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Breakthrough
Britain
Ending the costs of social breakdown
Special report:
Gambling addiction in the UK
Dr Mark Griffiths,
professor of Gambling Studies,
International Gaming Research Unit
Division of Psychology, Nottingham Trent University,
Following considerable pressure from special interest groups arguing that our
Addictions Working Group had to address the problem of gambling we commi-
sione the following report from professor Mark Griffiths. There is evidence that
gambling contributes to high levels of family breakdown and is closely linked to
other addictions such as alcohol and drugs

Background: How have we got here?

On 18 October 2004 a Gambling Bill was introduced into Parliament. Following
consideration by the House of Commons and the House of Lords, it received
Royal Assent on 7 April 2005, and became the Gambling Act 2005. The initial
target for full implementation of the Act is 1 September 2007. It has been recog-
nised that the introduction of this new legislation may have important psychoso-
cial implications for the general public through changing patterns of gambling
and hence rates of problem gambling (Griffiths, 2004). Gambling is a popular
activity and recent national surveys into gambling participation (including the
National Lottery), show that over 70 per cent of adults gamble annually
(Sproston, Erens & Orford, 2000; Creigh-Tyte & Lepper, 2004).
Although most people gamble occasionally for fun and pleasure, gambling
brings with it inherent risks of personal and social harm. According to the one
and only national prevalence survey, there are approximately 300,000 problem
gamblers in the UK which equates to just under 1% of the adult population
(Sproston et al, 2000). Problem gambling can negatively affect significant areas
of a person’s life, including their physical and mental health, employment,
finances and interpersonal relationships (e.g. family members, financial
dependents) (Griffiths, 2004). There are significant co-morbidities with prob-
lem gambling, including depression, alcoholism, and obsessive-compulsive
behaviours. These co-morbidities may exacerbate, or be exacerbated by, prob-
lem gambling. Availability of opportunities to gamble and the incidence of
problem gambling within a community are known to be linked (Griffiths,
2003a; Abbott & Volberg, in press). A review of the accessibility and availabil-
ity of gambling addiction services, as well as raising awareness among general

Note: Much of the background material in this report was first published by the author in a previous
report for the British Medical Association, Gambling Addiction and its Treatment Within the NHS
(2007).

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Breakthrough Britain

practitioners (GPs) and other healthcare workers of these services and other
relevant treatments, is therefore essential as the target date for full implemen-
tation of the Gambling Act 2005 draws near.

Gambling legislation: Legalisation of gambling in the UK has largely been a

20th century development. Bingo was brought to Britain by troops returning
from the Second World War, and with the Betting and Gaming Act 1960, bingo
halls were set up throughout the country. The legalisation of casinos under the
1960 Act limited the number of gaming machines in each venue to 10,
although the difficulty in enforcing this led to further liberalisation under the
Gaming Act 1968. The 1960 Act also legalised off-course bookmakers for bet-
ting on competitive sports events. A 1934 Act legalised small lotteries, which
was further liberalised in 1956 and 1976. In 1994, the UK’s largest lottery – the
National Lottery – was introduced under government licence. Several games
are now run under this brand, including Lotto, Euro Millions, and
Thunderball.
Currently, most gambling in Britain is regulated by the Gambling
Commission on behalf of the DCMS under the Gambling Act 2005. This Act
of Parliament significantly updated gambling laws, including the introduction
of a new structure of protections for children and vulnerable adults, as well as
bringing the burgeoning Internet gambling sector within British regulation for
the first time. The Gambling Act 2005 extends to the whole of Great Britain.
Separate arrangements have been developed for Northern Ireland. The DCMS
is working with the Gambling Commission, local authorities, problem gam-
bling charities, the gaming industry, and other interested stakeholders to over-
see the implementation of the Act. The target for full implementation is 1
September 2007. The new system is based on tri-partite regulation by the new
Gambling Commission, licensing authorities and by the government.

Gambling Commission: The Gambling Commission, which replaced The

Gaming Board, is the new, independent, national regulator for commercial gam-
bling in Great Britain. It will issue operating licences to providers of gambling
and personal licences to certain personnel in those operations. Its remit will
encompass most of the main forms of commercial gambling, including casinos,
bingo, betting, gaming machines, pool betting and the larger charity lotteries. It
will license providers that operate premises and those that offer gambling through
‘remote’ technologies, like the internet and mobile telephones. The commission
may impose conditions on licences and issue codes of practice about how those
conditions can be achieved. Where licence conditions are breached, various
administrative and criminal sanctions can be applied.

Licensing authorities: Licensing authorities (in England and Wales, local

authorities, and in Scotland, Licensing Boards) will license gambling premises
and issue a range of permits to authorise other gambling facilities in their local-

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 addictions: special report: gambling addiction in the UK

ity. Authorities will be independent of government and the Gambling

Commission, but in the exercise of their functions they must have regard to
guidance issued by the commission. Authorities will have similar regulatory
powers to the commission with respect to their licensees, including powers to
impose conditions, but they will not be able to impose financial penalties. The
number of casinos, racecourses, bookies and bingo halls requiring a gaming
licence will be approximately 30,000.

The government: The government has responsibility for setting various

rules on how gambling is conducted. For example, it will make regulations
defining categories of gaming machine. Powers are also available for the
government to set licence conditions on operating and personal licences,
and for the government, in England and Wales, and the Scottish Executive,
in Scotland, to set conditions on premises licences. In some cases licensing
authorities will be able to alter these central conditions. The government
also wishes to see a sustainable programme of research into the causes of
problem gambling and into effective methods of counselling and treatment
intervention. The government has actively supported the creation of an
industry-funded Responsibility in Gambling Trust to take forward these
and other programmes.
An important aspect of the government’s policy is the power of the
Gambling Commission to intervene in the operation of gambling across the
entire industry so that it can address factors that evidence suggests are related
to risks of problem gambling. In this context, the government proposes new
safeguards for gaming machines. These will be enforced through statutory
instruments, licence conditions and codes of practice. They may include the
powers:

 To control speed of play

 To control game design features such as ‘near misses’ and progressive tiers,
which may reinforce incentives to repeat play
 To require information about odds and actual wins or losses in the play
session to be displayed on screen
 To require ‘reality checks’ or the need to confirm continuing play
 To implement loss limits set by players before starting through use of
smart card technology
 To vary stake and prize limits.

Dedicated gambling environments: At present there are approximately 140

casinos, 970 bingo halls, 8,800 betting offices, 1,760 arcades, 19,000 private
members clubs and 60 racecourses throughout the UK. An important element
of the introduction of the Gambling Act 2005 is the licensing of 17 new casi-
nos in addition to those already in existence. Licenses for eight large casinos,
eight smaller casinos and a super-casino are currently being offered. The new

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Breakthrough Britain

super-casino (provisionally awarded to Manchester) will have a 5,000 square

metre gaming area largely filled with 1,250 unlimited-jackpot slot machines.
The 16 smaller venues will offer fewer slot machines with much lower jackpots,
but will probably support more poker games.

Online gambling: The regulation of online gambling is fraught with problems.

Preventing underage gambling is difficult, if not impossible, as there is no way
of determining whether an adolescent or child is using a parents’ credit or debit
card to gamble online. Likewise, it is impossible to tell whether a person is
gambling while under the influence of alcohol or other drugs, or is suffering
from a gambling addiction. The 24-hour availability of online gambling is
problematic for those with, or at risk of developing, gambling problems, as
there is currently nothing stopping a person from gambling 24-hours a day
(Griffiths & Parke, 2002; Griffiths, 2003c).

Problem gambling: What do we know?

Definition of gambling: Gambling is a diverse concept that incorporates a
range of activities undertaken in a variety of settings. It includes differing sets
of behaviours and perceptions among participants and observers (Abbott &
Volberg, 1999). Predominantly, gambling has an economic meaning and usu-
ally refers to risking (or wagering) money or valuables on the outcome of a
game, contest, or other event in the hope of winning additional money or
material goods. The activity varies on several dimensions, including what is
being wagered, how much is being wagered, the expected outcome, and the
predictability of the event. For some things such as lotteries, most slot
machines and bingo, the results are random and unpredictable. For other
things, such as sports betting and horse racing, there is some predictability to
the outcome and the use of skills and knowledge (e.g. recent form, environ-
mental factors) can give a person an advantage over other gamblers. Some of
the UK’s most common types of offline commercial forms of gambling are
summarised below.

A summary of the most common forms of offline commercial gambling in the UK

The National Lottery: National lottery game where players pick six out of 49
numbers to be drawn bi-weekly for the chance to win a large prize. Tickets can
be bought in a wide variety of outlets including supermarkets, newsagents or
petrol stations.

Bingo: A game of chance where randomly selected numbers are drawn and
players match those numbers to those appearing on pre-bought cards. The first
person to have a card where the drawn numbers form a specified pattern is the
winner. Usually played in bingo halls but can be played in amusement arcades
and other settings (e.g. church hall).
Card games (e.g. poker, bridge, blackjack): Gambling while playing card games

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 addictions: special report: gambling addiction in the UK

either privately (e.g. with friends) or in commercial settings (e.g. land-based

casino) in an attempt to win money.

Sports betting: Wagering of money for example on horse races, greyhound races
or football matches. Usually in a betting shop in an attempt to win money.

Non-sports betting: Wagering of money on a non-sporting event (such as who

will be evicted from the ‘Big Brother’ house) usually done in a betting shop in
an attempt to win money.

Scratchcards: Instant win games where players typically try to match a number
of winning symbols to win prizes. These can be bought in the same types of
outlet as the National Lottery.

