key: cord-0746531-ruk2juo8
authors: Brodeur, Magaly; Audette-Chapdelaine, Sophie; Savard, Annie-Claude; Kairouz, Sylvia
title: Gambling and the COVID-19 pandemic: A scoping review
date: 2021-12-20
journal: Prog Neuropsychopharmacol Biol Psychiatry
DOI: 10.1016/j.pnpbp.2021.110389
sha: e16b8673198c086bace6213aafe21deb38fbcfec
doc_id: 746531
cord_uid: ruk2juo8

BACKGROUND: The impact of COVID-19 on mental health is tremendous. Since the beginning of the pandemic, several actors have raised concerns about the impact of the pandemic on gambling. Many actors fear a switch to online gambling in the context of the closure of many land-based gambling activities due to the restrictions imposed by public health authorities, such as physical distancing and lockdowns. This switch is worrisome because online gambling is considered a high-risk game. In that context, we need to know more about the impacts of the pandemic on gambling. This scoping review aims to summarize the literature that addresses the impacts of the COVID-19 pandemic on gambling. To our knowledge, this is the first review to focus on this subject. METHODS: An electronic literature search involving a strategy using keywords related to COVID-19 and gambling was conducted using MEDLINE, Academic Search Complete, CINAHL, PsychINFO, Social Works Abstract, and Socio Index databases on February 25th 2021. This search was combined with a manual search in Google Scholar. To be included, studies had to discuss gambling and COVID-19 as a primary theme, be written in English, and be published in a peer-reviewed journal. After collecting the information, we collated, summarized, and reported the results using narrative synthesis. RESULTS: The search identified 181 articles. After the removal of duplicates and screening, 24 full-text articles were reviewed and included in this study: 14 original articles, 8 commentaries or editorials, and 2 protocols. Contrary to expectations, preliminary evidence suggested that gambling behavior often either decreased or stayed the same for most gamblers during the pandemic. However, for the minority who showed increased gambling behavior, there was frequently an association with problem gambling. CONCLUSION: The available literature on COVID-19 and gambling is limited and the impact of the COVID-19 pandemic on gambling behavior and gambling problems is still unclear. Therefore, there is a need for more research on this topic, both qualitative and mixed methods studies, to better understand the impact of the pandemic on gambling. Considering the results, we need to be careful, particularly with problem gamblers and other subgroups of the population who seem to be more vulnerable to increased gambling habits during this pandemic period.

The impacts of the COVID-19 pandemic are significant. The COVID-19 crisis is putting considerable pressure on individuals, industries, health systems, and the economy. The extent of collateral damage caused by the pandemic has only begun to be understood.

COVID-19 has created a mental health crisis. Symptoms of anxiety and depression appear to occur more frequently since the beginning of the pandemic (Rajkumar, 2020) . In the past, it has been observed that people in isolation who are experiencing stress increase their use of substances, such as alcohol and drugs, to alleviate their negative emotions (Volkow, 2020) . The same phenomenon has been observed regarding gambling during a crisis (Economou et al., 2019; Jiménez-Murcia et al., 2013; Olason et al., 2015) .

Gambling disorder is a mental health issue that is becoming increasingly recognized as a major public health concern (Abbott, 2020; Delfabbro and King, 2020; Korn and Shaffer, 1999; Korn et al., 2003; Messerlian et al., 2005; Shaffer and Korn, 2002; van Schalkwyk et al., 2019; Wardle et al., 2019) . The prevalence of gambling disorder is estimated to be between 0.12% and 5.8% (Potenza et al., 2019) . In the DSM-5, gambling disorder is defined as persistent and recurrent problematic gambling behavior that can cause clinically significant impairment or distress (APA, 2013) . In the general population, different scales that are used to assess problem gambling classify gamblers into nonproblem gamblers, low-risk gamblers, moderate-risk gamblers, and problem gamblers (e.g., Problem Gambling Severity Index; Holtgraves, 2008) .

Psychiatric comorbidities, such as anxiety, depression, and substance use disorder, are common among "individuals with pathological gambling. 96% have been estimated to have one or more psychiatric disorders and 64% have been estimated to have three or more psychiatric disorders" (Kessler et al., 2008) . This situation is of particular concern in the context of the current pandemic, in which anxiety and depressive symptoms seem to be on the rise (Rajkumar, 2020) .

