Category Archives: Addiction

The highs of the prize: Are instant-win products a form of gambling?

A nine-year old boy walks into a shop and buys a packet of potato chips. An eight-year old girl walks into the same shop and buys a chocolate bar. Nothing particularly unusual except this particular packet of potato chips poses the question “Is there a spicy £100,000 inside?” in big letters on the front of the packet with the added rider “1000’s of real £5 notes to be won!” The bar of chocolate offers “£1 million in cash prizes – win instantly. Look inside to see if your a winner!!”. The boy opens up the bag of crisps but it contains nothing but crisps. He is very disappointed. The little girl opens up the chocolate bar and sees the all to familiar phrase “Sorry. You haven’t won this time but keep trying. Remember there’s £1 million in cash prizes to be won”. She too is very disappointed. Both of them decide to buy the product again to see if their luck will change. It doesn’t. This time a different chocolate bar says “Sorry this is not a winning bar. Better luck next time!” The most they are likely to win is another packet of crisps or some more chocolates.

This scenario describes a typical instant win product (whereby a consumer buys a particular product with the chance of instantly winning something else of financial value). This type of instant-win marketing has been around for some time and is not particularly new but it is the younger generation that is being targeted. In a different environment, it could be argued that these two children are “chasing” their losses in the same way a gambler chases theirs. All over the world, this type of marketing is becoming more prevalent with big multi-national companies also employing its use to increase sales (e.g., MacDonalds).

In gambling situations after losing money, gamblers often gamble again straight away or return another day in order to get even. This is commonly referred to as “chasing” losses. Chasing is symptomatic of problem gambling and is often characterized by unrealistic optimism on the gambler’s part. All bets are made in an effort to recoup their losses. The result is that instead of “cutting their losses” gamblers get deeper into debt pre-occupying themselves with gambling, determined that a big win will repay their loans and solve all their problems. Although not on this scale, the scenario outlined above appears to be a chasing-like experience akin to that found in gambling. To children, this type of behaviour appears to be a gambling-type experience and is similar to other gambling pre-cursors that I have highlighted in some of my papers such as the playing of marbles, card flipping, and sports card playing. For instance, in sports card playing, it is not uncommon for adolescents to keep buying packs of cards to get their favorite baseball or football star. Products like crisps and chocolate are popular and appeal not only to the young but to adults too. However, the fact that such promotions are often coupled with the appearance of teenage idols (e.g., famous pop groups or top soccer sporting heroes) suggests that it is younger people that are being aimed for.

Manufacturers of instant-win products claim that people buy their products because customers want them. They further claim that the appeal of a promotion is secondary to the appeal of the product. This may well be true with most people but instant-win promotions obviously increase sales otherwise so many companies would not resort to it in the first place. It would appear that most people have no problem on moral (or other) grounds with companies who use this type of promotion. However, there are those (such as those who work in the area of youth gambling) who wonder whether this type of promotion exploits the vulnerable in some way (i.e., children and adolescents). The question to ask is whether young children and adolescents are actually engaging in a form of gambling by buying these types of products.

Gambling is normally defined as the staking of money (or something of financial value) on the uncertain outcome of a future event. Technically, instant-win promotions are not a form of gambling. This is because (by law) manufacturers are required to state that “no purchase is necessary”. This whole practice it is little more than a lottery except that in very small letters at the bottom of the packet there is the added phrase “No purchase necessary – see back for details”. However, very few people would know this unless they bought the product in the first place, and secondly, the likelihood is that a vast majority will not do this anyway – particularly children and adolescents.

The small print usually reads “No purchase necessary. Should you wish to enter this promotion without purchasing a promotional pack, please send your name and address clearly printed on a plain piece of paper. If you are under 18, please ask a parent or guardian to sign your entry. An independently supervised draw will be made on your behalf, and should you be a winner, a prize will be sent to you within 28 days”. I have tried writing to companies to ascertain how many people utilize this route but (to date) I have been unsuccessful in gaining any further information. It is highly likely that very few people write to the companies concerned. There is a high likelihood that the companies in question have the empirical evidence but unfortunately it is not in the public domain. If it is assumed that the number of people who actually write to the companies for their names to be put into an independently supervised draw is very low, it can be argued that to all intents and purposes that people who buy such products are engaged in a form of gambling.

Since the introduction of the UK National Lottery and instant scratchcards in the mid-1990s, a “something-for-nothing” culture appears to have developed where people want to win big prizes on lots of different things. Children themselves are growing up in an environment where gambling is endemic. Having examined a variety of instant-win promotions, I am in little doubt that they should be viewed as gambling pre-cursors in that they are gambling-like experiences without being a form of gambling with which anyone can identify. It is unlikely that great numbers of children will develop a problem with this activity, but there is the potential concern that a small minority will. Research has consistently shown that the earlier that a child starts to gamble the more likely they are to develop a gambling problem.

Evidence that instant-win products are problematic to young children is mostly anecdotal. For instance, a number of years ago, I appeared on a UK daytime television programme with a mother and her two children (aged nine and ten years of age) who literally spent all their disposable income on instant-win promotions. These two children had spent hundreds of pounds of their pocket money in the hope of winning the elusive prizes offered but never won more than another bag of potato chips. The mother claimed they had “the gambling bug” and was “terrified they will have problems when they grow up”. She claimed she had done her utmost to stop them using their pocket money in this way but as soon as her back was turned they were off to the local corner shop to buy instant-win products. This wasn’t just restricted to products they enjoyed anyway. For instance, when they went to the supermarket to shop the children just fill up the shopping trolley with anything that has an instant-win promotion including tins of cat food – even though they didn’t have a cat!

Harsh critics of instant-win promotions might advocate a complete banning of these types of marketing endeavors. However, this is impractical if not somewhat over the top. What is more, there is no empirical evidence (to date) that there is a problem. However, this does not mean that such practices should not be monitored. Instant-win marketing appears to be on the increase and it may be that young children are particularly vulnerable to this type of promotion if anecdotal case study accounts are anything to go by.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (1989). Gambling in children and adolescents. Journal of Gambling Behavior, 5, 66-83.

Griffiths, M.D. (1995). Adolescent Gambling. London : Routledge.

Griffiths, M.D. (1997). Instant-win promotions: Part of the gambling environment? Education and Health, 15, 62-63.

Griffiths, M.D. (2002). Gambling and Gaming Addictions in Adolescence. Leicester: British Psychological Society/Blackwells.

Griffiths, M.D. (2003). Instant-win products and prize draws: Are these forms of gambling? Journal of Gambling Issues, 9. Located at: http://jgi.camh.net/doi/full/10.4309/jgi.2003.9.5

Griffiths, M.D. (2005). Does advertising of gambling increase gambling addiction? International Journal of Mental Health and Addiction, 3(2), 15-25.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3) (pp.11-20). San Diego: Academic Press.

Griffiths, M.D. (2013). Responsible marketing and advertising of gambling. i-Gaming Business Affiliate, August/September, 50.

Griffiths, M.D., King, D.L. & Delfabbro, P.H. (2009). Adolescent gambling-like experiences: Are they a cause for concern? Education and Health, 27, 27-30.

Hayer, T. & Griffiths, M.D. (2015). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-based Approaches to Prevention and Treatment (Second Edition) (pp. 539-558). New York: Kluwer.

Zangeneh, M., Griffiths, M.D. & Parke, J. (2008). The marketing of gambling. In Zangeneh, M., Blaszczynski, A., and Turner, N. (Eds.), In The Pursuit Of Winning (pp. 135-153). New York: Springer.

Aid and a bet: A brief look at the prevention of problem gambling

While prevention efforts targeting addictive disorders are widely used, there are relatively limited data are available on their effectiveness (particularly in the gambling studies field). According to the US Preventive Services Task Force, prevention has historically been divided into three stages. The term primary prevention has been used to describe measures employed to “prevent the onset of a targeted condition”. Secondary prevention has been used to describe measures that “identify and treat asymptomatic persons who have already developed risk factors or pre-clinical disease but in whom the condition is not clinically apparent”. Tertiary prevention has been used to describe “efforts targeting individuals with identified disease in which the goals involve restoration of function, including minimizing or preventing disease-related adverse consequences”. These divisions of prevention thus focus on different targets, with primary efforts tending to target the general population, secondary efforts at risk or vulnerable groups, and tertiary efforts individuals with an identified disorder.

Primary prevention is typically considered the most cost-effective form of prevention as it helps reduce suffering, cost and burden associated with a disorder. Primary prevention efforts related to problem gambling have generally involved education initiatives. Examples include television commercials, billboards, posters, and postcards, that may feature brief problem gambling screening instruments or advertise gambling helplines and treatment services. Despite widespread use, most primary prevention efforts in gambling have not been empirically validated.

The content and impact of primary prevention is strongly influenced by knowledge of the impact of the behaviour or disorder being prevented. For example, prevention efforts targeting tobacco smoking cessation have changed significantly as more information concerning the health impact of tobacco smoke have become available. Unfortunately, few large-scale, well-designed studies have investigated the health impact of different levels or types of gambling (e.g., recreational, problem, and pathological).

Some primary prevention efforts targeting children and adolescents may influence adult gambling behaviors. Some of these studies have published promising results but all studies have shortcomings (e.g., cross-sectional designs that don’t allow for assessment of lasting positive effects on gambling attitudes or behaviour). Basically, it’s unclear if the positive effects found will be maintained into adulthood or if the same interventions employed on adolescent populations would be effective for adults. Research on prevention programs outside of the gambling field has suggested that regardless of delivery mode (didactic lecture, videotapes, posters, pamphlets, guest speakers etc.), the ‘information only’ approach has relatively little effect on behavioural change.

Another feature to be considered in primary prevention is the impact of gambling availability on the development of problem gambling. Over the past several decades, there has been a rapid increase in the availability of legalized gambling worldwide. Data suggest that concurrent with the increase in availability there have been increase in the rates of recreational, problem and pathological gambling. The extent to which gambling should be regulated and/or restricted remains an area of active debate, with the decisions holding considerable potential impact on public health and prevention efforts. In summary, although primary prevention efforts related to adult gambling exist, they are relatively few in number, particularly when considering the public health impact of problem gambling.

