Problem and pathological gambling in North American Aboriginal populations: a review of the empirical literature

Social Connectedness and Associations with Gambling Risk in New Zealand

Multiple factors are associated with disordered gambling, with some populations having a greater risk for developing disordered gambling than others. The present study, utilising data previously collected for a New Zealand (NZ) national gambling survey, explored the associations of social connectedness and leisure activities with risky gambling behaviour and quality of life. Poorer social connectedness and leisure activities were found to be associated with increased gambling risk and poorer quality of life, respectively. Social connectedness and leisure activities strongly predicted type of gambling activities and quality of life. Furthermore, Māori (NZ's indigenous population) had lower social connectedness and fewer leisure activities, and a greater gambling risk, as well as higher psychological distress, than the NZ European/Other population. These findings indicate that the risk of progressing from recreational gambling to risky gambling is relatively higher for Māori, and that social connectedness and leisure activities could be contributing factors for this increased risk. It is, therefore, important that social connectedness and leisure activities are seriously considered in public health and treatment efforts to reduce gambling harm for vulnerable populations.

Indigenous Gambling and Problem Gambling in Canada

The present study provides a profile of Canadian Indigenous gambling and problem gambling using the 2018 Canadian Community Health Survey (CCHS) (n = 23,952 adults; 1,324 Indigenous) and an online panel survey of 10,199 gamblers (n = 589 Indigenous). The relative popularity of different types of gambling was similar between Indigenous and non-Indigenous samples. However, there was higher Indigenous participation in electronic gambling machines (EGMs), bingo, instant lotteries, overall gambling and a higher rate of problem gambling (2.0% versus 0.5%). Variables predictive of Indigenous problem gambling were EGM participation, gambling fallacies, having a mental or substance use disorder, sports betting, and male gender. Compared to non-Indigenous problem gamblers, Indigenous problem gamblers had higher substance use and lower impulsivity. In general, variables predictive of Indigenous problem gambling were the same ones predictive of problem gambling in all populations, with elevated Indigenous problem gambling rates primarily being due to elevated rates of these generic risk factors. Many of these risk factors are modifiable. Particular consideration should be given to reducing the disproportionate concentration of EGMs in geographic areas having the highest concentration of Indigenous people and ameliorating the disadvantageous social conditions in this population that are conducive to mental health and substance use problems.

Problem Gambling Risk Among Older Francophones in Ontario Canada: Surprising Results that Contradict Previous Findings of Gambling in Minority Groups

Gambling is a popular activity among older adults. Despite this increase in popularity little research has examined gambling among this group. This is especially true for minority older adults, like Francophones in Ontario. The purpose of this study was to better understand gambling in a sample of older Francophones from North-Eastern Ontario, the first study to do so. A sample of 181 older (over 55 years) Francophones from Northeastern Ontario (M age = 68.7, SD 7.6) was recruited. This sample was compared to a sample of older adults with English as their native language that had been previously collected (Norris and Tindale in The meaning of gambling among Ontario seniors in small and rural communities, Final report to the Ontario Problem Gambling Research Centre, 2006; Tindale and Norris in Gambling among intergenerational and multi-ethnic families, Final report to the Ontario Problem Gambling Research Centre, 2012). In addition to demographic measures the participants filled out a questionnaire that included measures of gambling behaviours and attitudes the Windsor Screen, The Problem Gambling Severity Index of the Canadian Problem Gambling Inventory, The Center for Epidemiologic Studies Depression Scale and the CAGE Alcohol Screen. Contrary to expectations, the Francophone sample had lower scores on the problem gambling measures with a smaller proportion of the sample in the categories indicating a high risk for problem gambling. This surprising result might be due to the protective effect of a positive ethnolinguistic identity. However, more research will need to be done to better understand these unanticipated results. The findings of this study help us better understand gambling among older adults in a minority group.

Psychosocial risk factors in disordered gambling: A descriptive systematic overview of vulnerable populations

BACKGROUND

Gambling is a behaviour engaged in by millions of people worldwide; for some, gambling can become a severely maladaptive behaviour, and previous research has identified a wide range of psychosocial risk factors that can be considered important for the development and maintenance of disordered gambling. Although risk factors have been identified, the homogeneity of risk factors across specific groups thought to be vulnerable to disordered gambling is to date, unexplored.

METHODS

To address this, the current review sought to conduct a systematic overview of literature relating to seven vulnerable groups: young people and adolescents, older adults, women, veterans, indigenous peoples, prisoners, and low socio-economic/income groups.