Roulette: Game in which players try to predict where a spinning ball will land
on a 36-numbered wheel. This game can be played with a real roulette wheel
(e.g. in a casino) or on an electronic gaming machines (e.g. in a betting shop).

Slot machines (e.g. fruit machines, fixed odds betting terminals): These are
stand-alone electronic gaming machines that come in a variety of guises. These
include many different types of ‘fruit machine’ (typically played in amusement
arcades, family leisure centres, casinos, etc) and fixed odds betting terminals
(FOBTs) typically played in betting shops.

Football pools: Weekly game in which players try to predict which football
games will end in a score draw for the chance of winning a big prize. Game is
typically played via door-to-door agents.

Spread betting: Relatively new form of gambling where players try to predict
the ‘spread’ of a particular sporting activity such as the number of runs scored
in a cricket match or the exact time of the first goal in a football match in an
attempt to win money. Players use a spread betting agency (a type of spe-
cialised book maker).

As can be seen above, gambling is commonly engaged at a variety of envi-

ronments including those dedicated primarily to gambling (e.g. betting
shops, casinos, bingo halls, amusement arcades), those where gambling is
peripheral to other activities (e.g. social clubs, pubs, sports venues), and
those environments where gambling is just one of many things that can be

Notes Most of these forms of gambling can now be done via other gambling channels including the inter-
net, interactive television and/or mobile phone. [b] There are other types of gambling such as dice
(casino-based ‘craps’), keno (a fast draw lottery games) and video lottery terminal machine.
However, these are either unavailable or very rare in the UK. [c] Technically, activities such as specu-
lation on the stock market or day trading are types of gambling but these are not typically viewed as
commercial forms of gambling and they are not taxed in the same way.

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done (e.g. supermarkets, post offices or petrol stations). In addition, most

types of gambling can now be engaged in remotely via the Internet, interac-
tive television and/or mobile phone. This includes playing roulette or slot
machines at an online casino, the buying of lottery tickets using a mobile
phone or the betting on a horse race using interactive television. In these
remote types of gambling, players use their credit cards, debit cards or other
electronic forms of money to deposit funds in order to gamble (Griffiths,
2005a). Issues surrounding remote gambling will be examined later in this
report.

Definition of terms: In the UK, the term ‘problem gambling’ has been used by
many researchers, bodies, and organisations, to describe gambling that com-
promises, disrupts or damages family, employment, personal or recreational
pursuits (Budd Commission, 2001; Sproston et al, 2000; Griffiths, 2004). The
two most widely used screening instruments worldwide are the Diagnostic and
Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) for pathological
gambling (American Psychiatric Association, 1994), and the South Oaks
Gambling Screen (SOGS) (Lesieur & Blume, 1987) (see Appendices 1 and 2).
Both screening instruments were used to measure problem gambling in the
only British Gambling Prevalence Survey (BGPS) to date. Further, these two
screening tools are the most widely used by UK researchers and other UK serv-
ice providers in patient consultations (e.g. GamCare). The screens are based on
instruments used for diagnostic purposes in clinical settings, and are designed
for use in the general population (Sproston et al, 2000).
There is some disagreement in the literature as to the terminology used, as
well as the most appropriate screens to diagnose and measure the phenome-
non. Researchers internationally are beginning to reach a consensus over a
view of problem gambling that moves away from earlier, clinical often heav-
ily DSM-based definitions. For instance, early conceptions of ‘pathological
gambling’ were of a discrete ‘disease entity’ comprising a chronic, progressive
mental illness, which only complete abstinence could hope to manage. More
recent thinking regards problem gambling as behaviour that exists on a con-
tinuum, with extreme, pathological presentation at one end, very minor
problems at the other, and a range of more or less disruptive behaviours in
between. Moreover, this behaviour is something that is mutable. Research
suggests it can change over time as individuals move in and out of problem-
atic status and is often subject to natural remission (Hayer, Meyer &
Griffiths, 2005). Put more simply, gamblers can often move back to non-
problematic recreational playing after spells of even quite serious problems.
This conception fits in with an emphasis on more general public health, with
a focus on the social, personal and physical ‘harms’ that gambling problems
can create among various sectors of the population, rather than a more nar-
row focus on the psychological and/or psychiatric problems of a minority of
‘pathological’ individuals. Such a focus tends also to widen the net to encom-

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pass a range of problematic behaviours that can affect much larger sections
of the population.
The screening tools that are currently used to diagnose the existence and
severity of problem gambling reflect this change of focus. There have been crit-
icisms of both the DSM-IV and the SOGS. In part, these criticisms stem from
an acknowledgment that both screens were designed for use in clinical settings,
and not among the general population, within which large numbers of individ-
uals with varying degrees of problems reside. Other alternative screening
instruments have been developed, and these are increasingly being used inter-
nationally (Abbott, Volberg, Bellringer & Reith, 2004). One such screening tool
is the Problem Gambling Severity Index (PGSI), which was developed in
Canada and has been used in that country, the USA and Australia. This screen
will replace the SOGS in the upcoming BGPS. This survey will provide com-
prehensive data on the prevalence and distribution of problem gambling in this
country. It will therefore be useful for practitioners to have some understand-
ing of the types of screening tools it will use, as well as the different orienta-
tions that lie behind them.
A ‘harm based’ conception of problem gambling has implications for policy
and treatment. Given that the most severe cases of pathological gambling are
one of the most difficult disorders to treat (Volberg 1996), and given that, at
various points in their lives, hundreds of thousands of people in the general
population may experience some degree of gambling-related harms, it
becomes important to provide intervention strategies that can prevent this
potentially larger group developing more serious problems. To this end, public
health education and awareness-raising initiatives come to the fore, and these
are recognised internationally as the most cost-effective way of dealing with
problem gambling in the long term. (Shaffer, Hall & Vander Bilt, 1999; Abbott
et al 2004; National Gambling Impact Study Commission, 1999). Such strate-
gies have been successfully deployed in countries such as Australia, New
Zealand and Canada.
There is a multitude of terms used to refer to individuals who experience
difficulties related to their gambling. These reflect the differing aims and
emphases among various stakeholders concerned with treating patients, study-
ing the phenomenon, and influencing public policy in relation to gambling leg-
islation. Besides ‘problem’ gambling, terms include (but are not limited to)
‘pathological’, ‘addictive’, ‘excessive’, ‘dependent’, ‘compulsive’, ‘impulsive’ ‘disor-
dered’, and ‘at-risk’ (Griffiths & Delfabbro, 2001; Griffiths, 2006). Terms are
also employed to reflect more precisely the differing severities of addiction. For
example, ‘moderate’ can refer to a lesser level of problem, and ‘serious problem
gambling’ for the more severe end of the spectrum.
Although there is no absolute agreement, commonly ‘problem gambling’ is
used as a general term to indicate all of the patterns of disruptive or damaging
gambling behaviour. This report follows this precedent, employing the use of
the term ‘problem gambling’ to refer to the broad spectrum of gambling-relat-

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Breakthrough Britain

ed problems. Problem gambling must be distinguished from social gambling

and professional gambling. Social gambling typically occurs with friends or
colleagues and lasts for a limited period of time, with predetermined accept-
able losses. There are also those who gamble alone in a non-problematic way
without any social component. In professional gambling, risks are limited and
discipline is central. Some individuals can experience problems associated with
their gambling, such as loss of control and short-term chasing behaviour
(whereby the individual attempts to recoup their losses) that do not meet the
full criteria for pathological gambling (American Psychiatric Association,
1994).

Social Context: Research into gambling practices, the prevalence of problem

gambling, and the socio-demographic variables associated with gambling and
problem gambling, has not been considered part of mainstream health research
agendas until quite recently. The BGPS (Sproston et al, 2000) was the first
nationally representative survey of its kind conducted in Britain. The extent of
gambling activity, as measured in the survey, revealed gambling to be a popular
activity in Britain. In the year covered by the survey, gambling was engaged in by
almost three-quarters of the population (72%), with the most popular gambling
activity being the National Lottery Draw (i.e., Lotto). Two-thirds of the popula-
tion bought a National Lottery ticket in the year covered by the survey (65%),
while the next most popular gambling activity was the purchase of scratchcards
(22%), followed by playing fruit machines (14%), horse race gambling (13%),
football pools (9%) and bingo (7%). For a large number of people (39% of those
who purchased national Lottery tickets), the National Lottery Lotto game was
the only gambling activity they participated in.
The BGPS also found that men were more likely than women to gamble
(76% of men and 68% of women gambled in the year covered by the survey),
and tended to stake more money on gambling activities. The gambling activi-
ties men and women participate in were also varied. Men were more likely to
play football pools and fruit machines, bet on horse and dog races, and to make
private bets with friends, while women were more likely to play bingo, and
tended to participate in a lesser number of gambling activities overall
(Sproston et al, 2000).
There are also cultural variations in the prevalence and type of gambling
activities. For instance, in other cultures there is greater participation in games
like dice, or betting on cockfights. The type of gambling activity engaged in
also differs according to social class. Although gambling is popular among
people of all social classes, people in social class I are more likely to go to casi-
nos (5%) than play bingo (3%), while the opposite is true among people in
social class V, who have a participation rate in bingo of 20 per cent and casinos
only 1 per cent. Income is a factor in gambling participation, with people liv-
ing in low-income households (under £10,400) being the least likely to gamble.
In general, participation in gambling activities tends to increase along with

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 addictions: special report: gambling addiction in the UK

household income until around the level of £36,000, after which participation
rates level off and decline slightly (Sproston et al, 2000). However, it must be
noted that those in the lower classes spending the same amount on gambling
as those in higher social classes will be spending a disproportionately higher
amount of disposable income on gambling.
Examination of prevalence and socio-demographic variables associated with
problem gambling underaken in the BGPS revealed that between 0.6 per cent
and 0.8 per cent (275,000 to 370,000 people) of the population aged 16 and
over were problem gamblers (Sproston et al, 2000). In comparison to other
countries (such as Australia, the United States, New Zealand and Spain which
have problem gambling rates of 2.3, 1.1, 1.2 and 1.4% respectively), the num-
ber of problem gamblers in Britain is – based on the 2000 prevalence survey –
relatively low (Sproston et al, 2000).

