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Introduction to the Special Issue on
‘‘Relations Between Gambling and Alcohol Use’’
Sherry H. Stewart
Dalhousie University
Matt G. Kushner
University of Minnesota
It has long been recognized that gambling is an activity that is often combined with
alcohol intake. Not only do the behaviors of drinking and gambling frequently co-
occur, alcohol use disorders and pathological gambling are also commonly co-morbid
conditions in both clinical and non-clinical samples. This article introduces a special
issue of the Journal of Gambling Studies focusing on cutting edge findings on the relations
between gambling and alcohol use behaviors and their associated disorders. We set the
stage for the following series of six novel empirical papers and integrative commentary
by reviewing the theoretical pathways through which alcohol use and gambling
disorders may be linked. We conclude by describing some of the novel contributions of
each of the empirical studies from within the context of these theoretical models.
KEY WORDS: pathological gambling; alcohol abuse; alcohol dependence;
co-morbidity.
It has long been recognized that gambling is an activity that is
often combined with drinking alcohol (Adler & Goleman, 1969). In
many parts of the world, alcohol is available at locations where
gambling occurs, and vice versa. According to a survey study by Focal
Research (1998), about three-quarters of regular video lottery terminal
Please address correspondence to Sherry H. Stewart, Department of Psychology, Dalhousie
University, Life Sciences Centre, 1355 Oxford Street, Halifax, Nova Scotia, Canada, B3H 4J1.
E-mail: sherry.stewart@dal.ca.
Journal of Gambling Studies, Vol. 21, No. 3, Fall 2005 (Ó 2005)
DOI: 10.1007/s10899-005-3097-5
223
1050-5350/05/0900-0223/0 Ó 2005 Springer Science+Business Media, Inc.
(VLT) gamblers in the Canadian province of Nova Scotia (where VLTs
are located in bars) self-report drinking alcohol while they gamble.
This figure has been confirmed in experimental, laboratory-based
research (Stewart, McWilliams, Blackburn, & Klein, 2002). In this
study, regular gamblers were given the opportunity to purchase
alcoholic or non-alcoholic beverages, while they gambled or engaged
in a control activity of movie watching. Those randomly assigned to the
gambling condition were more likely to purchase alcoholic than non-
alcoholic beverages (73% vs. 20%, respectively), whereas no such bias
toward alcoholic beverage consumption was observed among regular
gamblers assigned to the movie watching condition (40% drank
alcoholic and 47% drank non-alcoholic beverages).
Not only do the behaviors of drinking and gambling frequently
co-occur, the forms of psychopathology associated with excesses in
these behaviors (i.e., alcohol use disorders and pathological gambling)
are also commonly co-morbid conditions (see reviews by Crockford &
el-Guebaly, 1998; Grant, Kushner, & Kim, 2002). Research with clinical
populations has shown that rates of pathological gambling are
significantly elevated among those with an alcohol use disorder (e.g.,
Daghestani, Elenz, & Crayton, 1996; Lesieur & Heineman, 1988) and,
conversely, rates of alcohol use disorders are significantly increased
among pathological gamblers (e.g., Ramirez, McCormick, Russo, &
Taber, 1983). The high rates of co-morbidity of alcohol use disorders
with pathological gambling have also been confirmed in epidemiolo-
gical studies with non-clinical samples drawn from the general
population (e.g., Cunningham-Williams, Cottler, Compton, & Spitzna-
gel, 1998; Smart & Ferris, 1996; Welte, Barnes, Wieczorek, Tidwell, &
Parker, 2001).
Despite the high overlap of gambling and drinking at the
behavioral and diagnostic levels, very little is known about the precise
nature of this overlap. As illustrated in Figure 1, there are at least three
ways in which heavy drinking and excessive gambling might be related
to one another. First, it could be that gambling disorders cause or
exacerbate problems with alcohol use as is depicted in the top row of
Figure 1. For example, an individual might begin to abuse alcohol (or
escalate his or her abuse of alcohol) in an attempt to self-medicate for
distress brought on by his or her problematic gambling (e.g., financial
losses, relationship difficulties) (Stewart et al., 2002). Second, it could
be that excessive drinking causes or exacerbates problems with
224 JOURNAL OF GAMBLING STUDIES
gambling as is depicted in the middle row of Figure 1. For example,
alcohol intoxication could cause increased risk taking during gambling
bouts, resulting in greater gambling problems (e.g., greater financial
losses) (Kyngdon & Dickerson, 1999). Both of these mechanisms
assume that problem drinking and problem gambling are causally
related to one another, and suggest that these disorders represent
distinct taxons. A third possibility assumes no causal relationship
between drinking and gambling and instead posits the presence of a
third variable that is causally related to both drinking and gambling
disorders as is depicted in the bottom row of Figure 1. For example,
drinking and gambling problems could share a common genetic
vulnerability (Slutske et al., 2000) or a common underlying dysregu-
lation in the dopamine system (Potenza, 2001; Stewart, Collins,
Blackburn, Ellery, & Klein, 2005). This latter model is consistent both
with the view that the two problems represent distinct taxons and with
the possibility of a common, single underlying taxon (see Figure 1).