RESULTS

Multiple risk factors associated with disordered gambling were identified; some appeared consistently across most groups, including being male, co-morbid mental and physical health conditions, substance use disorders, accessibility and availability of gambling, form and mode of gambling, and experience of trauma. Further risk factors were identified that were specific to each vulnerable group.

CONCLUSION

Within the general population, certain groups are more vulnerable to disordered gambling. Although some risk factors are consistent across groups, some risk factors appear to be group specific. It is clear that there is no homogenous pathway in to disordered gambling, and that social, developmental, environmental and demographic characteristics can all interact to influence an individual's relationship with gambling.

Practical Treatments Considering the Role of Sociocultural Factors on Problem Gambling

Reviews of problem gambling (PG) literature increasingly recognize the ways in which different ethnic groups are affected by gambling behaviors, yet discourse, which considers sociocultural factors within PG, remains limited. Literature on this topic is influenced by large inconsistencies amongst research studies, overlapping terminology, and variability in the validity of research studies, making conclusions difficult to draw. Despite these discrepancies, this paper explores how sociocultural factors influence PG among diverse cultural groups and provides specific practical implications for treating PG disorders in culturally diverse populations. Notable factors that exacerbate PG behavior cross-culturally include substance abuse, low socioeconomic status, lack of social activities, and geographic location. Culturally sensitive treatment options such as Motivational Interviewing and Cognitive Behavioral Therapy have been identified as effective treatments for PG with culturally diverse populations. This paper extends current thought by providing practical treatment recommendations that consider the subtle nuances of diverse populations. It explains how treatment providers and behavioral addiction professionals can increase their understanding and skills when conceptualizing PG clients from a diverse background.

Problem-gambling severity and psychiatric disorders among American-Indian/Alaska native adults

INTRODUCTION

Little is known about the association between problem-gambling severity and psychiatric disorders among American-Indian/Alaska-Native (AI/AN) individuals. Thus, we examined these factors among a nationally representative sample of AI/AN and other American adults in the USA.

METHOD

Using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data, we conducted separate Wald tests and multinomial logistic regression analyses comparing AI/AN to black/African American, white/Caucasian, and all other racial/ethnic groups, respectively.

RESULTS

Relative to other American adults, AI/AN adults were least likely to report non-/low-frequency gambling (NG: AI/AN 66.5%, white/Caucasian 70.5%, black/African American 72.8%, other racial/ethnic group 72.3%) and most likely to report low-risk gambling (LRG: AI/AN 30.1%, white/Caucasian 26.5%, black/African American 23.4%, other racial/ethnic group 24.7%). The association between at-risk/problem-gambling (ARPG) and any past-year Axis-I disorder was stronger among AI/AN versus other American adults. Although ARPG and LRG were associated with multiple past-year Axis-I and lifetime Axis-II psychiatric disorders in both AI/AN and other American adults, LRG was more strongly associated with both Axis-I disorders (particularly major depression, generalized anxiety disorder and nicotine dependence) and Cluster-B Axis-II (particularly antisocial personality disorder) disorders in AI/AN versus other American adults.

DISCUSSION

A stronger association between problem-gambling severity and past-year psychiatric disorders among AI/AN relative to other American adults suggests the importance of enhancing mental health and problem-gambling prevention and treatment strategies that may help AI/AN individuals.

Components of Impulsivity in Gambling Disorder

This study examined the structure of impulsivity within gambling disorder. A group of 51 men and 53 women with gambling disorder completed self-report and behavioral measures of impulsivity. Principal component analyses found two factors. The first was interpreted as measuring trait impulsivity. This factor correlated with problem gambling severity, presence of comorbid mental health and substance use disorders, history of brain injury, and was higher in Aboriginal participants. The second factor had high loadings on the self-reported sensation-seeking scales and the behavioural measures of response impulsivity. This factor correlated with overall gambling involvement but not with indicators of pathology. Higher scores were associated with younger age. These results are consistent with an evolving model of the etiology of disordered gambling that suggests that sensation-seeking is related to gambling involvement but that trait impulsivity and mental health struggles are associated with the development of gambling disorder.

