Psychological and Social Factors Associated with Problem Gambling in Ontario: A One Year Follow- Up Study

Transcription

1 Psychological and Social Factors Associated with Problem Gambling in Ontario: A One Year Follow- Up Study October 2003 Jamie Wiebe Responsible Gambling Council (Ontario) Brian Cox University of Manitoba Agata Falkowski-Ham Responsible Gambling Council (Ontario)

2 i Table of Contents TABLE OF CONTENTS...I LIST OF TABLES AND FIGURES... II EXECUTIVE SUMMARY...III 1.0 INTRODUCTION LITERATURE REVIEW DESIGN AND METHODOLOGY SAMPLE MEASUREMENT INSTRUMENT DATA ANALYSIS LIMITATIONS STABILITY AND CHANGE IN GAMBLING LEVELS CPGI GAMBLING LEVELS CPGI ITEM ENDORSEMENT DEMOGRAPHIC CHARACTERISTICS GAMBLING ACTIVITIES PSYCHOLOGICAL AND SOCIAL DIMENSIONS ASSOCIATED FEATURES OF DSM PATHOLOGICAL GAMBLING MENTAL HEALTH TREATMENT DEPRESSION LONELINESS, SOCIAL SUPPORT, DISTRESS LIFE EVENTS PREDICTING INCREASES IN PROBLEM GAMBLING SCORES DISCUSSION REFERENCES APPENDIX A APPENDIX B: APPENDIX C*... 60

3 ii List of Tables and Figures Table 4.1: CPGI level at time 1 and time 2 12 Table 4.2: Endorsement of CPGI items by CPGI level at time 2 16 Table 4.3: Endorsement of CPGI items (time 2) by movement 17 Table 4.4: Demographic characteristics by CPGI level a time 2 18 Table 5.1: Gambling activities by CPGI level at time 2 19 Table 5.2: Gambling activities by movement 20 Table 5.3: Favourite gambling activity by CPGI level at time 2 21 Table 5.4: Favourite gambling activity by movement 22 Table 5.5: Whom the respondents gambles with by CPGI level at time 2 23 Table 5.6: Whom the respondent gambles with by movement 24 Table 6.1: DSM-IV Questions by CPGI level at time 2 26 Table 6.2: DSM-IV Questions by movement 26 Table 6.3: Reasons for seeing a mental health professional by CPGI level at 27 time 2 Table 6.4: Depression by CPGI level at time 2 28 Table 6.5: Reasons participants stopped doing things they used to do by CPGI 29 level at time 2 Table 6.6: Average score on psychosocial measures by CPGI level at time 2 29 Table 6.7: Average score on psychosocial measures by movement 30 Table A1: CPGI level by whether the participant was interviewed or not 39 Table A2: Demographic characteristics of people who were interviewed and 39 those who were not interviewed Table A3: CPGI level by whether the participant was interviewed or not. 40 Table A4: Contact Summary for Ontario Gambling Follow-up Study Sample 2 41 Table C1: The result of the simulated data, the results from the real CPGI data and a list of the differences between the two. 60 Figure 4.1: CPGI level at time 2 for non-problem gamblers at time 1 13 Figure 4.2: CPGI level at time 2 for at risk gamblers at time 1 13 Figure 4.3: CPGI level at time 2 for moderate gamblers at time 1 14 Figure 4.4: CPGI level at time 2 for severe gamblers at time 1 14 Figure 5.1: Average number of hours spent on gambling each month by CPGI 22 level at time 2 Figure 5.2: Average number of hours spent on gambling each month by movement 23

4 iii EXECUTIVE SUMMARY In 2001, the Responsible Gambling Council and the Canadian Centre on Substance Abuse conducted a gambling prevalence study in Ontario with a sample of 5,000 adults 18 years and older (Wiebe, Single & Falkowski-Ham, 2001). The study provided baseline information on the nature and extent of gambling and gambling problems in Ontario communities, and on the characteristics, behaviours and consequences associated with problem gambling. The present study builds on the Ontario prevalence study by following up a sample of participants approximately one year later. The present study employs a longitudinal design to monitor stability and change in problem gambling levels among those identified as having problems in the earlier study. The strength of a longitudinal design is that it allows for an examination of whether non-problem and problem gambling status remains stable or varies over time, and identifies the circumstances associated with any such changes. The results from this study are presented in two reports. This report Psychological and Social Factors Associated with Problem Gambling in Ontario: A One Year Follow-up Study examines the relationship between problem gambling and depression, distress, loneliness, life events and social support. The companion report Exploring the Evolution of Problem Gambling: A One Year Follow-up Study by Wiebe, Single and Falkowski-Ham (2003) examines the development and types of gambling-related problems that individuals experience (i.e. financial, relationships, etc.), how they address these problems, and how individuals have been negatively impacted by other s gambling. A total of 448 participants from the original prevalence study were recontacted approximately one year later, and the Canadian Problem Gambling Index (CPGI) was re-administered to assess current problem gambling status. In

