Self-exclusion from gambling: A toothless tiger?

While there is evidence for self-exclusion (SE) as an individual-level harm reduction intervention, its effects on reducing harm from gambling at the population level remain unclear. Based on a review of national legal frameworks and SE programs, including their utilization and enforcement in selected high-income societies, the present analysis aims to explore the reach and strengths of SE in the protection of gamblers in these jurisdictions. It places particular emphasis on SE programs' potential to prevent and minimize gambling harm at the population level. The overview examined SE in Finland, Germany, Italy, Massachusetts (USA), Norway, Sweden, and Victoria (Australia). These jurisdictions differ considerably in how gambling is regulated as well as in how SE is implemented and enforced. The reach and extent of enforcement of SE apparently vary with the polity's general policy balance between reducing gambling problems and increasing gambling revenue. But in any case, though SE may benefit individual gamblers and those around them, it does not appear to be capable of significantly reducing gambling harm at the population level. To render SE programs an effective measure that prevents gamblers and those linked to them from financial, social, and psychological harm, utilization needs to be substantially increased by reforming legal regulations and exclusion conditions.

Gambling formats, involvement, and problem gambling: which types of gambling are more risky?

BACKGROUND: The recognition of problem gambling as a public health issue has increased as the availability of gambling expands. Research has found that some formats of gambling are more closely linked to problem gambling than others. Conflicting evidence, however, has emerged, suggesting that the most important consideration is involvement (i.e., number of gambling formats an individual participates in). This debate has important implications for the regulation of gambling formats and for the allocation of problem gambling prevention and treatment services. METHOD: Analyses utilized the Baseline General Population Survey (BGPS) and the Baseline Online Panel Survey (BOPS) of Massachusettscollected in 2013-2014. The BGPS contains a representative sample of 9523 Massachusetts adults and the BOPS contains a sample of 5046 Massachusetts adults. All participants were administered the same comprehensive survey of their past year gambling behavior and problem gambling symptomology. Only those who gambled regularly in the past 12 months (n = 5852) were included. The Problem and Pathological Gambling Measure was used to classify gambling behavior. Within the sample, there were 446 problem gamblers. We assessed: 1) whether some gambling formats are more related to problem gambling; 2) whether problem gambling is positively related to high involvement in gambling; 3) the relationship between involvement in gambling and intensity of gambling; and 4) whether gambling formats mediate the relationship between gambling involvement and problem gambling. RESULTS: Groups of monthly gamblers participating in casino gambling, bingo, and sports betting contained a higher proportion of problem gamblers. High gambling involvement was also positively associated with problem gambling; however, a large minority of gamblers experienced problems when engaging in only one or two forms of gambling. Gambling involvement was also positively associated with intensity of gambling. Therefore, intensity of gambling may be partly driving the relationship between involvement and problem gambling. Specific gambling formats mediated the relationship between involvement and problem gambling. CONCLUSIONS: The gambling format an individual participates in is connected to whether an individual is likely to experience problem gambling. We also found that the level of involvement (and its relationship to intensity) may affect the likelihood that an individual will experience problematic gambling behavior. Ultimately, the type of gambling format an individual partakes in does mediate the relationship between problem gambling and involvement. In Massachusetts, participating in casino gambling was more closely associated with problem gambling than other formats across all levels of involvement.

Correlates of At-Risk and Problem Gambling Among Veterans in Massachusetts.

Few studies have examined problem gambling among veterans and, of those studies, there are conflicting conclusions surrounding correlates of problem gambling in veterans. Our study aims to assess problem gambling prevalence among veterans using non-Veterans Affairs data and to evaluate correlates of problem gambling among veterans in a general population sample. We obtained a probability sample of adult Massachusetts residents using address based sampling in 2013-2014. Participants completed a questionnaire on demographics, veteran status, and gambling behaviors and motivations. We identified n = 129 problem gamblers from a sample of n = 9578 participants. Of the problem gamblers who had veteran status information, 20.6% were veterans. Due to sample size limitations, we analyzed veteran problem and at-risk gamblers compared to veteran recreational gamblers. Having friends and family members engaged in gambling and engaging in more gambling formats were significantly, positively associated with veteran problem and at-risk gambler status. Participating in raffles in the past year was associated with lower odds of being a veteran problem and at-risk gambler compared to veteran recreational gamblers (OR 0.31, 95% CI 0.18-0.52). These discriminators of at-risk and problem gambling may be useful in developing clinical treatment approaches for veteran problem gamblers. Future studies should focus on changes in the prevalence of veteran problem gambling and additional correlates that may better capture social support domains and gambling activity among veterans.