Since the beginning of the pandemic, several actors have raised concerns about the impact of the pandemic on gambling. Many actors fear a switch to online gambling in the context of the closure of many land-based gambling activities because of the restrictions imposed by public health authorities, such as physical distancing and lockdowns (Davies, 2020; Griffiths et al., 2020; King et al., 2020) . The situation is worrisome, as online gambling is considered a high-risk activity given its accessibility, velocity, and, among others, the anonymity it provides Hing et al., 2015) .

The purpose of this review is to summarize the literature that addresses the impacts of the COVID-19 pandemic on gambling. In the present context, conducting an up-to-date assessment of the situation to guide public policies related to gambling and to reduce the harm associated with gambling is important. As outlined by Langham et al. (2016) , "[h]arm from gambling is known to impact individuals, families, and communities; and theses harms are not restricted to people with gambling disorder".

This study is a scoping review. This type of review is generally used in new areas of research with emerging evidence to capture the current state of understanding (Anderson et al., 2008; Levac et al., 2010) . More precisely, scoping reviews are "exploratory projects that systematically map the literature available on a topic, identifying the key concepts, theories, sources of evidence, and gaps in the research" (CIHR, 2010) .

This scoping review followed the methodological framework developed by Arksey and O'Malley and refined by Levac et al. (Arksey and O'Malley, 2005; Levac et al., 2010) . The process followed five key steps: 1) identifying the research question, 2) identifying relevant studies, 3) selecting studies, 4) charting the data, and 5) collating, summarizing, and reporting the results. The primary research question guiding this review is "What are the impacts of COVID-19 on gambling?" This review follows the PRISMA guidelines for scoping review (PRISMA-ScR) (Tricco et al., 2018) .

An electronic literature search was conducted on February 25th 2021, in six databases: MEDLINE with Full Text, CINAHL with Full Text, PsychINFO, Academic Search Complete, Social Work Abstract, and SocINDEX. An experienced information specialist helped develop a search strategy using a controlled vocabulary (MeSH) and keywords related to the concepts "gambling" (S1) and "COVID-19" (S2) (see Box 1). An electronic search was also conducted on Google Scholar to include all articles published until February 25th 2021. The search identified 181 articles.

Study eligible for the review needed to meet the following inclusion criteria: 1) Main theme is related to both gambling and COVID-19; 2) English-language publication; 3) Published in a peer-reviewed journal.

After the removal of duplicates, titles and abstracts were reviewed by SA-C to determine inclusion for full-text review. Two independent researchers, MB and SA-C, reviewed each article retained for full-text review. Discrepancies were resolved by consensus. 38 articles were retained for detailed evaluation by team members MB and SA-C. 14 of the 38 articles were excluded. A final sample of 24 articles was included in the review. As this is a review on an emerging theme, we included all relevant commentaries and editorials in our selection, and no critical appraisal was made (see Fig. 1 ).

Two researchers, MB and SA-C, extracted the information from the 24 articles. Descriptive characteristics, such as the names of authors, year, region/country, population, aim, design, and conclusion, were collected (see Table 1 ). After collecting the information, we collated, summarized, and reported the results using narrative synthesis (Popay et al., 2006) . Narrative synthesis is an approach to synthesize "findings from multiple studies that relies primarily on the use of words and text to summarize and explain the findings" (Popay et al., 2006) .

The majority of the 24 studies were published in 2020 (Auer et al., 2020; Czegledy, 2020; Frisone et al., 2020; Gainsbury et al., 2020; Griffiths et al., 2020; Håkansson, 2020a Håkansson, , 2020b Håkansson, , 2020c Håkansson et al., 2020a Håkansson et al., , 2020b Hunt et al., 2020; Lindner et al., 2020; Ng Yuen and Bursby, 2020; Price, 2020; Sharman, 2020; Turner, 2020; Wardle, 2020; Yahya and Khawaja, 2020) , while 6 of the studies were published in 2021 (Donati et al., 2021; George, 2020 , Håkansson et al., 2021 Lischer et al., 2021; Sharman et al., 2021; Wardle et al., 2021) .