Profiling: The BGPS revealed that there were a number of socio-demographic

factors statistically associated with problem gambling. These included being
male, having a parent who was or who has been a problem gambler, being sep-
arated or divorced and having a low income. Low income is one of the most
consistent factors associated with problem gambling worldwide. This may be
both a cause and an effect. Being on a low income may be a reason to gamble
in the first place (i.e., to try and win money). Additionally, gambling may lead
to low income as a result of consistent losing. In Britain, people in the lowest
income categories are three times more likely to be classed a problem gambler
than average (Sproston et al, 2000). Although many people on low incomes
may not spend more on gambling, in absolute terms, than those on higher
wages, they do spend a much greater proportion of their incomes than these
groups. The links with general ‘disadvantage’ should also be noted. Research
shows that those who experience unemployment, poor health, housing and
low educational qualifications have significantly higher rates of problem gam-
bling than the general population (Griffiths & Delfabbro, 2001; Griffiths,
2006).
The American Psychiatric Association (1994) claims that approximately one
third of problem gamblers are women. In the USA this loosely corroborates the
results of the BGPS that showed that approximately 1.3 per cent of men and 0.5
per cent of women in Britain could be classified as problem gamblers (Sposton et
al, 2000). Results of the BGPS also showed that the prevalence of problem gam-
bling decreased with age. For instance, the prevalence of problem gambling was
1.7 per cent among people aged between 16 and 24, but only 0.1 per cent among
the oldest age group. Further, the prevalence was highest among men and women
aged between 16 and 24 (2.3% and 1.1% respectively).
The types of games played also impact on the development of gambling
problems. This has consequences for understanding the risk factors involved in
the disorder, as well as the demographic profile of those individuals who are
most susceptible. For instance, certain features of games are strongly associat-

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ed with problem gambling. These include games that have a high event fre-
quency (i.e., that are fast and allow for continual staking), that involve an ele-
ment of skill or perceived skill, and that create ‘near misses’ (i.e., the illusion
of having almost won) (Griffiths, 1999). Size of jackpot and stakes, probability
of winning (or perceived probability of winning), and the possibility of using
credit to play are also associated with higher levels of problematic play (Parke
& Griffiths, 2006; in press). Games that meet these criteria include electronic
gaming machines (EGMs) and casino table games.
According to the BGPS, the most problematic type of gambling in Britain is
associated with games in a casino, (8.7% of people who gambled on this activ-
ity in the past year were problem gamblers according to the SOGS, and 5.6%
according to the DSM-IV). Groups most likely to experience problems with
casino-based gambling were single, unemployed males, aged under 30. Other
subgroups include slightly older single males, aged over 40, often retired, who
are also more likely to be of Chinese ethnicity (Fisher, 2000) and adolescent
males who have problems particularly with fruit machines (Griffiths, 1995;
2002). The problem of adolescent gambling will be examined in more detail
below.
The BGPS also indicated that other types of gambling activities were
engaged in by problem gamblers. These included betting on events with a
bookmaker (SOGS 8.1%; DSM-IV 5.8%), and betting on dog races (SOGS
7.2%; DSM-IV 3.7%). Problem gamblers were less likely to participate in the
National Lottery Draw (1.2% of people who gambled on this activity in the past
year were problem gamblers according to the SOGS; 0.7 according to the
DSM-IV), or playing scratchcards (SOGS1.7%; DSM-IV 1.5%). In addition,
problem gambling prevalence was associated with the number of gambling
activities undertaken, with the prevalence of problem gambling tending to
increase with the number of gambling activities participated in. As noted
above, for a large number of people, the National Lottery Draw was the only
gambling activity they engage in, and problem gambling prevalence among
people who limit their gambling to activities such as the National Lottery and
scratchcards was very low at 0.1 per cent. As might be expected, problem gam-
bling was associated with higher expenditure on gambling activities.
Internationally, as in almost every other country worldwide, the greatest
problems are, to a very considerable degree, associated with non-casino EGMs
such as arcade ‘fruit machines’ (Griffiths, 1999; Parke & Griffiths, 2006). It has
been found that as EGMs spread, they tend to displace almost every other type
of gambling as well as the problems that are associated with them. EGMs are
the fastest-growing sector of the gaming economy, currently accounting for
some 70 per cent of revenue. Australia’s particularly high rates of problem gam-
bling are almost entirely accounted for by its high density of these non-casino
machines. It is likely that Britain’s relatively lower rates of problems associated
with EGMs is explained by its current legislative environment, which limits the
numbers of machines in what are relatively regulated venues. This situation

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 addictions: special report: gambling addiction in the UK

will change however, as the Gambling Act comes into force, allowing larger
numbers of higher stakes machines into casinos, bingo halls and other gam-
bling venues. All of this indicates that attention should be focused on EGMs as
a source of risk.
The spread of EGMs also impacts on the demographic groups who experi-
ence problems with gambling. Until very recently, such problems were pre-
dominantly found in males, but as EGMs proliferate, women are increasingly
presenting in greater numbers, so that in some countries (e.g. the USA), the
numbers are almost equal. This trend has been described as a ‘feminisation’ of
problem gambling (Volberg, 2001). These types of games appear to be partic-
ularly attractive to recent migrants, who are also at high risk of developing
gambling problems. It has been suggested that first generation migrants may
not be sufficiently socially, culturally or even financially adapted to their new
environment to protect them from the potential risks of excessive gambling
(Productivity Commission, 1999; Shaffer, LaBrie & LaPlante, 2004). Many are
therefore vulnerable to the development of problems. This highlights the need
for healthcare professionals to be aware of the specific groups – increasingly,
women and new migrants, as well as young males and adolescents, who may
present with gambling problems which may or may not be masked by other
symptoms.
Variations in gambling preferences are thought to result from both differ-
ences in accessibility and motivation. Older people tend to choose activities
that minimise the need for complex decision-making or concentration (e.g.
bingo, slot machines), whereas gender differences have been attributed to a
number of factors, including variations in sex-role socialisation, cultural dif-
ferences and theories of motivation (Griffiths, 2006). Variations in motivation
are also frequently observed among people who participate in the same gam-
bling activity. For example, slot machine players may gamble to win money, for
enjoyment and excitement, to socialise and to escape negative feelings
(Griffiths, 1995). Some people gamble for one reason only, whereas others
gamble for a variety of reasons. A further complexity is that people’s motiva-
tions for gambling have a strong temporal dimension; that is, they do not
remain stable over time. As people progress from social to regular and finally
to excessive gambling, there are often significant changes in their reasons for
gambling. Whereas a person might have initially gambled to obtain enjoyment,
excitement and socialisation, the progression to problem gambling is almost
always accompanied by an increased preoccupation with winning money and
chasing losses.

Youth gambling
Adolescent gambling is a cause for concern in the UK and is related to other
delinquent behaviours. For instance, in one study of over 4,500 adolescents,
gambling was highly correlated with other potentially addictive activities such

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as illicit drug taking and alcohol abuse (Griffiths & Sutherland, 1998). Another
study by Yeoman and Griffiths (1996) demonstrated that around 4 per cent of
all juvenile crime in one UK city was slot machine related based on over 1,850
arrests in a one-year period. It has also been noted that adolescents may be
more susceptible to problem gambling than adults. For instance, in the UK, a
number of studies have consistently highlighted a figure of up to 5 to 6 per cent
of pathological gamblers among adolescent fruit machine gamblers (see
Griffiths, [2002; 2003b] for an overview of these studies). This figure is at least
two to three times higher than that identified in adult populations. On this evi-
dence, young people are clearly more vulnerable to the negative consequences
of gambling than adults.
A typical finding of many adolescent gambling studies has been that
problem gambling appears to be a primarily male phenomenon. It also
appears that adults may to some extent be fostering adolescent gambling.
For example, a strong correlation has been found between adolescent gam-
bling and parental gambling (Wood & Griffiths, 1998; 2004). This is partic-
ularly worrying because a number of studies have shown that individuals
who gamble as adolescents, are then more likely to become problem gam-
blers as adults (Griffiths, 2003b). Similarly, many studies have indicated a
strong link between adult problem gamblers and later problem gambling
among their children (Griffiths, 2003b). Other factors that have been linked
with adolescent problem gambling include working class youth culture,
delinquency, alcohol and substance abuse, poor school performance, theft
and truancy (e.g. Griffiths, 1995; Yeoman & Griffiths, 1996; Griffiths &
Sutherland, 1998).
The main form of problem gambling among adolescents has been the play-
ing of fruit machines. There is little doubt that fruit machines are potentially
‘addictive’ and there is now a large body of research worldwide supporting this.
Most research on fruit machine gambling in youth has been undertaken in the
UK where they are legally available to children of any age. The most recent
wave of the UK tracking study carried out by MORI and the International
Gaming Research Unit (2006) found that fruit machines were the most popu-
lar form of adolescent gambling with 54 per cent of their sample of 8,017 ado-
lescent participants. A more thorough examination of the literature summaris-
ing over 30 UK studies (Griffiths, 2003b) indicates that:

 At least two-thirds of adolescents play fruit machines at some point dur-

ing adolescence
 One-third of adolescents will have played fruit machines in the last month
 That 10% to 20 % of adolescents are regular fruit machine players (playing
at least once a week) (17% in the latest 2006 MORI/IGRU survey)
 That between 3% and 6% of adolescents are probable pathological gam-
blers and/or have severe gambling-related difficulties (3.5% down from
4.9% in the latest 2006 MORI/IGRU survey).