The importance of friends and family to recreational gambling, at-risk gambling, and problem gambling.

BACKGROUND: The variables correlated with problem gambling are routinely assessed and fairly well established. However, problem gamblers were all 'at-risk' and 'recreational' gamblers at some point. Thus, it is instructive from a prevention perspective to also understand the variables which discriminate between recreational gambling and at-risk gambling and whether they are similar or different to the ones correlated with problem gambling. This is the purpose of the present study. METHOD: Between September 2013 to May 2014, a representative sample of 9,523 Massachusetts adults was administered a comprehensive survey of their past year gambling behavior and problem gambling symptomatology. Based on responses to the Problem and Pathological Gambling Measure, respondents were categorized as Non-Gamblers (2,523), Recreational Gamblers (6,271), At-Risk Gamblers (600), or Problem/Pathological Gamblers (129). With the reference category of Recreational Gambler, a series of binary logistic regressions were conducted to identify the demographic, health, and gambling related variables that differentiated Recreational Gamblers from Non-Gamblers, At-Risk-Gamblers, and Problem/Pathological Gamblers. RESULTS: The strongest discriminator of being a Non-Gambler rather than a Recreational Gambler was having a lower portion of friends and family that were regular gamblers. Compared to Recreational Gamblers, At-Risk Gamblers were more likely to: gamble at casinos; play the instant and daily lottery; be male; gamble online; and be born outside the United States. Compared to Recreational Gamblers, Problem and Pathological Gamblers were more likely to: play the daily lottery; be Black; gamble at casinos; be male; gamble online; and play the instant lottery. Importantly, having a greater portion of friends and family who were regular gamblers was the second strongest correlate of being both an At-Risk Gambler and Problem/Pathological Gambler. CONCLUSIONS: These analyses offer an examination of the similarities and differences between gambling subtypes. An important finding throughout the analyses is that the gambling involvement of family and friends is strongly related to Recreational Gambling, At-Risk Gambling, and Problem/Pathological Gambling. This suggests that targeting the social networks of heavily involved Recreational Gamblers and At-Risk Gamblers (in addition to Problem/Pathological Gamblers) could be an important focus of efforts in problem gambling prevention.

Risk Factors for Problem Gambling in California: Demographics, Comorbidities and Gambling Participation.

While population surveys have been carried out in numerous jurisdictions internationally, little has been done to assess the relative strength of different risk factors that may contribute to the development of problem gambling. This is an important preparatory step for future research on the etiology of problem gambling. Using data from the 2006 California Problem Gambling Prevalence Survey, a telephone survey of adult California residents that used the NODS to assess respondents for gambling problems, binary logistic regression analysis was used to identify demographic characteristics, health-related behaviors, and gambling participation variables that statistically predicted the odds of being a problem or pathological gambler. In a separate approach, linear regression analysis was used to assess the impact of changes in these variables on the severity of the disorder. In both of the final models, the greatest statistical predictor of problem gambling status was past year Internet gambling. Furthermore, the unique finding of a significant interaction between physical or mental disability, Internet gambling, and problem gambling highlights the importance of exploring the interactions between different forms of gambling, the experience of mental and physical health issues, and the development of problem gambling using a longitudinal lens.

An Examination of a Proposed DSM-IV Pathological Gambling Hierarchy in a Treatment Seeking Population: Similarities with Substance Dependence and Evidence for Three Classification Systems.

