A research plan to define Canada's first low-risk gambling guidelines

Gambling, tobacco use, and health among individuals in substance use disorder treatment

BACKGROUND AND OBJECTIVES

Gambling is highly comorbid with disordered use of tobacco and other drugs, and may increase relapse risk among substance use disorder (SUD) patients. We investigated associations between gambling and tobacco use behaviors among SUD patients to inform clinical care.

METHODS

Patients (N = 651, 170 female) from 25 residential SUD treatment programs in California completed surveys about tobacco use, health, and gambling. Using multivariate regression, we examined associations between gambling, tobacco use behaviors, and mental and physical health.

RESULTS

Past-year gamblers were more likely than non-gamblers to be current smokers (adjusted odds ratio [AOR] = 1.44, 95% confidence interval [CI] = 1.03, 2.01). Smokers who gambled had higher mean Heaviness of Smoking Index (HSI) scores (mean difference = +0.32, 95% CI = 0.04, 0.60), and more often reported smokeless tobacco use (AOR = 1.73, 95% CI = 1.16, 2.58), compared to non-gambling smokers. Past-year problem gamblers were more likely than all others (non-gamblers and non-problem gamblers) to be current smokers (AOR = 1.44, 95% CI = 1.08, 1.90) and to report high psychosocial stress (AOR = 1.87, 95% CI = 1.34, 2.61). Smokers with problem gambling also had higher HSI scores (mean difference = +0.54, 95% CI = 0.14, 0.95) compared to smokers without problem gambling.

DISCUSSION AND CONCLUSIONS

Gambling and problem gambling were associated with tobacco use and heavier smoking. SUD patients with gambling comorbidity may be heavier smokers and may need concurrent treatment for tobacco use and problem gambling.

SCIENTIFIC SIGNIFICANCE

This study provides novel data regarding gambling and tobacco use behaviors among SUD patients.

Gambling consumption and harm: a systematic review of the evidence

The total consumption model (TCM) postulates a close link between total consumption and levels of harm within the population, which has important implications for prevention. This review aimed to explore evidence relating to the application of the TCM and theoretical elements associated with it (i.e. the distribution of harms; the concentration of consumption) to gambling by reviewing evidence pertaining to the distribution of harms across the population; the concentration of gambling consumption; and evidence of the validity of the TCM in gambling. Systematic literature searches were performed using MEDLINE, PsycINFO, and Web of Science databases, restricted to publications between January 1, 2010, and March 29, 2023. The search identified seven studies examining risk curves for gambling harm, of which only two employed continuous consumption measures. This nascent literature suggests mixed evidence for the relationship between gambling consumption (e.g. losses, frequency, expenditure, and expenditure as a percentage of income) and risk of harm. Five publications found that the concentration of gambling consumption was high among those experiencing gambling harms, with some evidence that spending is more concentrated for certain games (e.g. online casinos) than for others (e.g. lotteries). Finally, four studies assessed the TCM, suggesting close association between gambling consumption and problem gambling, lending empirical support to the validity of the TCM. However, robust evidence is nascent and further research is required to assess these relationships.

One size does not fit all. Should gambling loss limits be based on income?

Background

Previous research has suggested empirically based gambling loss limits, with the goal of preventing gambling related harm in the population. However, there is a lack of studies relating gambling loss limits to individual factors such as income. The current study examines whether gambling loss limits should be income-specific.

Materials and methods

The dataset was derived from three representative cross-sectional surveys of the Norwegian population and consisted of 14,630 gamblers. Four income groups, based on a quartile approximation, were formed. Gambling related harm was measured with the Problem Gambling Severity Index (PGSI), and precision-recall (PR) analyses were used to identify loss limits for the different income groups at two levels of gambling severity: moderate-risk gambling and problem gambling.

Results

For both levels of gambling severity, we found the lowest income group to have the lowest gambling loss limits, and the highest income group to have the highest loss limits, which compared to the loss limits for the total sample, were lower and higher, respectively. Calculating the cut-offs for moderate-risk gamblers, we found a consistently ascending pattern from the lowest to the highest income group. Calculating the cut-offs for problem gamblers, we found a similar pattern except for the two middle income groups.

Conclusion

The results suggest that income moderates empirically derived gambling loss limits. Although replication is required, income-based gambling loss limits may have higher applied value for preventing gambling related harm, compared to general loss limits aimed at the entire population.

In search of lower risk gambling levels using behavioral data from a gambling monopolist

BACKGROUND AND AIMS

Lower-risk recommendations for avoiding gambling harm have been developed as a primary prevention measure, using self-reported prevalence survey data. The aim of this study was to conduct similar analyses using gambling company player data.