12
 addictions: special report: gambling addiction in the UK

All studies have reported that boys play on fruit machines more than girls and
that as fruit machine playing becomes more regular it is more likely to be a pre-
dominantly male activity. Research has also indicated that very few female ado-
lescents have gambling problems on fruit machines. Research suggests that
irregular (‘social’) gamblers play for different reasons than the excessive
(‘pathological’) gamblers. Social gamblers usually play for fun and entertain-
ment (as a form of play), because their friends or parents do (i.e., it is a social
activity), for the possibility of winning money, because it provides a challenge,
because of ease of availability and there is little else to do, and/or for excitement
(the ‘buzz’).
Pathological gamblers appear to play for other reasons such as mood modi-
fication and as a means of escape. As already highlighted, young males seem to
be particularly susceptible to fruit machine addiction with a small but signifi-
cant minority of adolescents in the UK experiencing problems with their fruit
machine playing at any one time. Like other potentially addictive behaviours,
fruit machine addiction causes the individual to engage in negative behaviours.
This includes truanting in order to play the machines, stealing to fund machine
playing, getting into trouble with teachers and/or parents over their machine
playing, borrowing or the using of lunch money to play the machines, poor
schoolwork, and in some cases aggressive behaviour (Griffiths, 2003b). These
behaviours are not much different from those experienced by other types of
adolescent problem gambling. In addition, fruit machine addicts also display
bona fide signs of addiction including withdrawal effects, tolerance, mood
modification, conflict and relapse.
It is clear that for some adolescents, gambling can cause many negative
detrimental effects in their life. Education can be severely affected and they
may have a criminal record as most problem gamblers have to resort to ille-
gal behaviour to feed their addiction. Gambling is an adult activity and the
government should consider legislation that restricts gambling to adults
only.

Pathological features
Though many people engage in gambling as a form of recreation and enjoy-
ment, or even as a means to gain an income, for some, gambling is associated
with difficulties of varying severity and duration. Some regular gamblers per-
sist in gambling even after repeated losses and develop significant, debilitating
problems that typically result in harm to others close to them and in the wider
community (Abbott & Volberg, 1999).
In 1980, pathological gambling was recognised as a mental disorder in the
third edition of the Diagnostic and Statistical Manual (DSM-III) under the sec-
tion ‘Disorders of Impulse Control’ along with other illnesses such as klepto-
mania and pyromania (American Psychiatric Association, 1980). Adopting a
medical model of pathological gambling in this way displaced the old image

13
Breakthrough Britain

that the gambler was a sinner or a criminal. In diagnosing the pathological

gambler, the DSM-III stated that the individual was chronically and progres-
sively unable to resist impulses to gamble and that gambling compromised, dis-
rupted or damaged family, personal, and vocational pursuits. The behaviour
increased under times of stress and associated features included lying to obtain
money, committing crimes (e.g. forgery, embezzlement or fraud), and conceal-
ment from others of the extent of the individual’s gambling activities. In addi-
tion, the DSM-III stated that to be a pathological gambler, the gambling must
not be due to antisocial personality disorder.
These criteria were criticised for (i) a middle class bias, i.e., the criminal
offences like embezzlement, income tax evasion were ‘middle class’ offences,
(ii) lack of recognition that many compulsive gamblers are self-employed and
(iii) exclusion of individuals with antisocial personality disorder (Lesieur,
1988). Lesieur recommended the same custom be followed for pathological
gamblers as for substance abusers and alcoholics in the past (i.e., allow for
simultaneous diagnosis with no exclusions). The new criteria (DSM-III-R,
American Psychiatric Association, 1987) were subsequently changed taking on
board the criticisms and modelled extensively on substance abuse disorders
due to the growing acceptance of gambling as a bona fide addictive behaviour.
In 1989 however, Rosenthal conducted an analysis of the use of the DSM-III-
R criteria by treatment professionals. It was reported that there was some dis-
satisfaction with the new criteria and that there was some preference for a
compromise between the DSM-III and the DSM-III-R. As a consequence, the
criteria were changed for DSM-IV.
The updated DSM-IV consists of 10 diagnostic criteria (see appendix 1). A
‘problem gambler’ is diagnosed when three or more of criteria A1-A10 are met,
and a score of five or more indicates a ‘probable pathological gambler.’ The
diagnosis is not made if the gambling behaviour is better accounted for by a
manic episode (criterion B) (American Psychiatric Association, 1994).
Problems with gambling may also occur in individuals with antisocial person-
ality disorder and it is possible for an individual to be diagnosed with both
pathological gambling and manic episode gambling behaviour if criteria for
both disorders are met (American Psychiatric Association, 1994).
According to the American Psychiatric Association (1994) DSM IV
“Pathological gambling typically begins in early adolescence in males and later
in life in females. Although a few individuals are “hooked” with their very first
bet, for most the course is more insidious. There may be years of social gam-
bling followed by an abrupt onset that may be precipitated by greater exposure
to gambling or by a stressor. The gambling pattern may be regular or episodic,
and the course of the disorder is typically chronic. There is generally a progres-
sion in the frequency of gambling, the amount wagered, and the preoccupation
with gambling and obtaining money with which to gamble. The urge to gam-
ble and gambling activity generally increase during periods of stress or depres-
sion” (p.617).

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 addictions: special report: gambling addiction in the UK

SOGS is based on the DSM-III criteria for pathological gambling and is at

present the most widely used screen instrument for problem gambling used
internationally. It consists of 20 questions on gambling behaviour from which
a total score (ranging from 0 to 20) of positive responses is calculated. A score
of three to four indicates a ‘problem gambler’ and five or more indicates a
‘probable pathological gambler’ (see appendix 2).

Internet and remote gambling

A recent report published by the Department of Culture, Media and Sport
(2006) noted that online gambling had more than doubled in the UK since
2001. Worldwide there are around 2,300 sites with a large number of these
located in just a few particular countries. For instance, around 1000 sites are
based in Antigua and Costa Rica alone. The UK has about 70 betting and lot-
tery sites but as yet no gaming sites (e.g., online casinos featuring poker, black-
jack, roulette, etc.). The findings reported that there were approximately one
million regular online gamblers in Britain alone making up nearly one-third of
Europe’s 3.3 million regular online gamblers. It was also reported that women
were becoming increasingly important in the remote gambling market. For
instance, during the 2006 World Cup, it was estimated that about 30% of those
visiting key UK based betting websites were women. The report also reported
that Europe’s regular online gamblers staked approximately £3.5 billion pounds
a year at around an average of £1000 each. It was also predicted that mobile
phone gambling was also likely to grow, further increasing accessibility to
remote gambling.
The introduction of the internet and other remote gambling developments
(such as mobile phone gambling, interactive television gambling) has the
potential to lead to problematic gambling behaviour and is likely to be an issue
over the next decade. Remote gambling presents what could be the biggest cul-
tural shift in gambling and one of the biggest challenges concerning the psy-
chosocial impact of gambling. To date, there has been little empirical research
examining remote gambling in the UK. The one and only prevalence survey
was published in 2001 (from data collected in 1999) when internet gambling
was almost non-existent (Griffiths, 2001). Many gamblers however, are techno-
logically proficient and use the internet and mobile phones regularly.
To date, knowledge and understanding of how the internet, mobile phones
and interactive television affect gambling behaviour is sparse. Globally speak-
ing, proliferation of internet access is still an emerging trend and it will take
some time before the effects on gambling behaviour surface (on both adults
and young people). However, there is strong foundation to speculate on the
potential hazards of remote gambling. These include the use of virtual cash,
unlimited accessibility, and the solitary nature of gambling on the internet as
potential risk factors for problem gambling development (Griffiths & Parke,
2002; Griffiths, 2003c; 2005; Griffiths, Parke, Wood & Parke, 2005).