As this special issue highlights, research is now emerging that
begins to clarify the nature of the relationship between alcohol use
disorders and pathological gambling. The set of five empirical papers
in the current special issue illustrates the novel approaches that
researchers are using to enhance understanding of the functional
interplay between excessive drinking and problematic gambling
behavior. We are also very fortunate to have an integrative commentary
Gambling
Disorder
Alcohol
Disorder
Gambling
Disorder
Alcohol
Disorder
3rd
Variable
Gambling Disorder
Alcohol Disorder
(Dual Taxon)
(Dual Taxon)
(Dual or Single Taxon)
Figure 1
An illustration of theoretical associations in gambling disorder –
alcohol disorder co-morbidity
225SHERRY H. STEWART AND MATT G. KUSHNER
on the set of studies by an addictions expert to conclude the special
issue (Nathan, this issue).
The studies included in this special issue span a variety of
populations. These include community-recruited gamblers serving as
research volunteers (Ellery, Stewart, & Loba, this issue; Zack, Stewart,
Klein, Loba, & Fragopoulos, this issue), problem gamblers attempting
recovery through self-change efforts or gambling treatment services
(Hodgins, Peden, & Cassidy, this issue; Stinchfield, Kushner, & Winters,
this issue), and problem gambling help-line callers (Potenza, Steinberg,
& Wu, this issue). The variety of populations included in these studies
should enhance generalizability of the findings.
The studies in this special issue have also made use of a wide variety
of methodologies to enhance our understanding of the relations
between gambling and drinking problems. Two of the studies are lab-
based experimental studies (Ellery et al., this issue; Zack et al., this
issue), while the other three are clinical studies (Hodgins et al., this
issue; Potenza et al., this issue; Stinchfield et al., this issue). The clinical
studies include both cross-sectional (Potenza et al., this issue) and
longitudinal (Hodgins et al., this issue; Stinchfield et al., this issue)
investigations. The clinical studies help establish the extent and impact
of co-morbid gambling and alcohol use problems, while the exper-
imental studies provide insight into the mechanisms underlying this
form of co-morbidity.
The clinical studies (Hodgins et al., this issue; Potenza et al., this
issue; Stinchfield et al., this issue) make use of both standardized
questionnaires and structured interviews to investigate the extent and
implications of alcohol – gambling disorder co-morbidity. Such
measures include the Gambling Helpline Form (Potenza et al.,
2004), the Structured Clinical Interview for DSM-IV (Spitzer, Williams,
& Gibbon, 1994), and the Gambling Treatment Outcome Monitoring
System (Stinchfield & Winters, 2001). The lab-based experimental
studies make use of both well-established and novel, cutting-edge
paradigms to examine functional relations between drinking and
gambling behaviors and events. These experimental methodologies
include the alcohol challenge paradigm (see Newlin & Thomson,
1990) and a cognitive paradigm known as the Implicit Association Test
(see Greenwald, & Banaji, 1995; Greenwald, McGhee, & Schwartz,
1998; Wiers, van Woerden, Smulders, & de Jong, 2002) to study the
effects of alcohol on aspects of gambling play (Ellery et al., this issue)
226 JOURNAL OF GAMBLING STUDIES
and the cognitive associations between gambling and drinking con-
cepts (Zack et al., this issue) among regular gamblers.
Each of the empirical studies contained in this special issue bears
directly or indirectly on clarification of the mechanisms involved in
alcohol – gambling disorder co-morbidity. For example, the finding by
Ellery et al. (this issue) that alcohol challenge leads to more intensive
gambling behavior is consistent with the second model presented in
Figure 1 (middle row). In this case, problem drinking could cause
problem gambling if frequent experiences of alcohol intoxication
result in more serious negative outcomes from gambling. However, the
fact that alcohol led to increased risk taking only among those with
pathological gambling in the Ellery et al. (this issue) study suggests that
the findings are more consistent with a model in which alcohol
intoxication contributes to pathological gambling maintenance.
