key: cord-0726014-2ivpzj72 authors: Hodgins, David C.; Stevens, Rhys M.G. title: The impact of COVID-19 on gambling and gambling disorder: emerging data date: 2021-04-19 journal: Curr Opin Psychiatry DOI: 10.1097/yco.0000000000000709 sha: 52246d0943d20adf4f3cae25e6b983f33f363a03 doc_id: 726014 cord_uid: 2ivpzj72 PURPOSE OF REVIEW: The lockdown response to the COVID-19 pandemic has significantly impacted commercial gambling in many jurisdictions around the world. The goal of this review is to systematically identify and describe the survey data and findings to date examining the effect on individual gambling and gambling disorder. RECENT FINDINGS: Of the 17 publications meeting inclusion criteria, the majority reported cross-sectional assessments (n = 11, 65%) and remainder were longitudinal in that they had earlier gambling data for participants (n = 6, 35%). Not surprisingly given the closure of land-based gambling, an overall reduction in gambling frequency and expenditure was reported in all studies. The estimate of the proportion of participants in both the general population and the population that gambles who increased overall gambling or online gambling was variable. The most consistent correlates of increased gambling during the lockdown were increased problem gambling severity, younger age groups, and being male. SUMMARY: These results suggest that the impacts of the COVID-19 pandemic on gambling and problematic gambling are diverse – possibly causing a reduction in current or future problems in some, but also promoting increased problematic gambling in others. The longer-term implications of both the reduction in overall gambling, and the increase in some vulnerable groups are unclear, and requires assessment in subsequent follow-up studies. However, in the short term, individuals with existing gambling problems should be recognized as a vulnerable group. The response to the COVID-19 pandemic has significantly impacted commercial gambling in jurisdictions around the world. Numerous land-based gambling venues such as casinos, bingo halls, horseracing tracks, bars and clubs with electronic gambling machines (EGMs), lottery retailers, betting shops and poker rooms were forced to close, in particular during the first phase 'lockdown' in March and April 2020 [1] [2] [3] [4] . Since the initial lockdown, some venues re-opened fully or in a modified fashion, some remain open and others have closed during the second wave restrictions. Like the course of the pandemic itself, the future availability of gambling is unknown and unpredictable. This paper reviews evidence to date on the impact on individuals of these effects. At the same time that land-based gambling accessibility decreased, online gambling sites continued to operate. Some media reports indicated that business had, in fact, flourished and that the pandemic served to promote this increasingly popular gambling format [5, 6] . Online gambling sites typically include the full range of types of gambling, including lottery ticket sales, casino table games such a roulette, blackjack and craps, slot machines, online poker and sports betting. With the exception of sports betting, which was affected by the cessation or reduction of professional sports worldwide, all other types have been continuously available from both legally regulated and unregulated site operators. Some jurisdictions, however, have taken steps such as limiting advertising [7] and imposing a daily betting cap to minimize potential harms during the pandemic [8] . Gambling, a leisure pursuit for most individuals, has the potential to cause harm to the gambler, their family and the community [9, 10] . It is considered to be a potentially addictive behaviour, which for some individuals can lead to gambling disorder (GD). GD is characterized by the continuation of gambling despite negative impacts, increased priority to gambling compared with other life interests, and impairment of control over gambling involvement [11] . Individuals with GD tend to gamble more frequently on all gambling formats, although faster-paced forms of gambling such as EGMs and certain casino table games are considered particularly problematic [12] . Online gambling is considered to be a particularly problematic gambling format, given the relative lack of constraints on how and when it can be accessed, its solitary nature, and the wide variety of types of gambling available. Research consistently shows higher rates of GD among online gamblers versus individuals who only gamble at land-based venues [13, 14] . However, the direction of causality is unclear. It is possible that online gambling is associated with GD mostly because it provides additional and more flexible opportunities for individuals with GD to access gambling versus directly facilitating GD. Consistent with this, online gamblers tend to gamble at land-based venues as well as online. Nonetheless, one significant concern raised with respect to the pandemic lockdown of land-based venues is that individuals will migrate to online gambling formats for the first time, and that this involvement will increase vulnerability to negative harms and GD [15, 16] . Similarly, another