Sexual abuse, residential schooling and probable pathological gambling among Indigenous Peoples

Sexual abuse leads to short-term and long-lasting pervasive outcomes, including addictions. Among Indigenous Peoples, sexual abuse experienced in the context of residential schooling may have led to unresolved grief that is contributing to social problems, such as pathological (disordered) gambling. The aim of this study is to investigate the link between child sexual abuse, residential schooling and probable pathological gambling. The participants were 358 Indigenous persons (54.2% women) aged between 18 and 87 years, from two communities and two semi-urban centers in Quebec (Canada). Probable pathological gambling was evaluated using the South Oaks Gambling Screen (SOGS), and sexual abuse and residential schooling were assessed with dichotomous questions (yes/no). The results indicate an 8.7% past-year prevalence rate of pathological gambling problems among participants, which is high compared with the general Canadian population. Moreover, 35.4% were sexually abused, while 28.1% reported having been schooled in a residential setting. The results of a logistic regression also indicate that experiences of child sexual abuse and residential schooling are associated with probable pathological gambling among Indigenous Peoples. These findings underscore the importance of using an ecological approach when treating gambling, to address childhood traumas alongside current addiction problems.

Gambling harms and gambling help-seeking amongst indigenous Australians

This paper aimed to analyze the harms arising from gambling and gambling-related help-seeking behaviour within a large sample of Indigenous Australians. A self-selected sample of 1,259 Indigenous Australian adults completed a gambling survey at three Indigenous sports and cultural events, in several communities and online. Based on responses to the problem gambling severity index (PGSI), the proportions of the sample in the moderate risk and problem gambler groups were higher than those for the population of New South Wales. Many in our sample appeared to face higher risks with their gambling and experience severe gambling harms. From PGSI responses, notable harms include financial difficulties and feelings of guilt and regret about gambling. Further harms, including personal, relationship, family, community, legal and housing impacts, were shown to be significantly higher for problem gamblers than for the other PGSI groups. Most problem gamblers relied on family, extended family and friends for financial help or went without due to gambling losses. Nearly half the sample did not think they had a problem with gambling but the results show that the majority (57.7 %) faced some risk with their gambling. Of those who sought gambling help, family, extended family, friends and respected community members were consulted, demonstrating the reciprocal obligations underpinning traditional Aboriginal culture. The strength of this finding is that these people are potentially the greatest source of gambling help, but need knowledge and resources to provide that help effectively. Local Aboriginal services were preferred as the main sources of professional help for gambling-related problems.

The gambling behavior of indigenous Australians

The gambling activities of minority groups such as Indigenous peoples are usually culturally complex and poorly understood. To redress the scarcity of information and contribute to a better understanding of gambling by Indigenous people, this paper presents quantitative evidence gathered at three Australian Indigenous festivals, online and in several Indigenous communities. With support from Indigenous communities, the study collected and analyzed surveys from 1,259 self-selected Indigenous adults. Approximately 33 % of respondents gambled on card games while 80 % gambled on commercial gambling forms in the previous year. Gambling participation and involvement are high, particularly on electronic gaming machines (EGMs), the favorite and most regular form of gambling. Men are significantly more likely to participate in gambling and to gamble more frequently on EGMs, horse/dog races, sports betting and instant scratch tickets. This elevated participation and frequency of gambling on continuous forms would appear to heighten gambling risks for Indigenous men. This is particularly the case for younger Indigenous men, who are more likely than their older counterparts to gamble on EGMs, table games and poker. While distinct differences between the gambling behaviors of our Indigenous sample and non-Indigenous Australians are apparent, Australian Indigenous behavior appears similar to that of some Indigenous and First Nations populations in other countries. Although this study represents the largest survey of Indigenous Australian gambling ever conducted in New South Wales and Queensland, further research is needed to extend our knowledge of Indigenous gambling and to limit the risks from gambling for Indigenous peoples.

Risk factors for problem gambling among indigenous Australians: an empirical study

Despite a long history of gambling amongst many Indigenous peoples, knowledge about contemporary Indigenous gambling is sparse. In Australia, previous studies of Indigenous gambling have been severely limited in number, scope and rigour. The research reported in this paper is based on the first Indigenous-specific quantitative gambling research undertaken in Australia since 1996 and draws on the largest sample to date. This study examined numerous aspects of gambling among Indigenous Australians. After appropriate consultations and permission, the study collected surveys from 1,259 self-selected Indigenous adults in 2011 at three Indigenous festivals, online and in several Indigenous communities. This paper draws on these data to identify problem gambling risk factors by comparing selected socio-demographic characteristics, early exposure to gambling, gambling motivations, gambling behaviour, gambling cognitions, and substance use while gambling, amongst non-problem, low risk, moderate risk and problem gamblers. A logistic regression investigated the difference between problem gamblers and all other PGSI groups. Risk factors associated with being a problem gambler were: being older, commencing gambling when under 10 years old, always being exposed to adults gambling as a child, using alcohol and/or drugs while gambling, having family and friends who gamble, having an addiction to gambling and not gambling to socialise, having a high expenditure on commercial gambling, and living in a state or territory other than NSW or QLD. Public health measures to address these risk factors are identified.

