Journal of Gambling Studies, Vol. 21, No. 3, Fall 2005 (Ó 2005) DOI: 10.1007/s10899-005-3097-5
Introduction to the Special Issue on ‘‘Relations Between Gambling and Alcohol Use’’ Sherry H. Stewart Dalhousie University Matt G. Kushner University of Minnesota
It has long been recognized that gambling is an activity that is often combined with alcohol intake. Not only do the behaviors of drinking and gambling frequently cooccur, alcohol use disorders and pathological gambling are also commonly co-morbid conditions in both clinical and non-clinical samples. This article introduces a special issue of the Journal of Gambling Studies focusing on cutting edge findings on the relations between gambling and alcohol use behaviors and their associated disorders. We set the stage for the following series of six novel empirical papers and integrative commentary by reviewing the theoretical pathways through which alcohol use and gambling disorders may be linked. We conclude by describing some of the novel contributions of each of the empirical studies from within the context of these theoretical models. KEY WORDS: co-morbidity.
pathological
gambling;
alcohol
abuse;
alcohol
dependence;
It has long been recognized that gambling is an activity that is often combined with drinking alcohol (Adler & Goleman, 1969). In many parts of the world, alcohol is available at locations where gambling occurs, and vice versa. According to a survey study by Focal Research (1998), about three-quarters of regular video lottery terminal Please address correspondence to Sherry H. Stewart, Department of Psychology, Dalhousie University, Life Sciences Centre, 1355 Oxford Street, Halifax, Nova Scotia, Canada, B3H 4J1. E-mail:
[email protected].
223 1050-5350/05/0900-0223/0 Ó 2005 Springer Science+Business Media, Inc.
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(VLT) gamblers in the Canadian province of Nova Scotia (where VLTs are located in bars) self-report drinking alcohol while they gamble. This figure has been confirmed in experimental, laboratory-based research (Stewart, McWilliams, Blackburn, & Klein, 2002). In this study, regular gamblers were given the opportunity to purchase alcoholic or non-alcoholic beverages, while they gambled or engaged in a control activity of movie watching. Those randomly assigned to the gambling condition were more likely to purchase alcoholic than nonalcoholic beverages (73% vs. 20%, respectively), whereas no such bias toward alcoholic beverage consumption was observed among regular gamblers assigned to the movie watching condition (40% drank alcoholic and 47% drank non-alcoholic beverages). Not only do the behaviors of drinking and gambling frequently co-occur, the forms of psychopathology associated with excesses in these behaviors (i.e., alcohol use disorders and pathological gambling) are also commonly co-morbid conditions (see reviews by Crockford & el-Guebaly, 1998; Grant, Kushner, & Kim, 2002). Research with clinical populations has shown that rates of pathological gambling are significantly elevated among those with an alcohol use disorder (e.g., Daghestani, Elenz, & Crayton, 1996; Lesieur & Heineman, 1988) and, conversely, rates of alcohol use disorders are significantly increased among pathological gamblers (e.g., Ramirez, McCormick, Russo, & Taber, 1983). The high rates of co-morbidity of alcohol use disorders with pathological gambling have also been confirmed in epidemiological studies with non-clinical samples drawn from the general population (e.g., Cunningham-Williams, Cottler, Compton, & Spitznagel, 1998; Smart & Ferris, 1996; Welte, Barnes, Wieczorek, Tidwell, & Parker, 2001). Despite the high overlap of gambling and drinking at the behavioral and diagnostic levels, very little is known about the precise nature of this overlap. As illustrated in Figure 1, there are at least three ways in which heavy drinking and excessive gambling might be related to one another. First, it could be that gambling disorders cause or exacerbate problems with alcohol use as is depicted in the top row of Figure 1. For example, an individual might begin to abuse alcohol (or escalate his or her abuse of alcohol) in an attempt to self-medicate for distress brought on by his or her problematic gambling (e.g., financial losses, relationship difficulties) (Stewart et al., 2002). Second, it could be that excessive drinking causes or exacerbates problems with
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Figure 1 An illustration of theoretical associations in gambling disorder – alcohol disorder co-morbidity
Gambling Disorder Gambling Disorder
(Dual Taxon)
(Dual Taxon)
(Dual or Single Taxon)
3rd Variable
Alcohol Disorder Alcohol Disorder Gambling Disorder Alcohol Disorder