5 iv the original study, the CPGI was used to classify participants as non-gamblers, non-problem gamblers, at risk of developing problems, experiencing moderate problems, and experiencing severe problems. The results revealed substantial change in gambling status over the oneyear period in both directions that is, some people who originally reported problems improved in status, and others originally without problems or with less severe problems deteriorated in status. Improvements in status were most noteworthy among those originally identified with less than severe gambling problems. Among those classified as at-risk of developing problems in the original study, 53 changed status to non-problem gamblers, and an additional 6 changed to non-gamblers at the one-year follow-up. Among individuals classified as experiencing moderate problems in the initial survey, 38 had moved to at-risk of developing problems one year later, and 26 had moved to non-problem gambling status. The majority of people classified as non-problem gamblers in the initial survey remained non-problem gamblers one year later (85). The group classified with severe gambling problems at the outset demonstrated far more stability in their gambling levels than those in the at-risk or moderate problem groups. The majority (80) of these individuals continued to have severe problems one year later. While there was an overall trend towards reductions in problem gambling, it is interesting to note that approximately 10 of participants at each gambling level progress to more serious problems. That is, approximately 10 of nonproblem gamblers in the initial survey were classified as at-risk of developing problems one year later. Similarly, 10 of those initially classified as at-risk of developing problems were classified as experiencing moderate problems one year later. Finally, approximately 10 of those classified as experiencing moderate problems at the outset were found to be experiencing severe

6 v problems at the one-year follow-up. Replication studies are required to validate this observation. In terms of social and psychological factors, the results revealed strong relationships between gambling problems at follow-up and depression, distress, loneliness, life events and low social support. The factors related to increased CPGI scores from time 1 to time 2 included increased loneliness and distress and decreased social support from friends. Combined, the results conveyed a profile of individuals with gambling problems as emotionally distressed and lonely, and having low social support. A series of analyses were conducted to examine the social and psychological variables most predictive of time 2 CPGI scores, over-and-above the predictive effects of gambling symptom severity observed one year previously. First, the results showed that time 1 CPGI scores are a powerful predictor of time 2 CPGI scores, accounting for almost 50 of the variation in time 2 CPGI scores. This predictive effect of time 1 CPGI scores on time 2 CPGI scores therefore represented the benchmark that other variables were forced to overcome. When loneliness, low social support, life events and emotional distress were examined simultaneously, emotional distress was the only significant variable in predicting increases in gambling problems. A limitation of the present research is the fact that much of the findings were cross sectional in nature. However, the findings suggest that several of the psychosocial dimensions are promising candidate variables that may act as true vulnerabilities for subsequent gambling problems. This possibility will require a more extensive longitudinal study that would include these promising variables at baseline along with gambling problem measures. This type of design would help to determine whether individuals in society who are emotionally vulnerable are those most at risk of developing gambling problems over time. As well, longerterm follow-up studies with non-gamblers and a larger number of individuals with

7 vi gambling-related problems are required to confirm the patterns of stability and change in gambling levels observed in the present study.

8 1 1.0 Introduction Over the last decade, Ontarians have experienced a large increase in gambling and gambling opportunities. This shift in the role of gambling in society is accompanied with concerns about potential social and economic costs. The study Measuring Gambling and Problem Gambling in Ontario, funded by the Ontario Problem Gambling Research Centre, examined gambling patterns and the prevalence of problem gambling among adult Ontarians (Wiebe, Single & Falkowski-Ham, 2001). The prevalence study provides baseline information about the nature and extent of gambling problems in Ontario communities, and on the characteristics, behaviours and consequences of uncontrolled gambling behaviour. The present study, also funded by the Ontario Problem Gambling Research Centre, builds on the Ontario prevalence study by following up a sample of participants from the prevalence study approximately one year later. A limitation of snapshot prevalence studies is that they provide no indication of changes in gambling behaviour over time, or the factors associated with the progression of gambling problems, or recovery from such problems. In addition, time constraints associated with telephone surveys severely limit the depth and type of investigation. This follow-up study measures changes in gambling levels (i.e. nonproblem and problem gambling) as measured by the Canadian Problem Gambling Index (CPGI), examines the social and psychological correlates associated with problem gambling, provides an in-depth examination of the types and characteristics of gambling problems, strategies used to alleviate concerns created by gambling, and ways in which individuals are being negatively impacted by others gambling. The results from the follow-up study are presented in two separate reports: Psychological and Social Factors Associated with Problem Gambling in Ontario: A One Year Follow-up Study (Wiebe, Cox & Falkowski-Ham, 2003) and Exploring the Evolution of Problem Gambling: A One Year Follow-up Study (Wiebe, Single & Falkowski-Ham, 2003).

