ABSTRACT

Issue address: Those seeking help for gambling problems having a high prevalence of smoking and may increase their rate of smoking when gambling. This may raise awareness of the increased risk from some problem gamblers to all gamblers (and staff) for tobacco-related health problems and may support legislation that restricts smoking in gambling environments.

Methods: Clients attending a day treatment centre for their problem gambling were invited to complete a questionnaire around smoking rates and an estimate of the smoking rates on gambling and non-gambling days. Perceptions were invited around effects of smoking and smoking changes when gambling.

Results: The response rate was 100% (n=79). 67% were tobacco smokers compared with 25% of the New Zealand population, most (89%) starting their tobacco use prior to their first gambling. Just 2.5% had given up smoking. Most (82%) perceived their smoking increased during gambling.

Conclusion: Prevalence rate of tobacco use by problem gamblers seeking help for their gambling behaviour is high and their tobacco consumption appears to increase substantially while gambling.

Key words: Smoking, problem gambling, passive smoking, addiction.
Health Promotion Journal of Australia 2003; 14:192-5

So what?
Extended gambling sessions (continuous gambling episodes) typically experienced by problem gamblers may make gambling venues higher-risk environments for smoking-related health problems than previously considered for all gamblers and staff. Smoke-free gambling environments may be an important health promotion goal from the dimension of harm reduction around gambling.

INTRODUCTION

Use of tobacco by those in New Zealand (NZ) gambling venues anecdotally appears high, with limited research overseas providing some support (1,2). However, as the general population prevalence of tobacco use is just one in four (3), this suggests that there may be a greater concentration of tobacco smokers in gambling environments with its concomitant elevated health risk. Although the prevalence of problem gambling (ie those who experience harm or cause harm to others as a result of their gambling) (4) in the general population is low (1%-4.9%) (4,5), the prevalence will be considerably higher in gambling environments, especially those with gambling machines, where it has been suggested that one in five weekly players of gambling machines may have problems (4).

Those seeking help for gambling problems are usually experiencing serious problems (6). Unlike other addictions, continued gambling appears to offer those gambling excessively an apparent solution to their growing financial problems, often resulting in a delay in seeking help until all access to gambling money has been lost. Therefore, many gamblers experiencing problems are often under high levels of emotional as well as financial stress, with associated anxiety and mood disorders that may be medicated by their gambling (7-8) and, perhaps, through the use of nicotine (9). Recent research suggests that smoking is associated with severity of gambling problems, including family and social problems and psychiatric symptoms (10). In addition, problem gamblers may spend longer in gambling venues (4), with the result that the impact of the smoking behaviour of problem gamblers may be greater than that of non-problem gamblers.

This study proposed to identify the prevalence of tobacco use by problem gamblers who sought help for their gambling behaviour and whether their tobacco use increased during gambling. If this were the case, it could raise awareness of the possibility of higher risk for consequential harm from excessive smoking in gambling environments and consideration around addressing tobacco use in counselling for problem gambling.

METHODS

Clients attending three community treatment clinics for problem gambling over a continuous three-week period were invited to complete a questionnaire covering commencement of smoking in relation to their gambling, tobacco use on gambling and non-gambling days, reason for smoking, effects of tobacco use when gambling, attitude to their gambling venues becoming smoke-free, and problematic mode of gambling. To enhance both candour and completion, the questionnaire was anonymous and brief (nine questions - copy available from first author); however, all were invited to include comments about their smoking and gambling if they desired. Problem gambling mode was sought for comparison with all clients as one indicator that the anonymous sample corresponded with problem gambling help seekers to New Zealand services. Participation was restricted only to clients who were attending for their own gambling problems.

Rates of tobacco use were compared with that of the general population and rates of use on both gambling and non-gambling days were also compared. The questionnaire was piloted with clients in a group setting and minor changes made before commencing the survey.

RESULTS

Seventy-nine clients participated (100% response rate). Fifty-three of the 79 clients were current smokers while two had previously smoked but given it up.

Modes of gambling identified by the problem gamblers were similar in proportions to all problem gamblers seeking help in New Zealand during the previous year, suggesting the sample was representative of help-seeking problem gambling population in New Zealand (6).

