Prevalence of gambling disorder and its correlates among homeless men in Osaka city, Japan

Abstract

Internationally, the prevalence of gambling disorder has been reported to be higher among homeless people than the general population; however, little is known about the factors associated with gambling disorder in this population. The present study aimed to investigate the prevalence of gambling disorder and its associated factors among homeless men using shelters in Osaka City. A cross-sectional survey was conducted from 30 to 2018 to 4 January 2019, using the 2017 Japanese National Survey of Gambling (JNSG) questionnaire, supplemented with questions about homeless experiences, drinking, and smoking. Using the South Oaks Gambling Screen, the presence of gambling disorder was determined by a score ≥ 5 out of 20. Multivariate logistic regression was conducted to explore factors associated with lifetime gambling disorder. Lifetime and past-year prevalence of gambling disorder among 103 participants was 43.7% (95% confidence interval [CI]: 34.5–53.3) and 3.9% (95% CI: 1.5–9.6), respectively, which are higher than the 6.7% and 1.5% found among men in the 2017 JNSG. Reasons reported for currently gambling less were primarily financial. Factors associated with lifetime GD included “more than 20 years since the first incidence of homelessness” (adjusted odds ratio [AOR]: 4.97, 95% CI: 1.50–16.45) and “more than five incidences of homelessness” (AOR: 4.51, 95% CI: 1.06–19.26). When homeless individuals with gambling disorder try to rebuild and stabilize their lives, the presence or resurgence of gambling disorder may hinder the process and pose a risk of recurring homelessness. Comprehensive support services for homeless individuals with gambling disorder are required. (250 words)

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ORIGINAL PAPER
Accepted: 27 March 2022 / Published online: 15 June 2022
© The Author(s) 2022
Extended author information available on the last page of the article
Prevalence of gambling disorder and its correlates among
homeless men in Osaka city, Japan
ChiyoungHwang1· TaichiTakano2· RyuheiSo1,3 · EthanSahker1,7 ·
ShoKawakami2· CharlesLivingstone4· NaokoTakiguchi5· MasakoOno-Kihara6·
MasahiroKihara6· Toshi A.Furukawa1
Journal of Gambling Studies (2023) 39:1059–1076
https://doi.org/10.1007/s10899-022-10121-x
1 3
Abstract
Internationally, the prevalence of gambling disorder has been reported to be higher among
homeless people than the general population; however, little is known about the factors as-
sociated with gambling disorder in this population. The present study aimed to investigate
the prevalence of gambling disorder and its associated factors among homeless men using
shelters in Osaka City. A cross-sectional survey was conducted from 30 to 2018 to 4 Janu-
ary 2019, using the 2017 Japanese National Survey of Gambling (JNSG) questionnaire,
supplemented with questions about homeless experiences, drinking, and smoking. Using
the South Oaks Gambling Screen, the presence of gambling disorder was determined by
a score ≥ 5 out of 20. Multivariate logistic regression was conducted to explore factors as-
sociated with lifetime gambling disorder. Lifetime and past-year prevalence of gambling
disorder among 103 participants was 43.7% (95% condence interval [CI]: 34.5–53.3) and
3.9% (95% CI: 1.5–9.6), respectively, which are higher than the 6.7% and 1.5% found
among men in the 2017 JNSG. Reasons reported for currently gambling less were primar-
ily nancial. Factors associated with lifetime GD included “more than 20 years since the
rst incidence of homelessness” (adjusted odds ratio [AOR]: 4.97, 95% CI: 1.50–16.45)
and “more than ve incidences of homelessness” (AOR: 4.51, 95% CI: 1.06–19.26). When
homeless individuals with gambling disorder try to rebuild and stabilize their lives, the
presence or resurgence of gambling disorder may hinder the process and pose a risk of
recurring homelessness. Comprehensive support services for homeless individuals with
gambling disorder are required. (250 words)
Keywords Gambling · Homelessness · Addiction · Prevalence · Associated factors
Introduction
With the global proliferation of commercialized gambling, it appears that homeless people
are particularly vulnerable to gambling addiction. Despite dierences between countries in
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Journal of Gambling Studies (2023) 39:1059–1076
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which studies have been conducted, survey instruments, and targeted subgroups within the
homeless population, the prevalence of gambling disorder (GD) or pathological gambling
among homeless people ranges from 12 to 24.6% for lifetime incidence (Matheson et al.,
2014; Nower et al., 2015), and 5.5–23.6% for past-year incidence (Shaer et al., 2002;
Sharman et al., 2015, 2016; Wieczorek et al., 2019). These rates far exceed those of the
general population. For example, homeless people in the United Kingdom were 16 times
more likely to have a gambling problem than the general population (Sharman et al., 2015).