Gambling behavior and problem gambling reflecting social transition and traumatic childhood events among Greenland Inuit: a cross-sectional study in a large indigenous population undergoing rapid change

An increase in social pathologies is a key feature in indigenous populations undergoing transition. The Greenland Inuit are a large indigenous population constituting a majority in their own country, which makes it possible to investigate differences within the population. This led us to study gambling behavior and problem gambling among Greenland Inuit in relation to the ongoing social transition and traumatic events during childhood. A large representative cross-sectional study was conducted among Greenland Inuit (n = 2,189). Data was collected among adults (18+) in 9 towns and 13 villages in Greenland from 2005 to 2010. Problem gambling, gambling behavior and traumatic childhood events were measured through a self-administered questionnaire. The lie/bet screen was used to identify past year and lifetime problem gambling. Social transition was measured as place of residence and a combination of residence, education and occupation. The lifetime prevalence of problem gambling was 16 % among men and 10 % among women (p < 0.0001); and higher in towns (19 %) compared to the capital of Nuuk (11 %) and in villages (12 %) (men only, p = 0.020). Lifetime problem gambling was associated with social transition (p = 0.023), alcohol problems in childhood home (p = 0.001/p = 0.002) and sexual abuse in childhood (women only, p = 0.030). A comparably high prevalence of lifetime problem gambling among Greenland Inuit adds problem gambling to the list of social pathologies in Greenland. A significant association between lifetime problem gambling, social transition and traumatic childhood events suggests people caught between tradition and modern ways of life are more vulnerable to gambling problems.

Aboriginal Gambling and Problem Gambling: A Review

The prevention of gambling-related problems amongst Aboriginal communities has been neglected by most public health strategies which concentrate on mainstream populations. Research indicates that rates of problem gambling are higher for Aboriginal groups than the general population. Specific cultural, familial, and social patterns influence gambling by Aboriginal groups, which are individually different, making it difficult to implement a cohesive strategy to address gambling-related harms. Because of this complexity, a thorough literature review is necessary to identify gaps in policy and research. This paper uses a public health framework to consider multi-dimensional influences (personal, environmental, economic, cultural and social) that affect gambling uptake. Such analysis is also important for identifying risk factors which facilitate the development and maintenance of problem gambling and potentially for underpinning protection, prevention and treatment programs. It is advised that strategies be developed in consultation with Aboriginal peoples to guide public health policy and research to minimise any gambling-related harms.

Gambling behavior subtypes among respondents with gambling-related problems in a population-based sample

Latent class analysis was used to delineate distinctive subgroups of gamblers and examine whether they differed by demographics and gambling severity. Data from three Canadian provinces focused on respondents who reported at least some risk of problem gambling in the past year (N=1,071). Three latent classes were distinguished: a low on most items group (class 1), a behaviorally conditioned/substance abusing impulsive/emotionally vulnerable (or all types) group (class 2), and a familial-genetic/behaviorally conditioned group (class 3). Gamblers in classes 2 and 3 were most likely to be moderate-risk and problem gamblers. Community-based prevention efforts may need to address each subgroup differently but also according to their characteristics.

Sociodemographic and substance use correlates of gambling behavior in the Canadian general population

This study describes sociodemographic and substance use correlates of gambling behaviors, measured among 9,481 past-year gamblers from the Canadian general population. Compared to non-problem gamblers in this study (N=8,035), the 98 problem gamblers who scored 8 or more points on the Canadian Problem Gambling Research Index were more likely to report being "drunk or high" while gambling (adjusted odds ratio [AOR]: 8.92; 95% confidence interval [CI]: 5.46,14.55; p<.001), to admit to having an alcohol or drug problem (AOR: 3.80; 95% CI:2.21,6.52; p<.001), and to use electronic gambling devices (AOR: 4.85; 95% CI: 3.08-7.66; p<.001).

Prevalence of the addictions: a problem of the majority or the minority?