METHODS

The sample (N = 35,753) were Norsk Tipping website customers. Gambling indicators were frequency, expenditure, duration, number of gambling formats and wager. Harm indicators (financial. social, emotional, harms in two or more areas) were derived from the GamTest self-assessment instrument. Receiver operating characteristics (ROC) curves were performed separately for each of the five gambling indicators for each of the four harm indicators.

RESULTS

ROC areas under the curve were between 0.55 and 0.68. Suggested monthly lower-risk limits were less than 8.7 days, expenditure less than 54 €, duration less than 72-83 min, number of gambling formats less than 3 and wager less than 118-140€. Most risk curves showed a rather stable harm level up to a certain point, from which the increase in harm was fairly linear.

DISCUSSION

The suggested lower-risk limits in the present study are higher than limits based on prevalence studies. There was a significant number of gamblers (5-10%) experiencing harm at gambling levels well below the suggested cut-offs and the risk increase at certain consumption levels.

CONCLUSIONS

Risk of harm occurs at all levels of gambling involvement within the specific gambling commercial environment assessed in an increasingly available gambling market where most people gamble in multiple commercial environments, minimizing harm is important for all customers.

Not Too Much, Not Too Often, and Not Too Many: the Results of the First Large-Scale, International Project to Develop Lower-Risk Gambling Guidelines

Until now, there has been no evidence-based, specific advice for people who gamble who want to reduce their risk of experiencing gambling harms. This paper presents the results from the first large-scale, comprehensive, international project to develop lower-risk gambling guidelines. Specifically, we calculated relative risk estimates to determine risk of harm across the range of possible limits for gambling frequency, expenditure, and number of types of gambling engaged in; conducted an online survey (n = 4583) of people who gamble to assess whether they understood and found credible the proposed quantitative limits; conducted a series of interviews and focus groups with people who gamble to assess self-control strategies and reactions to proposed quantitative limits; conducted a meta-analysis of problem gambling risk factors in the general population; and consulted with a pan-Canadian, multi-sectoral committee of stakeholders. Project outcomes were examined and deliberated by a working group of scientists who decided upon a set of recommendations for lower-risk gambling. This paper presents these recommendations.

The intergenerational transmission of gambling and other addictive behaviors: Implications of the mediating effects of cross-addiction frequency and problems

INTRODUCTION

This study examined the degree to which perceptions of familial and household participation in gambling and other addictive behaviors in youth was associated with frequency and problem severity of gambling, alcohol and/or drug use in participants as adults.

METHOD

The study measured perceived frequency of gambling, alcohol use, drug use and other potentially addictive behaviors in family/household members and the frequency and problem severity of gambling, alcohol, and drugs in an epidemiological sample of adults 18 and older (N = 3,499; m = 48.26 %, f = 51.74 %).

RESULTS

About 23.45 % of participants reported their father gambled when they were a child or adolescent, followed by mother (13.56 %), grandfather (9.73 %), or grandmother (7.83 %). A pathway model demonstrated cross-addiction inter- and intra-generational influences. Gambling by a father, mother or brother; substance use by a sister; and/or engagement in other behaviors by a brother, sister, grandmother or other household member was related to higher frequency of participant gambling (ps < 0.05), and, in turn, to higher levels of gambling, alcohol, and drug use problem severity (ps < 0.05).

DISCUSSION

Findings demonstrate the complex contributions of specific family and household members in the transmission of addictive behaviors. Frequency of gambling, alcohol use, and drug use mediated the relationship of perceived family behavior with and across addictions. In addition, perceptions regarding use of alcohol and/or other drugs, or engagement in other behaviors by family or household members was related not only to participants' alcohol and drug use but also to problem gambling frequency and severity.

Harm as reported by affected others: A population-based cross-sectional Finnish Gambling 2019 study

This study investigates the prevalence of being an affected other (AO) of a person with problem gambling; and the associations between being an AO and socio-demographics, gambling behaviour, health-related correlates and the amount and type of gambling-related harm (GRH) for the AOs. Furthermore, perspectives of the affected family members (AFMs) and close friends (ACFs) were acknowledged. Cross-sectional, random sample Finnish Gambling population-based survey data (n = 3,994) were collected in 2019. AOs were identified using a question with seven options. Information on GRH was sought using structured questions. One-fifth (21.2 %) of all respondents were AOs, men being typically ACFs and women being more often AFMs. Being an AO was associated with younger age, gambling participation, having a gambling problem of their own and health barriers such as psychological distress. AFMs experienced GRH more often and the amount of different GRHs was greater among the AFMs. The most common harm category experienced by the AOs was emotional harm. Both health-related issues and the amount of GRHs was largest among the AFMs. A substantial amount of GRH was also experienced by ACFs. The study suggests that support could be tailored for AFMs and ACFs, based on their AO status and individual needs. A public health approach for effective harm prevention in primary, secondary and tertiary levels are discussed.