15
Breakthrough Britain

There is no conclusive evidence that internet gambling is associated with

problem gambling although very recent studies using self-selected samples
suggest that the prevalence of problem gambling among internet gamblers is
relatively high (Griffiths & Barnes, 2005; Wood, Griffiths & Parke, in press).
What is clear, however, is that online gambling has strong potential to facilitate,
or even encourage, problematic gambling behaviour (Griffiths, 2003c). Firstly,
the 24-hour availability of Internet gambling (and other remote forms) allows
a person to potentially gamble non-stop (Griffiths, 1999). The privacy and
anonymity offered by internet gambling enables problem gamblers to contin-
ue gambling without being ‘checked’ by gambling venue staff concerned about
behaviour or amount of time spent gambling (Griffiths et al, 2005). Friends
and family may also be oblivious to the amount of time an individual spends
gambling online. In addition, the use of electronic cash may serve to distance
a gambler from how much money he or she is spending, in a similar way that
chips and tokens used in other gambling situations may allow a gambler to
‘suspend judgement’ with regard to money spent (Griffiths & Parke, 2002).
There are a number of factors that make online activities, such as internet
gambling, potentially seductive and/or addictive including anonymity, conven-
ience, escape, accessibility, event frequency, interactivity, short-term comfort,
excitement and loss of inhibitions (Griffiths, 2003c; Griffiths et al, 2005).
Further, there are many other specific developments that look likely to facili-
tate uptake of remote gambling services including (i) sophisticated gaming
software, (ii) integrated e-cash systems (including multi-currency), (iii) multi-
lingual sites, (iv) increased realism (e.g. ‘real’ gambling via webcams), (v) live
remote wagering (for both gambling alone and gambling with others), and (vi)
improving customer care systems (Griffiths, 2003c).
To a gambling addict, the internet could potentially be a very dangerous
medium. For instance, it has been speculated that structural characteristics of
the software itself might promote addictive tendencies. Structural characteris-
tics promote interactivity and to some extent define alternative realities to the
user and allow them feelings of anonymity - features that may be very psycho-
logically rewarding to some individuals. There is no doubt that internet usage
among the general population will continue to increase over the next few years.
Despite evidence that both gambling and the internet can be potentially addic-
tive, there is no evidence (to date) that internet gambling is ‘doubly addictive’
particularly as the internet appears to be just a medium to engage in the behav-
iour of choice. What the internet may do is facilitate social gamblers who use
the internet (rather than Internet users per se) to gamble more excessively than
they would have done offline (Griffiths, 2003c; Griffiths et al, 2005). In addi-
tion, a recent survey of British Internet gambling sites showed very low levels
of social responsibility (Smeaton & Griffiths, 2004).
Technological advance in the form of remote gambling is providing ‘conve-
nience gambling’. Theoretically, people can gamble all day, every day of the
year. This will have implications for the social impact of internet gambling.

16
 addictions: special report: gambling addiction in the UK

There are a number of social issues concerning internet gambling. Some of the
major concerns are briefly described below and adapted from Griffiths and
Parke (2002).

Gate-keeping and protection of the vulnerable: There are many groups of vul-
nerable individuals (e.g. young people, problem gamblers, drug/alcohol
abusers, the learning impaired) who in offline gambling would be prevented
from gambling by responsible members of the gaming industry. Remote gam-
bling operators however, provide little in the way of ‘gatekeeping’. In cyber-
space, how can you be sure that young people do not have access to internet
gambling by using a parent’s credit card? How can you be sure that a young
person does not have access to internet gambling while they are under the
influence of alcohol or other intoxicating substances? How can you prevent a
young problem gambler who may have been barred from one internet gam-
bling site, simply clicking to the next internet gambling link?

Electronic cash: For most gamblers, it is very likely that the psychological value
of electronic cash (e-cash) will be less than ‘real’ cash (and similar to the use of
chips or tokens in other gambling situations). Gambling with e-cash may lead
to a ‘suspension of judgment’. The ‘suspension of judgment’ refers to a struc-
tural characteristic that temporarily disrupts the gambler’s financial value sys-
tem and potentially stimulates further gambling. This is well known by both
those in commerce (i.e., people typically spend more on credit and debit cards
because it is easier to spend money using plastic) and by the gaming industry.
This is the reason that ‘chips’ are used in casinos and why tokens are used on
some slot machines. In essence, chips and tokens ‘disguise’ the money’s true
value (i.e., decrease the psychological value of the money to be gambled).
Tokens and chips are often re-gambled without hesitation as the psychological
value is much less than the real value.

Increased odds of winning in practice modes: One of the most common ways that
gamblers can be facilitated to gamble online is when they try out games in the
‘demo’, ‘practice’ or ‘free play’ mode. Further, there are no restrictions preventing
children and young people playing (and learning how to gamble) on these prac-
tice and demonstration modes. Recent research (Sevigny et al, 2005) showed that
it was significantly more commonplace to win while ‘gambling’ on the first few
goes on a ‘demo’ or ‘free play’ game. They also reported that it was commonplace
for gamblers to have extended winning streaks during prolonged periods while
playing in the ‘demo’ modes. Obviously, once gamblers start to play for real with
real money, the odds of winning are considerably reduced. This has some serious
implications for young people’s potential gambling behaviour.

Online customer tracking: Perhaps the most worrying concerns over remote
gambling is the way operators can collect other sorts of data about the gambler.

17
Breakthrough Britain

Remote gamblers can provide tracking data that can be used to compile cus-
tomer profiles. When signing up for remote gambling services, players supply
lots of information including name, address, telephone number, date of birth,
and gender. Remote gambling service providers will know a player’s favourite
game and the amounts that they have wagered. Basically they can track the
playing patterns of any gambler. They will know more about the gambler’s
playing behaviour than the gamblers themselves. They will be able to send the
gambler offers and redemption vouchers, complimentary accounts, etc. The
industry claims all of these things are introduced to enhance customer experi-
ence. More unscrupulous operators however, will be able to entice known
problem gamblers back on to their premises with tailored freebies (such as the
inducement of ‘free’ bets in the case of remote gambling).

Given the brief outline above, remote gambling could easily become a medium
for problematic gambling behaviour. Even if numbers of problem remote gam-
blers are small (and they by no means necessarily are), remote gambling
remains a matter of concern. Remote gambling is a relatively new phenomenon
and is likely to continue expanding in the near future. It is therefore crucial that
the new legislation does nothing to facilitate the creation or escalation of prob-
lems in relation to remote gambling. The recent decision by the US to ban
internet gambling by making it illegal to pay with debit and credit cards is like-
ly to drive the problem internet gambling “underground” and result in even
less protection for vulnerable gamblers. New innovative ways of paying elec-
tronically for internet gambling will emerge and the prohibitive stance taken by
the US is likely to have little long-lasting protective effect.

Consequences and co-morbidities

Problem gambling is often co-morbid with other behavioural and psychologi-
cal disorders, which can exacerbate, or be exacerbated by, problem gambling.
Some of the psychological difficulties a problem gambler may experience
include anxiety, depression, guilt, suicidal ideation and actual suicide attempts
(Daghestani et al, 1996; Griffiths, 2004). Problem gamblers may also suffer
irrational distortions in their thinking (e.g. denial, superstitions, overconfi-
dence, or a sense of power or control) (Griffiths, 1994a). Increased rates of
attention-deficit hyperactivity disorder (ADHD), substance abuse or depend-
ence, antisocial, narcissistic, and borderline personality disorders have also
been reported in pathological gamblers (APA, 1994; Griffiths, 1994b). There is
also some evidence that co-morbidities may differ among demographic sub-
groups and gambling types. For instance, young male slot machine gamblers
are more likely to abuse solvents (Griffiths, 1994c).
There is frequently a link with alcohol or drugs as a way of coping with anx-
iety or depression caused by gambling problems, and, conversely, alcohol may
trigger the desire to gamble (Griffiths, Parke & Wood, 2002). According to the

18
 addictions: special report: gambling addiction in the UK

DSM IV, pathological gamblers tend to be highly competitive, energetic, rest-

less, easily bored, and believe money is the cause of, and solution to, all their
problems (see also Parke, Griffiths & Irwing, 2004). According to the
American Psychiatric Association, pathological gamblers may also be overly
concerned with the approval of others and may be extravagantly generous.
Further, when not gambling, they may be workaholics or ‘binge’ workers who
wait until they are up against deadlines before really working hard.
Pathological gamblers may also be prone to stress-related physical illnesses
including insomnia, hypertension, heart disease, stomach problems (e.g. pep-
tic ulcer disease) and migraine (Daghestani et al, 1996; Abbot & Volberg, 2000;
Griffiths, Scarfe & Bellringer, 2001; Griffiths, 2004). Like other addictive
behaviours, while engaged in gambling, the body produces increased levels of
endorphins (the body’s own morphine like substance), and other ‘feel good’
chemicals like noradrenaline and seretonin (Griffiths, 2006). Many of these
physical negative effects may stem from the body’s own neuro-adaptation
processes.
Health-related problems due to problem gambling can also result from with-
drawal effects. Rosenthal and Lesieur (1992) found that at least 65 per cent of
problem gamblers reported at least one physical side-effect during withdrawal
including insomnia, headaches, upset stomach, loss of appetite, physical weak-
ness, heart racing, muscle aches, breathing difficulty and/or chills. Their results
were also compared to the withdrawal effects from a substance-dependent con-
trol group. They concluded that problem gamblers experienced more physical
withdrawal effects when attempting to stop than the substance-dependent group.
Interpersonal problems suffered by problem gamblers include conflict with
family, friends and colleagues, and breakdown of relationships, often culminat-
ing in separation or divorce (Griffiths, 2004, 2006). The children of problem
gamblers also suffer a range of problems, and tend to do less well at school
(Jacobs, Marston, Singer et al, 1989; Lesieur & Rothschild, 1989). School- and
work-related problems include poor work performance, abuse of leave time
and job loss (Griffiths, 2002). Financial consequences include reliance on fam-
ily and friends, substantial debt, unpaid creditors and bankruptcy (Griffiths,
2006). Finally, there may be legal problems as a result of criminal behaviour
undertaken to obtain money to gamble or pay gambling debts (Griffiths,
2005b; 2006). The families of problem gamblers can also experience substan-
tial physical and psychological difficulties (Griffiths & Delfabbo, 2001;
Griffiths, 2006).
High levels of substance misuse and some other mental disorders among
problem gamblers highlight the importance of screening for gambling prob-
lems among participants in alcohol and drug treatment facilities, mental health
centres and outpatient clinics, as well as probation services and prisons.
Unfortunately, ‘beyond programmes that provide specialised problem gam-
bling services, few counselling professionals screen for gambling problems
among their clients. Even when a gambling problem is identified, non-special-

19
Breakthrough Britain

ist professionals are often uncertain about the appropriate referrals to make or
what treatments to recommend (Abbott et al, 2004). There is clearly a need for
education and training in the diagnosis, appropriate referral and effective
treatment of gambling problems.
Given the co-morbidity of alcoholism with gambling addiction, the recent
introduction of 24-hour licensing may have an impact on the prevalence of
gambling addiction. It is important that post-evaluative studies undertaken by
the Department for Culture, Media and Sport (DCMS) to monitor the impact
of the introduction of 24-hour licensing consider any potential impact this will
have on levels of gambling addiction.