However, risk factors for GD among homeless people and how these dier from those of
the general population are not fully understood. In both homeless and general populations,
being male and young are factors associated with GD (Johansson et al., 2009; Nower et al.,
2015; Shaer et al., 2002; Wieczorek et al., 2019). Yet, factors such as comorbid psychiat-
ric disorders—including alcohol and substance use disorders—the form and frequency of
gambling, the number and duration of homelessness experiences, and negative life events
experienced prior to homelessness have only been identied in a single study or shown con-
icting results in dierent studies (Nower et al., 2015; Shaer et al., 2002; Sharman et al.,
2016; Wieczorek et al., 2019). For instance, Nower et al. (2015) reported that in a homeless
sample of predominantly African American men in the United States, those with problem
gambling were more likely to meet the diagnostic criteria of bipolar disorder, post-traumatic
stress disorder (PTSD), antisocial personality disorder (ASPD), and nicotine, alcohol, or
other substance abuse or dependence than those without. However, Sharman et al. (2016)
found no association between the high prevalence rate of alcohol dependence (23.6%) and
other substance dependence (31.9%) among their participants and gambling problems. Fur-
thermore, among homeless people in the United State participating in substance use disor-
der programs, those with more severe gambling problems tended to be homeless more often
and at younger ages (Shaer et al., 2002), while other studies have found no such trend
(Nower et al., 2015; Wieczorek et al., 2019). Regarding the pre- and post-temporal relation-
ship between gambling problems and homelessness, only Sharman et al. (2016) reported
that in 82.4% of problem gamblers, gambling problems preceded homelessness.
Gambling is technically illegal in Japan. However, some forms of gambling, such as
lotteries and horse, bicycle, boat, and motorbike racing, are allowed as “public gambling.”
Moreover, “Pachinko” and “Pachislot” (electronic gaming machine [EGM]) parlors are
ubiquitous across Japan and easily accessible. Internationally, EGMs are recognized as
an important gambling form; however, legal loopholes in Japan render EGMs acceptable.
Gamers win tokens, which are non-monetary prizes, and tokens are then sold to third-party
vendors for cash equivalent values. According to the 2017 Japan National Survey of Gam-
bling (JNSG, 2017), the prevalence of GD in the general population was 3.6% and 0.8%
for lifetime and past-year, respectively (6.7% and 1.5% among men, respectively) with
approximately 80% of people with GD spent their money mainly on EGMs (Higuchi &
Matsushita, 2017).
There are currently no methodologically valid epidemiological studies, and only frag-
mented reports have focused on GD among homeless people in Japan. The ndings of a
comprehensive nationwide survey indicated that 1.1–10.3% of homeless people were recog-
nized by service providers as engaging in problem gambling (Specied Non-prot Organi-
zation National Homeless Support Network, 2011). Moreover, in the national survey on the
conditions of the homeless, 8.8% of respondents reported “drinking and gambling” as their
reason for living on the streets (Ministry of Health, Labour and Welfare, 2016). Further, a
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study of cognitive dysfunction with a sample of 16 homeless men in Tokyo found that ve
met the criteria of “pathological gambling” (Pluck et al., 2015). Considering these reports,
homeless people are likely a high-risk population for GD in Japan. However, Japan does not
recognize GD among homeless people as a public health concern; therefore, there is no sup-
port system to adequately address these concerns. To develop prevention, intervention, and
support measures for homeless people with GD, it is necessary to investigate the prevalence
of GD and its characteristics among this population.
The present study aims to provide initial epidemiological information on homelessness
and GD in Osaka, Japan’s second largest city, where one of the best-known shelters for
homeless people is located. First, we will describe prevalence of potential GD and the situ-
ation of gambling activities among homeless men staying in shelters in Osaka City. Second,
we will investigate associated factors between homelessness and GD.
Methods
Study Design and setting
We conducted a cross-sectional survey between December 30, 2018 and January 4, 2019,
in Osaka City. Osaka City has the largest homeless population in the country as well as
Tokyo. According to the Japanese National survey on “the actual conditions of the homeless
2019,” which is conducted every year by the Ministry of Health, Labour and Welfare, 4,555
homeless people were visually identied in Japan’s streets, parks, train stations, riversides,
and other facilities in 2018, and of them, 1,002 (981 men and 21 women) were identied
in Osaka City, including those who made use of free public shelters (Ministry of Health,
Labour and Welfare, 2019).
The free public shelters, which constitute the study setting, are located in an area with the
highest number of homeless people in Osaka City. This area is the largest gathering place
of day labor recruiters and job seekers in western Japan, called “Yoseba,“ and many cheap
simple accommodations for day laborers are available here. Due to the recession and aging
of the day laborers, many day laborers become homeless. This area has many public and
private support services not only for such homeless people but also for other economically
and socially vulnerable individuals.
The free public shelters provided by the Osaka City government are available for only
men and ordinarily allow for a one-night stay. During this survey, the Osaka City govern-
ment conducted a social welfare program for homeless people, the Emergency Accommoda-
tion Support Project (EASP), which oered accommodation and meals for six consecutive
days around the New Year. Those who applied for EASP had to consult and register with
the local municipality. Those needing care due to poor health or advanced age were pref-
erentially placed in a care center, while others were placed in standard shelters. In 2018,
344 individuals registered with the EASP. Among these, all 265 homeless men staying in
shelters (age rang = 26–83 years [M ± SD = 60.5 ± 8.1]; monthly income range = ¥0–160,000
[M ± SD = 38,684 ± 30,275, median: 30,000]) were potential participants in this study.
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Procedure
During the EASP, all shelter users were informed about the study, including that they could
not participate if they were intoxicated. Posters, which contained all the information, were
put up on the walls of the shelters. Research sta orally requested research cooperation at
every lunch meal and distributed yers each bed. Those who were willing to participate
in the survey registered in front of the shelters and were given an invitation stating their
full-name, and details of the survey: purpose, contents, date, and time and location of the
survey. Data were collected individually at a nearby interview oce, a 5-minute walk from
the shelters, to protect participants’ privacy. Each survey took approximately 40–60 min.