Secondary prevention efforts involve measures that target individuals with risk factors for or pre-clinical forms of a disorder. Secondary prevention measures in general constitute important interventions in general medical settings. Although it is likely that generalist physicians encounter individuals with gambling problems in their provision of clinical care, the extent to which they are trained to examine for or feel comfortable in assessing gambling problems warrants consideration. However, a significant minority of gamblers report health problems as a direct result of their gambling. This indicates that gambling in its most excessive forms should be viewed as a serious health issue to be taken seriously by the medical profession. Adverse health consequences for both the gambler and their partner include depression, insomnia, intestinal disorders, migraines, and other stress-related disorders. General practitioners routinely ask patients about smoking and drinking but gambling is something that is not generally discussed. Problem gambling may be perceived as a somewhat ‘grey area’ in the field of medicine and it is therefore is very easy to deny that medics should be playing a role. If the main aim of practitioners is to ensure the health of their clients, then it is quite clear that an awareness of gambling and the issues surrounding should be an important part of basic knowledge.

Efficient screening methods for problematic gambling behaviours could be of significant value in general medical settings. Several brief screening instruments for problem and pathological have been developed. Although it is likely too early to develop practice guideline for problem and pathological gambling prevention efforts within a general medical setting, generalist physicians could regularly assess patients’ gambling histories, sensitively broach the topic of the possible existence of gambling problems with those patients suspected of engaging problematically in gambling, thoughtfully motivate individuals with gambling problems to seek treatment, and appropriately refer individuals with gambling problems to a self-help group or a gambling to facilitate engagement in locally available gambling treatment.

Brief screening instruments could also be of significant utility in other settings, including mental health and addiction treatment offices, jails and other forensic facilities, and gambling venues. Individuals within these settings should be aware of the high rates of problem gambling in specific groups (e.g., males, adolescents, and individuals with histories of incarceration or psychiatric [including substance use] disorders). Given the high rates of co-occurrence of gambling and other psychiatric disorders, screening of individuals with problem or pathological gambling for other psychiatric disorders (and vice versa) could enhance tertiary prevention efforts (i.e., providing treatment that more effectively reduces the harm associated with each disorder).

Individuals attending gambling venues represent important areas for secondary prevention efforts. Many gambling venues train their staff to identify potential problem or pathological gamblers and advertise within the facilities methods for patrons to obtain help (e.g., through gambling helplines and/or self-exclusion programs). Specific populations, although at arguably lower risk, might require unique prevention efforts. For example, gambling problems are more prevalent in men than women, and there exist gender-related differences in problem gambling behaviours (e.g., women generally beginning to gamble and developing problems with gambling later in life). As such, prevention efforts for men and women might preferentially target specific venues or age groups.

Tertiary prevention efforts, involving reducing disorder-related harm in affected individuals, include treatment efforts, and behavioural and pharmacological therapies for problem gambling. ‘Early’ tertiary prevention efforts involve moving individuals with recently recognized gambling problems into treatment (e.g., through gambling helplines) and non-treatment-related methods for helping individuals with gambling problems refrain from gambling (e.g., through availability and maintenance of casino self-exclusion policies).

Gambling helplines are widely around the world. Information from helpline callers can help enhance prevention efforts. However, further work is needed to examine directly the effectiveness of helplines with regard to treatment referral follow-up. That is, information obtained from callers willing to be called back several months following initial contact with the helpline would be valuable in assessing the extent to which problem gamblers have benefited from the helpline intervention. Self-exclusion policies exist in casinos and other gambling venues (e.g., bookmakers) around the world. Although the precise rules and regulations vary according to geographic location and individual casino, they generally involve voluntary self-exclusion for a period of time (e.g., 6 months to five years).

Increased knowledge regarding the impact of different types/levels of gambling behaviours on health and wellbeing would be extremely valuable in generating guidelines for healthy gambling and primary prevention efforts. An increased understanding of high-risk and vulnerable populations, facilitated through biological, psychological/psychiatric and social investigations, and the natural histories of gambling behaviors within these groups will help enhance secondary and early tertiary prevention efforts. As in other fields of medicine, the effectiveness of individual prevention strategies will need to be empirically validated. Targeted efforts in these areas should lead to a decrease in suffering attributable to problem gambling.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading 

Griffiths, M.D. (2003). Adolescent gambling: Risk factors and implications for prevention, intervention, and treatment. In D. Romer (Ed.), Reducing Adolescent Risk: Toward An Integrated Approach (pp. 223-238). London: Sage.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association.

Griffiths, M.D. (2008). Youth gambling education and prevention: Does it work? Education and Health, 26, 23-26.

Griffiths, M.D. (2010). The gaming industry’s role in the prevention and treatment of problem gambling. Casino and Gaming International, 6(1), 87-90.

Griffiths, M.D. (2012). Self-exclusion services for online gamblers: Are they about responsible gambling or problem gambling? World Online Gambling Law Report, 11(6), 9-10.

Hayer, T., Griffiths, M.D. & Meyer, G. (2005). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-Based Approaches to Prevention and Treatment (pp. 467-486). New York: Springer.

Hayer, T. & Griffiths, M.D. (in press). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-based Approaches to Prevention and Treatment (Second Edition). New York: Kluwer.

Korn, D., Shaffer HJ. (1999). Gambling and the health of the public: Adopting a public health perspective. Journal of Gambling Studies, 15, 289-365.

Meyer, G., Hayer, T. & Griffiths, M.D. (2009). Problem Gaming in Europe: Challenges, Prevention, and Interventions. New York: Springer.

Potenza, M. & Griffiths, M.D. (2004). Prevention efforts and the role of the clinician. In J.E. Grant & M. N. Potenza (Eds.), Pathological Gambling: A Clinical Guide To Treatment (pp. 145-157). Washington DC: American Psychiatric Publishing Inc.

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Shaffer, H., Korn DA. (2002). Gambling and related mental disorders: A public health analysis. Annual Review of Public Health, 23, 171-212.

US Preventive Services Task Force (1996). Guide to clinical preventative services (2nd edition). Baltimore, MD: Williams & Wilkens.

Slots of fun: What should parents and teachers know about adolescent gambling? (Part 2)

Today’s blog is the second part of a two-part article (the first of which can be found here). The previous blog briefly examined risk factors in adolescent gamblers and signs of problem gambling in adolescents. The three lists below highlight some early warning signs of a possible gambling problem, some definite signs and a thumbnail profile of a problem gambler. This is followed by some (hopefully) helpful tips and hints.

Early warning signs of a gambling addiction

  • Unexplained absences from home
  • Continual lying about day-to-day movements
  • Constant shortage of money
  • General increase in secretiveness
  • Neglect of studies, family, friends, health and appearance
  • Agitation (if unable to gamble)
  • Mood swings
  • Loss of friends and social life
  • Gambling seen as a legitimate way of making money

Signs of a definite gambling problem

  • Large debts (which are always explained away)
  • Trouble at school or college about non-attendance
  • Unexplained borrowing from family and friends
  • Unwillingness to repay borrowed money
  • Total preoccupation with gambling and spending money on gambling
  • Gambling alone for long periods
  • Constantly chasing losses in an attempt to win money back
  • Constantly gambling until all money is gone
  • Complete alienation and rejection from family and friends
  • Lying about the extent of their gambling to family and friends
  • Committing crimes as a way of getting money for gambling or paying off debts
  • Gambling overriding all other interests and obligations

Profile of the problem adolescent gambler

  • Unwilling to accept reality and has a lack of responsibility for gambling
  • Gambles to escape deeper problems (and the gambling environment may even be a substitute for parental affection)
  • Insecure and feels inferior to parents and elders
  • Wants good things without making an effort and loves games of chance
  • Likes to be a ‘big shot’ and feels it’s important to win (gambling offers them status and a way of defining achievement)
  • Likes to compete
  • Feels guilty with losses acting as a punishing behaviour
  • May be depressed
  • Low self-esteem and confidence
  • Other compulsive and/or addictive traits

Finally it is worth noting some of the ‘trigger’ situations and circumstances that a gambling problem might first come to light. Paul Bellringer has highlighted an array of situations that provide an opportunity to help the gambler focus on their need to change. These are:

  • Acceptance by the gambler that control has been lost: This is the step before they ask for help.
  • Asking for help: Having realised for themselves that gambling has taken control over their life, they may reach out to those closest to them
  • Observation of too much time spent in a gambling environment: Such observations by friends or family may provoke discussion as to how this is affecting the life of a gambler.
  • Getting in to financial trouble/Accumulation of debts: This might be a crisis point at which problem gambling might raise its head for the first time.
  • Uncovered lies: Realization that the gambler has been caught lying may lead to admissions about their gambling problems
  • Dwindling social circles/Losing close relationships: These observation may again lead to problem gambling being discovered by family or friends.
  • Discovered crime: This is usually a real crisis point that the family may discover the truth for the first time.
  • Homelessness: Being thrown out of the family home may be the trigger for problem gamblers to be honest for the first time about the mess they are in. 

Discovering that you are the parent of an adolescent problem gambler can be highly stressful – particularly as it is often a problem that parents feel they have to face on their own. Before getting involved with their children parents have to understand the problem as well as the process of problem gambling. By the time a young gambler acknowledges they have a problem, the family may have already gone through a lot of emotional turmoil including feelings of anger, sadness, puzzlement and guilt. Parents should try and get in touch with a helping agency as soon as possible. The following points are appropriate for parents either during or as a follow-up to their initial contact with a helping agency.