Structural characteristics in gambling

Gambling is a multifaceted rather than unitary phenomenon. Consequently, many
factors may come into play in various ways and at different levels of analysis (e.g.
biological, social or psychological). Theories may be complementary rather than
mutually exclusive, which suggests that limitations of individual theories might be
overcome through the combination of ideas from different perspectives. This has
often been discussed in terms of recommendations for an ‘eclectic’ approach to
gambling or a distinction between proximal and distal influences upon gambling
(Walker, 1992). For the most part however, such discussions have been descriptive
rather than analytical, and so far, few attempts have been made to explain why an
adherence to a singular perspective is untenable. Put very simply, there are many
different factors involved in how and why people develop gambling problems.
Central to the latest thinking is that no single level of analysis is considered suffi-
cient to explain either the aetiology or maintenance of gambling behaviour.
Moreover, this view asserts that all research is context-bound and should be
analysed from a combined, or biopsychosocial, perspective (Griffiths, 2005c).
Variations in the motivations and characteristics of gamblers and in gambling
activities themselves mean that findings obtained in one context are unlikely to be
relevant or valid in another.
Another factor central to understanding gambling behaviour is the structure
of gambling activities. Griffiths (1993; 1995; 1999) has shown that gambling
activities vary considerably in their structural characteristics, such as the prob-
ability of winning, the amount of gambler involvement, the use of the near
wins, the amount of skill that can be applied, the length of the interval between
stake and outcome and the magnitude of potential winnings. Structural varia-
tions are also observed within certain classes of activities such as slot machines,
where differences in reinforcement frequency, colours, sound effects and
machines’ features can influence the profitability and attractiveness of
machines significantly (Griffiths & Parke, 2003; Parke & Griffiths, 2006; in
press). Each of these structural features may (and almost certainly does) have
implications for gamblers’ motivations and the potential ‘addictiveness’ of
gambling activities.

20
 addictions: special report: gambling addiction in the UK

For example, skilful activities that offer players the opportunity to use com-
plex systems, study the odds and apply skill and concentration appeal to many
gamblers because their actions can influence the outcomes. Such characteris-
tics attract people who enjoy a challenge when gambling. They may also con-
tribute to excessive gambling if people overestimate the effectiveness of their
gambling systems and strategies. Chantal and Vallerand (1996) have argued
that people who gamble on these activities (e.g. racing punters) tend to be
more intrinsically motivated than lottery gamblers in that they gamble for self-
determination (i.e., to display their competence and to improve their perform-
ance).
People who gamble on chance activities, such as lotteries, usually do so for
external reasons (i.e., to win money or escape from problems). This finding
was confirmed by Loughnan, Pierce and Sagris (1997) in their clinical survey
of problem gamblers. Here, racing punters emphasised the importance of skill
and control considerably more than slot machine players. Although many slot
machine players also overestimate the amount of skill involved in their gam-
bling, other motivational factors (such as the desire to escape worries or to
relax) tend to predominate. Thus, excessive gambling on slot machines may be
more likely to result from people becoming conditioned to the tranquilising
effect brought about by playing rather than just the pursuit of money.
Another vital structural characteristic of gambling is the continuity of the
activity; namely, the length of the interval between stake and outcome. In near-
ly all studies, it has been found that continuous activities (e.g. racing, slot
machines, casino games) with a more rapid play-rate are more likely to be asso-
ciated with gambling problems (Griffiths, 1999). The ability to make repeated
stakes in short time intervals increases the amount of money that can be lost
and also increases the likelihood that gamblers will be unable to control spend-
ing. Such problems are rarely observed in non-continuous activities, such as
weekly or bi-weekly lotteries, in which gambling is undertaken less frequently
and where outcomes are often unknown for days. Consequently, it is important
to recognise that the overall social and economic impact of expansion of the
gambling industry will be considerably greater if the expanded activities are
continuous rather than non-continuous.

Situational characteristics in gambling

Other factors central to understanding gambling behaviour are the situational
characteristics of gambling activities. These are the factors that often facilitate
and encourage people to gamble in the first place (Griffiths & Parke, 2003).
Situational characteristics are primarily features of the environment (e.g.,
accessibility factors such as location of the gambling venue, the number of ven-
ues in a specified area, possible membership requirements, etc.) but can also
include internal features of the venue itself (décor, heating, lighting, colour,
background music, floor layout, refreshment facilities, etc.) or facilitating fac-

21
Breakthrough Britain

tors that may influence gambling in the first place (e.g., advertising, free travel
and/or accommodation to the gambling venue, free bets or gambles on partic-
ular games, etc.) or influence continued gambling (e.g., the placing of a cash
dispenser on the casino floor, free food and/or alcoholic drinks while gam-
bling, etc.) (Griffiths & Parke, 2003; Abbott & Volberg, in press).
These variables may be important in both the initial decision to gamble and
the maintenance of the behaviour. Although many of these situational charac-
teristics are thought to influence vulnerable gamblers, there has been very lit-
tle empirical research into these factors and more research is needed before any
definitive conclusions can be made about the direct or indirect influence on
gambling behaviour and whether vulnerable individuals are any more likely to
be influenced by these particular types of marketing ploys. The introduction of
super-casinos into the UK will almost certainly see an increase in these types
of situational marketing strategies and should also provide an opportunity to
research and monitor the potential psychosocial impact.

Impact of the Gambling Act 2005 on problem gambling

Although the BGPS found that Britain has a comparatively low rate of problem
gambling (between 0.6% and 0.8% or 275,000 to 370,000 people; Sproston et al,
2000), this figure should be considered in the context of the (relatively) limit-
ed gambling opportunities available to the public at the time the survey was
conducted in 1999. It has been predicted that the future expansion in gambling
opportunities enabled by the Gambling Act 2005 (see appendix 5) can be
expected to result in an increase in problem gambling in the UK (Griffiths,
2004). This is because the new legislation, due for full implementation in 2007,
will significantly increase access to EGM’s and other continuous gambling
forms, including online gambling. Risk profiles are also likely to change, with
disproportionate increases in problem gambling among women, ethnic and
new migrant minorities. There is also concern about adolescent gambling
although the latest national prevalence survey did show that adolescent prob-
lem gambling is on the decrease (currently 3.5% in 2006, down from 4.9% in
2000) (MORI/International Gaming Research Unit, 2006). Newer technologies
however, like internet gambling may be more attractive to this sub-group.
While research is starting to suggest that increases in problems may level out
over time (Abbott & Volberg, in press), this appears to be part of a complex
process involving, among other things, social adaptation, the implementation
of public health policies and the provision of specialist treatment services. It
also appears to be an uneven process that affects different groups of people in
different ways.
The Gambling Act 2005 enhances opportunities to gamble in a multitude of
ways, and research has shown that increasing the availability of particular
forms of gambling can have a significant impact on the prevalence of problem
gambling within a community (Griffiths, 1999; 2003a). It is important to

22
 addictions: special report: gambling addiction in the UK

appreciate the differences between various forms of gambling and their link to
problem gambling, as increasingly evidence suggests that some types of gam-
bling are more strongly associated with gambling-related problems than others
(see section on ‘Profiling’ above) (Abbott & Volberg, 1999).
Abbott (in press) has noted that in periods when new EGMs are being intro-
duced or made highly accessible, substantial changes can occur over relatively
short periods of time in the population sectors at highest risk for problem gam-
bling. The RIGT notes that in that situation, existing services may need to
change to be able to engage and work effectively with large numbers of differ-
ent types of problem gambler. With disproportionate increases in problem
gambling expected among women, youth, and ethnic and new migrant minori-
ties, the development of targeted services and services that are culturally and
demographically appropriate may be essential.
Abbott and Volberg (in press) have noted that raising public awareness of the
risks of excessive gambling, expanding services for problem gamblers and
strengthening regulatory, industry and public health harm reduction measures
appear to counteract some adverse effects from increased availability. What is not
known however, is how quickly such proactive mechanisms can have a significant
impact and whether or not they can prevent problem gambling if they are intro-
duced concurrently with increased access to ‘harder’ and more ‘convenient’ forms
of gambling such as Internet gambling (Griffiths, Parke, Wood & Parke, 2005).

Where do we go from here? What can we do?

Although gambling is clearly of policy interest it has not been traditionally
viewed as a public health matter (Griffiths, 1996; Korn, 2000). Furthermore,
research into the health, social and economic impacts of gambling are still at
an early stage. There are many specific reasons why gambling should be viewed
as a public health and social policy issue - particularly given the massive
expansion of gambling opportunities across the world. The following provides
some recommendations to consider relating to policy initiatives.

Research: Understanding problem gambling is seriously hindered by a lack of

high quality data, both internationally and especially in the UK. It is important to
expand the research base on the causes, progression, distribution and treatment
of gambling problems. One way to begin tackling the problem could be to link up
with overseas networks and researchers in order to pool knowledge and expert-
ise. The RIGT should also provide funding for major research programmes.
Gambling as a health issue could also be included in other national surveys on
health (such as the General Health Survey). In short there should be:

 Regular surveys of problem gambling services, including helplines and

formal treatment providers, and evaluations of the effectiveness and effi-
cacy of these services.