Participants were remunerated with ¥1,000 for participating.
Measures
We used the structured questionnaire of the 2017 Japan National Survey of Gambling
(JNSG 2017), which was conducted by the Kurihama Medical and Addiction Center, com-
missioned by the Japan Agency for Medical Research and Development. The questionnaire
included basic demographic information such as age, educational qualications, marital sta-
tus, and estimated annual income during the current and most frequent gambling periods, as
well as questions about gambling-related experiences, screening of problem gambling, risk
perception, and help-seeking behaviors related to gambling problems. In the questionnaire
of the JNSG 2017, gambling frequency and annual income were assessed as multiple-choice
responses. This was supplemented with questions about homelessness experiences (e.g.,
duration between the rst incidence of homelessness and the date of the survey, number of
homelessness experiences, use of public social resources), smoking status, and alcohol use.
The South Oaks Gambling Screen (SOGS; Lesieur & Blume, 1987) was used to deter-
mine potential GD. It consists of 20 items; items with two choices are scored 0 for not appli-
cable and 1 for applicable; items with three choices are scored 0 for not applicable, and 1
for all others; and items with four choices are scored 1 only if the two most frequent choices
are selected. Possible total scores range from 0 to 20, and following the JNSG criteria, a
score of ≥ 5 indicates potential GD. In the present study, the Cronbach’s alpha coecient of
the Japanese version of SOGS (Kido & Shimazaki, 2007; Saito, 1996) was 0.88 for lifetime
prevalence and 0.68 for the past year.
The Problem Gambling Severity Index (PGSI; Ferris & Wynne, 2001) was used to iden-
tify problem gambling risk in the past year. The PGSI consists of nine items scored as
never = 0, sometimes = 1, most of the time = 2, and almost always = 3. Total scores range from
0 to 27 and are categorized according to the JNSG criteria as 0 = no risk, 1–2 = low risk,
3–7 = medium risk, and 8–27 = high risk. The Cronbach’s alpha coecient of the Japanese
version of the PGSI (So et al., 2019) in the present study was 0.80.
The Alcohol Use Disorders Identication Test (AUDIT) was used to assess the risk for
alcohol use disorder (Babor et al., 2001). The AUDIT consists of 10 items regarding alcohol
use, alcohol use disorder symptoms, and alcohol-related problems. Each item is scored on a
scale of 0–4, with overall scores ranging from 0 to 40. We followed the Japanese criteria: a
score of 0–7 = no problem, 8–15 = hazardous use, and 16–40 = potential alcohol dependence.
The Cronbach’s alpha coecient of the Japanese version of the AUDIT (Hiro & Shima,
1996) for the present study was 0.90.
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The order in which the questionnaires were presented is as follows: (1) demographic
information, (2) homelessness history, (3) gambling experiences, (4) PGSI, (5) SOGS, (6)
help seeking behaviors, (7) smoking status, and (8) alcohol use.
Statistical analysis
First, descriptive analyses were performed using the participants’ sociodemographic char-
acteristics and their gambling experiences. We then recorded the characteristics of their
gambling activities for the period when they had gambled the most and during the past year.
We categorized the data and described the distribution by age, time elapsed since the rst
incident of homelessness, number of homelessness experiences, gambling frequency, age at
onset of gambling, monthly and annual income (as of December 2018), PGSI scores, and
AUDIT scores. As public gambling is illegal for those under the age of 20 in Japan—except
for Pachinko and Pachislot, which are allowed from the age of 18—we categorized the age
of gambling initiation as “< 20 years” and “≥ 20 years.” We examined whether the continu-
ous variables were normally distributed through histograms and the Shapiro-Wilk test. We
conducted the Mann-Whitney U test as a sensitivity analysis where possible.
Second, we used univariable and multivariable logistic regression analyses to explore
factors associated with potential GD according to the criteria of SOGS. As this is the rst
investigation on GD among homeless people in Japan, a two-step exploratory approach
was conducted. In the rst step, bivariate analyses and chi-square tests were performed
to investigate the cross-sectional associations between “potential GD (lifetime)” and each
independent variable. The odds ratio (OR), 95% condence interval (CI), and p-values were
calculated. Second, to identify strong correlates of lifetime GD, we simultaneously entered
the following characteristics in a multivariable logistic regression: a priori selection of well-
established risk factors for GD (Johansson et al., 2009), including young age (< 30 years
old), smoking, alcohol dependence, and imprisonment history as well as the variables that
were associated with p ≤ .10 in the rst step; we then selected only those that maintained a
signicance of p ≤ .10. The adjusted OR, corresponding 95% Cis, and p-values were calcu-
lated. The p-values were two-sided with a signicance level of 0.05. Finally, we conducted
a sensitivity analysis, in which we entered all the covariates. Statistical analyses were per-
formed using JMP Pro14 (SAS Institute Inc. Cary, NC, USA).
Ethics
This study was conducted in accordance with the Declaration of Helsinki. Ethical approval
was obtained from the institutional review board of the second author’s institution and the
ethics committee of the rst author’s institution. We informed the participants about the
study procedures and that participation was entirely voluntary. There were no disadvantages
associated with refusing participation, and participation could be withdrawn at any point
during the survey. We obtained written informed consent.