  • Remember that you are not the only family facing this problem.
  • You may be able to help your child by talking the problem through but it is probably better if a skilled person outside the family is also involved.
  • Keep in mind that it is a serious matter and that the gambler cannot “just give up”.
  • Take a firm stand; whilst it might feel easier to give in to demands and to believe everything they say, this allows your child to avoid facing the problem.
  • Remember that your child likes to gamble and is getting something from the activity quite apart from money.
  • Do not forget that gamblers are good at lying – to themselves as well as you
  • Let your child know that you believe it is a problem even though they may not admit it.
  • Encourage your child all the time as they have to be motivated to change
  • Be prepared to accept that your child may not be motivated to change until they are faced with an acute crisis.
  • Leave the responsibility for gambling and its consequences with the gambler, but also help them to face up to it and to work at overcoming the dependency.
  • Do not condemn them, as it is likely to be unhelpful and may drive them further into gambling.
  • Setting firm and fair boundaries for your child’s behaviour is appropriate and is likely to be constructive in providing a framework with which to address the dependency.
  • Despite what your child may have done it is important to let them know that you still love them. This should be done even if you have to make a ‘tough love’ decision such as asking them to leave home.
  • Do not trust them with money until the dependency has been broken. If they are agreeable it is a helpful strategy for a defined short period of time to manage their money for them. In addition, help develop their financial management skills.
  • Encourage other alternative activities. Try to identify other activities that the child is good at and encourage them in that.
  • Give praise for any achievements (however small) although don’t go over the top.
  • Provide opportunities to contribute to the family or the running of the house to develop responsibility.
  • Try to listen with understanding and look at them with pleasure. Communication channels between child and parent can easily be blocked so simple measures can pay big dividends.
  • Bear in mind that as a parent you will need support too through this long process of helping the child. You will need the support of your family and may also need additional support from a helping agency.

Having successfully broken a dependency on gambling, it is important to put in place measures that will help prevent gambling relapses. Useful strategies include the following:

  • Place a limit on future gambling, or avoid gambling altogether.
  • Internalise learning and avoid reverting to ingrained reactions to difficult or stressful situations.
  • Watch for situations and circumstances that trigger the urge to gamble and be ready to face them.
  • Nurture self-esteem – work at feeling good about yourself.
  • Develop a range of interests that, preferably, meet similar needs to those that were previously being met by gambling.
  • Spend time and energy working at building good human relationships.
  • Reassess the significance of money and endeavour to reduce its importance in your life.
  • Continue to explore, on occasion, reasons why gambling became so significant in your life.

Other more general steps that gamblers should be encouraged to do include:

  • Be honest with themselves and others
  • Deal with all outstanding debts
  • Accept responsibility for their gambling
  • Abstain from gambling while trying to break the dependency
  • Talk about how gambling makes them feel
  • Take one day at a time
  • Keep a record of ‘gambling-free’ days
  • Be positive and not give up after a ‘slip’ or a ‘lapse’
  • Reward themselves after a gambling-free period
  • Develop alternative interests

Parents and practitioners should also be aware that problems are likely to be avoided when the young gambler keeps in control of the situation and ensures that their gambling remains a social activity. The following brief guide is aimed particularly for working with young gamblers but applicable to everyone. It will help ensure that gambling remains an enjoyable and problem-free experience. It is wise to remember that:

  • When you are gambling you are buying entertainment, not investing money
  • You are unlikely to make money from gambling
  • The gaming industry and the government are the real winners
  • You should only gamble with money that you can afford to lose
  • You should set strict limits on how much you will gamble
  • To make profit from gambling you should quit when ahead
  • Gambling should only take up a small amount of your time and interest
  • Problems will arise if you become preoccupied with gambling
  • Gambling within your means is a fun and exciting activity
  • Gambling outside your means is likely to create serious problems
  • You should not gamble to escape from worries or pressures
  • The feeling of being powerful and in control when gambling is a delusion
  • A gambling dependency is as damaging as other addictions
  • Always gamble responsibly

Hopefully the two parts of this blog have highlighted a potential danger among children and adolescence. It covered risk factors, warning signs to look for, and strategies to help those with a problem. Through education and awareness, it is hoped that gambling problems will be viewed no differently from other potentially addictive substances and that schools will take the issue seriously.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK 

Further reading

Bellringer, P. (1999). Understanding Problem Gamblers. London : Free Association Books.

Griffiths, M.D. (1995). Adolescent Gambling. London: Routledge.

Griffiths, M.D. (2002). Gambling and Gaming Addictions in Adolescence. Leicester: British Psychological Society/Blackwells.

Griffiths, M.D. (2003). Adolescent gambling: Risk factors and implications for prevention, intervention, and treatment. In D. Romer (Ed.), Reducing Adolescent Risk: Toward An Integrated Approach (pp. 223-238). London: Sage.

Griffiths, M.D. (2008). Adolescent gambling in Great Britain. Education Today: Quarterly Journal of the College of Teachers. 58(1), 7-11.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3) (pp.11-20). San Diego: Academic Press.

Griffiths, M.D. (2013). Adolescent gambling via social networking sites: A brief overview. Education and Health, 31, 84-87.

Griffiths, M.D. & Linsey, A. (2006). Adolescent gambling: Still a cause for concern? Education and Health, 24, 9-11.

Griffiths, M.D. & Parke, J. (2010). Adolescent gambling on the Internet: A review. International Journal of Adolescent Medicine and Health, 22, 59-75.

Griffiths, M.D. & Wood, R.T.A. (2000). Risk factors in adolescence: The case of gambling, video-game playing and the internet. Journal of Gambling Studies, 16, 199-225.

Slots of fun: What should parents and teachers know about adolescent gambling? (Part 1)

Research has consistently shown that a small but significant minority of adolescents have a gambling problem. It has also been noted that adolescents may be more susceptible to problem gambling than adults. In Great Britain, the most recent statistics suggest that around 2% of adolescents have a gambling problem. This figure is two to three times higher than that identified in the adult population. On this evidence, young people are clearly more vulnerable to the negative consequences of gambling than adults.

A typical finding of many adolescent gambling studies has been that problem gambling appears to be a primarily male phenomenon. It also appears that adults may to some extent be fostering adolescent gambling. For example, a strong correlation has been found between adolescent gambling and parental gambling. Similarly, many studies have indicated a strong link between adult problem gamblers and later problem gambling amongst their children. Other factors that have been linked with adolescent problem gambling include working class youth culture, delinquency, alcohol and substance abuse, poor school performance, theft and truancy.

One consequence of the research into adolescent gambling is that we can now start to put together a ‘risk factor model’ of those individuals who might be at the most risk of developing problem gambling tendencies. Based on summaries of empirical research, a number of clear risk factors in the development of problem adolescent gambling emerge. Adolescent problem gamblers are more likely to:

  • Be male (16-25 years)
  • Have begun gambling at an early age (as young as 8 years of age)
  • Have had a big win earlier in their gambling careers
  • Consistently chase losses
  • Gamble on their own
  • Have parents who gamble
  • Feel depressed before a gambling session
  • Have low self-esteem
  • Use gambling to cultivate status among peers
  • Be excited and aroused during gambling
  • Be irrational (i.e. have erroneous perceptions) during gambling
  • Use gambling as a means of escape
  • Have bad grades at school
  • Engage in other addictive behaviours (smoking, drinking alcohol, illegal drug use)
  • Come from the lower social classes
  • Have parents who have a gambling (or other addiction) problem
  • Have a history of delinquency
  • Steal money to fund their gambling
  • Truant from school to go gambling

There are also some general background factors that might increase the risk of becoming a problem gambler. Common factors include:

  • Broken, disruptive or very poor family
  • Difficult and stressful situations within the home
  • Heavy emphasis on money within the family
  • The death of a parent or parental figure in their childhood
  • Serious injury or illness in the family or themselves
  • Infidelity by parents
  • High incidence of abuse (verbal, physical and/or sexual)
  • Feeling of rejection as a child
  • Feelings of belittlement and disempowerment

This list is probably not exhaustive but incorporates what is known empirically and anecdotally about adolescent problem gambling. As research into the area grows, new items to such a list will be added while factors, signs and symptoms already on these lists will be adapted and modified. Gambling has often been termed the ‘hidden addiction’. The main reasons for this arise from the problem with the identification. This is because:

  • There are no observable signs or symptoms like other addictions (e.g. alcoholism, heroin addiction etc.)
  • Money shortages and debts can be explained away with ease in a materialistic society
  • Adolescent gamblers do not believe they have a problem or wish to hide the fact
  • Adolescent gamblers are exceedingly plausible and become adept at lying to mask the truth
  • Adolescent gambling may be only one of several excessive behaviours

Although there have been some reports of a personality change in young gamblers many parents may attribute the change to adolescence itself (i.e., evasive behaviour, mood swings etc. are commonly associated with adolescence). It is quite often the case that many parents do not even realize they have a problem until their son or daughter is in trouble with the police. I have noted there are a number of possible warning signs to look for although individually, many of these signs could be put down to adolescence. However, if several of them apply to a child or adolescent it could be that they will have a gambling problem. The signs include:

  • No interest in school highlighted by a sudden drop in the standard of schoolwork
  • Unexplained free time such as going out each evening and being evasive about where they have been
  • Coming home later than expected from school each day and not being able to account for it
  • A marked change in overall behaviour (that perhaps only a parent would notice). Such personality changes could include becoming sullen, irritable, restless, moody, touchy, bad-tempered or constantly on the defensive
  • Constant shortage of money
  • Constant borrowing of money
  • Money missing from home (e.g., from mother’s purse or father’s wallet)
  • Selling personal possessions and not being able to account for the money
  • Criminal activity (e.g., shoplifting in order to sell things to get money for gambling)
  • Coming home hungry each afternoon after school (because lunch money has been spent on gambling)
  • Loss of interest in activities they used to enjoy
  • Lack of concentration
  • A “couldn’t care less” attitude
  • Lack of friends and/or falling out with friends
  • Not taking care of their appearance or personal hygiene
  • Constantly telling lies (particularly over money)

However, many of these ‘warning signs’ are not necessarily unique to gambling addictions and can also be indicative of other addictions (e.g. alcohol and other drugs). Confirming that gambling is indeed the problem may prove equally as difficult as spotting the problem in the first place. Directly asking an individual if they have a problem is likely to lead to an outright denial. Talking with them about their use of leisure time, money and spending preferences, and their view about gambling in general is likely to be more effective. Part 2 to follow in my next blog!