9 2 This report, Psychological and Social Factors Associated with Problem Gambling in Ontario: A One Year Follow-up Study, examines the relationship between depression, distress, loneliness, life events and social support to time 2 CPGI level and movement on the CPGI from baseline to follow-up. The companion report, Exploring the Evolution of Problem Gambling: A One Year Follow-up Study (Wiebe, Single & Falkowski-Ham, 2003), examines the development and types of gambling-related concerns experienced by individuals (i.e. financial, relationships, etc.), how these concerns are addressed, and looks at ways in which people are being negatively impacted by someone else s gambling. To provide context, both this report and the companion report include a section that presents the stability and change in gambling levels, as measured by the CPGI, over a one-year period.

10 3 2.0 Literature Review During the past two decades, there has been a broad expansion of gambling across Canada and the United States (Shaffer, Hall & Vander Bilt, 1997). Ontario has three commercial casinos, five charity casinos, 15 racetrack facilities, as well as lotteries and bingo (Ontario Lottery and Gaming Corporation, 2003). Currently, there are 16,458 electronic gambling machines in the province, or 1 per 524 adults. Of all the provinces, Ontario draws the most revenue from gambling at nearly $2.34 billion in 2001/2002 (Stefaniuk, 2003). The broad expansion of gaming is accompanied with concerns about potential social and economic consequences. In 2001 a gambling prevalence study was conducted in Ontario with a representative sample of 5,000 adults 18 years and older. The Canadian Problem Gambling Index (CPGI) was used to categorize gambling behaviour into five separate categories: non-gambler, nonproblem gambling, at-risk, moderate gambling problems and severe gambling problems. The results showed that 3.8 of adults 18 years and older in Ontario have moderate (3.1) or severe (0.7) gambling problems (Wiebe, Single & Falkowski-Ham, 2001). The prevalence study provides important information on the extent and distribution of problem gambling in Ontario, as well as an examination of demographic, social and personal dimensions related to gambling levels. As a cross-sectional design, however, this study only provides a snapshot of current gambling practices in the province. In addition, given the time constraints associated with telephone interviews, the depth of information that can be collected is limited. Longitudinal designs are needed to monitor changes in problem gambling levels, as well as identify the factors associated with movement from lower to higher levels of problematic gambling, and from problem gambling to non-problem gambling. Follow-up studies also allow for more indepth investigation of key variables. In 1998, Abbott, Williams and Volberg (1999) followed up 217 participants from the original sample of 4,053 people who participated in New Zealand s 1991

11 4 prevalence study. The results provide valuable insight into changes in gambling patterns over a 7-year period. The results showed that over three-quarters (77) of those who were current problem gamblers at time 1 shifted into non-problem gambling at time 2, and 45 of current probable pathological gamblers at time 1 shifted to non-problem gambling. An unexpected finding was the large decrease in the percentage of lifetime problem or probable pathological gamblers, a measure that should not shift with time. As noted by the authors, these findings raise important questions about the test retest reliability of the lifetime SOGS-R measure. The factors associated with problem gambling outcome seven years later included a preference for track betting, a higher 1991 current SOGS-R score and experiencing alcohol-related problems in Given the present state of knowledge, there appears to be no single root cause of problem and pathological gambling (NORC, 1999); instead a variety of factors come into play. The National Council of Welfare (1996) reviewed the results of eight Canadian adult prevalence studies in an attempt to identify the profile of a problem gambler. The review identified a fairly consistent pattern between problem gambling and being male, single and under the age of 30 years. In the Ontario prevalence study, young adults (18-24 years of age) were almost twice as likely as the general population to have moderate to severe gambling problems (7 vs. 3.8). Similarly, in his review of prevalence studies, Korn (2000) observed that being male, young, and having a concurrent substance abuse or mental illness placed people at greater risk for gamblingrelated problems. In the NORC study (1999), problem gamblers were more likely than nonproblem gamblers to have been on social assistance, declared bankruptcy, have mental illness issues, received mental health care in the past year and have been arrested or incarcerated. Volberg and Abbott (1994) found that the variables that discriminated most between the combined problem-pathological and no problem groups were ethnicity, age, parental history (having a parent with a gambling problem), marital status and household size.

12 5 A number of studies have specifically examined the link between emotional states and gambling levels (Jacobs, 1986; 1987; Rosental, 1993). However, because this research tends to rely on cross-sectional designs, the temporal sequence of gambling and various emotional indicators is difficult to establish with any reliability. McCormick et al. (1984) explored the relationship between diagnosable disorders of affect and pathological gambling. The sample consisted of 50 pathological gamblers admitted to an inpatient gambling treatment program. Of the total sample, 38 patients (76) had major depressive disorder. As noted by the authors, an interesting question is whether the depression creates a motivation to escape these feeling through gambling or if the gambling losses create the depression. In the study group, participants were unable to report reliably the temporal relationship between early gambling and early depressive episodes. Beaudoin and Cox (1999) examined the characteristics of 57 adults seeking treatment for gambling problems. Approximately 30 of the sample reported receiving mental health services in the past, most commonly for depression. Furthermore, 40 of the sample reported gambling to rid unpleasant feelings. These results suggest that, for some people, gambling may act as a coping mechanism for depression. Pathological gambling often occurs in conjunction with other behavioural problems, including substance abuse, mood disorders, and personality disorders (Blaszczynsk & Steele, 1998; NORC, 1999). The joint occurrence of two or more psychiatric problems, termed comorbidity, is an important, though complicating factor in studying the basis of this disorder. Is problem or pathological gambling a unique pathology that exists on its own or is it merely a symptom of a common predisposition, genetic or otherwise, that underlies all addictions? Recently, detailed structural and open-ended interviews with problem gambling clients at the Addictions Foundation of Manitoba found that, in addition to feelings of depression, many problem gamblers reported that they gambled in bars and in casinos to ease their profound sense of loneliness. A study by Brown