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Journal of Gambling Studies (2023) 39:1059–1076
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Results
Participants
Of the 265 homeless men staying in shelters, 112 (42.3%) voluntarily participated in this
survey. The nal number of valid respondents was 103 (38.9%). Nine participants were
excluded due to inconsistent answers regarding the time since the rst incidence of home-
lessness, the number of homelessness experiences, and their social support usage. Table 1
and Supplementary File 1 show participant demographics and other characteristics. The
mean age of the participants was 58 years (SD = 8.5, median = 58, range = 30–73), and
89.3% (n = 92) participants earned an income through some type of work, such as relief
unemployment work provided by Osaka City municipality, daily labor work, and/or alumi-
num can collection. The median monthly income was ¥40,000 (M ± SD = 49,229 ± 37,992,
range = 0–150,000).
Gambling experience and the prevalence of potential gambling disorder
Data on gambling experience and GD are shown in Tables 2 and 3, and Supplementary File
1. According to the SOGS criteria, prevalence of lifetime potential GD was 43.7% (n = 45),
and past-year prevalence was 3.9% (n = 4). Further, 7.8% (n = 8) met the criteria for high-
risk gambling (PGSI: 8–27 points) in the past year. Among the 45 participants with potential
GD (lifetime), 17.8% (n = 8) were high-risk gamblers, 35.6% (n = 16) were moderate-risk
gamblers, and 15.6% (n = 7) were low-risk gamblers according to PGSI criteria. For those
who gambled, the median age at which they started was 18 years (M ± SD = 19.5 ± 6.37,
range: 10–56) and their rst form of gambling was Pachinko and Pachislot (71.1%). Of the
participants, 88.7% (n = 86) stated that they no longer gambled as much as they did previ-
ously, primarily because they did not have enough money (n = 46).
Among those with a potential GD in their lifetimes (n = 45), 68.9% (n = 31) were aware
that they had lost or almost lost someone and/or something important to them at home,
work, or school because of their gambling. However, only 15.6% (n = 7) of the respondents
had sought help regarding their debt and gambling problems from a specialist or counselor.
Associations between Homelessness and Gambling Disorder
Table 4 and Supplementary File 2 show a comparison of participants’ characteristics, with
or without potential lifetime GD based on SOGS criteria, according to the bivariate logistic
regression analysis. In this rst step of our multivariable logistic regression analysis, eight
variables were signicant at p ≤ .10, including “previously married,” “≥20 years since the
rst incidence of homelessness,” “≥5 homelessness episodes,” “experience of using social
support,” “early gambling onset,” “close relatives and friends with gambling problems,”
“current smoking,” and “potential alcohol dependence.” The age of gambling initiation var-
ied between those with GD (median = 18, M ± SD = 18.4 ± 6.41, range = 12–56) and those
without (median = 18, M ± SD = 20.4 ± 6.26, range = 10–40), at p < .05. In the second step of
our regression model, we entered variables selected beforehand, which included smoking,
alcohol dependence, imprisonment history, and the variables with a signicance level of
p ≤ .10 in the rst step. Younger age was also selected as one of the important variables but
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n(%)
Age (years)
≤ 39 2 (1.9)
40–49 16 (15.5)
50–59 41 (39.8)
60–69 39 (37.9)
≥ 70 5 (4.9)
Marital status
Never married 74 (71.8)
Divorced 24 (23.3)
Unmarried partner 3 (2.9)
Widowed 2 (1.9)
Educational qualicationsa
Middle school graduate 54 (52.4)
High school graduate 37 (35.9)
Graduate from a higher education institute 12 (11.7)
Time elapsed since the rst homelessness incidence
< 1 year 9 (8.7)
1 year–less than 5 years 11 (10.7)
5 years–less than 10 years 23 (22.3)
10 years–less than 20 years 30 (29.1)
20 years–less than 30 years 20 (19.4)
≥ 30 years 10 (9.7)
Number of homelessness episodes in lifetime
1 49 (47.6)
2–4 37 (35.9)
≥ 5 17 (16.5)
Experience of using social support in lifetime (multiple answers allowed)
Welfare: home 47 (45.6)
Welfare: facility 16 (15.5)
Independent living support facilities 28 (27.2)
Income in December 2018 (¥)
None 11 (10.7)
< 30,000 15 (14.6)
30,000–59,999 42 (40.8)
60,000–89,999 15 (14.6)
90,000–119,999 12 (11.7)
≥ 120,000 8 (7.8)
Current smoking behaviour
Yes 77 (74.8)
No 26 (25.2)
Current alcohol use (AUDIT score)
Potential alcohol dependence (15–40) 17 (16.5)
Hazardous use (8–14) 15 (14.6)
No risk (1–7) 36 (35.0)
Non-drinker (0) 35 (34.0)
Table 1 Demographic and other characteristics of participants (N = 103)
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not included in the multivariable logistic regression model because only two of our partici-
pants were younger than 30 years. “Experience of using social support,” “current smoking,”
“potential alcohol dependence,” and “have been imprisoned” were removed from the nal
model (p > .10). Table 5 shows the results of the multivariable logistic regression model,
the p-values of which were all statistically signicant. Marital status was only marginally
associated with GD (AOR: 3.13, 95% CI: 1.00–9.81, p-value: 0.0497). Finally, a sensitivity
analysis, in which we entered all the covariates was conducted. The resulting coecients
were similar and overlapping with those that we found with our primary approach in listed
Table 5 (Supplementary File 3).