Current smoking status
Twenty-four (30.4%) clients stated they did not smoke and had not done so in the past and were advised they did not need to continue the survey. Fifty-three (67%) clients acknowledged that they currently smoked tobacco. Two (2.5%) clients reported they used to smoke but had given up.

Smoking before gambling
Of the 53 gamblers who were current smokers, 48 (90.6%) were tobacco smokers prior to gambling while one (1.9%) reported commencing smoking at about the same time as they started gambling.

Tobacco consumption rates on a non-gambling day
Clients selected one of four categories of rates of smoking that they would average on a non-gambling day.

Although the tobacco use rates of these clients (when not gambling) have been compared with the smoking rates of the New Zealand population, the problem gambling help-seeking profile varies from the compared NZ population in several important aspects (eg problem gambling help-seeking is lower for females, however NZ population smoking higher for (younger) females; average age of problem gambling help-seeking reflects a narrower age range than NZ population),(6) and a direct comparison may not be appropriate. However, without placing undue importance on the figures, the national rate of smoking tobacco is considerably lower than that of those seeking help for gambling problems in the current study (67%) while tobacco consumption for problem gamblers on non-gambling days were somewhat higher than national rates.

Tobacco consumption rates on a gambling day
Clients who smoked tobacco were asked to select one of four categories of smoking that they would average on a gambling day. The non-gambling rate question was separated from the gambling rate question (question 2 and 7) to encourage recollection rather than matching.

There was a significant increase in the rate of smoking on gambling days (p<0.0001; Wilcoxin paired rank test).

To check robustness of these responses clients were asked to mark a Likert scale in response to the question: 'Does your smoking change when you are gambling?' Responses tended to be polarised with the majority indicating an increase in smoking rates when gambling when measured by either method, with a relatively strong concurrence between each measure (r=0.63).

Of the clients (n=49; four data missing) who either perceived that they smoked more on a gambling day or recorded an increase in the amount smoked when compared with their selection on a non-gambling day, 40 clients (81.6%) responded that their smoking rate increased when gambling.

Reasons for smoking
Fifty-five per cent (n=28) of clients who were current smokers (n=51; two data missing) smoked for relaxation, while 24% (n=12) smoked to reduce stress and tension from not smoking. A further 22% (n=11) identified both reasons for their smoking. The reasons for smoking were then compared with the clients' perception of the relationship of their tobacco use with their gambling.

Perception of effects of smoking while gambling
Clients were asked to select the phrase that best described their perception of the effects of smoking when gambling.

Although clients were able to readily describe the reasons for smoking, they were less able to determine the effects that tobacco provided when gambling, despite a significant increase in its use while gambling. Twelve of the 22 clients who stated that smoking had no relationship to their gambling indicated by other questions that they smoked more when gambling. Specific comments suggested a range of perceptions of the relationship between smoking and gambling, rather than consensus.

Comments by clients
Just five clients elected to write comments around their smoking behaviour in the survey. The comments were:

• "When I smoked and gambled the two together helped me drown my problems. I also found I was more easy to talk to in some circles and in others not."
• "Be more likely to stay less amount of time and money. Where there are pokies make it no smoking."
• "Smoked less when stress out on gambling."
• "Tend to have a smoke if I'm losing a lot of money or have just lost everything. Also 'victory' smokes if have a big (or even small) win."
• (A non-smoking gambler) "If I'm not playing the pokies it drives me out of pubs."

Access to smoking necessary for gambling
Clients were asked if smoking were banned at a gambling venue, whether their regular venue or not, would they still attend that gambling venue.

There was an almost equal allocation of responses as to whether they would continue to attend their gambling venue if it became smoke-free. Of those with higher rates of smoking (up to two packets a day or more on either a gambling or non-gambling day), 64.7% (n=11) responded that they would not attend a gambling venue that banned smoking, while for lower tobacco consumers (up to one packet a day or less) this reduced to 36.4% (n=12), with the significance being borderline on a gambling day (p=0.07) and not significant on a non-gambling day (p=0.18).

DISCUSSION

The prevalence of smoking was high (67%) among the help-seeking problem gamblers, all of whom were experiencing serious gambling problems. This may have little clinical significance unless the process can be explained together with what function tobacco may serve in problem gambling behaviour. One possible hypothesis is that the tobacco use and gambling may have a moderating effect on the problem gamblers' emotions, which they consciously or subconsciously seek. The change in the rate of smoking while gambling suggests some as yet indeterminate effect is occurring and may warrant further research.