13 6 and Conventry (1997) of women with gambling problems found that the most common motivations for women gambling were boredom, loneliness, and isolation. Trevorrow and Moore (1998) found that women who were classified as having gambling problems were significantly lonelier (more alienated) than nongamblers and non-problem gamblers. The researchers conclude that their study is suggestive of loneliness (or alienation) as either a consequence or a vulnerability factor for problem gambling, but a longitudinal research design would be needed to clarify this issue (Trevorrow and Moore, 1998: 263). Life stressors have also been identified as an important component in the development of gambling problems. The General Theory of Addictions (Jacobs, 1986) proposes that certain personality characteristics and life events influence the development of gambling problems. Jacobs suggests that excessive gambling may result from a history of negative childhood experiences. Additionally, personal vulnerability has been linked by some researchers to negative childhood experiences of inadequacy, inferiority, low self-esteem and rejection (McCormick et al., 1987, McCormick et al., 1989). A study by Taber et al. (1987) has found that out of 44 individuals admitted to an inpatient gambling treatment program, 23 had experienced severe trauma during their lives and another 16 reported moderately heavy trauma. Furthermore, those with traumatic experiences also reported higher rates of substance abuse, depression, and anxiety than those without such experiences. Finally, strong or weak social support networks can aid treatment or further a gambling addiction. Addiction research has found that strong family or friendship bonds, and general involvement of family and friends in the affected persons life are some of the protective factors against an addiction (AADAC, 2001). The present study adds to the limited available knowledge by employing a longitudinal design to monitor stability and change in problem gambling levels over a one-year period. This study also provides detailed information on the relationship between depression, distress, loneliness, life events and social support and gambling levels in the general population.

14 7 The results of this study are presented in four separate sections. The first section examines changes in gambling levels among participants over an approximate one-year period. This is followed by an examination of gambling activities, favourite activities, the amount of time spent gambling and who participants gamble with by time 2 CPGI level and by movement on the CPGI from time 1 to time 2 (those with increased CPGI levels, decreased levels and the same CPGI levels). The next section examines the relationship between problem gambling and various psychological and social dimensions, including DSM pathological gambling criteria, mental health treatment, depression, loneliness, distress, life events and social support. The report concludes with a discussion of the salient findings in terms of the psychosocial factors related to problem gambling and highlights areas for further research.

15 8 3.0 Design and Methodology 3.1 Sample In the Ontario prevalence study, 5,000 Ontario residents 18 years and older were interviewed by telephone between March and May 2001 (time 1). In the present study, 448 participants from the prevalence study were re-contacted by telephone in August 2002 (time 2). Initially, the names of 723 participants from time 1 were sent to the research firm to be contacted. This sample was comprised of all respondents who scored one or more on the CPGI screen, and 150 randomly selected non-problem gamblers (score of 0 on the CPGI). The data collection agency, however, was unable to complete enough interviews. As a result, they were asked to re-contact any respondent who refused, as well an additional 500 randomly selected nonproblem gamblers were sent to supplement the original sample. In total, 603 respondents were successfully contacted by telephone, and 457 agreed to participate in the study. Later, the data for nine people at time 2 was deleted when it was discovered that they were not the same people interviewed at time 1. Thus, among those successfully contacted on the telephone, 74.3 of participants agreed to participate, among eligible participants, the response rate was 42.7 (see Appendix A). This response rate is in the middle range of rates achieved in Canada for general population gambling prevalence studies. Appendix A compares the time 1 gambling levels and demographic characteristics of those who were interviewed and those who were not successfully contacted or refused to participate. The results show that the least likely group to participate are individuals with severe gambling problems. It is not known whether this lower response rate is related to refusals to participate, or an inability to successfully contact those with severe gambling problems. Either way, caution needs to be exercised in reviewing the results related to individuals with severe gambling problems. In terms of demographics, younger participants (18-24 years), and those with completed high school education are under-