gambling as is depicted in the middle row of Figure 1. For example, alcohol intoxication could cause increased risk taking during gambling bouts, resulting in greater gambling problems (e.g., greater financial losses) (Kyngdon & Dickerson, 1999). Both of these mechanisms assume that problem drinking and problem gambling are causally related to one another, and suggest that these disorders represent distinct taxons. A third possibility assumes no causal relationship between drinking and gambling and instead posits the presence of a third variable that is causally related to both drinking and gambling disorders as is depicted in the bottom row of Figure 1. For example, drinking and gambling problems could share a common genetic vulnerability (Slutske et al., 2000) or a common underlying dysregulation in the dopamine system (Potenza, 2001; Stewart, Collins, Blackburn, Ellery, & Klein, 2005). This latter model is consistent both with the view that the two problems represent distinct taxons and with the possibility of a common, single underlying taxon (see Figure 1). As this special issue highlights, research is now emerging that begins to clarify the nature of the relationship between alcohol use disorders and pathological gambling. The set of five empirical papers in the current special issue illustrates the novel approaches that researchers are using to enhance understanding of the functional interplay between excessive drinking and problematic gambling behavior. We are also very fortunate to have an integrative commentary
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on the set of studies by an addictions expert to conclude the special issue (Nathan, this issue). The studies included in this special issue span a variety of populations. These include community-recruited gamblers serving as research volunteers (Ellery, Stewart, & Loba, this issue; Zack, Stewart, Klein, Loba, & Fragopoulos, this issue), problem gamblers attempting recovery through self-change efforts or gambling treatment services (Hodgins, Peden, & Cassidy, this issue; Stinchfield, Kushner, & Winters, this issue), and problem gambling help-line callers (Potenza, Steinberg, & Wu, this issue). The variety of populations included in these studies should enhance generalizability of the findings. The studies in this special issue have also made use of a wide variety of methodologies to enhance our understanding of the relations between gambling and drinking problems. Two of the studies are labbased experimental studies (Ellery et al., this issue; Zack et al., this issue), while the other three are clinical studies (Hodgins et al., this issue; Potenza et al., this issue; Stinchfield et al., this issue). The clinical studies include both cross-sectional (Potenza et al., this issue) and longitudinal (Hodgins et al., this issue; Stinchfield et al., this issue) investigations. The clinical studies help establish the extent and impact of co-morbid gambling and alcohol use problems, while the experimental studies provide insight into the mechanisms underlying this form of co-morbidity. The clinical studies (Hodgins et al., this issue; Potenza et al., this issue; Stinchfield et al., this issue) make use of both standardized questionnaires and structured interviews to investigate the extent and implications of alcohol – gambling disorder co-morbidity. Such measures include the Gambling Helpline Form (Potenza et al., 2004), the Structured Clinical Interview for DSM-IV (Spitzer, Williams, & Gibbon, 1994), and the Gambling Treatment Outcome Monitoring System (Stinchfield & Winters, 2001). The lab-based experimental studies make use of both well-established and novel, cutting-edge paradigms to examine functional relations between drinking and gambling behaviors and events. These experimental methodologies include the alcohol challenge paradigm (see Newlin & Thomson, 1990) and a cognitive paradigm known as the Implicit Association Test (see Greenwald, & Banaji, 1995; Greenwald, McGhee, & Schwartz, 1998; Wiers, van Woerden, Smulders, & de Jong, 2002) to study the effects of alcohol on aspects of gambling play (Ellery et al., this issue)
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and the cognitive associations between gambling and drinking concepts (Zack et al., this issue) among regular gamblers. Each of the empirical studies contained in this special issue bears directly or indirectly on clarification of the mechanisms involved in alcohol – gambling disorder co-morbidity. For example, the finding by Ellery et al. (this issue) that alcohol challenge leads to more intensive gambling behavior is consistent with the second model presented in Figure 1 (middle row). In this case, problem drinking could cause problem gambling if frequent experiences of alcohol intoxication result in more serious negative outcomes from gambling. However, the fact that alcohol led to increased risk taking only among those with pathological gambling in the Ellery et al. (this issue) study suggests that the findings are more consistent with a model in which alcohol intoxication contributes to pathological gambling maintenance. As another example, the finding by Zack et al. (this issue) regarding conditioned associations between gambling win outcomes and alcohol cues on the Implicit Association Task is consistent with the first model depicted in Figure 1 (top row). In this case, problem gambling could cause problem drinking if exposure to gambling outcome cues prompts thoughts about drinking, which in turn promotes problematic drinking following exposure to a gambling win. However, a problem with drawing the conclusion that pathological gambling causes alcohol disorders on the basis of the Zack et al. (this issue) findings is the inherent circularity of the argument: it suggests that individuals are drinking frequently while gambling prior to developing the co-morbid alcohol disorder. Potenza et al.’s (this issue) findings are partially