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bellringer, P. (1999). Understanding Problem Gamblers. London : Free Association Books.

Griffiths, M.D. (1995). Adolescent Gambling. London: Routledge.

Griffiths, M.D. (2002). Gambling and Gaming Addictions in Adolescence. Leicester: British Psychological Society/Blackwells.

Griffiths, M.D. (2003). Adolescent gambling: Risk factors and implications for prevention, intervention, and treatment. In D. Romer (Ed.), Reducing Adolescent Risk: Toward An Integrated Approach (pp. 223-238). London: Sage.

Griffiths, M.D. (2008). Adolescent gambling in Great Britain. Education Today: Quarterly Journal of the College of Teachers. 58(1), 7-11.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3) (pp.11-20). San Diego: Academic Press.

Griffiths, M.D. (2013). Adolescent gambling via social networking sites: A brief overview. Education and Health, 31, 84-87.

Griffiths, M.D. & Linsey, A. (2006). Adolescent gambling: Still a cause for concern? Education and Health, 24, 9-11.

Griffiths, M.D. & Parke, J. (2010). Adolescent gambling on the Internet: A review. International Journal of Adolescent Medicine and Health, 22, 59-75.

Griffiths, M.D. & Wood, R.T.A. (2000). Risk factors in adolescence: The case of gambling, video-game playing and the internet. Journal of Gambling Studies, 16, 199-225.

A night on the tiles: A brief look at addiction to ‘Scrabble’

In previous blogs I have covered some arguably frivolous (and alleged) addictions including addictions to cryptic crosswords and Sudoku. Today’s blog looks at an equally frivolous topic in the same vein – Scrabble addiction. I have to be honest and say that I love playing Scrabble and have been playing a lot against the computer over the last few weeks (and is one of the reasons I decided to write an article on the topic). According to a 2004 article ‘Scrabble addicts’ in The Independent by John Walsh, there are numerous celebrity Scrabble lovers including Robbie Williams, Kylie Minogue, Nigella Lawson, Christina Aguilera, Sting, Avril Lavigne and Alison Steadman. He also  asserted that the secret of Scrabble’s success is threefold.

“First, it’s a game of skill (like chess) that depends on the luck of the tiles you get (like cards). Second, it deploys a commodity common to every human being, namely words. Third, anyone can play it”.

Back in 2000, I published a paper on the psychology of games in Psychology Review and what makes a good game. These are all applicable to Scrabble. I noted in that article that:

  • All good games are relatively easy to play but can take a lifetime to become truly adept. In short, there will always room for improvement.
  • For games of any complexity there must be a bibliography that people can reference and consult. Without books and magazines to instruct and provide information there will be no development and the activity will die.
  • There needs to be competitions and tournaments. Without somewhere to play (and likeminded people to play with) there will be little development within the field over long periods of time.
  • Finally – and very much a sign of the times – no leisure activity can succeed today without corporate sponsorship of some kind.

But is there any evidence to suggest Scrabble can be addictive? Jan Kern published a book in 2009 called Eyes on Line: Eyes on Life – A Journey Out of Online Addictions. She noted the case of Tom who started out his story by saying: “Hi, my name is Tom, and I’m an addict. I don’t have a problem with the bottle or with any kind of pharmaceutical product, legal or illegal. No, my problem is with games. I’m addicted to them…And now the Internet has made this potential to get hooked all too easy. My particular poison these days is online Scrabble”. I then came across these examples:

  • Extract 1: “[I] have struggled with Scrabble addiction. When I play Scrabble on the Internet, I lose all track of time. I promise myself I’ll just play one game, and the next thing I know, the sun is coming up and my eyes are a shade of crimson. I’m just glad to know that I’m not the only one” (Raphael Pope-Sussman, New York Times, 2007).
  • Extract 2: “I read ‘Addicted to L-U-V’ while I was in the midst of a Scrabble game…Whenever I encounter a new word, I calculate the number of letters, roots, prefixes and suffixes. I’ve got it bad. My Scrabble buddies both live out of state…When we are together, we have cut-throat marathon games…When we’re apart, we practice our addiction online” (Cheryl Beatty, New York Times, 2007).
  • Extract 3: “Phew! I am not the only one! Scrabble with my friends and daughter was my addiction for years. These days I play it on my computer when I take a break from work…O.K., that’s enough writing; time to get back to another game of Scrabble” (Beth Rosen, New York Times, 2007).

These extracts were all published in response to American journalist and film director Nora Ephron’s 2007 article ‘Addicted to L-U-V’ in the New York Times about her addiction to the word game Scrabble. In her article, Ephron admitted that:

“I stumbled onto something called Scrabble Blitz. It was a four-minute version of Scrabble solitaire, on a Web site called Games.com, and I began playing it without a clue that within 24 hours – I am not exaggerating – it would fry my brain…I began having Scrabble dreams in which people turned into letter tiles that danced madly about. I tuned out on conversations and instead thought about how many letters there were in the name of the person I wasn’t listening to. I fell asleep memorizing the two- and three-letter words that distinguish those of us who are hooked on Scrabble from those of you who aren’t…My brain turned to cheese. I could feel it happening. It was clear that I was becoming more and more scattered, more distracted, more unfocused…I instantly became an expert on how the Internet could alter your brain in a permanent way”.

Ephron went on to report comments from other people in the online Scrabble games (“I’m an addict, lol”, “I can’t stop playing this, ha ha”). Ephron concluded she was no different from the other players. She then went onto say:

“The game of Scrabble Blitz eventually became too much for the Web site. Lag was a huge problem. From time to time, the Scrabble Blitz area would shut down for days, and when it returned, so did all the addicts, full of comments about how they had barely withstood life without the game. I began to get carpal tunnel syndrome from playing. I’m not kidding. I realized I was going to have to kick the habit…I was saved by what’s known in the insurance business as an act of God: Games.com shut down Scrabble Blitz. And that was that. It was gone”.

Obviously I’m sceptical about whether there are genuine cases of addiction to Scrabble (particularly as there is nothing in the psychological literature whatsoever). There have also been other lengthy first-person journalistic accounts of Scrabble addiction such as the 2011 article by James Brown in the Sabotage Times (who also did some interesting background research for his article). According to Brown, the recent upsurge in Scrabble began in 2007 when Indian brothers Rajat and Jayant Agarwalla developed a Scrabble application for Facebook (‘Scrabulous’). It quickly became the most popular game on Facebook (but was then removed due to a legal dispute with the original developers of Scrabble – Hasbro and Mattel. The game later returned as Lexulous). Brown then confessed:

Hello, my name’s James and I am a Scrabble addict. I have been playing it all day everyday from last Christmas until my summer holiday when two weeks without a computer allowed me to crack the habit. I am not alone, there are over a hundred thousand Scrabble players on Facebook. We play each other at any time of day or night because we are situated all over the world and timezones are helpful like that. We decide how long we will allow for each move to take, how many people can play, and what standard we play at…On an hourly basis day after day I played people in Australia, Britain, South Africa, India, the West Indies and pretty much anywhere else where the Scrabble application could work. Eventually I spent more time talking and playing with these new Scrabble partners than I did the people I lived with. It was madness. A genuine obsession, I would go as far as to say addiction. I was late to pick my son up from school, late to sports matches I was playing in, I ignored writing work I had to do, I took the computer to bed with me and played last thing at night until my eyes hurt and then started again as soon as I woke up… For me it eventually became too much. One day I looked at the 18 consecutive games I had going on at once, many of them with just two minutes at a time to play my word, and realised what that would look like if I actually had 18 people with 18 boards in the room with me. This moment of clarity gave me some perspective on how it had consumed my life”.

I have to admit that this case account is quite compelling and does at least suggest Scrabble could be potentially addictive. Finally, as a Professor of Gambling Studies I was also interested in Brown’s analogy between Scrabble and gambling as he noted:

“Not knowing what letters would appear next had that random appeal that watching a horse race has.  The excitement at using all seven letters and scoring a bingo, or taking a game to the very last tile to reach a conclusion was immense, there was always just one more game, one more opponent, maybe the same one you’d already played five times that day and you wanted to take another victory from or avenge an earlier defeat. The international 24 hour pull of the game is relentless, for some it over-comes loneliness for others it fuels addictive personalities”.

Playing with what you get given is almost an outlook on life itself. However, unlike life, I seriously doubt whether excessive and/or addictive playing of Scrabble will ever become the topic of scientific study.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Brown, J. (2011). Scrabble addict. Sabotage Times, May 16. Located at: http://sabotagetimes.com/life/scrabble-addict/

Ephron, N. (2007). Addicted to L-U-V. New York Times, May 13. Located at: http://www.nytimes.com/2007/05/13/opinion/13ephron.html

Griffiths, M.D. (2000). The psychology of games. Psychology Review, 7(2), 24-26.

Hayward, A. (2014). Can New Words With Friends reignite your competitive pseudo-Scrabble addiction? MacWorld, October 14. Located at: http://www.macworld.com/article/2825932/can-new-words-with-friends-reignite-your-competitive-pseudo-scrabble-addiction.html

Kern, J. (2009). Eyes on Line: Eyes on Life – A Journey Out of Online Addictions. Accessible Publishing Systems PTY, Ltd.

Walsh, J. (2004). Scrabble addicts. The Independent, October 9. Located at: http://www.independent.co.uk/news/uk/this-britain/scrabble-addicts-535160.html

I love view: Can Google Glass be addictive?

Last week, The Guardian (and news media all over the world) reported the story of a man being treated for internet addiction disorder brought on by his excessive use of Google Glass. According to The Guardian’s report:

“The man had been using the technology for around 18 hours a day – removing it only to sleep and wash – and complained of feeling irritable and argumentative without the device. In the two months since he bought the device, he had also begun experiencing his dreams as if viewed through the device’s small grey window…[The patient] had checked into the Sarp [Substance Addiction Recovery Program] in September 2013 for alcoholism treatment. The facility requires patients to steer clear of addictive behaviours for 35 days – no alcohol, drugs, or cigarettes – but it also takes away all electronic devices. Doctors noticed the patient repeatedly tapped his right temple with his index finger. He said the movement was an involuntary mimic of the motion regularly used to switch on the heads-up display on his Google Glass”.