16 9 represented. While the transient nature of young adults may explain the reduced participation rate among this group, the link with education is not as clear. 3.2 Measurement Instrument The questionnaire assessed participation in a range of gambling activities, levels of problem gambling, various psychological and social dimensions and demographics (see Appendix B). Specifically: Sections of the Canadian Problem Gambling Index (CPGI) were readministered to examine participation in gambling activities and assess levels of problem gambling. The CPGI classifies participants as nongamblers, non-problem gamblers, at risk, moderate problems and severe problems (see Wiebe, Single & Falkowski-Ham, 2001, for details on the CPGI). Questions were included to assess the associated features of pathological gambling noted in the DSM-III-R and DSM-IV. These questions were used in a clinical study with gambling treatment clients (Beaudoin & Cox, 1999). These items are assessed in addition to the core features or symptoms of gambling that are used in diagnostic decision-making. Participants were also asked if they had received treatment for mental health issues in the past, and if so, what was the nature of these concerns. Emotional Distress was measured by the 14-item distress index used in the National Comorbidity Survey (NCS; Kessler et al., 1994). The NCS was one of the largest and most comprehensive community mental surveys ever conducted. The NCS Distress Index asks respondents to rate severity of 14 items over the past 30 days. Most of the items relate to psychological symptoms of depression (e.g., feelings of worthlessness, loss of interest in things) and anxiety (frightened). A detailed psychometric study of the NCS Distress Index found strong support for this instrument (McWilliams, Cox, & Enns, 2003). The UCLA Loneliness Scale (Russell, Peplau, & Cutrona, 1980; Russell, Peplau, & Ferguson, 1978) is a 20-item item scale that is a general measure of the important psychological construct of loneliness. The scale went through careful and extensive psychometric evaluation development and it contains multiple lines of evidence for its validity and reliability (Russell et al., 1978; 1980).

17 10 To assess stressful life events that had occurred over the past year, the Life Events Inventory (Cochrane & Robertson, 1972) was used. This is a 55-item index that asks respondents about the occurrence of specific life events (i.e., marital separation, retirement) The LEI is frequently used in mental health and addictions research, including community surveys and follow-up studies. We calculated a total score based on total number of life events experienced in the year prior to follow-up testing. The LEI allows researchers to assess the severity of environmental or social stressors, which might then interact with individual psychological characteristics such as distress or loneliness. The Multidimensional Scale of Perceived Social Support (Zimet et al., 1988) was used to measure levels of social support. This consists of 12 items that assess three separate facets of social support: Special Person, Family, and Friends. Either separate subscales or a total score can be calculated. The MSPSS is a brief and effective way to assess major domains of social support. It has sound psychometric properties and the separate scales were supported though factor analysis (Zimet et al., 1988). Demographic variables included gender, age, employment, educational attainment, and household income. 3.3 Data Analysis The McNemar chi-square statistic was used to examine changes in gambling levels from time 1 to time 2, and the chi-square statistic was used to examine the relationship between gambling status and various psychological and social variables. Hierarchical regression analysis was used to examine the best psychosocial predictors of increases in CPGI score from time 1 to time Limitations In reviewing the results, it is important to keep in mind some of the limitations associated with this study: This study includes both prospective and retrospective data. While the CPGI was administered at both time 1 and time 2, all other variables were measured at time 2 only, and therefore are retrospective in nature. Observed statistical relationships in this study only signify associations between variables, not necessarily causal relationships.

18 11 The lower response rate, particularly among individuals with severe gambling problems and younger participants, may represent a selection bias. As such, the results may not be generalizable to certain groups of individuals with gambling problems. Due to the small number of individuals with moderate (n=36) and severe gambling problems (n=12) at time 2, and the relatively few individuals with increased CPGI scores from time 1 to time 2, the results need to be viewed with caution. Limitations of the psychometric properties of the CPGI have implications for the study s findings. The CPGI (Ferris and Wynne, 2001) has a testretest reliability of r=0.78 over a period of three to four weeks. Therefore, some of the shifts observed in the present study may be due to measurement error. Due to these limitations, this study needs to be viewed as an exploratory investigation of the change versus stability of problem gambling.

19 Stability and Change in Gambling Levels This section examines changes in gambling levels among participants from time 1 to time 2. Data is also presented that examines the nature of problems that individuals are experiencing, as measured by the individual CPGI items. This information is provided by time 2 gambling level, as well as by respondents movement on the CPGI: whether the individual s CPGI level increased (more problematic), stayed the same, or decreased (less problematic) since baseline. The section concludes with an examination of demographic characteristics associated with gambling levels and movement. 4.1 CPGI Gambling Levels Changes in CPGI level from time 1 to time 2, just over a one-year period, appear in Table 4.1. Although it appears that the proportion of individuals with severe problems increased from time 1 (1.1) to time 2 (2.7), this change was not statistically significant. However, significant reductions were observed among those gambling at-risk (37.3 to 20.8) and those with moderate gambling problems (13.8 to 8.1). A significant increase was observed among the proportion of non-problem gamblers from time 1 (47.7) to time 2 (64.0). Analysis was also conducted that examined changes in average CPGI scores from time 1 to time 2 using a paired Student s t-test. The CPGI provides a score between 0 and 27, with higher scores associated with increased problems. The results were significant (p=.012) with an overall decrease in CPGI scores from an average of 1.2 at time 1 (sd=2.2) to 1.0 at time 2 (sd=2.4). Table 4.1: CPGI level at time 1 and time 2 CPGI Time 1 Time 2 Non-gamblers Non-problem At risk Moderate Severe N