18-Item Version of the Short Gambling Harm Screen (SGHS-18): Validation of Screen for Assessing Gambling-Related Harm among Finnish Population

Background and aims: It is common for gambling research to focus on problem and disordered gambling. Less is known about the prevalence of gambling-related harms among people in the general population. This study aimed to develop and validate the 18-item version of the Short Gambling Harms Screen (SGHS-18). Methods: Population-representative web-based and postal surveys were conducted in the three geographical areas of Finland (n = 7186, aged 18 or older). Reliability and internal structure of SGHS-18 was assessed using coefficient omega and via confirmatory factor analysis (CFA). Four measurement models of SGHS-18 were compared: one-factor, six-factor, a second-ordered factor model and a bifactor model (M4). Results: The analysis revealed that only the bifactor model had adequate fit for SGHS-18 (CFI = 0.953, TLI = 0.930, GFI = 0.974, RMSEA = 0.047, SRMR = 0.027). The general factor explained most of the common variance compared to specific factors. Coefficient omega hierarchical value for global gambling harm factor (0.80) was high, which suggested that SGHS-18 assessed the combination of general harm constructs sufficiently. The correlation with the Problem and Pathological Gambling Measures (PPGM) was 0.44, potentially reflecting that gambling harms are closely—although not perfectly—aligned with the mental health issue of problem gambling. SGHS-18 scores were substantially higher for participants who gambled more often, who spent more money or who had gambling problems, demonstrating convergent validity for the screen. Discussion: The SGHS-18 comprehensively measures the domains of gambling harm, while demonstrating desirable properties of internal consistency, and criterion and convergent validity.

The Gambling Consumption Mediation Model (GCMM): A Multiple Mediation Approach to Estimate the Association of Particular Game Types with Problem Gambling

Bivariate associations of problem gambling with participation in particular game types often decrease when adjusting for demographics or consumption behavior (e.g., number of game types played). A summary of 14 peer-reviewed studies showed inconsistencies as well as conceptual and methodological challenges. The aim of this study was to expand previous research by a combination of (1) sophisticated feature-engineering, which disaggregates gambling intensity into facets within and beyond a game type of interest, and (2) the application of mediation models. Data comprised last year gamblers of three merged cross sectional Icelandic gambling surveys of 2007, 2011, and 2017 (N = 4422). For each of 15 game types (12-month time frame), a parallel multiple mediation model was applied to disaggregate bivariate associations of last year game type participation and problem gambling (Problem Gambling Severity Index) by six mediating mechanisms: (1) demographic problem gambling propensity, (2) number of game types played, (3) gambling frequency within the type, (4) maximum gambling frequency across all types beyond, (5) usual spending within the type, (6) maximum usual spending across all types beyond. Games showed two distinct profiles via which mediator they mostly impacted problem gambling: Electronic gaming machines offline, scratch cards offline, live betting online, and poker offline as well as online impacted problem gambling mostly via gambling frequency within, whereas all other types mostly impacted via the number of game types played. The applied mediation models answer the question by which mechanism game types impact problem gambling in a more exhaustive way than previous research.

Public Perceptions of Harm for Nine Popular Gambling Products

Gambling causes significant levels of harm globally and is recognised as a serious public health issue. To reduce gambling-related harm, various strategies and policies have been recommended, including decreasing the availability of gambling products, restricting gambling advertising, and implementing public education campaigns. Government willingness to implement such strategies will be influenced by levels of public support, which in turn will be dependent on public perceptions of the harm caused by gambling products. The aim of the present study was to assess public perceptions of the harm associated with individual gambling products to inform future gambling reform. A sample of 2112 Australian adults provided perceived harm ratings for nine popular gambling products that are known to be associated with gambling-related harm: electronic gambling machines, casino table games, sports betting, bingo, scratch tickets, private betting, horse/dog races, keno, and the lottery. Binary logistic regressions were used to identify factors associated with harm perceptions. Only electronic gambling machines (70%), casino table games (64%), betting on horse/dog races (59%), and sports betting (53%) were perceived by a majority of respondents as being harmful. Less frequent gambling and experiencing greater levels of gambling-related harm were associated with higher harm perceptions. Many potentially harmful gambling products may not be recognised as such by the public, which is likely to reduce support for recommended harm-reduction strategies and policies. Efforts are needed to ensure Australians in general and gamblers in particular understand the levels of harm associated with popular gambling products.

