essay on problem gambling

How gambling affects the brain and who is most vulnerable to addiction

Once confined mostly to casinos concentrated in Las Vegas and Atlantic City, access to gambling has expanded dramatically, including among children

Vol. 54 No. 5 Print version: page 62

• Personality
• Video Games

It has never been easier to place a bet. Once confined mostly to casinos concentrated in Las Vegas and Atlantic City, gambling has expanded to include ready access to lotteries and online games and video games with gambling elements for adults and children.

Sports betting is now legal in 37 states plus Washington, DC, with six more considering legislation, according to American Gaming Association data from early 2023. People can gamble around the clock from anywhere and, increasingly, at many ages, including teenagers and even young children who are well below the legal age for gambling.

As access to gambling has expanded, psychologists and other experts have become concerned not just that more people will give it a try, but that more will develop gambling problems. And while it is still too soon to know what the long-term effects will be, evidence is growing to suggest that young people, especially boys and men, are among those particularly vulnerable to gambling addiction—the same demographic most often participating in the newest forms of gambling: sports betting and video game-based gambling.

People in their early 20s are the fastest-growing group of gamblers, according to recent research. And many kids are starting younger than that. Nearly two-thirds of adolescents, ages 12 to 18, said they had gambled or played gambling-like games in the previous year, according to a 2018 Canadian survey of more than 38,000 youth funded by the government of British Columbia ( Understanding the Odds , McCreary Centre Society, 2021 [PDF, 1.1MB] ). Starting young carries a relatively high burden of psychological distress and increased chances of developing problems.

Researchers are now working to refine their understanding of the psychological principles that underlie the drive to gamble and the neurological underpinnings of what happens in the brains of gamblers who struggle to stop. Counter to simplistic assumptions about the role that the neurotransmitter dopamine plays in addictions ( Nutt, D. J., et al., Nature Reviews Neuroscience , Vol. 16, No. 5, 2015 ), research is showing variations in the volume and activity of certain areas of the brain related to learning, stress management, and rewards processing that might contribute to problematic gambling.

Understanding what makes certain people vulnerable to developing problems could ultimately lead to better strategies for prevention and treatment, and also elucidate the evolving health impacts of gambling, the consequences of starting young, and even the role that the government should play in addressing those issues.

As it stands, the National Institutes of Health has agencies dedicated to problem alcohol use and drug use, but there are no official efforts aimed at problem gambling, and there are no federal regulations against advertisements for sports betting, said social worker Lia Nower, JD, PhD, director of the Center for Gambling Studies at Rutgers University in New Jersey. That means kids can see ads, often featuring their sports heroes promoting gambling, at any time of day or night. “It’s the wild, wild west with regard to gambling,” Nower said.

Examining the risks

Most adults and adolescents in the United States have placed some type of bet, and most do it without problems. But a significant subset of people who start gambling go on to develop gambling disorder, defined in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) as a persistent, recurrent pattern of gambling that is associated with substantial distress or impairment.

Gambling problems, previously called pathological gambling, were considered an impulse control disorder until 2013, when the DSM-5 classified them as an addictive disorder. That made gambling addiction the first, and so far the only, defined behavioral addiction in the clinical section of DSM-5 (with some hints that video gaming disorder might ultimately follow, experts say). Like addictions to alcohol and drugs, gambling addictions are characterized by an increasing tolerance that requires more gambling as time goes on to feel satisfied. People with the disorder can also experience withdrawal that causes irritability when they try to quit.

Over the last 20 years or so, researchers have refined their understanding of how common gambling addictions are and who is most vulnerable. Among adults, the estimated proportion of people with a problem ranges from 0.4% to 2%, depending on the study and country. Rates rise for people with other addictions and conditions. About 4% of people being treated for substance use also have gambling disorder, as do nearly 7% of psychiatric inpatients and up to 7% of people with Parkinson’s disease. An estimated 96% of people with gambling problems have at least one other psychiatric disorder. Substance use disorders, impulse-control disorders, mood disorders, and anxiety disorders are particularly common among people with gambling problems ( Potenza, M. N., et al., Nature Reviews Disease Primers , Vol. 5, No. 51, 2019 ).

Vulnerability is high in people with low incomes who have more to gain with a big win, added psychologist Shane Kraus, PhD, director of the Behavioral Addictions Lab at the University of Nevada, Las Vegas. Young people, especially boys and men, are another susceptible group. Up to 5% of adolescents and young adults who gamble develop a disorder. And men outnumber women at a ratio of about 2 to 1 among people with gambling addictions, although there are a growing number of women with the disorder.

Despite concerns, scientists have yet to document a consistent rise in the rates of gambling problems in recent years, said Jeffrey Derevensky, PhD, a psychologist and director of the International Centre for Youth Gambling Problems and High-Risk Behaviours at McGill University. Still, because more people now have access to gambling, evidence suggests that overall numbers of problems appear to have risen, Derevensky said. After Ohio legalized sports betting, for example, the number of daily calls to the state’s gambling helpline rose from 20 to 48, according to the Ohio Casino Control Commission. Other states have reported similar trends.