consistent with a possible common cause for both pathological gambling and alcohol use disorders. Specifically, this team found that those problem gamblers self-reporting a history of problem drinking were more likely than other gambling helpline callers to report other problem behaviors suggestive of impulse control problems. Thus, impulsivity is a possible third variable that might contribute to the development of both alcohol use disorders and pathological gambling. This explanation suggests a single (common) taxon for both disorders suggesting that the two are subsumed under a more general category of impulse control problems. However, if this were the case, all individuals with pathological gambling should show multiple impulse control problems. Perhaps co-morbid pathological gambling – alcohol use disorder
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involves a subtype of pathological gambling representing a separate taxon in which impulse control problems increases risk for multiple addictive and problem behaviors including alcohol problems. The results of the studies by Hodgins et al. (this issue) and Potenza et al. (this issue) which examined rates of alcohol use disorder in currently problematic gamblers also have implications for understanding the nature of the relationship between the two disorders. Specifically, the two studies converged in finding that the vast majority of their co-morbid cases involved current gambling problems with a past (rather than current) history of alcohol problems. This is interesting because it is inconsistent with either of the first two models presented in Figure 1, because if the alcohol disorder or pathological gambling causes (or maintains) the other, then both problems should be current at the same time. This finding is, however, consistent with a modified version of the second model illustrated in Figure 1 (middle row). More specifically, it is consistent with the notion that the alcohol disorder causes the gambling disorder in the first place, but then the alcohol disorder resolves and the gambling disorder is maintained by factors other than heavy drinking. The findings of the study by Stinchfield et al. (this issue) also have important implications for understanding the connection between problematic alcohol use and pathological gambling. This study investigated the impact of pathological gambling treatment on both gambling outcomes and substance use outcomes among those problem gamblers with high and low frequency alcohol use. As noted by Grant et al. (2002), if the gambling disorder is causal (model 1 in Figure 1), as a consequence of pathological gambling treatment, one would expect good gambling outcome (since gambling treatment would be unaffected by alcohol) and good substance outcome (since substance use would be improved by gambling treatment response). If the alcohol disorder is causal (model 2 in Figure 1), as a consequence of pathological gambling treatment, one would expect poor gambling outcome (since gambling treatment response would be worsened by alcohol) and poor substance outcome (since substance abuse would not be affected by gambling treatment). Finally, if a common third variable causes both the alcohol and gambling disorder (model 3 in Figure 1), as a consequence of pathological gambling treatment, one would expect good gambling outcome (since gambling treatment would be unaffected by alcohol) and poor substance outcome
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(since substance abuse would not be affected by gambling treatment). Stinchfield et al.’s (this issue) findings are most consistent with the second model, where the gambling disorder is causal, since gambling and substance abuse outcomes were both good for the problem gamblers who were frequent drinkers. The present set of papers illustrates that researchers are now going well beyond simple epidemiological investigations to establish the extent of the overlap between pathological gambling and alcohol use disorders and toward investigations that advance understanding of the mechanisms that underlie this high overlap. Ultimately, the results of such investigations should contribute to the improvement of interventions for those suffering from this common form of addictive disorder co-morbidity. ACKNOWLEDGMENTS Preparation of this manuscript and special issue were supported in part from grants from the Ontario Problem Gambling Research Centre and the Nova Scotia Gaming Foundation to the first author and from the National Institute on Alcoholism and Alcohol Abuse awarded to the second author. The first author is supported through a Canadian Institutes of Health Research Investigator Award. We gratefully acknowledge the editorial assistance of Dr. Howard Shaffer and the research assistance of Ellen Rhyno in putting together this special issue.
NOTE 1. Some of the articles contained in this special issue represent papers presented at a symposium on the co-morbidity of alcoholism and pathological gambling held at the 2002 Annual Meeting of the Research Society on Alcoholism in San Francisco, California (see summary by symposium co-chairs, Stewart & Kushner, 2003).
REFERENCES Adler, N., & Goleman, D. (1969). Gambling and alcoholism: Symptom substitution and functional equivalents. Quarterly Journal of Studies on Alcohol, 30, 733–736.