20 13 The following four figures show the movement in gambling levels from time 1 to time 2 by time 1 CPGI gambling level. For instance, Figure 4.1 shows that the large majority of individuals classified as non-problem gamblers at time 1 (n=211) remained the same at time 2 (84.8). However, 10 of those classified as non-problem gamblers at time 1 progressed to at risk gambling at time 2. Figure 4.1: CPGI level at time 2 for non-problem gamblers at time (n=9) nongamblers 84.8 (n=179) 10.4 (n=22) 0.5 (n=1) 0.0 (n=0) non-problem at risk moderate severe Figure 4.2 shows the change in gambling status observed among time 1 at risk gamblers (n=165). As shown, just over one quarter (27.9) remained at risk gamblers at time 2, with the majority reducing their gambling to less problematic levels. Similar to the results noted above, just over 10 progressed to a more problematic level in just over a one-year period. Figure 4.2: CPGI level at time 2 for at risk gamblers at time (n=9) 53.3 (n=88) nongamblers nonproblem 27.9 (n=46) 11.5 (n=19) 1.8 (n=3) at risk moderate severe Figure 4.3 shows changes from time 1 to time 2 for individuals classified as having moderate problems at time 1 (n=61). Just over one quarter (26.2)

21 14 continued to have moderate gambling problems at follow-up. The majority decreased their gambling to less problematic levels (37.7 at risk, 26.2 nonproblem). Again, just under 10 (8.2) moved to more problematic levels, in that they were now experiencing severe gambling problems. Figure 4.3: CPGI level at time 2 for moderate problem gamblers at time (n=1) nongamblers 26.2 (n=16) 37.7 (n=23) 26.2 (n=16) 8.2 (n=5) non-problem at risk moderate severe As shown in Figure 4.4, there was a fair amount of stability in gambling levels among those classified as having severe gambling problems at baseline (n=5). Over an approximate one-year period, the large majority (80.0) of individuals with severe gambling problems continued to have severe problems. One individual, representing 20.0 of the sample, reduced their gambling from the severe problem level to an at risk level. Figure 4.4: CPGI level at time 2 for severe gamblers at time (n=4) (n=0) 0.0 (n=0) nongamblers nonproblem 20.0 (n=1) 0.0 (n=0) at risk moderate severe

22 15 In total, the majority (55.4) of respondents remained at the same CPGI level from time 1 to time 2, 33.3 moved to a lower level, and just over 10 (11.3) moved to more problematic levels at time 2. One type of measurement error that could account for the observed shifts in gambling levels is regression toward the mean (Campbell and Kenny, 1999). Anytime a variable is measured with less than perfect reliability, scores will change from time 1 to time 2. Scores at the extremes of the distribution will change in a more noticeable manner. High scores can only move down and low scores can only move up so extreme scores will tend to change the most in the direction of the mean. At the same time scores in the middle of the distribution will move up or down. Since we are dealing with extreme scores in a distribution we cannot rule out the possibility that changes observed from time 1 to 2 are due to regression to the mean. To examine how regression to the mean would impact the changes in categories in the CPGI, a number of simulations were conducted (see Appendix C). The results revealed a number of notable discrepancies between the results obtained and what would be expected from regression toward the mean. The relatively constant 10 shift upwards appears to be inconsistent with regression to the mean. More people that were non-problem gamblers (a score of 0 on the CPGI) stayed at that level than would be expected with regression toward the mean. Most of the severe problem gamblers from time 1 remained severe problem gamblers at time 2. Regression toward the mean would have predicted that most of these extreme scores would have regressed downwards. However, the very small sample size of severe problem gamblers must be considered. Finally, there also appears to be more movement downwards, and less movement upwards for moderate problem gamblers than would be expected. Therefore, while regression toward the mean is a factor when using any measure with less than perfect reliability, a number of the observed shifts in this study are not consistent with this type of measurement error.

23 CPGI Item Endorsement Table 4.2 shows the endorsement of the CPGI items by time 2 gambling level. Among all CPGI levels, the most commonly endorsed items include feeling guilty, chasing losses, and betting more than one can afford to lose. Respondents experiencing severe gambling problems are also likely to report being criticized about their gambling, feeling that they might have a problem with gambling, and feeling that gambling has caused them health problems. Table 4.2: Endorsement of CPGI items (time 2) by CPGI level at time 2 CPGI level CPGI items Nonproblem At risk Moderate Severe Total Gamblers Feel guilty about the way you gamble *** Chasing losses *** Bet more than could afford to lose *** Have people criticized your betting *** Feel that you might have a problem with gambling *** Feel gambling has caused you any health problems *** Need to gamble with larger amounts of money to get the same feeling of excitement *** Feel your gambling has caused financial problems *** Borrow money or sold anything to get money to gamble *** N *** p<0.001 Examination of CPGI item endorsement by movement shows that those who progressed to more problematic levels of gambling are the most likely to endorse all the items on the CPGI (see Table 4.3). Consistent with the results above, guilt feelings, chasing losses and betting more than one can afford to lose are the most common characteristics associated with increases in problematic levels of gambling.