The story was based on a case study that has just been published in the journal Addictive Behaviors by Dr. Kathryn Yung and her colleagues from the Department of Mental Health, Naval Medical Center in San Diego (United States). The authors claim that the paper (i) reported the first ever case of internet addiction disorder involving the problematic use of Google Glass, (ii) showed that excessive and problematic uses of Google Glass can be associated with involuntary movements to the temple area and short-term memory problems, and (iii) highlighted that the man in their case study displayed frustration and irritability that were related to withdrawal symptoms from excessive use of Google Glass. For those reading this who have not yet come across what Google Glass is, the authors provided a brief description: 

Google Glass™ was named as one of the best inventions of the year by Time Magazine in 2012. The device is a wearable mobile computing device with Bluetooth connectivity to internet-ready devices. Google Glass™ has an optical head-mounted display, resembling eyeglasses; it displays information in a Smartphone-like, but hands-free format that is controlled via voice commands and touch”.

The man that came in for treatment was a 31-year old enlisted service member who had served seven months in Afghanistan. Although he did not suffer any kind of post-traumatic stress disorder (PTSD) he was reported by the authors as having a mood disorder, most consistent with a substance-induced hypomania overlaying a depressive disorder, anxiety disorder with characteristics of social phobia, obsessive–compulsive disorder, and severe alcohol and tobacco use disorders”. His referral to the substance use program was because he had resumed problematic alcohol drinking following a previous eight-week intensive outpatient treatment. It was only after re-entering the program that staff noticed other behaviours that were nothing to do with his alcohol problem. More specifically, they reported that:

“The patient had been wearing the Google Glass™ device each day for up to 18 h for two months prior to admission, removing the device during sleep and bathing. He was given permission by his superiors to use the device at work, as the device allowed him to function at a high level by accessing detailed and complicated information quickly. The patient shared that the Google Glass™ increased his confidence with social situations, as the device frequently became an initial topic of discussion. All electronic devices and mobile computing devices are customarily removed from patients during substance rehabilitation treatment. The patient noted significant frustration and irritability related to not being able to use the device during treatment. He stated, ‘The withdrawal from this is much worse than the withdrawal I went through from alcohol’, He noted that when he dreamed during his residential treatment, he envisioned the dream through the device. He would experience the dream through a small gray window, which was consistent with what he saw when wearing the device while awake. He reported that if he had been prevented from wearing the device while at work, he would become extremely irritable and argumentative. When asked questions by the examiner, the patient was noted on exam to reach his right hand up to his temple area and tap it with his forefinger. He explained that this felt almost involuntary, in that it was the familiar motion he would make in order to turn on the device in order to access information and answer questions. He found that he almost ‘craved’ using the device, especially when trying to recall information”.

Even though my primary area of research interest in behavioural addictions, the thing that caught my attention in the description above was the observation that his dreams were experienced in the way he viewed things through Google Glass while he was awake. On first reading this I thought this sounding very much like some research I have been doing with my colleague Angelica Ortiz de Gortari on Game Transfer Phenomena (GTP) in which gamers transfer aspects of their game playing into real life situations. Our work is an extension of the so-called Tetris Effect where Tetris players see falling blocks before their eyes even when they are not playing the game. It appears the authors of this case study has also made the same connection as they reported:

The patient’s experiences of viewing his dreams through the device appear to be best explained solely by his heavy use of the device and may be consistent with what is referred to as the ‘Tetris Effect’. When individuals play the game Tetris for long periods of time, they report seeing invasive imagery of the game in their sleep (Stickgold, Malia, Maguire, Roddenberry, & O’Connor, 2000). Interestingly, Stickgold et al. noted that patients with amnesia due to traumatic brain injury, who had trouble with short-term memory recall, reported invasive imagery of the game during sleep even though they did not recall playing the game (Stickgold et al., 2000). Technology-assisted learning devices and video gaming appear to be powerful methods to aid in the acquisition of new information. Further studies in the field of traumatic brain injury utilizing gaming and technology-assisted learning are needed”.

At the end of the 35-day inpatient stay, the outcome was reported as being good. The patient reported he felt less irritable, and he was making far fewer compulsive movements to his temple. However, no further follow-up was reported by Yung and her colleagues. There are, of course, wider questions about whether addiction to the internet even exists although the article in The Guardian did provide a link to a comprehensive and systematic review of internet addiction that I co-authored with Dr. Kuss and others in the journal Current Pharmaceutical Design. As regular readers of my blog will be aware, I believe that there is a fundamental difference between addictions on the internet and addictions to the internet. The vast majority of people appear to have addictions on the internet (such as gambling addiction, gaming addiction, sex addiction, shopping addiction, etc.) where the internet facilitates other addictive behaviours. However, there is growing evidence of internet-only addictive behaviour (with social networking addiction being the most common).

In relation to this case study, there have been some that have said that the study doesn’t have face validity because the battery life of Google Glass is so small that it is impossible to spend up to 18 hours a day wearing it. (For instance, check out an interesting article written by Taylor Hatmaker published by the Daily Dot). I ought to add that one of the study’s co-authors, Dr. Andrew Doan did say to various news outlets that:

“A wearable device is constantly there – so the neurological reward associated with using it is constantly accessible. There’s nothing inherently bad about Google Glass. It’s just that there is very little time between these rushes. So for an individual who’s looking to escape, for an individual who has underlying mental dysregulation, for people with a predisposition for addiction, technology provides a very convenient way to access these rushes. And the danger with wearable technology is that you’re allowed to be almost constantly in the closet, while appearing like you’re present in the moment”.

Based on the two-page paper that was published, I don’t think there was enough evidence presented to say whether the man in question was addicted to the internet via Google Glass. There were certainly elements associated with addiction but that doesn’t mean somebody is genuinely addicted. Furthermore, most addictive behaviours have to have been present for at least six months before being diagnosed as a genuine addiction. In this case, the man had only been using Google Glass for two months before entering the treatment program.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Ghorayshi, A. (2014). Google glass user treated for internet addiction caused by device. The Guardian, October 14. Located at: http://www.theguardian.com/science/2014/oct/14/google-glass-user-treated-addiction-withdrawal-symptoms

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M.D. (2010). Internet abuse and internet addiction in the workplace. Journal of Worplace Learning, 7, 463-472.

Hatmaker, T. (2014). There is no such thing as Google Glass addiction. The Daily Dot, October 15. Located at: https://www.dailydot.com/technology/google-glass-internet-addiction/

Kuss, D.J., Griffiths, M.D. & Binder, J. (2013). Internet addiction in students: Prevalence and risk factors. Computers in Human Behavior, 29, 959-966.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2014).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, 20, 4026-4052.

Kuss, D.J., Shorter, G.W., van Rooij, A.J., Griffiths, M.D., & Schoenmakers, T.M. (2014). Assessing Internet addiction using the parsimonious Internet addiction components model – A preliminary study. International Journal of Mental Health and Addiction, 12, 351-366.

Kuss, D.J., van Rooij, A.J., Shorter, G.W., Griffiths, M.D. & van de Mheen, D. (2013). Internet addiction in adolescents: Prevalence and risk factors. Computers in Human Behavior, 29, 1987-1996.

Ortiz de Gotari, A., Aronnson, K. & Griffiths, M.D. (2011). Game Transfer Phenomena in video game playing: A qualitative interview study. International Journal of Cyber Behavior, Psychology and Learning, 1(3), 15-33.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2012). An introduction to Game Transfer Phenomena in video game playing. In J. Gackenbach (Ed.), Video Game Play and Consciousness (pp.223-250). Hauppauge, NY: Nova Science.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Altered visual perception in Game Transfer Phenomena: An empirical self-report study. International Journal of Human-Computer Interaction, 30, 95-105.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Auditory experiences in Game Transfer Phenomena: An empirical self-report study. International Journal of Cyber Behavior, Psychology and Learning, 4(1), 59-75.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Automatic mental processes, automatic actions and behaviours in Game Transfer Phenomena: An empirical self-report study using online forum data. International Journal of Mental Health and Addiction, 12, 432-452.

Stickgold, R., Malia, A., Maguire, D., Roddenberry, D., & O’Connor, M. (2000). Replaying the game: Hypnagogic images in normals and amnesics. Science, 290, 350–353.

Widyanto, L. & Griffiths, M.D. (2006). Internet addiction: A critical review. International Journal of Mental Health and Addiction, 4, 31-51.

Yung, K., Eickhoff, E., Davis, D. L., Klam, W. P., & Doan, A. P. (2014). Internet Addiction Disorder and problematic use of Google Glass™ in patient treated at a residential substance abuse treatment program. Addictive Behaviors, http://dx.doi.org/10.1016/j.addbeh.2014.09.024.

Joystick junkies: A brief overview of online gaming addiction

Over the last 15 years, research into various online addictions have greatly increased. Prior to the 2013 publication of the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there had been some debate as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Alongside this, there has also been debate as to whether those researching in the online addiction field should be researching generalized internet use and/or the potentially addictive activities that can be engaged on the internet (e.g., gambling, video gaming, sex, shopping, etc.).

It should also be noted that given the lack of consensus as to whether video game addiction exists and/or whether the term ‘addiction’ is the most appropriate to use, some researchers have instead used terminology such as ‘excessive’ or ‘problematic’ to denote the harmful use of video games. Terminology for what appears to be for the same disorder and/or its consequences include problem video game playing, problematic online game use, video game addiction, online gaming addiction, internet gaming addiction, and compulsive Internet use.

Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. According to Dr. Nancy Petry and Dr. Charles O’Brien, IGD will not be included as a separate mental disorder until the (i) defining features of IGD have been identified, (ii) reliability and validity of specific IGD criteria have been obtained cross-culturally, (iii) prevalence rates have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features have been evaluated.