Discussion
This is the rst epidemiological study in Japan investigating GD among homeless men.
First, as in previous international studies, this study found a high prevalence of GD in Japa-
nese homeless men. The lifetime prevalence in our study was 43.7% (n = 45) and 3.9%
(n = 4) in the past year, much higher than the prevalence rates for men in 2017 JNSG, which
were 6.7% and 1.5%, respectively (Higuchi & Matsushita, 2017). Compared with studies
in other countries such as Canada and the United States, where lifetime prevalence was
reported to be 10% (Matheson et al., 2014) and 12.0% (Nower et al., 2015), respectively,
the lifetime prevalence among homeless people in our study was especially high. However,
fewer Japanese were identied as “high-risk gamblers” in the past year using the PGSI
(7.8%) than in the United Kingdom—at 11.6% (Sharman et al., 2015) and 23.6% (Sharman
et al., 2016)—and Poland at 11.3% (Wieczorek et al., 2019). These dierences in problem
gambling prevalence rates among homeless populations may result from several factors,
including the prevalence of GD in each country; cultural context of gambling; denition and
characteristics of the homeless subgroups; and dierences in sampling methods, response
rates, scales used, and order of screens (Griths, 2015; Stevens & Young, 2008; Williams
et al., 2012).
Second, this study found factors associated with lifetime GD such as exceeding “more
than 20 years since the rst incidence of homelessness” and having “experienced homeless-
ness ve or more times.” Findings in previous studies concerning a potential relationship
between a long or frequent history of homelessness and GD were inconsistent (Nower et
al., 2015; Shaer et al., 2002; Wieczorek et al., 2019). Shaer et al. (2002) reported that
those who were pathological gamblers with substance use disorders tended to have become
homeless at a younger age and experience homelessness more often than non-pathological
n(%)
Imprisonment history in lifetime
Yes 17 (16.5)
No 86 (83.5)
¥: Japanese Yen
AUDIT: Alcohol Use Disorders Identication Test
aIn case of dropout, educational qualications were classied as the preceding educational level (14 high
school dropouts and three college dropouts)
Table 1 (continued)
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gamblers. Notably, the causality between gambling addiction and homelessness in our study
is unclear due to our cross-sectional design. However, GD may make it dicult for people
to overcome homelessness or may facilitate chronic and episodic homelessness. Of the total
sample of homeless, 68.9% (n = 71) had gambled in the past year, and one-third of them
(n = 24) were found to be at moderate to high risk of problem gambling, according to the
PGSI scores. Moreover, approximately half of the lifetime gambling participants cited that
the reason they no longer gambled as much as before was the lack of money. Therefore, the
low prevalence of GD in the past year shown in our study may be due to both spontaneous
recovery from GD and economic limitations, owing to homelessness temporarily restricting
gambling to levels that fail to meet diagnostic criteria for GD.
In this study, current alcohol dependence and smoking were not associated with lifetime
GD. This is despite higher rates of smoking and alcohol dependence in those with GD than
in those without it. Associations between alcohol and other substance use disorders and
GD are well-known (Lorains et al., 2011), and high proportions of nicotine, alcohol, or any
other substance dependence have been reported among homeless people with gambling
problems (Nower et al., 2015; Sharman et al., 2016). A potential reason for GD not being
associated with alcohol dependence and smoking in our results may be our exclusion of
inebriated people from participation. This may have resulted in lower participation by those
with alcohol problems, which may have aected the results. Furthermore, the 95% CIs were
very wide, suggesting insucient power, possibly leading to a Type 2 error. However, in a
study targeting British homeless people, alcohol and substance use disorders were also not
signicantly associated with past-year problem gambling (Sharman et al., 2016). Exhibiting
multiple addictions is a not infrequent issue. Some addictive behaviors do not necessarily
coexist, and others may arise during withdrawal from a specic addictive behavior. Low
income might limit access to and temporarily reduce the frequency of or expenditure on
addictive behaviors.
When homeless people with GD aim to rebuild and stabilize their lives, the presence or
resurgence of gambling problems and/or alcohol addiction are potential risks of recurrent
homelessness. Although nearly 70% of participants in this study with GD were aware of the
negative eects of gambling, 85.7% had never sought help. Homeless people tend to experi-
ence multiple and complex problems, and gambling problems may be overlooked or triaged
due to reduced priority (Vandenberg et al., 2021). Therefore, as part of a comprehensive
support system for homeless individuals, screening for gambling activities and their nega-
tive impact might be useful.
This study found that “early gambling onset” and having “close relatives and friends with
gambling problems” were associated with GD. These factors were also reported in previous
studies that targeted people who were not homeless (Black et al., 2013; Mann et al., 2017;
Mazar et al., 2018; Shaw et al., 2007; Volberg, 1994). In Japan, Pachinko and Pachislot
EGMs are popular forms of gambling, mainly used by men, and are legal for those older
than 18 years. Among our participants, EGMs were reported as the most used in the past
and the present. The proportion of those who had gambled in the past year was still high, at
68.9%. Preventive measures may need to include individuals with GD, those who are close
to individuals with GD, and recreational gamblers.