23
Breakthrough Britain

 Research into the efficacy of various approaches to the treatment of gam-

bling addiction needs to be undertaken.
 Research into the association of Internet gambling and problem gambling.
 Research into the impacts of gambling, including health, family, work-
place, financial and legal impacts.
 Longitudinal research into problem gambling, treatment, and the impact
of gambling legislation on prevalence of problem gambling. In particular,
why some people develop problems and, just as importantly, why the
majority do not develop problems.

Legislation – Limit the opportunities and accessibility to gamble: There is lit-

tle doubt that opportunities and accessibility to gamble will increase as a result
of both the Gambling Act and opportunities for remote gambling.
Underpinning this recommendation is psychological research into the ‘avail-
abilty hypothesis’ (Orford, 2002). What has generally been demonstrated from
research evidence in other countries is that where accessibility of gambling is
increased there is an increase not only in the number of regular gamblers but
also an increase in the number of problem gamblers (Griffiths, 1999) and sup-
ports the availability hypothesis. This obviously means that not everyone is
susceptible to developing gambling addictions but it does mean that at a soci-
etal (rather than individual) level, the more gambling opportunities, the more
problems. Therefore, number of outlets and opportunities could be capped
(such as putting a cap on the size and number of casinos nationally). Particular
psychological concern must be given to gambling in new media (e.g. Internet,
interactive television, and mobile phone gambling) that may affect individuals
in different ways.

Legislation – Raise the minimum age of all forms of commercial gambling

to 18 years: A public-health approach to gambling-related harm adopts a
broader conception of the causes of gambling-related problems. Traditional
approaches tend to focus on the characteristics that pre-dispose some gam-
blers to develop problems, whereas a public health approach focuses on the
characteristics of the environment that encourages excessive gambling (e.g.,
advertising, time restrictions etc.). The single most important measure would
be to raise the legal age of gambling. This would significantly reduce the age
at which children start to gamble and would also help gaming operators and
shopkeepers prevent underage gambling. Research by psychologists has con-
sistently shown that the younger a person starts to gamble, the more likely
they are to develop problems (Griffiths, 2002). Furthermore, gambling, like
other addictions involving alcohol and illicit drug use, are ‘disorders of youth-
ful onset’ (Teeson, Degenhardt & Hall, 2002). At present, many young adoles-
cents as young as 11 and 12 years of age can pass for being sixteen. An age rise
to 18 years would stop a lot of the very young adolescents gambling in the first
place. At the very least, there should be a review of slot machine gambling to

24
 addictions: special report: gambling addiction in the UK

assess whether slot machine gambling should be restricted to those over 18

years of age.

Education – Raise awareness about gambling among health practitioners and

the general public: There is an urgent need to enhance awareness within the
medical and health professions, and the general public about gambling-related
problems (Griffiths & Wood, 2000; Korn, 2000). The lack of popular and politi-
cal support for policies that increase price or reduce availability has encouraged
other approaches such as public education. Problem gambling is very much the
“hidden” addiction. Unlike (say) alcoholism, there is no slurred speech and no
stumbling into work. Furthermore, overt signs of problems often do not occur
until late in the pathological gambler’s career. When it is considered that prob-
lem gambling can be an addiction that can destroy families and have medical
consequences, it becomes clear that health professionals and the public should be
aware of the effects. General practitioners routinely ask patients about smoking
and drinking but gambling is something that is not generally discussed (Setness,
1997). Problem gambling may be perceived as a somewhat “grey” area in the field
of health and it is therefore is very easy to deny that health professionals should
be playing a role. Those who work with problem gamblers have a clear role in
educating both practitioners and the public about the psychosocial risks involved
in excessive gambling. In short, health practitioners should;

 Be aware of the types of gambling and problem gambling, demographic

and cultural differences, and the problems and common co-morbidities
associated with problem gambling.
 Be provided with education and training in the diagnosis, appropriate
referral and effective treatment of gambling problems must be addressed
within GP training.
 Understand the importance of screening patients perceived to be at
increased risk of gambling addiction.
 Be aware of the referral services available locally, and also support services.

Prevention: Set up both general and targeted gambling prevention initiatives:

There has been little in the way of prevention and intervention initiatives in the
UK and this is one area that psychologists can have a clear and direct role.
According to Korn (2002), the goals of gambling intervention are to (i) prevent
gambling-related problems, (ii) promote informed, balanced attitudes and
choices, and (iii) protect vulnerable groups. The guiding principles for action
on gambling are therefore prevention, health promotion, harm reduction, and
personal and social responsibility.
Throughout the world there are many actions and initiatives that are carried
out as preventative measures in relation to gambling. The most common
examples of these include: general awareness raising (e.g., public education
campaigns through advertisements on television, radio, newspapers); targeted

25
Breakthrough Britain

prevention (e.g., targeted education programs and campaigns for particular

vulnerable populations such as senior citizens, adolescents, ethnic minorities
etc.); awareness raising within gambling establishments (e.g., brochures and
leaflets describing problem gambling, indicative warning signs, where help for
problems can be sought etc.); training materials (e.g., training videos about
problem gambling shown in schools, job centres etc.); training of gambling
industry personnel (e.g., training managers of gambling establishments, and
those who actually have interaction with gamblers such as croupiers); and
Internet prevention (e.g., the development, maintenance and linking of prob-
lem gambling websites). Psychologists can be of direct help in all of these ini-
tiatives. Education and prevention programmes should also be targeted at chil-
dren and adolescents along with other potentially addictive and harmful
behaviours (e.g. smoking, drinking, and drug taking). More specifically, gam-
bling operators and service providers should:

 Supply information on gambling addiction, treatment and services to

patrons.
 Support development of centralised training for gambling venue staff to
ensure uniform standards and accreditation.
 Pay at least £10 million per annum to fund research, prevention, interven-
tion, and treatment programmes. This fund is administered by the
Responsibility in Gambling Trust.

Treatment – Introduce gambling support and treatment initiatives: In addi-

tion to the preventative measures outlined above, there are many support ini-
tiatives that could also be introduced. These include:

 The running of problem gambling helplines as a referral service.

 The running of telephone counselling for problem gamblers and those
close to them.
 The running of web-based chat rooms and online counselling for problem
gamblers and those close to them.
 The funding of outpatient treatment.
 The funding of in-patient and residential treatment.
 Training for problem gambling counsellors (volunteers or professionals;
face-to-face, telephone and/or online).
 Certification of problem gambling counsellors.

The intervention options for the treatment of problem gambling include1, but
are not limited to: counselling, psychotherapy, cognitive-behavioural therapy
(CBT), advisory services, residential care, pharmacotherapy, and/or combina-
tions of these (i.e., multi-modal treatment) Griffiths, 1996; Griffiths &
MacDonald, 1999; Griffiths & Delfabbro, 2001; Griffiths, Bellringer, Farrell-
Roberts & Freestone, 2001; Hayer et al, 2005.

26
 addictions: special report: gambling addiction in the UK

There is also a very recent move towards using the Internet as a route for
guidance, counselling and treatment (see Griiffiths & Cooper, 2003; Griffiths,
2005d; Wood & Griffiths, 2007). Treatment and support is provided from a
range of different people (with and without formal medical qualifications),
including specialist addiction nurses, counsellors, medics, psychologists, and
psychiatrists. There are also websites and helplines to access information (e.g.,
GamCare) or discuss gambling problems anonymously (e.g., GamAid), and
local support groups where problem gamblers can meet other people with sim-
ilar experiences (e.g. Gamblers Anonymous). Support is also available for
friends and family members of problem gamblers (e.g., Gam Anon).
Many private and charitable organisations throughout the UK provide sup-
port and advice for people with gambling problems. Some focus exclusively on
the help, counselling and treatment of gambling addiction (e.g., Gamblers
Anonymous, GamCare, Gordon House Association), while others also work to
address common addictive behaviours such as alcohol and drug abuse (e.g.
Aquarius, Addiction Recovery Foundation, Connexions Direct, Priory). The
method and style of treatment varies between providers and can range from
comprehensive holistic approaches to the treatment of gambling addiction (e.g.
encouraging fitness, nutrition, alternative therapies and religious counselling),
to an abstinence-based approach.
Many providers also encourage patients (and sometimes friends and fami-
lies) to join support groups (e.g., Gamblers Anonymous and Gam-Anon),
while others offer confidential one-to-one counselling and advice (e.g.,
Connexions). Most are non-profit making charities to which patients can self-
refer and receive free treatment. Independent providers that offer residential
treatment to gambling addicts are more likely to charge for their services. Some
provide both in-patient treatment and day-patient services (e.g. PROMIS), and
a decision as to the suitability of a particular intervention is made upon admis-
sion.
Due to the lack of relevant evaluative research, the efficacy of various forms
of treatment intervention is almost impossible to address. Much of the docu-
mentation collected by treatment agencies is incomplete or collected in ways
that makes comparisons and assessments of efficacy difficult to make. As
Abbott et al (2004) have noted, with such a weak knowledge base, little is
known about which forms of treatment for problem gambling in the U.K. are
most effective, how they might be improved or who might benefit from them.
However, their review did note that individuals who seek help for gambling
problems tend to be overwhelmingly male, aged between 18 to 45 years, and
whose problems are primarily with on- and off-course betting, and slot
machine use.
The gaming industry has typically viewed pathological gambling as a rare men-
tal disorder that is predominantly physically and/or psychologically determined. It
supports recent findings that suggest many problem gamblers have transient prob-
lems that often self-correct. Currently, gambling providers in the UK are not com-