Although there is now a rapidly growing literature on pathological video gaming, one of the key reasons that IGD was not included in the main text of the DSM-5 was that the SUDWG concluded that no standard diagnostic criteria were used to assess gaming addiction across these many studies. In 2013, some of my colleagues and I published a paper in Clinical Psychology Review examining all instruments assessing problematic, pathological and/or addictive gaming. We reported that 18 different screening instruments had been developed, and that these had been used in 63 quantitative studies comprising 58,415 participants. The prevalence rates for problematic gaming were highly variable depending on age (e.g., children, adolescents, young adults, older adults) and sample (e.g., college students, internet users, gamers, etc.). Most studies’ prevalence rates of problematic gaming ranged between 1% and 10% but higher figures have been reported (particularly amongst self-selected samples of video gamers). In our review, we also identified both strengths and weaknesses of these instruments.

The main strengths of the instrumentation included the: (i) the brevity and ease of scoring, (ii) excellent psychometric properties such as convergent validity and internal consistency, and (iii) robust data that will aid the development of standardized norms for adolescent populations. However, the main weaknesses identified in the instrumentation included: (i) core addiction indicators being inconsistent across studies, (iii) a general lack of any temporal dimension, (iii) inconsistent cut-off scores relating to clinical status, (iv) poor and/or inadequate inter-rater reliability and predictive validity, and (v) inconsistent and/or dimensionality.

It has also been noted by many researchers (including me) that the criteria for IGD assessment tools are theoretically based on a variety of different potentially problematic activities including substance use disorders, pathological gambling, and/or other behavioural addiction criteria. There are also issues surrounding the settings in which diagnostic screens are used as those used in clinical practice settings may require a different emphasis that those used in epidemiological, experimental, and neurobiological research settings.

Video gaming that is problematic, pathological and/or addictive lacks a widely accepted definition. Some researchers in the field consider video games as the starting point for examining the characteristics of this specific disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. My colleagues and I have begun to make an effort to integrate both approaches, i.e., classifying online gaming addiction as a sub-type of video game addiction but acknowledging that some situational and structural characteristics of the internet may facilitate addictive tendencies (e.g., accessibility, anonymity, affordability, disinhibition, etc.).

Throughout my career I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and likely reflects a common etiology of addictive behaviour. When I started research internet addiction in the mid-1990s, I came to the view that there is a fundamental difference between addiction to the internet, and addictions on the internet. However many online games (such as Massively Multiplayer Online Role Playing Games) differ from traditional stand-alone video games as there are social and/or role-playing dimension that allow interaction with other gamers.

Irrespective of approach or model, the components and dimensions that comprise online gaming addiction outlined above are very similar to the IGD criteria in Section 3 of the DSM-5. For instance, my six addiction components directly map onto the nine proposed criteria for IGD (of which five or more need to be endorsed and resulting in clinically significant impairment). More specifically: (1) preoccupation with internet games [salience]; (2) withdrawal symptoms when internet gaming is taken away [withdrawal]; (3) the need to spend increasing amounts of time engaged in internet gaming [tolerance], (4) unsuccessful attempts to control participation in internet gaming [relapse/loss of control]; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, internet gaming [conflict]; (6) continued excessive use of internet games despite knowledge of psychosocial problems [conflict]; (7) deception of family members, therapists, or others regarding the amount of internet gaming [conflict]; (8) use of the internet gaming to escape or relieve a negative mood [mood modification];  and (9) loss of a significant relationship, job, or educational or career opportunity because of participation in internet games [conflict].

The fact that IGD was included in Section 3 of the DSM-5 appears to have been well received by researchers and clinicians in the gaming addiction field (and by those individuals that have sought treatment for such disorders and had their experiences psychiatrically validated and feel less stigmatized). However, for IGD to be included in the section on ‘Substance-Related and Addictive Disorders’ along with ‘Gambling Disorder’, the gaming addiction field must unite and start using the same assessment measures so that comparisons can be made across different demographic groups and different cultures.

For epidemiological purposes, my research colleagues and I have asserted that the most appropriate measures in assessing problematic online use (including internet gaming) should meet six requirements. Such an instrument should have: (i) brevity (to make surveys as short as possible and help overcome question fatigue); (ii) comprehensiveness (to examine all core aspects of problematic gaming as possible); (iii) reliability and validity across age groups (e.g., adolescents vs. adults); (iv) reliability and validity across data collection methods (e.g., online, face-to-face interview, paper-and-pencil); (v) cross-cultural reliability and validity; and (vi) clinical validation. We aso reached the conclusion that an ideal assessment instrument should serve as the basis for defining adequate cut-off scores in terms of both specificity and sensitivity.

The good news is that research in the gaming addiction field does appear to be reaching an emerging consensus. There have also been over 20 studies using neuroimaging techniques (such as functional magnetic resonance imaging) indicating that generalized internet addiction and online gaming addiction share neurobiological similarities with more traditional addictions. However, it is critical that a unified approach to assessment of IGD is urgently needed as this is the only way that there will be a strong empirical and scientific basis for IGD to be included in the next DSM.

Note: A version of this article was first published on Rehabs.com

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders – Text Revision (Fifth Edition). Washington, D.C.: Author.

Demetrovics, Z., Urbán, R., Nagygyörgy, K., Farkas, J., Griffiths, M. D., Pápay, O., . . . Oláh, A. (2012). The development of the Problematic Online Gaming Questionnaire (POGQ). PLoS ONE, 7(5), e36417.

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10(4), 191-197.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, under review.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Kim, M. G., & Kim, J. (2010). Cross-validation of reliability, convergent and discriminant validity for the problematic online game use scale. Computers in Human Behavior, 26(3), 389-398.

King, D. L., Delfabbro, P. H., Griffiths, M. D., & Gradisar, M. (2011). Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation. Clinical Psychology Review, 31, 1110-1116.

King, D. L., Delfabbro, P. H., & Griffiths, M. D. (2012). Cognitive-behavioral approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

King, D.L., Haagsma, M.C., Delfabbro, P.H., Gradisar, M.S., Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Koronczai, B., Urban, R., Kokonyei, G., Paksi, B., Papp, K., Kun, B., . . . Demetrovics, Z. (2011). Confirmation of the three-factor model of problematic internet use on off-line adolescent and adult samples. Cyberpsychology, Behavior and Social Networking, 14, 657–664.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2013).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, in press.

Pápay, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment. New York: Elsevier.

Petry, N.M., & O’Brien, C.P. (2013). Internet gaming disorder and the DSM-5. Addiction, 108, 1186–1187.

Porter, G., Starcevic, V., Berle, D., & Fenech, P. (2010). Recognizing problem video game use. The Australian and New Zealand Journal of Psychiatry, 44, 120-128.

Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. Cyberpsychology and Behavior, 1, 237-244.

The weighting game: Gambling with the nation’s health (revisited)

A couple of weeks ago I wrote a blog on why problem gambling should be considered a health issue. Earlier this week, I came across an interesting study carried out by jackpot.co.uk who surveyed 2,131 online gamblers (58% males and 42% female) about their health. After the self-reported data had been collected, the gamblers were classed into one of nine categories based on the casino game type that the gambler played most often (i.e., slot machines, video poker, blackjack, roulette, dice/craps, baccarat, poker, pai gow, and ‘other’). The data were then tabulated so that all the health variables (including obesity) corresponded to the gambler’s preferred casino game.

I was interested in the findings not only because I am a Professor of Gambling Studies, but also because I was a member of the Department of Health’s Expert Working Group on Sedentary Behaviour, Screen Time and Obesity’ (a reference to our final report to the British government can be found in the ‘Further Reading’ section below). The study took an objective measurement of physical condition by asking each gambler their height (centimetres) and their weight (kilograms) to calculate each person’s Body Mass Index (BMI) by dividing the gamblers’ weight by height (metres) and dividing by height again (for example, someone who weighs 80kg and is 180cm tall, the BMI is 24.1 as this is 80/1.80)/1.80). The survey then asked s few general health and lifestyle questions (similar to ones that we have used in the last few British Gambling Prevalence Surveys:

  • Do you normally drink more than the recommended limit for weekly alcohol consumption (21 units of alcohol for men and 14 for women)? (Yes/No)
  • Do you smoke regularly? (Yes/No)
  • Do you normally engage in at least 30 minutes of physical activity, 5 times per week? (Yes/No)

Overall, the survey found that British casino gamblers as a group were no less healthy than the rest of the British population, with an average Body Mass index (BMI) of 27 (which is the same as the UK national average). However, the survey also reported that the average BMIs, health, and lifestyle choices (such as smoking cigarettes, engaging in exercise, and drinking alcohol varied considerably depending on the casino games that the respondents played. Here are some of the main findings:

  • Slots players were the least healthy. They took less exercise and had an average BMI of 31, pushing them into the category of obese (which is linked to increased chance of developing illnesses such as Type 2 diabetes and reduced life expectancy)
  • Roulette, blackjack, video poker and craps/dice players were not far behind slots players, each having BMI levels higher than the national average.
  • Those that played poker, baccarat and Pai Gow had an average BMI of 25 or under (well within the normal range recommended by the World Health Organisation.
  • Whilst drinking levels might be reasonably high among poker players, they were very exercise conscious, with 58% engaging in physical activity for at least 30 minutes, five times a week. For slots players the figure was 27% meeting this government recommended target.
  • Overall slots players drink the most, with 24.1% drinking over the recommended weekly limit. Poker players are not far behind on 23%. Female slots players were the biggest drinking subgroup, closely followed by male poker players.
  • Slots players also smoked more, with 24% being regular smokers (compared to the UK national average of 20%). Blackjack and roulette players smoked slightly more than average, on 21% and 22% respectively, while poker players smoked slightly less than average, on 19.5%.

None of these results is overly surprising as there are many studies (including my own) showing comorbidity between gambling and other potentially addictive behaviours. However, very few academic studies have ever looked at these health variables by game type. Although this was not an academic study, the results will likely be of interest to those in the gambling studies field.