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n(%)
Gambling experience (N = 103)
In lifetime 97 (94.2)
In the past year 71 (68.9)
Potential GD (SOGS score ≥ 5) (N = 103)
In lifetime 45 (43.7)
In the past year 4 (3.9)
Severity of gambling risk in the past 12 months (PGSI score) (N = 71a)
High-risk gambler (8–27) 8 (11.3)
Moderate-risk gambler (3–7) 16 (22.5)
Low-risk gambler (1–2) 16 (22.5)
Non-problem gambler (0) 31 (43.7)
Age at onset of gambling (years old) (N = 97b)
< 20 33 (34.0)
≥ 20 64 (66.0)
Form of gambling rst engaged in (N = 97b)
Pachinko (EGM) 64 (66.0)
Pachislot (EGM) 5 (5.2)
Horse racing 15 (15.5)
Boat racing 5 (5.2)
Bicycle racing 1 (1.0)
Lottery 2 (2.1)
Mahjong, shogi, card betting 2 (2.1)
Other 3 (3.1)
Whether they had close associations with those with gambling problems (N = 103)
Yes 36 (35.0)
No 67 (65.0)
Close relatives and friends with gambling problems
(multiple answers allowed) (N = 36)
Fathers 15 (41.7)
Mothers 6 (16.7)
Siblings 4 (11.1)
Spouse and/or cohabitants 1 (2.8)
Other relatives 3 (8.3)
Friends and/or signicant others 19 (52.8)
When they had gambled the most (N = 97b)
Before the rst homelessness incident 67 (69.1)
Before, during, and after the rst homelessness incident 15 (15.5)
After the rst homelessness incident 15 (15.5)
Reasons for not gambling as much as before (N = 86c)
I do not have the money for it 46 (53.5)
It costs a lot 13 (15.1)
Realized it was waste of money time/money 10 (11.6)
Lost interest 5 (5.8)
I would have become too into it 3 (3.5)
I just wanted to try it 2 (2.3)
I cannot win any more 2 (2.3)
Table 2 Gambling experience, prevalence of gambling disorder, and severity of gambling risk among the
participants
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Limitations
This study has some limitations. First, the sample was limited in its representation, and the
Table 3 Participants’ gambling activities in their lifetimes (when they gambled the most) and in the past year
Participants who have ever gambled in
their lifetimes
(n = 97):
When they gambled the most
Participants who
have gambled in
the past year
(n = 71)
Gambling frequency
Everyday 37 (38.1) 1 (1.4)
1–6 times a week 46 (47.4) 35 (49.3)
1–3 times a month 9 (9.3) 24 (33.8)
< Once a month 5 (5.2) 11 (15.5)
Forms of gambling with most money spent
Pachinko (EGM) 46 (47.4) 25 (35.2)
Pachislot (EGM) 16 (16.5) 14 (19.7)
Horse racing 18 (18.6) 17 (23.9)
Boat racing 6 (6.2) 9 (12.7)
Bicycle racing 2 (2.1) 1 (1.4)
Motorbike racing 1 (1.0) 0 (0.0)
Lottery 2 (2.1) 3 (4.2)
Mahjong, shogi, card betting 4 (4.1) 1 (1.4)
Other 2 (2.1) 1 (1.4)
Annual income (¥)
< 1,000,000 17 (17.5) 55 (77.5)
1,000,000–1,999,999 20 (20.6) 13 (18.3)
2,000,000–2,999,999 15 (15.5) 1 (1.4)
3,000,000–3,999,999 17 (17.5) 1 (1.4)
4,000,000–5,999,999 19 (19.6) 1 (1.4)
≥ 6,000,000 9 (9.3) 0 (0.0)
EGM: Electronic Gaming Machine
¥: Japanese Yen
n(%)
I do not like the venue environment 1 (1.2)
Health reasons 1 (1.2)
No real reason 1 (1.2)
Other 2 (2.3)
GD: Gambling Disorder
SOGS: South Oak s Gambling Screening
PGSI: Problem Gambling Severity Index
EGM: Electronic Gaming Machine
aThose who had gambled in the past 12 month
bSix participants without gambling exper ience were not included
cThose who are not gambling as much as before
Table 2 (continued)
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Journal of Gambling Studies (2023) 39:1059–1076
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With GD Without
GD
OR 95% CI p-value
n = 45 n = 58
Age (years)
< 50 6 (13.3) 12 (20.7) 0.59 0.20–1.72 0.333
≥ 50 39 (86.7) 46 (79.3) Ref.
Educational status
Middle school graduate 23 (51.1) 29 (50.0) 1.05 0.48–2.28 0.911
High school graduate or higher 22 (48.9) 29 (50.0) Ref.
Marital status
Never married (Never married, unmarried partner) 28 (62.2) 49 (84.5) Ref.
Previously married (divorced, widowed) 17 (37.8) 9 (15.5) 3.31 1.30–8.39 0.010
Time elapsed since the rst homelessness incidence (years)
< 10 14 (31.1) 29 (50.0) Ref.
10–19 12 (26.7) 18 (31.0) 1.38 0.52–3.64 0.514
≥ 20 19 (42.2) 11 (19.0) 3.58 1.34–9.52 0.011
Number of homelessness episodes in lifetime
1 17 (37.8) 32 (55.2) Ref.
2–4 15 (33.3) 22 (37.9) 1.28 0.53–3.10 0.579
≥ 5 13 (28.9) 4 ( 6.9) 6.12 1.73–21.69 0.005
Experience of using social support in lifetime
Yes 32 (71.1) 30 (51.7) 2.30 1.01–5.24 0.046
No 13 (28.9) 28 (48.3) Ref.