Nineteen studies were from Europe, including six from Sweden (Håkansson et al., 2021; Håkansson, 2020a Håkansson, , 2020b Håkansson, , 2020c Håkansson et al., 2020b; Lindner et al., 2020) , eight from the UK Hunt et al., 2020; Sharman, 2020; Sharman et al., 2021 , Wardle, 2020 Yahya and Khawaja, 2020; Ng Yuen and Bursby, 2020) , two from Italy (Donati et al., 2021; Frisone et al., 2020) , one from Switzerland (Lischer et al., 2021) and two from a non-specific country or multiple countries (Auer et al., 2020; Håkansson et al., 2020a) . Three articles were from North America (all from Canada; Czegledy, 2020; Price, 2020; Turner, 2020) , one from Australia (Gainsbury et al., 2020) , and one from Asia (India) (George, 2020) . Country and region of origin were established by cross-referencing the country and region of origin of the authors and the content of the articles.

Fourteen studies were original articles (Auer et al., 2020; Donati et al., 2021; Frisone et al., 2020; Gainsbury et al., 2020; Håkansson, 2020a Håkansson, , 2020b Håkansson, , 2020c Håkansson et al., 2020b; Håkansson et al., 2021; Lindner et al., 2020; Lischer et al., 2021; Price, 2020; Sharman et al., 2021; Wardle et al., 2020) , eight were commentaries or editorials (Czegledy, 2020; George, 2020; Griffiths et al., 2020; Håkansson et al., 2020a; Sharman, 2020; Turner, 2020; Yahya and Khawaja, 2020; Ng Yuen and Bursby, 2020) , and two were protocols (Hunt et al., 2020; Wardle, 2020 ) (see Table 1 ).

Search strategy. S1: gambl* OR betting OR "electronic gaming machines" OR lotto OR casino OR poker OR bingo OR blackjack OR lottery OR "slot machine*" S2: covid OR coronavirus OR "2019-ncov" OR "sars-cov-2" OR "cov-19" OR pandemi*

All fourteen original studies used a quantitative design or mixeddesign. Among them, 4 studies used data from the industry, gambling authorities, or data from gambling treatment centers (Auer et al., 2020; Lindner et al., 2020; Håkansson, 2020c; Håkansson et al., 2021) , whereas 10 used a web-based survey or panel (Frisone et al., 2020; Gainsbury et al., 2020; Håkansson, 2020a Håkansson, , 2020b Håkansson et al., 2020b; Lischer et al., 2021; Price, 2020; Sharman et al., 2021; Wardle et al., 2020) and one used a phone survey (Donati et al., 2021) . One protocol used a web-based panel (Wardle, 2020) , while the other one, being a mixed-method study, used both a qualitative and quantitative design (Hunt et al., 2020) . As expected, the commentaries or editorial articles did not provide any methodology.

Eighteen studies focused on gambling, in general, during the pandemic (Czegledy, 2020; Donati et al., 2021; Frisone et al., 2020; Gainsbury et al., 2020; George, 2020; Griffiths et al., 2020; Håkansson, 2020a; Håkansson et al., 2021 Håkansson et al., , 2020a Håkansson et al., , 2020b Hunt et al., 2020; Lischer et al., 2021; Lindner et al., 2020; Sharman et al., 2021; Turner, 2020; Wardle, 2020; Yahya and Khawaja, 2020; Ng Yuen and Bursby, 2020) . Three addressed sports betting (Auer et al., 2020; Sharman, 2020; Wardle et al., 2020) , and four have a particular interest in online gambling (Auer et al., 2020; Håkansson, 2020b Håkansson, , 2020c Price, 2020) .

Seventeen articles studied general populations, gamblers in general, or gamblers 18 years old and above (Auer et al., 2020; Czegledy, 2020; Donati et al., 2021; Gainsbury et al., 2020; George, 2020; Griffiths et al., 2020; Håkansson, 2020a Håkansson, , 2020b Håkansson, , 2020c Håkansson et al., 2021 Håkansson et al., , 2020a Lindner et al., 2020; Price, 2020; Sharman et al., 2021; Sharman, 2020; Turner, 2020; Yahya and Khawaja, 2020) . Four studies included gamblers aged less than 18 years (Frisone et al., 2020; Håkansson et al., 2020b; Hunt et al., 2020; Wardle, 2020) . Two articles looked at emerging adults aged between 16 and 24 years (Hunt et al., 2020; Wardle, 2020) . One article focused on elite athletes at least 15 years old , one on sport bettors that were already regular bettors before the pandemic , one on previously banned casino gamblers before the pandemic (Lischer et al., 2021) , and one article focused on gambling institutions and authorities during the pandemic (Ng Yuen and Bursby, 2020).