As evidence accumulates, it is important to examine the risks without overreacting before the data are in, said Marc Potenza, PhD, MD, director of Yale University’s Center of Excellence in Gambling Research. When casinos enter a region, he said, the area may experience a transient bump in gambling problems followed by a return to normal. Given how quickly gambling is evolving with digital technologies, only time will tell what their impact will be. “We don’t want to be overly sensationalistic, but we do wish to be proactive in understanding and addressing possible consequences of legalized gambling expansion,” he said.

From gaming to gambling

After years of studying the psychological effects of video game violence, psychologist James Sauer, PhD, a senior lecturer at the University of Tasmania in Australia, took notice when Belgium became the first country to ban a feature called loot boxes in video games in 2018. Loot boxes are digital containers that players can buy for a small amount of money. Once purchased, the box might reveal a special skin or weapon that enhances a character’s looks or gives a player a competitive advantage. Or it might be worthless.

On a Skype call after the news broke, Sauer, a psychological scientist and coexecutive director of the International Media Psychology Laboratory, talked with his collaborator, psychological scientist Aaron Drummond, PhD, of Massey University in New Zealand, about Belgium’s decision. Because loot boxes represent a financial risk with an unknown reward, Belgian policymakers had categorized them as a form of gambling, and those policymakers were not the only ones. Countries and states that have passed or considered regulations on loot boxes include Australia, the Netherlands, and Hawaii. But those regulations were contentious.

Sauer and Drummond discussed the need for more science to guide the debate. “We were trying to think about how we might contribute something sensible to a discussion about whether these in-game reward mechanisms should or should not be viewed as a form of gambling,” Sauer said.

To fill the evidence gap, the researchers watched online videos of players opening loot boxes in 22 popular and recently released games that had been rated by the Entertainment Software Ratings Board as appropriate for people ages 17 and younger. Nearly half of the games met the definition for gambling, the researchers reported in 2018, including Madden NFL 18 , Assassin’s Creed Origins , FIFA 18 , and Call of Duty: Infinite Warfare ( Nature Human Behaviour , Vol. 2, 2018 ). Among the criteria for qualifying as gambling was an exchange of real money for valuable goods with an unknown outcome determined at least partly by chance. Purchased objects had value that gave an advantage in the game and sometimes could be sold or traded to others for real money.

Loot boxes tap into the same psychological principles that draw people to slot machines, Sauer said. They may deliver a big payoff, but payoffs come at random intervals. Unlike rewards given after every repetition of a behavior, this type of variable ratio reinforcement, or intermittent reinforcement, exploits a cognitive distortion that makes a player or gambler view each loss as one step closer to a win and can lead to very rapid adoption of a behavior that can then be hard to extinguish, Sauer said. Animals exhibit the same patterns. “They feel sure that the reward is coming, but they can’t know when, so they keep repeating the behavior,” he said. “They continue even as rewards become less and less frequent and even stop entirely.”

After establishing that loot boxes, which generate billions of dollars in revenue for video game companies, are often in fact a type of gambling, studies by Sauer’s group and others since then have shown that people who spend more on loot boxes are often at higher risk of developing gambling problems, and that the connection is strongest in adolescence. Scientists are now working to untangle the question of whether buying loot boxes can cause gambling addictions, and at least some evidence supports this kind of gateway idea.

In one survey of 1,102 adults in the United Kingdom, about 20% of gamblers said that loot boxes were their first introduction to gambling and that their experiences with the game rewards made them think that other forms of gambling could be fun, according to a 2022 study ( Spicer, S. G., et al., Addictive Behaviors , Vol. 131, No. 107327, 2022 ). More than 80% of them had started buying loot boxes before they were 18. More recently, Canadian researchers surveyed hundreds of young adult video gamers at two time points, 6 months apart. Among those who were not gamblers when the study started, dozens went on to gamble over the course of the study, they reported in 2023, suggesting that loot boxes had opened the gambling floodgates ( Brooks, G. A., & Clark, L., Computers in Human Behavior , Vol. 141, No. 107605, 2023 ).

But the relationship can also go the other way. People who already gambled, the Canadian researchers found, spent more on loot boxes. And in the U.K. research, about 20% of people who started out with other types of gambling migrated to loot boxes—the same proportion that went in the other direction. Figuring out how loot boxes and gambling behavior influence each other remains a work in progress. “We just don’t have the data yet to understand the long-term consequences,” Sauer said.

Also contentious is the question of how loot boxes affect mental health. Sauer’s group has found a link between spending on loot boxes and severe psychological distress ( Scientific Reports , Vol. 12, No. 16128, 2022 ), while other research has failed to find the same association. Because kids are increasingly being exposed to gambling, it is an important question to sort through. “Some researchers have argued,” Sauer said, “that if we don’t want kids engaging with bona fide gambling behaviors, maybe we want to be wary about kids engaging with these...gambling-like reward mechanisms.”

Early exposure

Loot boxes are not the only avenue to gambling for kids. Online games that simulate gambling without financial risk are often available to very young children, said Derevensky, who once watched a young girl play a slot machine game on a tablet installed in an airport waiting area. She was earning points, not real money, and loving it. “She’s winning, and she’s saying to her dad, ‘I can’t wait until I play it for real,’” he said. “She must’ve been no more than 6 years old.”