concern is that individuals who already gamble online will increase their engagement, which might push them into problematic gambling. As well as affecting gambling availability, the social and financial effects of the pandemic might also influence people's desire to gamble. The stress and social isolation associated with the pandemic can lead to gambling as an emotional escape, a welldocumented and frequent motivation for gambling that is linked to GD [12] . These impacts might also lead to increased relapse among people in recovery from GD [17, 18] . The financial pressure of job insecurity and unemployment can motivate individuals to use gambling as a way to manage debts [19] . Speculative stock trading has been identified as an example of gambling-like behaviour. It has been reported that stock trading emerged as a popular distraction for novice investors during the lockdown and reports indicate popular trading platforms added millions of new accounts in the first four months of the year [20, 21] . The closure of land-based gambling venues also potentially impacts individuals with GD in positive ways. One potential positive effect is that the reduction of gambling availability provides an impetus for people to reduce or cease gambling [22] . In Canada, calls to the Ontario gambling helpline declined after the casinos closed [23] , suggesting fewer individuals were experiencing acute gambling-related problems. The pandemic is ongoing, and any initial effects on gambling and GD may or may not be sustained as the pandemic evolves and resolves. Although numerous types of research designs including qualitative and mixed methods can help us understand the effects, surveillance in the form of cross-sectional and longitudinal surveys is crucial [15] . The goal of this review is to identify and describe the survey data and findings to date examining the effect on individual gambling and GD. Specifically, we conducted a systematic search for published journal articles, research reports and unpublished manuscripts. The lockdown response to the COVID-19 pandemic has significantly reduced access to commercial gambling in many jurisdictions around the world. Not surprisingly given the closure of land-based gambling, an overall reduction in gambling frequency and expenditure was reported in all 17 studies reported to date. The most consistent correlates of the subgroup of people that increased gambling during the lockdown was increased problem gambling severity, younger age groups, and being male. The impact of the COVID-19 pandemic on gambling and problematic gambling are diverse -possibly causing a reduction in current or future problems in some, but also promoting increased problematic gambling in others. searched included the Gambling Research Exchange's Evidence Centre database, Google Scholar and PsyArXiv preprints. Searches employed a combination of keyword and controlled search terms (e.g., Medical Subject Headings) which resulted in the identification of 34 separate articles or reports. Seventeen articles and reports met the following criteria: collection of data from individual gamblers; published post-March, 2020; COVID effect assessed, and; English language. Of the 17 publications meeting inclusion criteria, seven appeared as peer-reviewed journal articles, three were preprints and seven were online reports which did not appear to have been peer-reviewed. Table 1 provides a description of each study, and Table 2 summarizes the findings concerning the COVID-19 impact on gambling. The surveys were conducted in a range of western middle-and upperincome countries. About half were designed to be representative of the adult population (n ¼ 9, 53%), and five of these weighted their sample based upon demographic characteristics. A number of surveys recruited the adult population of recent gamblers (n ¼ 3, 18%) or subpopulations of gamblers -online gamblers (n ¼ 1, 6%); land-based venue gamblers (n ¼ 1, 6%); regular online sports bettors (n ¼ 1, 6%). Two studies assessed special populations, including elite athletes and individuals recovered from substance use disorder. The studies most commonly utilized existing online panels or MTurk for recruitment (n ¼ 9, 53%). Two samples used the customer databases of online gambling providers. Two samples used multiple recruitment methods, including social media, previous research participants, and participants recruited by other participants (snowball method). All 17 were online surveys. The majority was cross-sectional assessments (n ¼ 11, 65%) and remainder was longitudinal in that they had collected earlier gambling data for participants (n ¼ 6, 35%). Most of the cross-sectional survey reports were silent on whether a subsequent follow-up of participants was planned. All the surveys provided specific data collection dates that aligned with the first lockdown period occurring from March to May 2020. Surveys in New Zealand [40] and Australia [26] also reported the results of a follow-up assessment to describe changes post lockdown. The Fluharty study in Great Britain [29 & ] reported an assessment conducted in early August, which was described as an easing of lockdown. Gambling behaviour