Age at onset of gambling (years old)a
< 20 35 (77.8) 29 (50.0) 2.78 1.14–6.76 0.023
≥ 20 10 (22.2) 23 (39.7) Ref.
When they had gambled the mosta
Before the rst homelessness incident 30 (66.7) 37 (63.8) Ref.
Before, during, and after the rst homelessness
incident
7 (15.6) 8 (13.8) 1.08 0.35–3.32 0.894
After the rst homelessness incident 8 (17.8) 7 (12.1) 1.41 0.46–4.33 0.549
Annual income when gambling the most (¥)a
< 2,000,000 16 (35.6) 21 (36.2) Ref.
2,000,000–3,999,999 14 (31.1) 18 (31.0) 1.02 0.39–2.65 0.966
≥ 4,000,000 15 (33.3) 13 (22.4) 1.51 0.56–4.06 0.410
Form of gambling when gambling the mosta
EGMs (Pachinko or Pachislot) 32 (71.1) 30 (51.7) 1.81 0.77–4.21 0.170
Other 13 (28.9) 22 (37.9) Ref.
Whether they had close associations with those with gambling
problems
Yes 26 (57.8) 10 (17.2) 6.57 2.66–16.19 < 0.0001
No 19 (42.2) 48 (82.8) Ref.
Current smoking behavior
Yes 40 (88.9) 37 (63.8) 4.54 1.55–13.28 0.004
No 5 (11.1) 21 (36.2) Ref.
Current alcohol use (AUDIT score)
Potential alcohol dependence (15–40) 12 (26.7) 5 ( 8.6) 6.00 1.68–21.48 0.006
Hazardous use (8–14) 7 (15.6) 8 (13.8) 2.19 0.63–7.65 0.220
Table 4 Bivariate analysis of characteristics of homeless men with or without potential gambling disorder in
their lifetimes (N = 103)
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Journal of Gambling Studies (2023) 39:1059–1076
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ndings may not be generalizable to the entire homeless population in Japan. Our partici-
pants were only men using the shelters. Moreover, there is a high prevalence of psychologi-
cal disorders and intellectual disabilities among homeless people (Morikawa et al., 2011;
Nishio et al., 2015; Okamura et al., 2015; Okuda, 2010), and those with severe mental
illness, including alcohol use disorder and intellectual disabilities, were not in scope in this
study. However, because homeless subgroups are a diverse and hard-to-reach population,
we consider this study’s setting suitable for an epidemiological study.
Second, potentially important variables were not measured. High rates of mental health
disorders are reported in both those with GD and the homeless population. However, we
used the same questionnaire as the JNSG 2017. In the present study setting, we determined
that screening participants’ mental disorders using valid and reliable methods was not pos-
AOR 95%
CI
p-value
Previously married (divorced, widowed) 3.13 1.00–
9.81
0.0497
≥ 20 years since the rst homelessness
incidence
4.97 1.50–
16.45
0.009
≥ 5 homelessness episodes 4.51 1.06–
19.26
0.042
Early gambling onset (< age 20) 4.69 1.46–
15.07
0.010
Had close relatives/friends with gambling
problems
5.85 1.96–
17.41
0.002
Potential gambling disorder (South Oaks Gambling Screening
score ≥ 5)
AOR: Adjusted Odds Ratio
CI: Condence Interval
aThose without gambling exper iences (n = 6) a re not included in the
analysis
Table 5 Multivariate analysis of
characteristics of homeless men
with or without potential gam-
bling disorder in their lifetimes
(N = 97a)
With GD Without
GD
OR 95% CI p-value
n = 45 n = 58
No risk (1–7) 16 (35.6) 23 (39.7) 2.00 0.75–5.35 0.168
Non-drinker (0) 10 (22.2) 22 (37.9) Ref.
Imprisonment history in lifetime
Yes 10 (22.2) 7 (12.1) 2.08 0.72–5.99 0.169
No 35 (77.8) 51 (87.9) Ref.
GD: Gambling Disorder (South Oaks Gambling Screening score ≥ 5)
EGMs: Electronic Gaming Machines
AUDIT: Alcohol Use Disorders Identication Test
OR: Odds Ratio
CI: Condence Interval
aSix participants without gambling exper ience were not included
Table 4 (continued)
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Journal of Gambling Studies (2023) 39:1059–1076
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sible. Future research should explore the association between GD and other mental disor-
ders among homeless population in more detail.
Third, 95% CIs of ORs and AORs were wide, indicating low power and uncertainty in
the current study’s estimates. This may be partly due to our approach to examine relation-
ships through ORs as some cells in the 2*2 tables had small sample sizes. Given the skewed
distributions of some variables, in order to increase interpretability, we prioritized analyses
with ORs. A sensitivity analysis using the original continuous scales conrmed the ndings
with ORs. We gained a unique opportunity in this study, but recruitment remained dicult
among this hard-to-reach population. Eect sizes and 95% CIs of any correlates identied
should be interpreted with caution. Furthermore, as this is a cross-sectional study, the results
do not demonstrate causality between GD and homelessness or between GD and the associ-
ated factors.
