drawn from two independent Canadian longitudinal cohort studies who reported gambling in the past year and were free of problem gambling at time 1. Multivariate Cox regression was employed to assess the impact over time of gambling above low-risk gambling thresholds (frequency ≥ 8 times per month; expenditure ≥75CAD per month; percent of household income spent on gambling ≥1.7%) on developing moderate harm and problem gambling. Covariates included presence of a DSM5 addiction or mental health disorder at time 1, irrational gambling beliefs, number of stressful life events in past 12 months, number of game types played each year, and playing electronic gaming machines or casino games.

RESULTS

In both samples, exceeding the low-risk gambling limits at time 1 significantly increased the risk of moderate harm (defined as ≥2 consequences on the Problem Gambling Severity Index [PGSI]) within 5 years after controlling for other modifiable risk factors. Other significant predictors of harm were presence of a mental disorder at time 1, cognitive distortions about gambling, stressful life events, and playing electronic gaming machines or casino games. In one sample, the five-year cumulative survival rate for moderate harm among individuals who stayed below all the low-risk limits was 95% compared to 83% among gamblers who exceeded all limits. Each additional low-risk limit exceeded increased the cumulative probability of harm by 30%. Similar results were found in models when the outcome was problem gambling.

CONCLUSIONS

Level of gambling involvement represents a highly modifiable risk factor for later harm. Staying below empirically derived safe gambling thresholds reduces the risk of harm over time.

Proximal and Distal Risk Factors for Gambling Problems Specifically Associated with Electronic Gaming Machines

Electronic gaming machines (EGMs) are widely used and the gambling product most commonly associated with harmful gambling. Understanding factors that increase the risk of problematic EGM play is therefore important. Previous studies into risk factors for EGM gambling have used measures of problem gambling based on an individual's total gambling activity, which therefore do not distinguish harmful gambling specifically associated with EGMs. This study used an EGM-specific measure (PGSI-EGM) to achieve its aim of identifying risk factors specifically associated with problematic EGM play. By removing nuisance effects from other gambling forms that higher-risk gamblers typically engage in, this approach provides a more accurate assessment of the determinants of EGM-related problems. An online survey was completed by 1932 at-least monthly EGM players in Australia. It measured demographics, EGM gambling behaviour, motivations, gambling urges, gambling fallacies, trait self-control, alcohol misuse, and the PGSI-EGM. A penalised regression model identified the most important proximal predictors of higher-risk EGM gambling as: higher gambling urges, higher levels of erroneous cognitions, playing EGMs more frequently, higher session expenditure, longer sessions, usually playing EGMs alone, and playing EGMs in more venues. Lower trait self control was the strongest distal determinant. Higher-risk EGM players tended to be younger, male, more educated, never married, to have higher (although still modest) incomes, and be more likely to have alcohol problems. These findings can inform interventions such as treatment, consumer education and venue interventions.

Deriving low-risk gambling limits from longitudinal data collected in two independent Canadian studies

AIMS

To derive low-risk gambling limits using the method developed by Currie et al. (2006) applied to longitudinal data.

DESIGN

Secondary analysis of data from the Quinte Longitudinal Study (n = 3054) and Leisure, Lifestyle and Lifecycle Project (n = 809), two independently conducted cohort studies of the natural progression of gambling in Canadian adults.

SETTING

Community-dwelling adults in Southeastern Ontario and Alberta, Canada.

PARTICIPANTS

A total of 3863 adults (50% male; median age = 44) who reported gambling in the past year.

MEASUREMENTS

Gambling behaviours (typical monthly frequency, total expenditure and percentage of income spent on gambling) and harm (experiencing two or more consequences of gambling in the past 12 months) were assessed with the Canadian Problem Gambling Index.

FINDINGS

The dose-response relationship was comparable in both studies for frequency of gambling (days per month), total expenditure and percentage of household income spent on gambling (area under the curve values ranged from 0.66 to 0.74). Based on the optimal sensitivity and specificity values, the low-risk gambling cut-offs were eight times per month, $75CAN total per month and 1.7% of income spent on gambling. Gamblers who exceeded any of these limits at time 1 were approximately four times more likely to report harm at time 2 [95% confidence interval (CI) = 2.9-6.6].