Toce-Gerstein et al. (Addiction 98:1661-1672, 2003) investigated the distribution of Diagnostic and Statistical Manual for Mental Disorders, 4th edition (DSM-IV) pathological gambling criteria endorsement in a U.S. community sample for those people endorsing a least one of the DSM-IV criteria (n = 399). They proposed a hierarchy of gambling disorders where endorsement of 1-2 criteria were deemed 'At-Risk', 3-4 'Problem gamblers', 5-7 'Low Pathological', and 8-10 'High Pathological' gamblers. This article examines these claims in a larger Australian treatment seeking population. Data from 4,349 clients attending specialist problem gambling services were assessed for meeting the ten DSM-IV pathological gambling criteria. Results found higher overall criteria endorsement frequencies, three components, a direct relationship between criteria endorsement and gambling severity, clustering of criteria similar to the Toce-Gerstein et al. taxonomy, high accuracy scores for numerical and criteria specific taxonomies, and also high accuracy scores for dichotomous pathological gambling diagnoses. These results suggest significant complexities in the frequencies of criteria reports and relationships between criteria.

Gambling and problem gambling in Sweden: changes between 1998 and 2009.

Gambling participation and rates of problem gambling change over time in response to a variety of factors including gambling availability, demographic changes and adaptation at individual and societal levels. These relationship are complex and only partially understood. The major aim of the present study was to provide general population estimates of gambling participation and problem gambling for Sweden and compare these estimates with estimates from a previous national study. The study was also designed to identify risk factors for problem gambling including change in these factors over time. Data are from the first phase of the Swedish Longitudinal Gambling Study (Swelogs) in which a representative sample of 8,165 people was assessed using validated problem gambling and other measures to facilitate comparison with findings from the 1997/1998 Swedish Gambling Study (Swegs). Overall, it was found that gambling participation reduced markedly, although in some population sectors increases were evident for some forms including poker and electronic gaming machines. Lifetime prevalence of probable pathological gambling increased; however, past 12 months probable pathological and problem gambling prevalence did not. Males, younger adults and people born outside Sweden were at high risk in both studies. Significant prevalence increases were evident for people aged 18-24 and those with low levels of education. The results indicate that relationships between gambling exposure, participation and problems are dynamic with shifting implications for public health and social policy.

A quick and simple screening method for pathological and problem gamblers in addiction programs and practices.

Despite high rates of comorbidity among pathological gambling, substance use disorders, and other psychiatric conditions, health professionals rarely screen their clients for gambling problems. We report on the performance of the NODS-CLiP, an existing brief, three-item screen for problem and pathological gambling, and an alternative four-item screen that demonstrates improved sensitivity, good positive and negative predictive power, and invariance across key demographic groups . Given the high rates of comorbidity, routine and accurate identification of gambling-related problems among individuals seeking help for substance abuse and related disorders is important. The original and the alternative brief screens are likely to be useful in a range of clinical settings.

An international perspective on youth gambling prevalence studies.

In the wake of rapid expansion of legal gambling internationally, studies of adolescent gambling involvement and problem gambling prevalence have been carried out in numerous jurisdictions. This paper reviews adolescent gambling prevalence studies that have been carried out in North America, Europe, and Oceania. Based on this review, work is clearly needed to assess the impact of survey methods on identified prevalence rates and to improve the measurement of problem gambling among adolescents. From a substantive perspective, several clear demographic and behavioral characteristics are associated with gambling involvement and problem gambling among youth. However, early assumptions about youth gambling and problem gambling must give way to more nuanced understandings of how these phenomena change in response to changes in the social and cultural environment. We may have traveled some distance down the road toward understanding the determinants as well as the distribution of youth gambling and problem gambling, but we still have a long way to go.

The NODS-CLiP: a rapid screen for adult pathological and problem gambling.

OBJECTIVES: To describe and evaluate tests of the performance of the NODS-CLiP, an efficient standardized diagnostic interview instrument for adult pathological and problem gambling. SETTING AND SAMPLES: Identical batteries of diagnostic questions about gambling behavior, motives, and thoughts were administered to participants in eight general adult population field studies conducted in the United States between 1999 and 2003, including six state-level random-digit-dial (RDD) telephone surveys, one national RDD survey, and one in-person systematic random sample survey of commercial gambling patrons in eight states. Total survey N = 17,180. Response rates ranged from 24 to 71%. MEASURES: Data from all experienced gamblers (N = 8,867) were re-analyzed to compare diagnostic status derived from the 17-item NORC Diagnostic Screen for Gambling Disorders (NODS), a validated DSM-IV-based instrument, with results from all 2- to 4-item subsets of NODS items. RESULTS: Three NODS questions pertaining to loss of Control, Lying, and Preoccupation (the "CLiP"), requiring one minute to administer, identified virtually all pathological gamblers and most problem gamblers diagnosed by the complete NODS. The CLiP has excellent sensitivity and specificity for NODS constructs. CONCLUSIONS: A two-stage NODS-CLiP procedure appears quite promising as an efficient epidemiological instrument for general population research and clinical triage for gambling disorders.