As another example, the finding by Zack et al. (this issue)
regarding conditioned associations between gambling win outcomes
and alcohol cues on the Implicit Association Task is consistent with the
first model depicted in Figure 1 (top row). In this case, problem
gambling could cause problem drinking if exposure to gambling
outcome cues prompts thoughts about drinking, which in turn
promotes problematic drinking following exposure to a gambling
win. However, a problem with drawing the conclusion that pathological
gambling causes alcohol disorders on the basis of the Zack et al. (this
issue) findings is the inherent circularity of the argument: it suggests
that individuals are drinking frequently while gambling prior to
developing the co-morbid alcohol disorder.
Potenza et al.’s (this issue) findings are partially consistent with a
possible common cause for both pathological gambling and alcohol
use disorders. Specifically, this team found that those problem
gamblers self-reporting a history of problem drinking were more likely
than other gambling helpline callers to report other problem
behaviors suggestive of impulse control problems. Thus, impulsivity
is a possible third variable that might contribute to the development of
both alcohol use disorders and pathological gambling. This explana-
tion suggests a single (common) taxon for both disorders suggesting
that the two are subsumed under a more general category of impulse
control problems. However, if this were the case, all individuals with
pathological gambling should show multiple impulse control prob-
lems. Perhaps co-morbid pathological gambling – alcohol use disorder
227SHERRY H. STEWART AND MATT G. KUSHNER
involves a subtype of pathological gambling representing a separate
taxon in which impulse control problems increases risk for multiple
addictive and problem behaviors including alcohol problems.
The results of the studies by Hodgins et al. (this issue) and
Potenza et al. (this issue) which examined rates of alcohol use disorder
in currently problematic gamblers also have implications for under-
standing the nature of the relationship between the two disorders.
Specifically, the two studies converged in finding that the vast majority
of their co-morbid cases involved current gambling problems with a
past (rather than current) history of alcohol problems. This is
interesting because it is inconsistent with either of the first two models
presented in Figure 1, because if the alcohol disorder or pathological
gambling causes (or maintains) the other, then both problems should
be current at the same time. This finding is, however, consistent with a
modified version of the second model illustrated in Figure 1 (middle
row). More specifically, it is consistent with the notion that the alcohol
disorder causes the gambling disorder in the first place, but then the
alcohol disorder resolves and the gambling disorder is maintained by
factors other than heavy drinking.
The findings of the study by Stinchfield et al. (this issue) also have
important implications for understanding the connection between
problematic alcohol use and pathological gambling. This study
investigated the impact of pathological gambling treatment on both
gambling outcomes and substance use outcomes among those prob-
lem gamblers with high and low frequency alcohol use. As noted by
Grant et al. (2002), if the gambling disorder is causal (model 1 in
Figure 1), as a consequence of pathological gambling treatment, one
would expect good gambling outcome (since gambling treatment
would be unaffected by alcohol) and good substance outcome (since
substance use would be improved by gambling treatment response). If
the alcohol disorder is causal (model 2 in Figure 1), as a consequence
of pathological gambling treatment, one would expect poor gambling
outcome (since gambling treatment response would be worsened by
alcohol) and poor substance outcome (since substance abuse would
not be affected by gambling treatment). Finally, if a common third
variable causes both the alcohol and gambling disorder (model 3 in
Figure 1), as a consequence of pathological gambling treatment, one
would expect good gambling outcome (since gambling treatment
would be unaffected by alcohol) and poor substance outcome
228 JOURNAL OF GAMBLING STUDIES
(since substance abuse would not be affected by gambling treatment).
Stinchfield et al.’s (this issue) findings are most consistent with the
second model, where the gambling disorder is causal, since gambling
and substance abuse outcomes were both good for the problem
gamblers who were frequent drinkers.
The present set of papers illustrates that researchers are now going
well beyond simple epidemiological investigations to establish the
extent of the overlap between pathological gambling and alcohol use
disorders and toward investigations that advance understanding of the
mechanisms that underlie this high overlap. Ultimately, the results of
such investigations should contribute to the improvement of interven-
tions for those suffering from this common form of addictive disorder
co-morbidity.
ACKNOWLEDGMENTS
Preparation of this manuscript and special issue were supported
in part from grants from the Ontario Problem Gambling Research
Centre and the Nova Scotia Gaming Foundation to the first author
and from the National Institute on Alcoholism and Alcohol Abuse
awarded to the second author. The first author is supported through
a Canadian Institutes of Health Research Investigator Award. We
gratefully acknowledge the editorial assistance of Dr. Howard Shaffer
and the research assistance of Ellen Rhyno in putting together this
special issue.
NOTE
1. Some of the articles contained in this special issue represent papers presented at a sympo-
sium on the co-morbidity of alcoholism and pathological gambling held at the 2002 Annual
Meeting of the Research Society on Alcoholism in San Francisco, California (see summary by
symposium co-chairs, Stewart & Kushner, 2003).
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