CONCLUSIONS

Longitudinal data in Canada suggest low-risk gambling thresholds of eight times per month, $75CAN total per month and 1.7% of income spent on gambling, all of which are higher than previously derived limits from cross-sectional data. Gamblers who exceed any of the three low-risk limits are four times more likely to experience future harm than those who do not.

Gambling Motives: Application of the Reasons for Gambling Questionnaire in an Australian Population Survey

The Reasons for Gambling Questionnaire (RGQ) consist of 15 items forming five factors: enhancement, social, money, recreation and coping. The RGQ was developed for use in the 2010 British Gambling Prevalence Survey (BGPS) and has now been employed in the second Social and Economic Impact Study (SEIS) of Gambling in Tasmania study conducted in 2011 in Australia. Given differences between Britain and Australia in terms of socio-demographic profiles, gambling cultures and attitudes, gambling access and availability, gambling regulation, and rates and patterns of gambling participation, the aims of this study were to analyse the RGQ data from the SEIS to: (1) determine the most commonly endorsed gambling motives in an Australian jurisdiction, (2) explore the factor structure of the RGQ in an Australian sample, and (3) explore how motives for gambling vary among different Australian population sub-groups. A representative sample of the Tasmanian population who had gambled in the previous 12 months (n = 2,796) were administered the RGQ via computer-assisted telephone interviewing. The five most commonly endorsed reasons for gambling were for fun (62%), followed by the chance of winning big money (52%), it being something to do with friends and family (48%), to be sociable (40%), and excitement (38%). A principal component analysis revealed a five-factor structure that is slightly different from that derived in the BGPS: money, regulate internal state, positive feelings, social, and challenge reasons. Finally, gambling motives varied according to socio-demographic factors, number of gambling activities, problem gambling severity, and participation on different gambling activities. Although some of these findings are consistent with those from the BGPS, there are also some slight differences, suggesting that there may be regional-specific variations in gambling motives.

Addiction-related genes in gambling disorders: new insights from parallel human and pre-clinical models

Neurobiological research supports the characterization of disordered gambling (DG) as a behavioral addiction. Recently, an animal model of gambling behavior was developed (rat gambling task, rGT), expanding the available tools to investigate DG neurobiology. We investigated whether rGT performance and associated risk gene expression in the rat's brain could provide cross-translational understanding of the neuromolecular mechanisms of addiction in DG. We genotyped tagSNPs (single-nucleotide polymorphisms) in 38 addiction-related genes in 400 DG and 345 non-DG subjects. Genes with P<0.1 in the human association analyses were selected to be investigated in the animal arm to determine whether their mRNA expression in rats was associated with the rat's performance on the rGT. In humans, DG was significantly associated with tagSNPs in DRD3 (rs167771) and CAMK2D (rs3815072). Our results suggest that age and gender might moderate the association between CAMK2D and DG. Moderation effects could not be investigated due to sample power. In the animal arm, only the association between rGT performance and Drd3 expression remained significant after Bonferroni correction for 59 brain regions. As male rats were used, gender effects could not be investigated. Our results corroborate previous findings reporting the involvement of DRD3 receptor in addictions. To our knowledge, the use of human genetics, pre-clinical models and gene expression as a cross-translation paradigm has not previously been attempted in the field of addictions. The cross-validation of human findings in animal models is crucial for improving the translation of basic research into clinical treatments, which could accelerate neurobiological and pharmacological investigations in addictions.

Validity of the Problem Gambling Severity Index interpretive categories

The Problem Gambling Severity Index (PGSI) is a widely used nine item scale for measuring the severity of gambling problems in the general population. Of the four gambler types defined by the PGSI, non-problem, low-risk, moderate-risk and problem gamblers, only the latter category underwent any validity testing during the scale's development, despite the fact that over 95% of gamblers fall into one of the remaining three categories. Using Canadian population data on over 25,000 gamblers, we conducted a comprehensive validity and reliability analysis of the four PGSI gambler types. The temporal stability of PGSI subtype over a 14-month interval was modest but adequate (intraclass correlation coefficient = 0.63). There was strong evidence for the validity of the non-problem and problem gambler categories however the low-risk and moderate-risk categories showed poor discriminant validity using the existing scoring rules. The validity of these categories was improved with a simple modification to the scoring system.

Disordered gambling among higher-frequency gamblers: who is at risk?