The survey also examined the most common platform on which the gamblers played casino games. The most common was the desktop computer (65%), followed by mobiles and tablets (20%) and land-based casinos (14%). This is not surprising given the survey was completed by online gamblers. Interestingly, desktop use was linked to higher levels of obesity, drinking and smoking. This is something that I would expect given that online gambling is the most sedentary of these activities.

There are (of course) some limitations with the data collected particularly as it comprised a self-selected sample of online gamblers that played via jackpot.co.uk websites. We have no idea as to whether the sample is representative of all online gamblers but as I noted above, it is no surprise that online gamblers preferred playing casino games online compared to offline (i.e., land-based casinos). The data were also self-report and are therefore open to any number of individual biases including recall biases and social desirability biases. Also, we have no geographical breakdown of the sample as the internet (by definition) is global. However, the sample size is good in comparison to many published studies on gambling and the sample included individuals that were actually gamblers (as opposed to university undergraduates or members of the general public). According to Sam Marsden (editor of jackpot.co.uk and author of the report):

“There’s an undeniable link connecting passive games like slots and video poker to unhealthy, sedentary lifestyles. On the other hand, games that require concentration, strategy and some physical stamina like poker and blackjack seem to fare much better in the health stakes. It seems it’s less a case of ‘you are what you eat’ and more ‘you are what you play’.”  

Although such a conclusion could be argued to be PR spin on the findings, the results suggest that more rigorous studies could be carried out in the area including secondary analyses of the robust datasets that already exist including the British Gambling Prevalence Surveys, the English Health Surveys, and the Scottish health Surveys.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Biddle, S., Cavill, N., Ekelund, U., Gorely, T., Griffiths, M.D., Jago, R., et al. (2010). Sedentary Behaviour and Obesity: Review of the Current Scientific Evidence. London: Department of Health/Department For Children, Schools and Families (126pp).

Griffiths, M.D. (2001). Gambling – An emerging area of concern for health psychologists. Journal of Health Psychology, 6, 477-479.

Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association (ISBN 1-905545-11-8).

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2010). Gambling, alcohol consumption, cigarette smoking and health: findings from the 2007 British Gambling Prevalence Survey. Addiction Research and Theory, 18, 208-223.

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2011). Internet gambling, health. Smoking and alcohol use: Findings from the 2007 British Gambling Prevalence Survey. International Journal of Mental Health and Addiction, 9, 1-11.

Marsden, S. (2014). Booze, bets, and BMI. Jackpot.co.uk, October 6. Located at: http://www.jackpot.co.uk/online-casino-articles/booze-bets-bmi

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Wardle, H., Griffiths, M.D., Orford, J., Moody, A. & Volberg, R. (2012). Gambling in Britain: A time of change? Health implications from the British Gambling Prevalence Survey 2010. International Journal of Mental Health and Addiction, 10, 273-277.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.

Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M. D., Constantine, R., & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: National Centre for Social Research.

The national wealth service: Problem gambling is a health issue

Over the last decade, the United Kingdom has undergone major changes of gambling legislation (most notably, the 2005 Gambling Act that came into force on September 1, 2007). The Gambling Act has provided the British public with increased opportunities and access to gambling like they have never seen before. Gambling legislation was revolutionized and many of the tight restrictions on gambling dating back to the 1968 Gaming Act were relaxed (particularly in relation to the advertising of gambling). The deregulation of gambling has also been coupled with the many new media in which people can gamble (internet gambling, mobile phone gambling, interactive television gambling, gambling via social networking sites). Given the expected explosion in gambling opportunities, is this something that the health and medical professions should be concerned about?

Gambling has not been traditionally viewed as a public health matter although research into the health, social and economic impacts of gambling has grown considerably since the 1990s. In August 1995, the British Medical Journal published an editorial called ‘Gambling with the nation’s health?’ which argued that gambling was a health issue because it widened the inequalities of income and that there was an association between inequality of income in industrialized countries and lower life expectancy. However, there are many other more specific reasons why gambling should be viewed as an issue for the medical profession.

According to the last British Gambling Prevalence Survey (BGPS) published in 2011, just under 1% of the British population have a severe gambling problem although the rate is approximately twice as high in adolescents, particularly as a result of problematic slot machine gambling. Disordered gambling is characterized by unrealistic optimism on the gambler’s part. All bets are made in an effort to recoup their losses. The result is that instead of “cutting their losses”, gamblers get deeper into debt pre-occupying themselves with gambling, determined that a big win will repay their loans and solve all their problems.

It is clear that the social and health costs of problem gambling can be large on both an individual and societal level. Personal costs can include irritability, extreme moodiness, problems with personal relationships (including divorce), absenteeism from work, family neglect, and bankruptcy. I have also reported in a number of my papers (including a 2007 report I wrote for the British Medical Association) that there can also be adverse health consequences for both the gambler and their partner including depression, insomnia, intestinal disorders, migraines, and other stress-related disorders. In the UK, preliminary analysis of the calls to the national gambling helpline also indicated that a significant minority of the callers reported health-related consequences as a result of their problem gambling. These include depression, anxiety, stomach problems, other stress-related disorders and suicidal ideation.

There are also other issues relating to problem gambling that may have medical consequences. One US study published in the Journal of Emergency Medicine by Dr. Robert Muellman and his colleagues found that intimate partner violence (IPV) was predicted by pathological gambling in the perpetrator. In a sample of 286 women admitted to the emergency department at a University Hospital in Nebraska, findings revealed that a woman whose partner was a problem gambler was 10.5 times more likely to be a victim of IPV than partners of a non-problem gambler.

Health-related problems due to problem gambling can also result from withdrawal effects. In a study published in the American Journal of the Addictions, Dr. Richard Rosenthal and Dr. Henry Lesieur found that at least 65% of pathological gamblers reported at least one physical side-effect during withdrawal including insomnia, headaches, upset stomach, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulty and/or chills. Their results were also compared to the withdrawal effects from a substance-dependent control group. They concluded that pathological gamblers experienced more physical withdrawal effects when attempting to stop than the substance-dependent group. I also found similar things in a small study that I published in the Social Psychological Review (with Michael Smeaton).

Pathological gambling is very much the ‘hidden’ addiction. Unlike (say) alcoholism, there is no slurred speech and no stumbling into work. Furthermore, overt signs of problems often don’t occur until late in the pathological gambler’s career. If problem gambling is an addiction that can destroy families and have medical consequences, it becomes clear that medical professionals should be aware of the effects of gambling in just the same way that they are with other potentially addictive activities like drinking (alcohol) and smoking (nicotine).

However, gambling addiction is an activity that is not (at present) being treated via the British National Health Service (NHS). This was shown in a paper that I published with Dr. Jane Rigbye in a paper we published in a 2011 issue of the International Journal of Mental Health and Addiction. We sent a total of 327 letters were sent to all Primary Care Trusts, Foundation Trusts and Mental Health Trusts in the UK requesting information about problem gambling service provision and past year treatment of gambling problems within their Trust under the Freedom of Information Act. Our findings showed that 97% of the NHS Trusts did not provide any service (specialist or otherwise) for treating those with gambling problems (i.e., only nine Trusts provided evidence of how they deal with problem gambling). Only one Trust offered dedicated specialist help for problem gambling. Our study showed there was some evidence that problem gamblers may get treatment via the NHS if that person has other co-morbid disorders as the primary referral problem.

Problem gambling is very much a health issue that needs to be taken seriously by all within the health and medical professions. General practitioners routinely ask patients about smoking and drinking but gambling is something that is not generally discussed. Problem gambling may be perceived as a somewhat ‘grey area’ in the field of health and it is therefore very easy to deny that those in the medical profession should be playing a role. If the main aim of practitioners is to ensure the health of their patients, then it is quite clear that an awareness of gambling and the issues surrounding it should be an important part of basic knowledge.

As briefly outlined above, opportunities to gamble and access to gambling have increased because of deregulation and technology. What has been demonstrated from research evidence in other countries is that – in general – where accessibility of gambling is increased there is an increase not only in the number of regular gamblers but also an increase in the number of problem gamblers – although this may not be proportional. This obviously means that not everyone is susceptible to developing gambling addictions but it does mean that at a societal (rather than individual) level, in general, the more gambling opportunities, the more problems. Other countries such as Australia, Canada and New Zealand have seen increases in problem gambling as a result of gambling liberalization. In the UK, the last BGPS showed that problem gambling in Great Britain had increased by 50% compared to the previous BGPS published in 2007. (However, the latest data from the combined Health Survey for England and the Scottish Health Survey in 2014 reported that problem gambling had fallen to about 0.5%).

Gambling is without doubt a health and issue and there is an urgent need to enhance awareness within the medical and health professions about gambling-related problems and to develop effective strategies to prevent and treat problem gambling. The rapid expansion of gambling represents a significant public health concern and health/medical practitioners also need to research into the impact of gambling on vulnerable, at-risk, and special populations. It is inevitable that a small minority of people will become casualties of gambling in the UK, and therefore help should be provided for the problem gamblers. Since gambling is here to stay and is effectively state-sponsored, the Government should consider giving priority funding (out of taxes raised from gambling revenue) to organizations and practitioners who provide advice, counselling and treatment for people with severe gambling problems.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3) (pp.11-20). San Diego: Academic Press.

Griffiths, M.D., Scarfe, A. & Bellringer, P. (1999). The UK National telephone Helpline – Results on the first year of operation. Journal of Gambling Studies, 15, 83-90.

McKee, M. & Sassi, F. (1995). Gambling with the nation’s health. British Medical Journal, 311, 521-522.

Muelleman, R. L., DenOtter, T., Wadman, M. C., Tran, T. P., & Anderson, J. (2002). Problem gambling in the partner of the emergency department patient as a risk factor for intimate partner violence. Journal of Emergency Medicine, 23, 307-312.

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Rosenthal, R. & Lesieur, H (1992). Self-reported withdrawal symptoms and pathological gambling. American Journal of the Addictions, 1, 150-154.

Setness, P.A. (1997). Pathological gambling: When do social issues become medical issues? Postgraduate Medicine, 102, 13-18.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.