Use of Self-control Strategies for Managing Gambling Habits Leads to Less Harm in Regular Gamblers

There is little research on the control strategies used by the general public to self-manage gambling habits and avoid harmful consequences. The current study sought to identify the most common self-control strategies of people who gamble regularly, the characteristics of those who use them, and assess the effectiveness of limit-setting strategies in reducing gambling-related harm. We recruited a large sample (N = 10,054) of Canadian adults who reported gambling activity in the past 12 months. Participants completed a survey that assessed gambling habits, use of control strategies including quantitative limit setting, and gambling related harm. The most common control strategies were setting predetermined spending limits, tracking money spent, and limiting alcohol consumption. The number of self-control strategies used by gamblers was positively associated with gambling involvement, annual income, problem gambling severity and playing electronic gaming machines. Approximately 45% of respondents failed to adhere to self-determined quantitative limits for spending, frequency, and time spent gambling. People who stayed within their gambling limits were less likely to report harm even after controlling for other risk factors. However, the effectiveness of remaining within one's personal spending limit decreased for those whose limits exceed $200CAN monthly. The findings support public health interventions that promote lower-risk gambling guidelines aimed at helping gamblers stay within spending, frequency and duration limits.

The prevention paradox applies to some but not all gambling harms: Results from a Finnish population-representative survey

BACKGROUND AND AIMS

The Prevention Paradox (PP) suggests that a large proportion of aggregate harm from gambling occurs to people who do not have a gambling disorder. However, it has not yet been tested using a population-representative sample. We aimed to test whether the PP applies to gambling in Finland. The prevalence rates of diverse harmful consequences from gambling were surveyed amongst a population-representative sample of past-year gamblers.

METHODS

The study used first wave data (N = 7,186) of Finnish Gambling Harms survey, collected via online and postal surveys in 2017. A subset of 3,795 adults (≥18 years), who had gambled at least monthly in 2016, were selected for analysis.

MEASUREMENTS

Gambling-related harms were evaluated with the 72-item Harms Checklist. Problem and Pathological Gambling Measure (PPGM) measured respondents' probable disordered gambling from the subset of items for impaired control (4 questions) and other issues (3 questions).

FINDINGS

Consistent with previous findings, the majority of harms were reported by those in the less severe PPGM categories (i.e. scoring <5). However, considering each domain separately, this was true only for financial, emotional/psychological, and work/study harms. The PP was not supported for health, relationship, or social deviance harms.

CONCLUSIONS

The population prevalence of the most serious harms (e.g. unsafe living conditions) is concentrated among those with severe impaired control issues. However, even excluding the ∼15% of harms occurring to occasional gamblers, most financial, emotional and work/study impacts occur to those with lower levels of control issues. Efforts at harm reduction should focus on the entire spectrum of issues that people experience from their gambling.

The Conceptual Framework of Harmful Gambling: A revised framework for understanding gambling harm

BACKGROUND AND AIMS

The Conceptual Framework of Harmful Gambling moves beyond a symptoms-based view of harm and addresses a broad set of factors related to the risks and effects of gambling harmfully at the individual, family, and community levels. Coauthored by international research experts and informed by multiple stakeholders, Gambling Research Exchange (GREO) facilitated the framework development in 2013 and retains responsibility for regular updates and mobilization. This review article presents information about the revised version of the Conceptual Framework of Harmful Gambling completed in late 2018.

METHODS

We describe eight interrelated factors depicted in the framework that represent major themes in gambling ranging from the specific (gambling environment, exposure, gambling types, and treatment resources) to the general (cultural, social, psychological, and biological influences). After outlining the framework development and collaborative process, we highlight new topics for the recent update that reflect changes in the gambling landscape and prominent discourses in the scientific community. Some of these topics include social and economic impacts of gambling, and a new model of understanding gambling related harm.

DISCUSSION AND CONCLUSIONS

We address the relevance of the CFHG to the gambling and behavioral addictions research community. Harm-based frameworks have been undertaken in other areas of addiction that can both inform and be informed by a model dedicated to harmful gambling. Further, the framework brings a multi-disciplinary perspective to bear on antecedents and factors that co-occur with harmful gambling.