data were collected in a variety of ways in the available surveys. One study uniquely used gambling expenditure data from an online provider. This type of behavioural data is more accurate than retrospective self-report, although it is limited in that it does not necessarily reflect all of an individual's informal gambling or gambling with other providers. All other studies relied on self-report. A number of surveys assessed gambling engagement for each type of gambling available locally using structured questions. Reports assessing recent gambling have previously been found to have good reliability [42] . A number of the cross-sectional studies used parallel questions to obtain a description of the individual's typical gambling in the time prior (e.g., 6, 12 months) to the pandemic. These reports are more subject to memory and other biases. Three longitudinal studies had self-reports from earlier time periods using the same assessment questions and, as such, assessed changes over time. Finally, a number of surveys assessed the perception of change in gambling versus assessing actual change (e.g., did your gambling increase, decrease or stay the same?). These questions are likely to be the least reliable and valid of the options as memory is possibly influenced by popular assumptions about the impact of the pandemic. Ten of the 17 studies incorporated a measure of problem gambling severity into their survey, in all cases the Problem Gambling Severity Index [43] , which is widely used in prevalence studies. Not surprisingly given the closure of land-based gambling venues, an overall reduction in gambling frequency and expenditure was reported in all 17 studies. Two studies assessed participants' perceptions of the reasons or motives for the decrease in their gambling. In a New Zealand study, the Health Promotion Agency presented a checklist of reasons to participants. The major reason for gambling online less was financial (50%) followed by not wanting to gamble around family (15%), thinking they were gambling too much (13%) and someone suggesting that they reduce gambling (11%) [39] . ]. Most frequently mentioned in the open-ended questions were no live sports (22%), shopping less overall (13%), only did the lotteries occasionally (9%), lack of interest (8%), and less money (8%). Within the checklist, no desire to gamble (30%), only gambling on occasion (28%), and only bet on sports events that are cancelled (28%) were most frequently mentioned. Highest frequency gamblers (i.e., those who reported gambling at least 9 of the 10 weeks) showed least reduction. The findings suggest that there was a significant decrease in the amount of money wagered by sports bettors during the COVID-19 pandemic (compared with before it) and that sports bettors did not switch to playing more online casino games and that there was also a significant reduction in playing online casino games among sports bettors. Bonny-Noach and Gold, 2020 [27] Proportion with great involvement in online gambling changes from 2% before to 11% after pandemic breakout. Individuals addicted to drugs other than cannabis most likely to increase online gambling. Substitution of drug addiction to other addictive behaviours such as gambling may increase when healthy activities are restricted. Small sample, few online gambling participants (N ¼ 16), unvalidated gambling measure. Brown and Hickman, 2020 [28] 11% increased and 14% decreased participation in at least one type of online gambling compared with two months prior. Men under age 30 in full-time employment most likely to increase online gambling; betting on sports in Australia showed largest increase. While this survey did not examine the implications of increased online gambling, the negative social impacts of gambling at a time of increased stress for many households should not be underestimated. This analysis has indicated some groups who are at risk for turning to and/or increasing rates of gambling when met with increased stressors. These risk groups may be targeted for interventions, by providing information of financial and debt support resources to lower the risk of turning towards gambling. Therefore, these specific groups may benefit from alternative opportunities to relieve their boredom that may provide more beneficial (and in turn, less harmful) coping behaviours, such as social support or connecting people digitally or through the use of community programmes such as Mutual Aid or schemes such as social prescribing. As lockdown restrictions eased, individuals of ethnic minority backgrounds, who were current smokers, and with lower education attainment were more likely to continue gambling at heightened rates. There was a slightly greater risk of dropout amongst individuals engaging in higher levels of gambling and it is therefore possible that the sampling was selective towards infrequent or nongamblers; no measure of problematic gambling. Online gambling increased for men but not women and was related to higher PG. Most gamblers said that compared to normal, they gambled about the same amount or less during lockdown. For many gamblers this decrease was situational, with many attributing the decrease in