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Crockford, D. N., & el-Guebaly, N. (1998). Psychiatric comorbidity in pathological gambling: A critical review. Canadian Journal of Psychiatry, 43, 43–50. Cunningham-Williams, R. M., Cottler, L. B., Compton, W. M., & Spitznagel, E. L. (1998). Taking a chance: Problem gamblers and mental health disorders – results from the St. Louis Epidemiological Catchment Area (ECA) study. American Journal of Public Health, 88, 1093–1096. Daghestani, A. N., Elenz, E., & Crayton, J. W. (1996). Pathological gambling in hospitalized substance abusing veterans. Journal of Clinical Psychiatry, 57, 360–363. Ellery, M., Stewart, S. H., & Loba, P. (this issue). Alcohol effects on video lottery terminal (VLT) play among probable pathological and non-pathological gamblers. Journal of Gambling Studies. Focal Research (1998). Nova Scotia Video Lottery Players’ Survey 1997/98. Halifax, Nova Scotia, Canada: Nova Scotia Department of Health, Problem Gambling Services. Grant, J., Kushner, M. G., & Kim, S. W. (2002). Pathological gambling and alcohol use disorder. Alcohol Health and Research World, 26, 143–150. Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition: Attitudes, self-esteem, and stereotypes. Psychological Bulletin, 102, 4–27. Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. K. (1998). Measuring individual differences in implicit cognition: The Implicit Association Task. Journal of Personality and Social Psychology, 74, 1464–1480. Hodgins, D. C., Peden, N., & Cassidy, E. (this issue). The association between comorbidity and outcome in pathological gambling: A prospective follow-up of recent quitters. Journal of Gambling Studies. Kyngdon, A., & Dickerson, M. (1999). An experimental study of the effect of prior alcohol consumption on a simulated gambling activity. Addiction, 94, 697–707. Lesieur, H. R., & Heineman, M. (1988). Pathological gambling among youthful multiple substance abusers in a therapeutic community. British Journal of Addiction, 83, 765–771. Nathan, P. E. (this issue). Commentary, Special Issue, Journal of Gambling Studies. Journal of Gambling Studies.. Newlin, D. B., & Thomson, J. B. (1990). Alcohol challenge with sons of alcoholics: A critical review and analysis. Psychological Bulletin, 108, 383–402. Potenza, M. N. (2001). The neurobiology of pathological gambling. Seminars in Clinical Neuropsychiatry, 6, 217–226. Potenza, M. N., Steinberg, M. A., McLaughlin, S. D., Wu, R., Rounsaville, B. J., Krishnan-Sarin, S., George, T. P., & O’Malley, S. S. (2004). Characteristics of tobacco-smoking problem gamblers calling a gambling helpline. American Journal on Addictions, 13, 471–493 . Potenza, M. N., Steinberg, M. A., & Wu, R. (this issue). Characteristics of gambling helpline callers with self-reported gambling and alcohol use problems. Journal of Gambling Studies. Ramirez, L. F., McCormick, R. A., Russo, A. M., & Taber, J. I. (1983). Patterns of substance abuse in pathological gamblers undergoing treatment. Addictive Behaviors, 8, 425–428. Slutske, W. E., Eisen, S., True, W. R., Lyons, M. J., Goldberg, J., & Tsuang, M. (2000). Common genetic vulnerability for pathological gambling and alcohol dependence in men. Archives of General Psychiatry, 57, 666–673. Smart, R. G., & Ferris, J. (1996). Alcohol, drugs, and gambling in the Ontario adult opulation, 1994. Canadian Journal of Psychiatry, 41, 36–45. Spitzer, R. L., Williams, J. B. W., & Gibbon, M. (1994). Structured Clinical Interview for DSM-IV. New York: New York State Psychiatric Institute, Biometrics Research Department. Stewart, S. H., & Kushner, M. G. (2003). Recent research on the comorbidity of alcoholism and pathological gambling. Alcoholism: Clinical and Experimental Research, 27, 285–291. Stewart, S. H., Collins, P., Blackburn, J. R., Ellery, M., & Klein, R. M. (2005). Heart rate increase to alcohol administration and video lottery terminal (VLT) play. Psychology of Addictive Behaviors, 19, 94–98. Stewart, S. H., McWilliams, L. A., Blackburn, J. R., & Klein, R. (2002). A laboratory-based investigation of relations among video lottery terminal (VLT) play, negative mood, and alcohol consumption in regular VLT players. Addictive Behavior, 27, 819–835.
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Stinchfield, R., Kushner, M. G., & Winters, K. C. (this issue). Alcohol use and prior substance abuse treatment in relation to gambling problem severity and gambling treatment outcome. Journal of Gambling Studies. Stinchfield, R., & Winters, K. C. (2001). Outcome of Minnesota’s gambling treatment programs. Journal of Gambling Studies, 17, 217–245. Welte, J., Barnes, G., Wieczorek, W., Tidwell, M., & Parker, J. (2001). Alcohol and gambling pathology among US adults: Prevalence, demographic patterns, and co-morbidity. Journal of Studies on Alcohol, 62, 706–712. Wiers, R. W., van Woerden, N., Smulders, F. T. Y., & de Jong, P. J. (2002). Implicit and explicit alcohol-related cognitions in heavy and light drinkers. Journal of Abnormal Psychology, 111, 648–658. Zack, M., Stewart, S. H., Klein, R. M., Loba, P., & Fragopoulos, F. (this issue). Contingent gambling– drinking patterns and problem drinking severity moderate implicit gambling-alcohol associations in problem gamblers. Journal of Gambling Studies.