Net losses: What are the downsides of online therapy for problem gamblers and clinicians?

In my last blog, I briefly looked at the advantages of online therapy. However, the growth of online therapy is not without its critics. I may have given the impression in my previous blog that online therapy has nothing but positive implications. However, this blog briefly examines some of the main criticisms that have been levelled against online therapy. This loist is not exhaustive but hopefully covers the key concerns:

  • Legal and ethical considerations: As Internet counselling services grow, attention will have to be focused on the specialist construction of a legal and ethical code for this type of work. Cyberspace transcends state and international borders, therefore, there are many legal and regulatory concerns. For example, client/doctor confidentiality regulations differ from one jurisdiction to another. It may not be legal for a clinician to provide chat-room services to problem gamblers who are in a jurisdiction in which the clinician is not licensed. Furthermore, some problem gamblers may be excluded from telehealth services because they lack the financial resources to access the Internet. One potential ethical and legal dilemma is the extent to which service quality can be ensured. It is possible that individuals who register to provide counselling services online do not have the qualifications and skills they advertise. They may not even be licensed to practice. There are also issues regarding the conduct of practitioners engaged in all forms of telecommunication therapy. For example: issues of informed consent, the security of electronic medical records, electronic claims submissions and so forth. Therapy provided over the Internet holds promise but there is a need to check that it works and see to it that, if it is done then it is done well. Underlying guidelines that are applicable to all forms of counselling are that: (i) the therapist must be trained, supervised and accountable with qualifications that can be checked against a list held by a mainstream organisation, and (ii) the nature of the contract between client and practitioner must be spelled out so clients understand the boundaries of what they are receiving for what they are paying.
  • Effectiveness of online therapy: There are a growing number of evaluation studies that have examined whether online therapy is an effective treatment approach. With specific regard to problem gambling, my research colleague Dr. Gerry Cooper reported that about 70% spoke of how they benefited from their exposure to and involvement with GAweb, an online peer support group. An evaluation that I carried out with Dr. Richard Wood of Gam-Aid also showed that participants derived great benefit from using the online service and was particularly attractive for problem online gamblers (that are already comfortable with interacting online).
  • Confidentiality: Online therapy may compromise privacy and confidentiality, particularly if a skilled computer ‘hacker’ is determined to locate information about a particular individual. There is also some evidence that as more personal information is required of counselling sites online, the attractiveness of these sites is reduced. On the other hand, one of the things that the Internet is especially helpful with is its ability to afford the consumer the control over self-disclosure. In this way, individuals may overestimate the degree to which their information is safe and secure from computer hackers.
  • Encryption: No online therapist can confidently promise a problem gamblers confidentiality given the limitations of the medium. That being said, there are some sites that now offer secure messaging systems that offer the same level of protection as banking institutions. To protect confidentiality, care will have to be taken to prevent inappropriate and deliberate hacking into counselling sessions on the Internet. There will need to be a continuous upgrading of technology to stay ahead of hackers’ ability to breach security.
  • Complicated payment structures: Given the cross-national nature of the Internet, there may be complicated pay structures for problem gamblers to overcome when selecting a therapist. While universally-accepted credit cards might actually make payment easier (since one can use their credit card online and the credit card company will automatically calculate the currency exchange for the transaction), one may not immediately understand how much the online counselling has cost in their own currency. They may not know this until their credit card invoice arrives at a later date.
  • Cost-effectiveness to the therapist: For the therapist, there is the problem that online counselling may be as time consuming as face-to-face therapy with substantially less financial remuneration.
  • Identity problems: One of the major potential problems is that online problem gamblers may not be who they say they are, i.e., counsellors may not always know the true identity of their online clients (although identity is an issue only applicable to those services that are not anonymous). This is clearly a major issue since some assumptions (rightly or wrongly) are made by the clinician depending on what the problem gambler presents (including age and other demographics). However, to some extent, these issues also apply to telephone and face-to-face counselling as the therapist has to accept what is said at face value. Additionally, some might argue that merely responding to the words that a problem gambler chooses to use necessitates more focus on the part of the therapist. As a result, this may lead to a more democratic counselling environment. In other words, the role of therapist and problem gambler becomes more equal in this situation. Some therapists may have difficulty adapting to these new roles.
  • Severity of client problems: Some clients’ problems may be just too severe to be dealt with over the Internet. To some extent, there can always be contingencies, but because people can come from anywhere in the world and have a multitude of circumstances, online clinicians may be hard-pressed to meet everyone’s needs. It is important to acknowledge that this is not a panacea; that online help will not solve everybody’s problems (to be sure, those who are illiterate will likely have a difficult time of it without some additional support nearby). On the other hand, it is likely to go a long way in helping a great many more people than otherwise would have been the case.
  • Client referral problems: One obvious difficulty for the counsellor is how to go about making a referral for someone in a faraway town or another country. Once again, one would need to establish basic contingencies. Over time, it could be expected there would be many more international-regional clearinghouses regarding where to get immediate assistance, but to date it is very difficult to know what services are available for many parts of the world.
  • Establishing client rapport: It could perhaps be argued that there might be difficulty in establishing rapport with someone that the therapist has never seen. This is an interesting area where clearly more information is needed. One might also argue that because the problem gambler is in a more equal relationship with the therapist, they will feel more comfort. That is, since the problem gambler controls all of the personal disclosure levers, rapport might be established much more easily.
  • No face-to-face contact: Online therapy leads to a loss of non-verbal communication cues such as particular body language, voice volume and tone of voice. Furthermore, the lack of face-to-face interaction between problem gambler and therapist could result in a wrong referral or diagnosis. What is known about online communication where cues are filtered out, is that it typically takes more work to accomplish a task where more than one person is involved. It may be the case that with time and experience, therapists who work online will develop skills that will help them compensate for the absence of visual cues. For example, they might become much more skilled and precise with the words they choose to use.
  • Incomplete information: The written information provided in online therapy may be incomplete. Online therapy (via e-mail) may not allow the opportunity for immediate follow-up questions. Making a provisional recommendation or diagnosis is fraught with potential problems. For instance, a problem gambler may describe problems that are symptomatic of other more serious underlying disorders. However, diagnostic processes are quite heterogeneous practices even in face-to-face settings. Diagnoses are often provisional and therapists usually require more information to validate initial observations. In fact, clinicians might have better access to their clients through e-mail than trying to track them down face-to-face or exchanging telephone answer messages, should they need further information. Still, the information derived from problem gamblers in online formats may be unverifiable, more so than in face-to-face contexts.
  • Loss of therapist contact: Although perhaps more of a possibility than a reality, therapists can just ‘disappear’ only to re-emerge weeks later saying that their server failed and/or leave a problem gambler mid-therapy with little that the problem gambler can do about it. The same problem could occur with some clinicians in face-to-face settings although being online may be more of a problem in finding out what has happened.
  • Commercial exploitation: Consumers theoretically are not always as anonymous as they might think when they visit health sites because some sites share visitors’ personal health information with advertisers and business partners without consumers’ knowledge or permission. Some sites allow third-party advertisers to collect visitors’ personal information without disclosing this practice. As a result, visitors may get e-mails from advertisers about their products and services. Information can be collected during a variety of tasks including the visiting of chat rooms and bulletin boards, searching for information, subscribing to electronic newsletters, e-mailing articles to friends or filling out health-assessment forms. This allows third parties to build detailed, personally identified profiles of individuals’ health conditions and patterns of Internet use. In relation to gamblers, this is a real issue. By virtue of posting to places where problem gamblers talk to each other online with an accurate e-mail address shown, online gambling operators have the potential to collect such information in order to later send junk e-mail promoting their gambling websites. Other questionable and fraudulent marketing practices by online operators have also been outlined in my previous blogs.
  • Emergency situations: Being online and geographically distant has the potential to cause problems in an acute situation. For instance, if a clinician does not know where a problem gambler lives or can be located, they cannot call for help in the case of an emergency such as a suicidal threat.
  • Convenience: Although convenience was outlined as an advantage in the previous section, it can also have a downside. For instance, it may mean that the problem gambler is less likely to draw on their own existing coping strategies and use the online therapist as a convenient crutch (something which is actively discouraged in face-to-face therapy).

Hopefully this blog has redressed the balance of my previous blog on the positive benefits of online therapy. Anyone that seeks online advice, help, and/or treatment needs to carefully do their own cost-benefit analysis as to whether such an online service will be of direct benefit to them after taking into account some of the disadvantages outlined here.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bloom, W. J. (1998). The ethical practice of Web Counseling. British Journal of Guidance and Counselling, 26 (1), 53-59.

Connall, J. (2000). At your fingertips: Five online options. Psychology Today, May/June, 40.

Griffiths, M.D. (2001). Online therapy: A cause for concern? The Psychologist: Bulletin of the British Psychological Society, 14, 244-248.

Griffiths, M.D. (2005). Online therapy for addictive behaviors. CyberPsychology and Behavior, 8, 555-561.

Griffiths, M.D. (2010). Online advice, guidance and counseling for problem gamblers. In M. Manuela Cunha, António Tavares & Ricardo Simões (Eds.), Handbook of Research on Developments in e-Health and Telemedicine: Technological and Social Perspectives (pp. 1116-1132). Hershey, Pennsylvania: Idea Publishing.

Griffiths, M.D. & Cooper, G. (2003). Online therapy: Implications for problem gamblers and clinicians, British Journal of Guidance and Counselling, 13, 113-135.

Rabasca, L. (2000). Self-help sites: A blessing or a bane? APA Monitor on Psychology, 31(4), 28-30.

Segall, R. (2000). Online shrinks: The inside story. Psychology Today, May/June, 38-43.

Wood, R.T.A. & Griffiths, M.D. (2007). Online guidance, advice, and support for problem gamblers and concerned relatives and friends: An evaluation of the Gam-Aid pilot service. British Journal of Guidance and Counselling, 35, 373-389.

Wood, R. T., & Wood, S. A. (2009). An evaluation of two United Kingdom online support forums designed to help people with gambling issues. Journal of Gambling Issues, 23, 5-30.

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