their gambling frequency to liking different types of gambling which were not possible during lockdown e.g. sports betting or preferring to physically gamble in betting shops. Therefore, the decrease will not necessarily be sustained. A much smaller proportion of gamblers reported gambling more during lockdown, and among this group, most said this was due to relieving boredom or for something to do, followed by the prospect of winning big money. Repeating a study of this nature in the future could give insight into the impact of easing lockdown restrictions on gambling behaviour or explore the impact of stricter restrictions (e.g., a potential second lockdown). Sampling from two overlapping baseline surveys is confusing; Attributing change to COVID is difficult. Hakansson, 2020 [32] 38% nongamblers, 51% reported no change in gambling, 4% reported increased gambling and 7% decreased gambling. Increased gambling associated with increased gambling problem severity and alcohol consumption; more than half of respondents reporting increased gambling were moderate-risk or problem gamblers (25% of this group had a history of self-exclusion). While the majority of respondents did not report altered gambling habits, and the proportion reporting an increase was smaller than the proportion reporting a decrease, a significant minority of respondents still reported increasing their gambling, and a consistent finding-both for overall gambling and for specific gambling types-was that this sub-group had markedly higher gambling problems. Those increasing their gambling had increased alcohol use during the pandemic, even when controlling for several other potential risk factors. The minority of respondents reporting an increase of other gambling in response to the rapid shortfall of sports events had very high rates of gambling problems. Nonrepresentative sample. Hakannson, 2020 [33] Percentage of past-year gamblers who gambled during the past 30 days (i.e., during lockdown), was the highest for online horse betting (90%), online casino (81%), online poker (74%) and online bingo (72%), as well as for the less frequent gambling within video games (86%), but lower for sports live betting (58%), nonlive sports betting (56%), electronic gambling machines (46%), land-based horse gambling (42%), and landbased casino games (26%). Moderate risk or PGs were more likely to continue gambling for most types, except online horse bettors. Some gender differences. Those reporting sports betting even during a period with decreased sports betting occasions proved to have markedly higher gambling problems and indebtedness, not employment status. COVID-19 may alter gambling, and online gamblers who maintain or initiate gambling types theoretically reduced by the crisis may represent a group at particular risk. Market survey sample of frequent gamblers. Online gambling is typical of problem gamblers in Sweden so may not be generalizable. 12% gamble less; 33% unchanged, and 7% more. Gambling change unrelated to depression, anxiety, alcohol increase, sex, other covariates, but increase related to PG severity. A small number of respondents reported increased gambling behavior during the crisis and few reported an increase in specific other gambling types in response to the decrease in traditional sports betting during the confinement. Among those who did report an increase in gambling, rates of gambling problems were high. Individuals who increase their gambling behavior in response to an overall crisis such as the COVID-19 pandemic may need specific preventive and supporting interventions and may be a group with a more pronounced change in life style habits during the crisis than others. Nearly one-third of gamblers reported ceasing gambling altogether during the lockdown. For the continuing gamblers, quantitative data indicated significant decreases in gambling frequency, time spent in gambling sessions, money spent, and the number of game types played. Gambling platform was the only gambling engagement metric where increases were found with 17% of the gambling sample migrating to online gambling during the lockdown. Nearly one-third of gamblers reported ceasing gambling altogether. For the continuing gamblers, quantitative data indicated significant decreases in gambling frequency, time spent in gambling sessions, money spent, and the number of game types played. Gambling online -among other biopsychosocial factors -was a significant predictor for classification as a problem gambler during the lockdown. There were Pre-COVID and COVID-Lockdown data collection periods; study was a supplement to a longitudinal study of gambling; the current study was uniquely positioned to examine pandemic related changes in gambling for two reasons. First, this study had quantifiable baseline gambling behavioral data that was collected from this sample six month prior to the lockdown in Canada, and second, data collection for the lockdown period began one month after lockdown was instituted in all provinces and concluded prior to any landbased establishment re-opening; sample was not necessarily representative of all gamblers as there was significant attrition between the first assessment (not included in these analyses) and the second assessment (this Pre-COVID sample). Price, 2020 [37, 38] 54% gambled online compared with 23% typically. 