In all articles, the authors raised concerns about the impact of the pandemic on gamblers or the gambling industry (Auer et al., 2020; Czegledy, 2020; Donati et al., 2021; Frisone et al., 2020; Gainsbury et al., 2020; George, 2020; Griffiths et al., 2020; Håkansson, 2020a Håkansson, , 2020b Håkansson, , 2020c Håkansson et al., 2021 Håkansson et al., , 2020a Håkansson et al., , 2020b Hunt et al., 2020; Lindner et al., 2020; Lischer et al., 2021; Price, 2020; Sharman et al., 2021 , Sharman, 2020 Turner, 2020; Wardle, 2020; Wardle et al., 2020; Yahya and Khawaja, 2020; Ng Yuen and Bursby, 2020) . Contrary to expectations, ten of the original studies reported that gambling behaviors decreased or stayed the same for most gamblers (Auer et al., 2020; Donati et al., 2021; Gainsbury et al., 2020; Håkansson, 2020a Håkansson, , 2020b Håkansson, , 2020c Håkansson et al., 2021 Håkansson et al., , 2020b Lindner et al., 2020; Wardle et al., 2020) . Lindner et al. (2020) demonstrated that the "total gambling activity decreased by 13.29% during the first phase of the outbreak compared to [the] forecast. Analyses of online gambling data revealed that although betting decreased substantially in synchrony with a slight decrease in online casino gambling, there was no increase in likely problematic, high-intensity gambling and neither did total online gambling increase". Håkansson (2020) found that only "four percent [4%] reported an overall gambling increase during the pandemic". In another study on elite athletes, Håkansson et al. (2020b) outlined that "gambling increase during the pandemic was rare but [was] related to gambling problems". In contrast, Donati et al. (2021) finds that even problem gamblers reduced their gambling behaviors and gambling cravings during the pandemic, and that no "shift toward online gambling and very limited shift towards other potential addictive and excessive behaviors" were found. Auer et al. (2020) also reached a similar conclusion, noting that "speculations that individuals may spend more time and money gambling online as a consequence of being confined in their house for long periods appear unfounded".

The exact risk factors associated with increased gambling behavior and gambling problems during the COVID-19 pandemic are still unclear. In five studies, the rare increases observed were always attributed to high-risk gamblers (Håkansson, 2020a (Håkansson, , 2020b Håkansson et al., 2020a Håkansson et al., , 2020b Lindner et al., 2020) . According to Håkansson (2020) , "increased gambling was independently and clearly associated with the problem gambling severity." In their study, Gainsbury et al. (2020) rather found that "individuals engaged in moderate-risk gambling, but not problem gambling, were more likely to report increased gambling frequency" during the pandemic. Frisone et al. (2020) found that problem gambling during the pandemic was mostly associated with "personality and sociodemographic characteristics", such as "age, male gender, low levels of study and impulsive characteristics play a decisive role in problem gambling".

Regarding the feared shift to online gambling, Auer et al. (2020) noted that "there was no conversion of money spent from sports betting to online casinos games […] and that frequent online sports bettors wagering upon online casino games stayed the same before and during the COVID-19 pandemic." Håkansson (2020) reported that "the minority reporting a switch to other gambling had a clear picture of problematic gambling involvement." He also came to the same conclusion in another study conducted with colleagues (Håkansson, 2020b) . Lindner et al. (2020) concluded that "although betting decreased substantially in synchrony with a slight increase in online casino gambling, there was no increase in high-intensity, likely problematic gambling". In contrast, a more recent study (Lischer et al., 2021) found a significant increase (p < 0.002) in online gambling among the studied population, and Håkansson (2020c) mentions an important "increase in horse betting during the sports lockdown" and warns against a "possible COVID-19-related migration between gambling types, indicating a volatility with potential impact on gambling-related public health."