BACKGROUND

When gambling opportunities are made available to the public in a given jurisdiction, some individuals participate occasionally and others more frequently. Among frequent gamblers, some individuals develop problematic involvement and some do not. This study addresses the association among demographic and social risk factors, frequency of gambling and gambling disorders.

METHOD

Data from an adult community sample (n=1372) were used to identify risk factors for higher-frequency gambling and disordered gambling involvement.

RESULTS

Individuals with higher intelligence, older individuals and more religious individuals were less frequent gamblers. Males, single individuals and those exposed to gambling environments (friends and family who gamble) and those who started to gamble at a younger age were more frequent gamblers. Excitement-seeking personality traits were also higher among more frequent gamblers. A different set of risk factors was associated with the likelihood of gambling disorder among these higher-frequency gamblers. These variables included mental health indicators, childhood maltreatment and parental gambling involvement. Among higher-frequency gamblers, individuals who smoke cigarettes, those with a diagnosis of alcohol or drug dependence or obsessive-compulsive disorder, those with higher anxiety or depression and those with higher impulsivity and antisocial personality traits were more likely to report gambling-related problems. These individuals were also more likely to report gambling on electronic gambling machines (e.g. slot machines).

CONCLUSIONS

These data suggest a model in which higher-frequency gambling, particularly with electronic gambling machines, when combined with any type of emotional vulnerability increased the likelihood of gambling disorder.

Examining the predictive validity of low-risk gambling limits with longitudinal data

AIMS

To assess the impact of gambling above the low-risk gambling limits developed by Currie et al. (2006) on future harm. To identify demographic, behavioural, clinical and environmental factors that predict the shift from low- to high-risk gambling habits over time.

DESIGN

Longitudinal cohort study of gambling habits in community-dwelling adults.

SETTING

Alberta, Canada.

PARTICIPANTS

A total of 809 adult gamblers who completed the time 1 and time 2 assessments separated by a 14-month interval.

MEASUREMENTS

Low-risk gambling limits were defined as gambling no more than three times per month, spending no more than CAN$1000 per year on gambling and spending less than 1% of gross income on gambling. Gambling habits, harm from gambling and gambler characteristics were assessed by the Canadian Problem Gambling Index. Ancillary measures of substance abuse, gambling environment, major depression, impulsivity and personality traits assessed the influence of other risk factors on the escalation of gambling intensity.

FINDINGS

Gamblers classified as low risk at time 1 and shifted into high-risk gambling by time 2 were two to three times more likely to experience harm compared to gamblers who remained low risk at both assessments. Factors associated with the shift from low- to high-risk gambling behaviour from time 1 to time 2 included male gender, tobacco use, older age, having less education, having friends who gamble and playing electronic gaming machines.

CONCLUSIONS

An increase in the intensity of gambling behaviour is associated with greater likelihood of future gambling related harm in adults.

Impulsivity and socio-economic status interact to increase the risk of gambling onset among youth

AIMS

To determine if impulsivity and socio-economic status (SES) interact to influence gambling onset in youth.

DESIGN

Longitudinal study of grade 7 students followed for 8 years.

SETTING

Montréal, Canada.

PARTICIPANTS

A total of 628 adult students aged 12.6 years on average at cohort inception.

MEASUREMENTS

Impulsivity and SES (parent education, area deprivation) were collected during secondary school. Age of gambling onset was collected retrospectively when participants were aged 20.3 years. Cox proportional hazards regression was used to model the association between time to first report of gambling and interaction terms for each of impulsivity and parent education, and impulsivity and area deprivation accounting for sex and ethnicity.

FINDINGS

Median (interquartile range) age of gambling onset was 17.0 (4.0) years. Impulsivity independently increased the risk of gambling onset among participants with no university-educated parent [hazard ratio (HR) 1.3; 95% confidence interval 1.1-1.5] and those living in highly deprived areas (HR 1.7; 1.5-2.0). Impulsivity was not associated with gambling onset among high SES youth. Among participants with high impulsivity, risks were elevated for those with no university-educated parent relative to one or more university-educated parent (HR 1.7; 1.1-2.7), and for participants living in deprived relative to advantaged areas (HR 5.0; 2.6-9.6). SES was not associated with gambling onset among participants with low impulsivity.

CONCLUSIONS

Impulsivity is a risk factor for gambling onset among low but not high SES youth, and low SES influences gambling onset primarily among impulsive youth. Gambling prevention programmes may need to consider potential interaction between impulsivity and SES.