32% of online gamblers indicated that COVID-19 influenced the decision to gamble; COVIDrelated financial impacts and higher anxiety and depression were associated with increased likelihood of online gambling; COVID-related employment impacts associated with PG and gambling motives; perceived or actual change in gambling not reported. Broadly speaking, this research has reaffirmed relationships articulated in past research on risky online gambling and comorbidities, including mental health concerns and substance use. Gambling behaviour questions not clearly described or reported. Analyses focused on comparing online to other gamblers and not migration. www.co-psychiatry.com The proportion of participants in both the general population and the population that gambles who reported an increase in overall gambling was more variable and ranged from 4 to 14% in the 4 studies providing this information. These estimates are unlikely to be precise, given the study methodologies. Two of these studies (9% [29 & ] and 14% [30] increase) used convenience samples recruited through social media and previous research participants. The other two estimates used unweighted online panels [33, 39] . Neither of these designs are optimal for estimating prevalence. A greater number of studies estimated the increase in online gambling specifically [24,28, ] that showed an increase in online gambling from 1.5% in October 2019 to 2.3% in May 2020. In comparison, the two highest estimates, 31% [37] (USA) and 26% [24] (Canada) were derived from online panels of past year gamblers. The range of estimated increase in online gambling was between 11 and 20% excluding the highest and lowest estimates. Numerous studies examined the characteristics of the subgroup of people whose gambling increased during the pandemic. The most frequently identified correlate was problem gambling severity index score and four studies found an association with increased problem severity and increased gambling [31 & ,33-35,41] . A single study found that moderate risk but not problem gambling status was associated with increased gambling [30] . Younger age was a significant correlate in five studies [24, 26, 28, 35, 39] , one of which also found that older age was also a correlate [26] . Men were found to be at increased risk in three studies [26,31 & ,35] , and women in another [29 & ]. Full-time employment [28,29 & ] and higher income [41] also facilitated increased gambling. In contrast, anxiety [29 & ], depression [29 & ], alcohol consumption [33] , drug addiction [27] were each significant in one sample. Finally, nonsmokers [29 & ] and individuals identifying as Maori in New Zealand [39] also were more likely to report gambling increase. Two studies assessed participants' perceptions of the reasons or motives for the increase in their gambling. Reasons for gambling more identified in the Health Promotion Agency's New Zealand study were being unable to go to their usual places to gamble (51%), boredom (34%), financial pressure (28%) need for relaxation (25%), online social occasions (16%) and stress (15%). In Great Britain, the YouGov study found that boredom was mentioned most frequently in response to open-ended questions (12%), followed by earning money (55%). The two most frequent reasons cited when participants completed a checklist were boredom (52%) and prospect of winning money (48%). In contrast, the Ontario survey [37, 38] , assessed motives for gambling online (versus change in gambling). Gambling to win back money lost gambling and gambling to earn income were associated with loss of employment and other negative financial impacts due to COVID-19. Gambling because it helps when nervous or depressed was associated with reduced work hours. Individuals who indicated that the pandemic influenced their decision to gamble online also had higher problem gambling severity in this study [37] . Three studies reported a further assessment post lockdown [26,29 & ,40]. In Great Britain, an assessment of those who had increased their gambling during lockdown (9%), conducted in early August during a period of 'relaxing of the lockdown restrictions' showed that 48% had maintained or further increased [29 & ]. This was associated with ethnic background, lower education, nonstudent status, and smoking. In Australia, an assessment in November post lockdown found that gambling rates were increasing relative to lockdown levels for most types of gambling with some returning to 2019 levels [26] . Predictors of continued elevated gambling were similar to those identified in the Great Britain study and included ethnic minority status, smoking and lower education. Lastly, in New Zealand, a post lock down re-assessment in June 2020, found that reduction in gambling relative to pre-pandemic was maintained, and that the proportion worrying about their gambling reduced from 17% during the lockdown to 11% [26] . An impressive number of independent assessments of the impact of COVID-19 on gambling are available at this point in time, although