24 17 Table 4.3: Endorsement of CPGI items (time 2) by movement Movement CPGI items Moved up Stayed the same Moved down Total Gamblers Feel guilty about the way you gamble *** Chasing loses *** Bet more than could afford to lose *** Have people criticized your betting*** Feel that you might have a problem with gambling *** Feel gambling has caused you any health problems** Need to gamble with larger amounts of money to get the same feeling of excitement *** Feel your gambling has caused financial problems *** Borrow money or sold anything to get money to gamble*** N ** p<.01; *** p< Demographic Characteristics The demographic characteristics associated with time 2 gambling levels, including non-gambling, are presented in Table 4.4. While significant relationships were observed with educational attainment and employment status, the relationships were not clear. Respondents with completed high school were the most likely to experience moderate gambling problems, and those with some post secondary education were the most likely to experience severe gambling problems. Unemployed respondents were the most likely to experience moderate gambling problems, and students were the most likely to experience severe gambling problems.

25 18 Table 4.4: Demographic characteristic by CPGI levels at time 2 CPGI level Nongamblers Nonproblem Atrisk Region Moderate Severe Total Population East Central East Toronto Central West Central South South West North Gender Male Female Age Marital status Married Living with a partner Widowed Divorced/separated Single Educational attainment * Some high school Completed high school Some post secondary Completed Postsecondary Completed postgraduate education Employment * Employed Unemployed Student Retired Other Household Income <$ <$ <$ <$ <$ $ N * p<0.05 In terms of CPGI movement, none of the demographic characteristics were significantly related to the direction of movement.

26 Gambling Activities Participants were provided with a list of gambling activities and asked if they had participated in any of these in the past 12 months. Table 5.1 shows gambling participation by time 2 CPGI level. Among all gamblers, the most common gambling activities are lottery, raffle or scratch tickets, followed by playing slots/vlts in casinos. Among the least common activities are betting on sports through a bookie, slots/vlts other than at a casino or racetrack, Internet gambling and speculative stock investments. Those with moderate gambling problems are the most likely group to play casino table games, sport select and visit casinos out of the province. Respondents experiencing severe gambling problems are the most likely to play slots or electronic gaming machines in a casino or racetrack, purchase scratch tickets, play Bingo and gamble on the Internet. Table 5.1: Gambling activities by CPGI level at time 2 CPGI level Gambling Activities Non problem At risk Moderate Severe Total Gamblers Lottery Raffles Scratch ** Slots/VLTs in casino *** Outcome of sporting events Slots/VLTs at race tracks *** Cards/board games with friends Horse Races Bingo *** Games of skill Arcade/video games Casinos out of province ** Casino table games ** Sport Select * Stocks Internet * Sports with bookie N * p<0.05; ** p<0.01; *** p<0.001 Table 5.2 shows gambling activities based on the direction of movement between time 1 and time 2. Participants with increased time 2 CPGI scores were

27 20 more likely than those with decreased scores or the same scores to gamble on a number of activities, particularly slots in a casino or racetrack, Bingo, casinos out of province, and scratch tickets. Table 5.2: Gambling activities by movement Movement Gambling activities Moved up Stayed the same Moved down Total Gamblers Lottery * Raffles ** Scratch ** Slots/VLTs in casino *** Outcome of sporting events Slots/VLTs at race tracks *** Cards/board games with friends Horse Races Bingo *** Games of skill Arcade/video games Casinos out of province ** Casino table games ** Sport Select Stocks Internet * Sports with bookie N * p<0.05; ** p<0.01; *** p<0.001 Participants were also asked to state their favourite gambling activity (see Table 5.3). Lottery tickets are the preferred gambling activity among the majority of non-problem gamblers. The most preferred activities among those gambling at severe levels are slot machines/vlts and Bingo, while those with moderate gambling problems tend to prefer slot machines/vlts.

28 21 Table 5.3: Favourite gambling activities by CPGI level at time 2 CPGI level Favourite Gambling Activities Nonproblem At risk Moderate Severe Total Gamblers Lottery tickets *** Slot machines/vlts * Scratch tickets Casino table games Bingo ** Card/board games with friends/family Outcome of sporting events Horse races Sport Select Raffles Games of skill Stocks * Casinos out of province Arcade/video games Internet Sports with bookies N * p<0.05; ** p<0.01; *** p<0.001 Table 5.4 presents respondents favourite gambling activity among individuals who moved up, stayed the same or moved down in their CPGI level. In many respects, these results mirror the analysis above. The favourite activity among individuals who increased their CPGI level from time 1 to time 2 is slot machines and VLTs (although the result was not statistically significant). Lottery tickets are the favourite gambling activity among those who stayed the same or moved down. In addition, individuals who moved up are the most likely group to identify Bingo and casino table games as their favourite activity.