Finally, gambling, alcohol problems, and imprisonment history were self-reported and
may therefore be underreported. People with addictive disorders tend to underestimate their
problems (Suurvali et al., 2009), and homeless people have greater diculties disclosing
their gambling problems (Holdsworth & Tiyce, 2012). Additionally, nine participants with
a long history of homelessness were excluded because they had diculty recalling their
personal history related to homelessness. Homeless people have been shown to struggle
with memory and other cognitive impairments (Ennis et al., 2015). This type of response
bias is inherent to any study with homeless populations, and we determined that removing
egregious instances on unreliable reporting was the best approach to adjust for such bias.
Conclusions
This study provided initial epidemiological information on GD among homeless men in
Japan. Overall, GD was found to be more prevalent among our sample than in the general
population. For those with a lifetime of GD, more time had elapsed since the rst incidence
of homelessness, and episodes of homelessness were more frequent than among those with-
out GD. Additionally, homeless men with GD were more likely to have started gambling
at a younger age and have close relatives and friends with gambling problems than those
without GD.
When homeless people with GD aim to rebuild and stabilize their lives, the presence or
resurgence of gambling problems poses a potential risk of being homeless again. Homeless
people often experience a combination of problems; thus, support for addressing gambling
problems needs to be included in a comprehensive support program. Preventive measures
should be taken at the population level and should include not only those with GD but also
those with recreational gambling behaviors and their social networks.
Supplementary information The online version contains supplementary material available at https://doi.
org/10.1007/s10899-022-10121-x.
Funding source Data collection of this study was funded by the policy proposal project of The Big Issue
Japan Foundation, a Japanese NPO. CH was supported by the 2019 Kyoto University School of Public Health
– Super Global Course; the Inter-Graduate School Program for Sustainable Development and Sustainable
Societies, Global Survivability Studies Program, Kyoto University; the Public Interest Incorporated Founda-
tion, The Kyoto University Foundation; and the Japan Society for the Promotion of Science (JSPS), KAKEN
Grant No. 19J15223.
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Journal of Gambling Studies (2023) 39:1059–1076
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Declarations
Conflict of interest The authors declare that they have no known competing nancial interests or personal
relationships that could have appeared to inuence the work reported in this paper.
Ethics The study procedures were performed in accordance with the Declaration of Helsinki. Ethical approval
was obtained from the Institutional Review Board of The Big Issue Japan Foundation (No. 1) and the ethics
committee of the Graduate School and Faculty of Medicine Kyoto University (R0618). We informed the
participants about the study and obtained written informed consent.
Author CRediT Statement Conceptualization: Chiyoung Hwang, Ryuhei So, Masahiro Kihara; Methodol-
ogy: Chiyoung Hwang, Masahiro Kihara; Formal analysis: Chiyoung Hwang, Masahiro Kihara; Investiga-
tion: Chiyoung Hwang, Taichi Takano, Sho Kawakami; Writing - original draft preparation: Chiyoung
Hwang; Writing - review and editing: Ryuhei So, Ethan Sarkar, Charles Livingstone, Naoko Takiguchi,
Masako Ono-Kihara, Masahiro Kihara, Toshi A Furuawa; Visualization: Chiyoung Hwang; Supervision:
Masahiro Kihara, Toshi A Furukawa; Project administration: Chiyoung Hwang, Taichi Takano; Funding
acquisition: Chiyoung Hwang, Taichi Takano, Sho Kawakami.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence,
and indicate if changes were made. The images or other third party material in this article are included in the
article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is
not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright
holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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Authors and Aliations
ChiyoungHwang1· TaichiTakano2· RyuheiSo1,3· EthanSahker1,7·
ShoKawakami2· CharlesLivingstone4· NaokoTakiguchi5· MasakoOno-Kihara6·
MasahiroKihara6· Toshi A.Furukawa1
Chiyoung Hwang MPH, BSN
hwang.chiyoung.44e@st.kyoto-u.ac.jp
Taichi Takano BA
t.takano@bigissue.or.jp
Ryuhei So MD, MPH
nexttext@gmail.com
Ethan Sahker PhD
sahker.ethan.2e@kyoto-u.ac.jp
Sho Kawakami BA
s.kawakami@bigissue.or.jp
Charles Livingstone MEc, PhD
Charles.livingstone@monash.edu
Naoko Takiguchi PhD
ntakiguchi@res.otani.ac.jp
Masako Ono-Kihara PhD
kihara.masako.0612@gmail.com
Masahiro Kihara MD, PhD
1075
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Journal of Gambling Studies (2023) 39:1059–1076
1 3
kihara.masahiro.44z@st.kyoto-u.ac.jp
Toshi A. Furukawa MD, PhD
furukawa@kuhp.kyoto-u.ac.jp
1 Department of Health Promotion and Human Behavior, Graduate School of Medicine, School
of Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, 606-8501 Kyoto, Japan
2 Not-for-Prot Organization, The Big Issue Japan Foundation, Osaka, Japan
3 Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
4 Gambling and Social Determinants Unit, School of Public Health and Preventive Medicine,
Monash University, Melbourne, Victoria, Australia
5 Department of Sociology, Otani University, Kyoto, Japan
6 Interdisciplinary Unit for Global Health, Center for the Promotion of Interdisciplinary
Education and Research, Kyoto University, Kyoto, Japan
7 Population Health and Policy Research Unit, Medical Education Center, Graduate School of
Medicine, Kyoto University, Kyoto, Japan
1076
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

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