the methodological quality varies dramatically. Despite this variability, a number of general trends are clear across jurisdictions. First, the expected reduction in gambling frequency and expenditure occurred during the lockdown when land-based opportunities were reduced. The reasons people provided for the reduction included lack of accessibility (e.g., no live sports, closed casinos), financial pressures and lack of interest. Post-pandemic follow-ups will reveal who returns and does not return to previous levels of gambling involvement. The results also showed that there is a subgroup of individuals who increased their gambling involvement by starting or increasing online gambling. Although there is inconsistency in results across studies, there is some convergence on vulnerabilities. A consistent predictor of the shift to increased gambling was higher problem gambling severity. Other indicators, typically correlated with problematic gambling, include younger age groups, males, and those with mental health concerns. In addition, financial pressures and boredom were also frequent motivators. Together, these indicators provide an informative profile of those at risk to whom public health messages, prevention and treatment could be targeted. Followup study data, though limited, identified potential predictors of those who maintain elevated gambling post lockdown, including individuals with ethnic backgrounds, lower education, nonstudent status, and smoking. Whether this elevation will continue when the pandemic stress is fully alleviated is unclear. The majority of the studies were cross-sectional assessments that rely on retrospective reports of gambling prior to the pandemic. Some have already, or plan to complete follow-up surveys with their participants, which will provide high-quality comparative information on post-pandemic status and its implications. However, at least four longitudinal studies exist that have gambling data collected prior to COVID-19 onset. All of these are well-positioned for further follow-ups, although, with the exception of Leonard and colleagues, it is unclear whether these are planned. The investigation by Auer et al. [25 & ], which focused specifically on online sports bettors, reported behavioural data from an online operator. The other three longitudinal studies [26,31 & & ] rely on self-report data. In all instances, gambling involvement was collected separately for each gambling activity, which is considered the best methodology [42] . The YouGov panel in Great Britain and the Biddle et al.'s study in Australia (Life in Australia panel) made use of existing, longstanding general population panels that were used to assess gambling among a host of other variables. These studies are likely best for estimating prevalence as they are less biased by individuals selecting in or out of participation of a survey identified as focusing on gambling. The Leonard and colleagues study [36 & ] used an existing Canadian online panel of people who were regular gamblers when first recruited in 2018. This type of design provides adequate subsample sizes of gamblers across all levels of involvement, which facilitates identifying differences in characteristics and trajectories. Although there was general convergence of results across these studies, it is always advantageous to obtain additional information to help confirm and contextualize results. The YouGov panel study, for example, incorporated a qualitative component in which a small subset of individuals was interviewed in detail. In one study that was screened out of this review, the pandemic effect in Sweden was assessed using industry sales data versus individual gambling reports [44 & ]. That study also showed an overall decrease in gambling of 13% with a slight increase in online casino gambling but not online gambling overall. This triangulation is important as it is a challenge to separate period effects of the pandemic from longer-term trends like the general reduction in gambling engagement exhibited in many mature gambling markets [45] . If post-pandemic gambling continues to be relatively low, this effect may be related to lingering pandemic effects, preexisting trends or both. These results suggest that the impacts of COVID-19 on gambling and problematic gambling are diverse -possibly causing a reduction in current or future problems in some, but also promoting increased problematic gambling in others. The longer-term implications of both the reduction in overall gambling, and the increase in some vulnerable groups are unclear, and will be better assessed in subsequent follow-up studies. The surveys reviewed in this paper were conducted at a time when land-based gambling was uniformly unavailable across jurisdictions. The gambling landscape during any follow-up studies will be more variable in terms of restriction (landbased casino openings, online betting caps) that will make examination of overall trends more complex. However, in the short term, individuals with existing gambling problems and other comorbidities need to be recognized as a vulnerable group. World Lottery Association. 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