Smoking has been identified as being associated with more severe gambling problems (10). Of interest would be the assessment of those affected by earlier-stage gambling problems (subclinical levels) and whether the prevalence of smoking reduced in this group. It is possible that smoking may have a role in persistence of gambling, despite growing problems. If so, control of smoking, public education and other prevention and protection measures may be an important goal for reasons other than physical costs of the smoking itself.

Some 82% of problem-gambling clients identified by at least one response that their rate of smoking increased once gambling began, with the rate of heavy smoking (up to two packets and more than two packets on a gambling day) being more than four times that of a non-gambling day.

Just under half (45%) of gamblers who smoked felt smoking provided an escape from the stress of not smoking, an indicator of dependence, while 41% responded that smoking assisted them to enjoy gambling. One smoker's comment identified that smoking and gambling together helped avoid problems and assisted them to socialise. However, many saw no relationship between their smoking and gambling.

A similar 45% of problem gamblers who smoked would be deterred from attending a gambling site by a smoking ban and this increased to two-thirds for heavier smokers. If smokers have a higher factor for problem gambling, this may suggest that non-smoking gambling environments may have important preventive implications for problem gambling.

Research in New Zealand identifies an overlap between certain ethnic groups (Maori, Pacific peoples) (3) who are higher tobacco consumers and have higher risks for gambling problems (5,6), with consequentially greater negative health effects.

These findings may have implications not only for problem gamblers, but for all gamblers and staff of gambling venues, where an estimated 8% of smoking-related deaths in NZ are attributable to passive smoking (3). Problem gamblers typically attend for longer gambling sessions than non-problem gamblers (4) and if the increased tobacco use found in this study is applicable to others with gambling problems, this may identify a source of health risk in gambling venues where smoking is permitted.

CONCLUSION

This study suggests that many gambling environments may be places of health risk, particularly for problem gamblers, because of high levels of tobacco smoke arising from escalating smoking rates. It may also point towards the need for further research into the role tobacco use has in the persistence of problem gambling. The study also may support restrictions around smoking in gambling environments, which may also inadvertently reduce the attraction of gambling venues for some gamblers experiencing problems with their gambling.

Authors

Sean Sullivan, Department of General Practice and Primary Health Care, University of Auckland, New Zealand
Hannah Beer, Department of Health Psychology, University of Auckland, New Zealand

References

1. Siegel M, Skeer M. Exposure to secondhand smoke and excess lung cancer mortality risk among workers in the '5 B's': bars, bowling alleys, billiard halls, betting establishments and bingo parlours. Tob Control 2003; 12(3):333-8.
2. Gupta R, Derevensky J. Adolescent gambling behaviour: a prevalence study and examination of correlates associated with problem gambling. J Gambl Stud 1998;14(4):319-45.
3. Ministry of Health, Tobacco Facts: May 2001. Wellington (NZ): Ministry of Health; 2001.
4. Productivity Commission. Australia's Gambling Industries. Canberra (ACT): Ausinfo; 1999.
5. Abbott M, Volberg R. Taking the Pulse on Gambling and Problem Gambling in NZ: A Report on Phase One of the National Prevalence Survey, No. 3. Wellington (NZ): Department of Internal Affairs; 2000.
6. Paton-Simpson G, Gruys M, Hannifin J. Problem Gambling Counselling in New Zealand: 2000 National Statistics. Wellington (NZ): Department of Internal Affairs; 2001.
7. Hollander E, Begaz T, DeCaria C. Pharmacologic approaches in the treatment of pathological gambling. CNS Spectr 1998;3(6): 72-82.
8. Sullivan S. Pathological gambling in New Zealand: the role of the GP. N Ethical J 2000;3(8): 11-8.
9. Henningfield J, Schuh L, Jarvick M. Pathophysiology of tobacco dependence. In: Bloom F, Kupfer D, editors. Psychopharmacology: The Fourth Generation of Progress. New York: Raven Press; 1995.
10. Petry N, Oncken C. Cigarette smoking is associated with increased severity of gambling problems in treatment-seeking gamblers. Addiction 2002;97(6): 745-53