An increasing number of research studies over the last three decades suggest that a wide range of substance and process addictions may serve similar functions. The current article considers 11 such potential addictions (tobacco, alcohol, illicit drugs, eating, gambling, Internet, love, sex, exercise, work, and shopping), their prevalence, and co-occurrence, based on a systematic review of the literature. Data from 83 studies (each study n = at least 500 subjects) were presented and supplemented with small-scale data. Depending on which assumptions are made, overall 12-month prevalence of an addiction among U.S. adults varies from 15% to 61%. The authors assert that it is most plausible that 47% of the U.S. adult population suffers from maladaptive signs of an addictive disorder over a 12-month period and that it may be useful to think of addictions as due to problems of lifestyle as well as to person-level factors.

Disordered gambling among racial and ethnic groups in the US: results from the national epidemiologic survey on alcohol and related conditions

INTRODUCTION

Prior research suggests that racial minority groups in the United States are more vulnerable to develop a gambling disorder than whites. However, no national survey on gambling disorders exists that has focused on ethnic differences.

METHODS

Analyses of this study were based on the National Epidemiologic Survey on Alcohol and Related Conditions, a large (N=43,093) nationally representative survey of the adult (> or =18 years of age) population residing in households during 2001-2002 period. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision diagnoses of pathological gambling, mood, anxiety, drug use, and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version.

RESULTS

Prevalence rates of disordered gambling among blacks (2.2%) and Native/Asian Americans (2.3%) were higher than that of whites (1.2%). Demographic characteristics and psychiatric comorbidity differed among Hispanic, black, and white disordered gamblers. However, all racial and ethnic groups evidenced similarities with respect to symptom patterns, time course, and treatment seeking for pathological gambling.

CONCLUSION

The prevalence of disordered gambling, but not its onset or course of symptoms, varies by racial and ethnic group. These varying prevalence rates may reflect, at least in part, cultural differences in gambling and its acceptability and accessibility. These data may inform the need for targeted prevention strategies for high-risk racial and ethnic groups.

A Cross-Cultural Study of Gambling Behaviour Among Adolescents

This study investigated whether the prevalence of weekly and problem gambling among youth varied according to cultural affiliation. A convenience sample of 1,265 Quebec high school students aged 12-18 was divided into three linguistic groupings: Anglophone (English), Francophone (French), and Allophone (other). Results revealed that the Allophone grouping contained the highest proportion of youth who gambled on a weekly basis and who reported gambling problems, followed by the Anglophone, and finally the Francophone groupings. Acculturation difficulties were associated with problem gambling. Few meaningful between-group differences were found with respect to factors related to problem gambling (i.e., comorbidity with other risk factors, coping, family functioning and resiliency). The results are discussed with respect to the influence of cultural background on gambling behavior.

The application of youth substance use media campaigns to problem gambling: a critical evaluation

Despite the negative impact that problem gambling poses on individuals and society there have been few gambling prevention campaigns specifically targeting youth. The authors review the literature on past and current drug, alcohol, and tobacco use prevention media campaigns, examining the similarities across 25 health communication programs with the aim of viewing their applicability for the prevention of youth problem gambling. Critical features of effective campaigns are identified and assessed in terms of their applicability for youth problem gambling. Recommendations for the design, implementation, and evaluation of a youth gambling media campaign are discussed.

Where is the syndrome? Examining co-occurrence among multiple problem behaviors in adolescence

The authors examined co-occurrence among a wide range of adolescent problem behaviors: alcohol, smoking, marijuana, hard drugs, sexual activity, major and minor delinquency, direct and indirect aggression, and gambling. Using a large self-report survey of high school students, confirmatory factor analysis was used to test the problem syndrome model proposed by problem behavior theory. A 3-factor model provided better overall fit than did a single problem syndrome factor model. Contingency table analyses were used to examine the co-occurrence of problem behaviors at different levels of involvement within individuals, as well as relative risk ratios. Analyses offered modest support for a limited problem syndrome encompassing the report of high-risk involvement with alcohol, minor delinquency, direct aggression, and, to a lesser extent, marijuana. For each problem behavior, the majority of adolescents did not report high-risk involvement, and only a minority reported any involvement with multiple behaviors.

Cross-cultural alexithymia: validity of the 20-item Toronto Alexithymia Scale in North American aboriginal populations

OBJECTIVE

The generalizability of the alexithymia construct to North American aboriginal culture was examined by assessing the replicability of the factor structure of the 20-item Toronto Alexithymia Scale (TAS-20) in two different adult samples. The study also assessed the reliability of the scale and the influence of gender, age, and education on alexithymia levels.