27
Breakthrough Britain

pelled to supply patrons with help and advice about gambling problems, and have
been reluctant to engage directly in interventions. Some gambling providers how-
ever, have taken the initiative to address the issue of gambling addiction within
their businesses. Secondary prevention efforts by the gaming industry have includ-
ed the development and implementation of employee training programmes,
mandatory and voluntary exclusion programmes and gambling venue partner-
ships with practitioners and government agencies to provide information and
improved access to formal treatment services (see appendix 4).
Implementation of secondary prevention efforts by the gaming industry,
such as employee training programmes and exclusion programmes, have not
always been of the highest quality and compliance has often been uneven. In
addition, observations from abroad appear to demonstrate that efforts by the
gaming industry to address gambling addiction tend to compete with heavily
financed gaming industry advertising campaigns that may work directly to
counteract their effectiveness (Griffiths, 2005e). Although advertising of gam-
bling is very restricted at present, this is likely to be become much more liber-
al over the next decade. As a minimum:

 Information about gambling addiction services, in particular services in

the local area, should be readily available to gamblers. Although some
gambling services (such as GamCare and GamAid) provide information to
problem gamblers about local services, such information is provided to
problem gamblers who have already been proactive in seeking gambling
help and/or information.
 Treatment for problem gambling should be provided under the NHS
(either as stand alone services or alongside drug and alcohol addiction
services) and funded either by the RIGT or other gambling-derived rev-
enue. Such provision could follow the tiered system of treatment used for
drug addiction, as outlined in the Department of Health Models of Care
(2002) document. Both the Budd Commission and the review commis-
sioned by the Responsibility in Gambling Trust (Abbott et al, 2004) recom-
mended the adoption of a system of stepped care for the treatment of prob-
lem gambling.
 Expand provision of nationally dedicated problem gambling treatment,
advice and counselling services both in and outside of the NHS. At pres-
ent, such provision is sparse and unevenly distributed throughout the
country. Wherever possible, information and treatment services should be
sited close to gambling venues, as research suggests that increased proxim-
ity of the former to the latter increases the efficacy of support.
 Funding should be sought from the Department of Health for the develop-
ment and evaluation of targeted services (such as for ethnic minorities,
young people, women, and family members)
Social policy – Embed problem gambling in public health policy: It is clear
that increased research into problem gambling is being taken seriously by

28
 addictions: special report: gambling addiction in the UK

many countries across the world. This needs to be embedded into public health
policy and practice (Shaffer and Korn, 2002). Such measures include:

 Adoption of strategic goals for gambling to provide a focus for public health
action and accountability. These goals include preventing gambling-relat-
ed problems among individuals and groups at risk for gambling addiction;
promoting balanced and informed attitudes, behaviours, and policies
toward gambling and gamblers by both individuals and communities; and
protecting vulnerable groups from gambling-related harm.
 Endorsement of public health principles consisting of three primary principles
that can guide and inform decision-making to reduce gambling-related
problems. These are ensuring that prevention is a community priority, with
the appropriate allocation of resources to primary, secondary and tertiary
prevention initiatives; incorporating a mental health promotion approach
that builds community capacity, incorporates a holistic view of mental
health, and addresses the needs and aspirations of gamblers, individuals at
risk of gambling problems, or those affected by them; and fostering person-
al and social responsibility for gambling policies and practices.
 Adoption of harm reduction strategies directed at minimizing the adverse
health, social, and economic consequences of gambling behaviour for indi-
viduals, families, and communities. These initiatives should include healthy-
gambling guidelines for the general public (similar to low-risk drinking
guidelines); vehicles for the early identification of gambling problems; non-
judgemental moderation and abstinence goals for problem gamblers, and
surveillance and reporting systems to monitor trends in gambling-related
participation and the incidence and burden of gambling-related illnesses.

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Appendix 1
DSM-IV Diagnostic criteria for Pathological Gambling
A. Persistent and recurrent maladaptive gambling behaviour as indicated by
five (or more) of the following:

1 is preoccupied with gambling (e.g. preoccupied with reliving past gam-

bling experiences, handicapping or planning next venture, or thinking of
ways to get money with which to gamble)
2 needs to gamble with increasing amounts of money in order to achieve the
desired excitement
3 has repeated unsuccessful efforts to control, cut back, or stop gambling
4 is restless or irritable when trying to cut down or stop gambling
5 gambles as a way of escaping from problems or of relieving a dysphoric
mood (e.g. feelings of helplessness, guilt, anxiety, depression)
6 after losing money gambling, often returns another day to get even (‘chas-
ing’ one’s losses)
7 lies to family members, therapist, or others to conceal extent of involve-
ment with gambling
8 has committed illegal acts such as forgery, fraud, theft, or embezzlement
to finance gambling
9 has jeopardised or lost a significant relationship, job, or educational or
career opportunity because of gambling
10 relies on others to provide money to relieve a desperate financial situation
caused by gambling.

B. The gambling behaviour is not better accounted for by a manic episode.

SOURCE: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, fourth
edition (DSM-IV), 1994, pp615-6

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Appendix 2

South Oaks Gambling Screen

1. Please indicate which of the following types of gambling you have done in your lifetime. For each type,
mark one answer: ‘not at all’, ‘less than once a week’, or ‘once a week or more’.

A: Not at all
B: Less than once a week
C: Once a week or more

A B C
____ ____ ____ a. played cards for money

____ ____ ____ b. bet on horses, dogs or other animals (in

off-track betting, at the track or with a
bookie)

____ ____ ____ c. bet on sports (parley cards, with a book

ie, or at jai alai)

____ ____ ____ d. played dice games (including craps, over

and under, or other dice games) for money

____ ____ ____ e. went to casino (legal or otherwise)

____ ____ ____ f. played the numbers or bet on lotteries

____ ____ ____ g. played bingo

____ ____ ____ h. played the stock and/or commodities

market

____ ____ ____ i. played slot machines, poker machines or

other gambling machines

____ ____ ____ j. bowled, shot pool, played golf or played

some other game of skill for money

2. What is the largest amount of money you have ever gambled with any one day?

___ never have gambled

___ more than $100 up to $1000
___ $10 or less
___ more than $1000 up to $10,000
___ more than $10 up to $100
___ more than $10,000

3. Do (did) your parents have a gambling problem?

___ both my father and mother gamble (or gambled) too much
___ my father gambles (or gambled) too much
___ my mother gambles (or gambled) too much
___ neither gambles (or gambled) too much

4. When you gamble, how often do you go back another day to win back money you lost?
___ never
___ some of the time (less than half the time) I lost
___ most of the time I lost
___ every time I lost

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 addictions: special report: gambling addiction in the UK

5. Have you ever claimed to be winning money gambling but weren’t really? In fact, you lost?
___ never (or never gamble)
___ yes, less than half the time I lost
___ yes, most of the time

6. Do you feel you have ever had a problem with gambling?

___ no
___ yes, in the past, but not now
___ yes

Ye s No

7. Did you ever gamble more than you intended?

____ ____

8. Have people criticized your gambling?

____ ____

9. Have you ever felt guilty about the way you gamble or what happens when you gamble?
____ ____

10. Have you ever felt like you would like to stop gambling but didn’t think you could?
____ ____

11. Have you ever hidden betting slips, lottery tickets, gambling money, or other signs of gambling from
your spouse, children, or other important people in you life?
____ ____

12. Have you ever argued with people you like over how you handle money?
____ ____

13. (If you answered ‘yes’ to question 12): Have money arguments ever centered on your gambling?
____ ____

14. Have you ever borrowed from someone and not paid them back as a result of your gambling?
____ ____

15. Have you ever lost time from work (or school) due to gambling?
____ ____

16. If you borrowed money to gamble or to pay gambling debts, where did you borrow from? (Check
‘yes’ or ‘no’ for each)
a. from household money
____ ____
b. from your spouse
____ ____
c. from other relatives or in-laws
____ ____

d. from banks, loan companies or credit unions

____ ____
e. from credit cards
____ ____
f. from loan sharks (Shylocks)
____ ____
g. your cashed in stocks, bonds or other securities
____ ____
h. you sold personal or family property
____ ____
ii. you borrowed on your checking account (passed bad checks)
____ ____
jj. you have (had) a credit line with a bookie
____ ____

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Breakthrough Britain

k. you have (had) a credit line with a casino

____ ____

Scores are determined by adding up the number of questions that show an ‘at risk’ response, indi-
cated as follows. If you answer the questions above with one of the following answers, mark that
the space next to that question:

Questions 1-3 are not counted.

___ Question 4: most of the time I lost, or every time I lost
___ Question 5: yes, less than half the time I lose, or yes, most of the time
___ Question 6: yes, in the past, but not now, or yes
___ Question 7: yes
___ Question 8: yes
___ Question 9: yes
___ Question 10: yes
___ Question 11: yes
Question 12 is not counted
___ Question 13: yes
___ Question 14: yes
___ Question 15: yes
___ Question 16a: yes
___ Question 16b: yes
___ Question 16c: yes
___ Question 16d: yes
___ Question 16e: yes
___ Question 16f: yes
___ Question 16g: yes
___ Question 16h: yes
___ Question 16i: yes
Questions 16j and 16k are not counted

Total = ________ (20 questions are counted)

**3 or 4 = potential pathological gambler (problem gambler)

**5 or more = probable pathological gambler

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