29 22 Table 5.4: Favourite gambling activities by movement Movement Favourite Gambling Activities Moved up Stayed the same Moved down Total Gamblers Lottery tickets *** Slot machines/vlts Scratch tickets Casino table games ** Bingo * Card/board games with friends/family Outcome of sporting events Horse races Sport Select Raffles Games of skill Stocks Casinos out of province Arcade/video games Internet Sports with bookies N * p<0.05; ** p<0.01; *** p<0.001 The figure below displays the average number of hours spent each month gambling by time 2 CPGI level. Clearly, the amount of time spent gambling increases with problematic levels of gambling (F{3, 317}=29.57, p<0.001). Whereas non-problem gamblers report spending approximately 2 hours a month gambling, those at the severe level gamble approximately 25 hours each month. Figure 5.1: Average number of hours spent on gambling each month by CPGI level at time (n=200) nonproblem 5.1 (n=79) 9.1 (n=31) 24.8 (n=11) at risk moderate severe Figure 5.2 shows the average number of hours spent on gambling by movement on CPGI from time 1 to time 2. Respondents who moved up in CPGI level from time 1 to time 2 spend significantly more time gambling (average 9.7

30 23 hours/month) than those who stayed the same (2.9 hours) or moved down (4.5 hours) (F {2, 318}=9.66, p<0.001). Figure 5.2: Average number of hours spent on gambling each month by movement (n=43) moved up 2.9 (n=188) stayed the same 4.5 (n=90) moved down A question was posed that asked participants whether they gamble alone or with others (X 2 =17.74, df=9, p<.05). As shown in Table 5.5, a large portion of all gamblers, regardless of CPGI level, report gambling alone. This may be related to the popularity of purchasing lottery tickets. Those with severe and moderate problems are more likely than expected to gamble with family, and those with severe problems are less likely to gamble with friends. Alternatively, those at-risk are more likely than expected to gamble with friends and less likely to gamble with family. Table 5.5: Whom the respondents gambles with by CPGI level at time 2 CPGI Level Non problem At risk Moderate Severe Total Gamblers Alone Friends Family Other N Table 5.6 shows that respondents with increased CPGI scores from time 1 to time 2 are the most likely group to gamble with family members, those with the same scores are the most likely group to gamble alone, and those with

31 24 decreased scores are the most likely group to gamble with friends (X 2 =21.15, df=6, p<0.01). Table 5.6: Whom the respondents gambles with by movement Movement Moved up Stayed the same Moved down Total Gamblers Alone Friends Family Other N

32 Psychological and Social Dimensions This section examines the relationship between problem gambling and various psychological and social dimensions, including DSM pathological gambling criteria, mental health treatment, depression, loneliness, social support, distress, and life events. Relationships are examined by time 2 CPGI level as well as by CPGI level movement. 6.1 Associated Features of DSM Pathological Gambling Table 6.1 shows the relationship between time 2 CPGI level and associated features of pathological gambling noted in the DSM-III-R and DSM-IV. These questions were used in a clinical study with gambling treatment clients (Beadoin & Cox, 1999). Those gambling at severe levels were the most likely to feel detached from their surroundings while gambling, take risks in life, view money as a solution to their problems, describe themselves as a big spender, and gamble as a way of escaping problems. With the exception of gambling to escape problems, there are few differences between at risk gambling and those with moderate problems on these same dimensions. There were no significant relationships between time 2 CPGI levels and describing oneself as competitive or easily bored.

33 26 Table 6.1: DSM-IV Questions by CPGI level at time 2 Nongamblers Nonproblem CPGI level At risk Moderate Severe Total Population Ever felt detached from surrounding while gambling *** Do you like a lot of risks in life? * Do you see money as the solution to almost all your problems *** Would you describe yourself as a big spender? *** Would you describe yourself as a competitive person Would you say that in general you are easily bored Ever gamble as a way of escaping life s problems *** N *p<0.05; ***p<0.001 Table 6.2 presents responses to DSM criteria and movement in CPGI level. Respondents who moved up on CPGI between time 1 and time 2 are the most likely to view money as the solution to almost all their problems, to describe themselves as big spenders and to gamble to escape life s problems. No other significant relationships were observed. Table 6.2: DSM-IV Questions by movement Movement Moved up Stayed the same Moved down Total Population Ever felt detached from surrounding while gambling? Do you like a lot of risks in life? Do you see money as the solution to almost all your problems * Would you describe yourself as a big spender? ** Would you describe yourself as a competitive person Would you say that in general you are easily bored Ever gamble to escape life s problems *** N *p<0.05; ** p<0.01; ***p<0.001