METHOD

The first sample was a community-based group of 123 aboriginal men and women; the second sample was 102 male aboriginal offenders. Both samples completed the TAS-20.

RESULTS

The replicability of the three-factor structure for the TAS-20 was supported in both groups using confirmatory factor analysis (CFA). The TAS-20 and its three factors demonstrated adequate internal reliability, and the variables of gender, age, and education accounted for small or nonsignificant amounts of variability in total TAS-20 and factor scale scores.

CONCLUSION

The results provide additional support for the factorial validity of the TAS-20 in diverse cultural groups.

The road less travelled: moving from distribution to determinants in the study of gambling epidemiology

This article reviews the current status of gambling epidemiology studies and suggests that it is time to move from general population-prevalence research toward the investigation of risk and protective factors that influence the onset of gambling disorders. The study of incidence among vulnerable and resilient populations is a road yet to be taken. In this review, we briefly introduce the history of the field and thoroughly review the epidemiologic research on disordered gambling before providing a critical assessment of the current diagnostic tools. Overall, the extant research shows that disordered gambling is a relatively stable phenomenon throughout the world. Given that certain segments of the population (for example, adolescents and substance users) have elevated prevalence rates, we suggest focusing future prevalence studies on groups with apparently increased vulnerability. Moreover, we suggest that, for the field of gambling studies to progress, researchers need to take the road less travelled and examine more carefully the onset and determinants of disordered gambling. That said, given the problems with the current diagnostic screens, investigators need to refine their theoretical concepts and the epidemiologic tools used to examine them before the field can travel down this new road.

Role of culture in gambling and problem gambling

There has been a significant gap in the gambling literature regarding the role of culture in gambling and problem gambling (PG). This paper aims to this such gap by presenting a systematic review of the cultural variations in gambling and PG as well as a discussion of the role cultural variables can play in the initiation and maintenance of gambling in order to stimulate further research. The review shows that although studies investigating prevalence rates of gambling and PG among different cultures are not plentiful, evidence does suggest certain cultural groups are more vulnerable to begin gambling and to develop PG. Significant factors including familial/genetic, sociological, and individual factors have been found in the Western gambling literature as playing important roles in the development and maintenance of PG. These factors need to be examined now in other cultural groups so we can better understand the etiological processes involved in PG and design culturally sensitive treatments. In addition, variables, such as cultural values and beliefs, the process of acculturation, and the influence of culturally determined, help-seeking behaviors need to be also examined in relation to the role they could play in the initiation of and maintenance of gambling. Understanding the contribution of cultural variables will allow us to devise better prevention and treatment options for PG. Methodological problems in this area of research are highlighted, and suggestions for future research are included.

Has there been a "feminization" of gambling and problem gambling in the United States?

This paper examines the question of whether there has been a "feminization" of gambling and problem gambling in the United States. Feminization refers to the idea that more women are gambling, developing problems and seeking help for problems related to gambling than in the past. Data from a theoretically derived sample of four states are examined to identify patterns in the distribution of gambling participation and the prevalence of problem gambling in the general population. Despite widespread acceptance of the notion of the feminization of gambling and problem gambling, men remain significantly more likely than women to participate regularly in most types of gambling. Most gambling activities remain highly gendered; however, in the United States, the widespread introduction of gaming machines is associated with increases in gambling and problem gambling among women. The present analysis highlights the importance of taking socio-demographic characteristics besides gender into account when considering the distribution of gambling and problem gambling in the general population.

Gambling and related mental disorders: a public health analysis

This article reviews the prevalence of gambling and related mental disorders from a public health perspective. It traces the expansion of gambling in North America and the psychological, economic, and social consequences for the public's health, and then considers both the costs and benefits of gambling and the history of gambling prevalence research. A public health approach is applied to understanding the epidemiology of gambling-related problems. International prevalence rates are provided and the prevalence of mental disorders that often are comorbid with gambling problems is reviewed. Analysis includes an examination of groups vulnerable to gambling-related disorders and the methodological and conceptual matters that might influence epidemiological research and prevalence rates related to gambling. The major public health problems associated with gambling are considered and recommendations made for public health policy, practice, and research. The enduring value of a public health perspective is that it applies different 'lenses' for understanding gambling behaviour, analysing its benefits and costs, as well as identifying strategies for action. Harvey A. Skinner (160, p. 286)