In four articles, an association between gambling and related known comorbidities, such as anxiety, depression, and substance use disorder, was highlighted (Håkansson, 2020; Håkansson et al., 2020b; Price, 2020; Sharman et al., 2021) . In his study of gambling behavior, Håkansson (2020) noted that "the group reporting increased gambling had higher rates of psychological distress […] and one of the clearest findings of the study has been that self-reported increase in alcohol consumption during the pandemic is associated with a self-reported increase in gambling." In his study, Price (2020) observed that "gambling under the influence of alcohol or cannabis increased the odds of high-risk gambling status by approximately 9 times (p < 0.01) […] and those screened for [a] moderate and severe form of anxiety (25.7%) and depression (12.6%) were more likely to gamble online during the first 6 weeks of emergency measures and be classified as high-risk gamblers." In their commentary exploring gambling during COVID-19, Håkansson et al. (2020a) cited a pilot study conducted early in the pandemic at the Gambling Disorder and Other Behavioral Addictions Unit of the Department of Psychiatry at the University Hospital of Bellvitge in Barcelona, Spain; the study found that "after two weeks of confinement, 12% […] reported worsening gambling […] 46% showed anxiety symptoms and 27% showed depressive symptoms" . Sharman et al. (2021) found that the impact of lockdown was significant on the "mental health of participants; whilst depression stress and anxiety remain highest in potential problem gamblers". Interestingly, in Ontario, Canada, Turner (2020) reported a decrease in calls to the National Gambling Helpline in the first weeks of the pandemic. However, this decrease was counterbalanced by a significant increase in calls in other crisis lines.

In commentaries and editorials, some authors expressed concern that access to care and services for gamblers and support groups, such as Gamblers Anonymous, has been limited because of the pandemic (Turner, 2020; Yahya and Khawaja, 2020) ; they outlined the need to raise awareness about problem gambling among the public and health professionals Yahya and Khawaja, 2020) . For their part, Griffiths et al. (2020) believed that COVID-19 is likely to create many more vulnerable people and exacerbate existing inequalities. George (2020) mentions that the pandemic creates a rare window of opportunity that should be seized, as lockdown is a favorable moment for treatment, detoxification, and rehabilitation of problem gamblers, as there are reduced opportunities to gamble. Some authors also focused on public policies put in place regarding gambling in response to the pandemic. As pointed out by Håkansson (2020) in the introduction of his article, "the overall concerns about an altered gambling behavior during the crisis have led several governments to take action through different measures, such as a limitation in gambling advertisements in Spain, deposit limits in Belgium, and a total ban in Latvia". In Sweden, the government has adopted legislation limiting deposits in online casinos and a limit on time spent gaming (Lindner et al., 2020) . Hunt et al. (2020) insists on the "urgent need to provide regulators, policymakers and treatment providers with evidence on the patterns and context of gambling during COVID-19 and its aftermath", essential to alleviate gambling harms. Gainsbury et al. (2020) , warn that policies need to be very well thought of. Too restrictive policies can lead to an increase of other forms of unregulated gambling activities that are known to exacerbate gambling issues.

The impact of the pandemic on the gambling industry has likewise been briefly discussed by some authors. Indeed, the gambling market has been considerably transformed by the pandemic. As outlined by Griffiths et al. (2020) , some operators have shown creativity by creating drive-thru gambling centers. However, as mentioned by Sharman (2020), the industry acted cautiously in some countries. In the UK, the most notable changes to gambling […] regulation have come from industryled self-regulation initiatives. Members of the Betting and Gaming Council […] agreed to a 10-point pledge during lockdown to encourage 'safer gambling', […] which was augmented by a voluntary reduction in gambling advertising on TV and radio". Czegledy (2020) suggest that the pandemic lockdowns should be used to implement long-needed changes within the land-based gambling industry, such as a complete re-evaluation of their operations. Ng Yuen and Bursby (2020) concerned for the increased uncertainty of the gambling industry sector, as caused by the pandemic.

During the past few years, gambling has been a public health issue that has attracted the increased attention of policymakers and sports associations. In pre-pandemic Europe, different authorities were trying to create distance between some sports, mainly football, and gambling (Sharman, 2020) . However, because of the pandemic, some football clubs found themselves in a precarious financial situation. This highlighted "how financially linking clubs [are] on gambling money" (Sharman, 2020) . This financial dependence on gambling money is of concern to Griffiths et al. (2020) , who noted that it "may also be tempting for governments to use gambling expansion and its subsequent revenues to recover resources which will be a priority with the inevitable economic depression looming".