Comparing the New Zealand and Swedish national surveys of gambling and problem gambling.

National surveys of gambling and problem gambling have recently been completed in New Zealand and Sweden. These studies are unique in that data collection was undertaken by official government statistical agencies, involved large, nationally representative samples, and attained high response rates. Comparison of the findings is facilitated by the use of similar procedures and instrumentation and is of interest in that both countries have similar per capita gambling expenditure and welfare states that have recently undergone major economic and social restructuring. Data on gambling participation, problem gambling prevalence and risk factors for problem gambling are presented and discussed. While there are a number of similarities and differences, the Swedish findings are more similar to those of an earlier national survey conducted in New Zealand during 1991. This suggests that risk factors are changing over time in relation to evolving patterns of gambling participation and attitudes towards gambling, a finding that has implications for future patterns of gambling and problem gambling in these and other countries.

A prospective study of problem and regular nonproblem gamblers living in the community.

Little is known about the life course of gambling problems and there have been no prospective studies of problem gambling. This article describes a study of 77 problem gamblers and 66 nonproblem gamblers recruited from a national prevalence survey in New Zealand in 1991 and reassessed in 1998. While most 1991 problem gamblers were nonproblematic at follow-up, a significant minority had developed more serious problems. Multiple logistic regression analysis identified more severe gambling problems, hazardous drinking, and a preference for track betting as the strongest independent predictors of subsequent problem gambling. These findings contradict conventional notions that pathological gambling is invariably a chronic or chronically relapsing disorder. The findings have implications for the interpretation of previous research, conduct of future research, and problem gambling policy and treatment.

A hierarchy of gambling disorders in the community.

AIMS: To help refine the definition and diagnosis of gambling disorders, we investigated the distribution among US gamblers of the 10 DSM-IV criteria for Pathological Gambling. DESIGN: We drew data from two stratified random surveys (n = 2417, n= 530) of gambling behavior and consequences among community-based samples of US adults. A fully structured questionnaire, administered by trained lay interviewers, screened for the life-time prevalence of problem and Pathological Gambling. Per DSM-IV definitions, anyone meeting five or more of 10 itemized criteria was considered a pathological gambler. We analyzed these criteria among all gamblers who met one or more criteria (n = 399). FINDINGS: Most gamblers who met only one or two criteria reported 'chasing their losses'. At subclinical levels (three to four criteria), gamblers also reported elevated rates of gambling-related fantasy: lying, gambling to escape and preoccupation. Pathological gamblers with five to seven criteria reported marked elevations of loss of control, withdrawal symptoms and tolerance (internalizing dimensions of dependence); risking their social relationships and needing to be bailed out financially (externalizing dimensions). Most of the highest-level pathological gamblers (eight to 10 criteria) reported committing illegal acts to support gambling. CONCLUSION: Dependence in a biobehavioral sense appears to be a hallmark of Pathological Gambling, but it marks only one threshold in a qualitative hierarchy of disorders beginning with a common subclinical behavior, 'chasing'. Epidemiological assessments and future DSM revisions might consider explicit recognition of a problem gambling disorder, identifying people presenting some cognitive symptoms of Pathological Gambling but not clear signs of dependence. Pathological gamblers in turn appear to have two distinct levels of severity.

A Reply to Gambino's "An Epidemiologic Note on Verification Bias: Implications for Estimation of Rates"

While two-stage designs in problem gambling research are expensive and relatively difficult to execute, they have the potential to yield more accurate prevalence estimates as well as valuable additional information about gambling and problem gambling in the community. However, gains in precision are heavily dependent on the accuracy of the screening methods used and the sample sizes involved. Sound practice requires reliable information about the variances and confidence levels associated with different screens. In the spirit of contributing to the ongoing dialog about ways to improve the measurement of problem gambling, we examine several reasons to question whether the revised estimates offered by Gambino are in fact an improvement.