The impacts of the pandemic on gambling are sprawling. To our knowledge, this review is the first to focus specifically on gambling and COVID-19. It provides an overview of the literature on gambling and COVID-19 published from the beginning of the pandemic until February 25th 2021. The preliminary results seem to point to an overall decrease in gambling since the beginning of the pandemic and suggest that problem gamblers appear to be at a greater risk.

Several limitations of this review should be outlined. First, it contains only published peer-reviewed articles and does not include grey literature. Second, in the original articles, six out of fourteen were from Sweden (Håkansson, 2020a (Håkansson, , 2020b (Håkansson, , 2020c Håkansson et al., 2021 Håkansson et al., , 2020b Lindner et al., 2020) . As there was no lockdown during the first wave of the pandemic in Sweden (Warren et al., 2021) , and some gambling restrictions, such as limited deposits and limited game times, were not applied in other countries (Lindner et al., 2020) , the results may be different in other jurisdictions and are therefore not generalizable. In that context, we must be careful and not conclude that the pandemic has not produced an exacerbation of gambling. Problem gamblers seem to be at risk. This is a previously known vulnerable group for whom it is important to remain vigilant, especially in the present context in which symptoms of anxiety and depression are on the rise (Rajkumar, 2020) .

So far, the literature on the subject remains limited. Indeed, no qualitative or mixed studies have been published. A better understanding of the experience of gamblers during the pandemic is essential. As outlined by Auer et al. (2020) , "The decrease in overall gambling might be due to several factors including individuals having less money to gamble because their occupational earning potential has been lower during the pandemic, individuals not wanting to gamble in front of their family members, or individuals spending more time on other activities such as spending 'quality time' with their families or finally having the time to do bigger jobs around the house and garden". In that context, we need to know more about such hypotheses. There is also a lack of studies on certain populations, such as LGBTQ+ and Aboriginal people. Finally, comparative studies on gambling policies adopted during the pandemic, the impacts of COVID-19 on the gambling industry, and alternative forms of gambling developed by gamblers, such as teenage football games or amateur low-tier friendship games, as outlined by Håkansson et al. (2020a) , are necessary.

It is important to note that this review covers articles published until February 25th, 2021. In that context, a larger number of included studies have mostly or exclusively focused on the first wave of the pandemic. Longitudinal studies or studies covering the impact of the entire pandemic on gambling and of subsequent waves are needed. Studies from around the world are also required to obtain a more complete picture of the problem. Given that the literature on gambling and COVID-19 is rapidly evolving, further reviews on the subject will be needed by the end of the pandemic. As noted by Griffiths et al. (2020) , "even in the midst of the pandemic, we need to be aware that gambling harms are still occurring".

The current literature indicates that problem gamblers, among others, are particularly vulnerable during the COVID-19 pandemic and that resources are needed to help and prevent increased harm. The pandemic still being active to this day, future research will be needed on this topic. Unforeseen consequences, impacts, and behavioral reactions are probable as the different waves of the pandemic are also situated in evolving contexts around the world. Future research should adopt a variety of methodology designs and focus on different populations and geographical areas, to better understand the impact of the COVID-19 pandemic on gambling. They will be necessary to reduce gambling harms and help the most vulnerable populations.

This material is the authors' own original work, which has not been previously published elsewhere.

The paper is not currently being considered for publication elsewhere.

All authors reviewed and accepted the final version of the article.

This research included no animal or human subjects.

This work was supported by the Ministry of Health and Social Services of the Government of Quebec in collaboration with the Quebec Research Fund and the Ministry of Innovation and Economy as part of the COVID-19 call for solutions (grant number #20-CP-00309). The

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We would like to thank Annie Desjardins, patient-partner, for her involvement in the study and the revision of the review.

funding body is not involved in the research, and the researchers are independent.

MB and SA-C designed the study and developed the search strategy. Study selection and data extraction were done by MB and SA-C. MB was responsible for drafting this manuscript and was supported by SAC, ACS, and SK. All authors have read and approved the final manuscript.

The authors declare that they have no competing interests.