By adolescence, about 40% of people have played simulated gambling games, studies show. These games often involve more winning than their real-world equivalents, Derevensky said. And that playful introduction without financial stakes can spark an interest. Work by his group and others has shown that teens who play simulated gambling games for points are at higher risk of having gambling problems later on ( Hing, N., et al., International Journal of Environmental Research and Public Health , Vol. 19, No. 17, 2022 ).

Seeing parents, siblings, or other members of the household gamble also normalizes gambling for kids, making them more likely to engage in gambling and other risky behaviors, including alcohol and drug use, Nower has found in her research ( Addictive Behaviors , Vol. 135, No. 107460, 2022 ). And the earlier kids get exposed to gambling through online games and other avenues, studies suggest, the more severe their gambling problems are likely to be later on ( Rahman, A. S., et al., Journal of Psychiatric Research , Vol. 46, No. 5, 2012 ).

“Kids as young as preschool are being bombarded with requests to buy things in video games,” Nower said. “A lot of kids move from betting on loot boxes in video games to playing social casino games that are free and then triage them to pay sites. You can’t really tell gambling from video gaming anymore. There’s so much overlap.”

The brain of a problem gambler

To understand why early exposure makes a difference, and why a subset of people develop gambling addictions, some scientists have been looking to the brain.

Studies have linked gambling disorders to variations in a variety of brain regions, particularly the striatum and prefrontal cortex, which are involved in reward processing, social and emotional problems, stress, and more. Some of these differences may be attributable to genetics. Twin studies and modeling work suggest that genes explain half or more of individual differences with gambling problems, specifically.

In people with gambling disorders as well as substance use disorders, a meta-analysis found that several studies showed less activity in the ventral striatum while anticipating monetary rewards ( Luijten, M., et al., JAMA Psychiatry , Vol. 74, No. 4, 2017 ). Along with other findings, those results suggest that this part of the brain contributes to impulsive behaviors for people with gambling problems.

Among other emerging insights, people with gambling problems also have smaller volumes in their amygdala and hippocampus, two regions related to emotional learning and stress regulation. Brain research might help explain why teenagers are particularly susceptible to gambling, Potenza said, including the observation that different parts of the brain mature at different rates in ways that predispose teenagers to gambling and other risk-taking behaviors. The prefrontal cortex, which regulates impulsivity and decision-making, is particularly late to develop, especially in boys.

Parsing out the details could lead to new treatments, Potenza said. For example, he and colleagues stimulated the prefrontal cortex of people with problematic gaming behavior and found improvements in their ability to regulate cravings and emotions ( European Neuropsychopharmacology , Vol. 36, 2020 ). The U.S. Food and Drug Administration has begun approving neuromodulatory approaches for using targeted brain stimulation to treat psychiatric conditions, including addictions, that could eventually help people with gambling problems, Potenza said.

New strategies for treatment would be welcome, experts say, as gambling is a particularly tricky addiction to treat, in part because it is easy to hide. As many as 90% or more of people with gambling problems never seek help ( Bijker, R., et al., Addiction , Vol. 117, No. 12, 2022 ).

For now, cognitive behavioral therapy is the most common form of treatment for gambling addiction, Nower said, and identifying pathways can tailor therapy to particular needs. She has proposed three main pathways that can lead to gambling problems ( Addiction , Vol. 117, No. 7, 2022 ). For one group of people, habitual gambling pushes them to chase wins until they develop a problem. A second group comes from a history of trauma, abuse, or neglect, and gambling offers an escape from stress, depression, and anxiety. A third group may have antisocial or impulsive personalities with risk-taking behaviors.

Betting on the game

For young adults who have grown up with video games and online gambling games, sports betting is the newest frontier—for both gamblers and researchers interested in understanding the consequences of early exposure to gambling.

Now legal in many states, the activity has exploded in popularity. An estimated 50 million people were expected to bet some $16 billion on the Super Bowl this year, according to the American Gaming Association, more than double the amount wagered the year before. (Official numbers are not yet available and are usually an underestimate because of “off the books” betting, Nower said.) At its peak, according to news reports, the betting platform FanDuel reported taking 50,000 bets per minute. Billions more were expected to be bet on March Madness.

Sports bettors trend young: The fastest-growing group of sports gamblers are between 21 and 24 years old, according to an analysis by Nower’s group of data from New Jersey, which legalized sports gambling in 2018. Compared with other kinds of gambling, the in-game betting offered during sports games is highly dependent on impulsivity, Nower said. There are opportunities to place bets during the game on everything from who will win the coin toss to which quarterback will throw 100 yards first to how long the national anthem will last. And impulsivity is particularly common in younger people and among sports fans caught up in the emotion of a game, Nower said.

Researchers are still collecting data to see if sports betting is causing a true surge in gambling problems, said Kraus, who is working on a longitudinal study of sports bettors that is following about 4,000 people over a year to see who is most likely to go from betting on a game to having problems with gambling. His group just collected their third wave of data and will be writing up a paper on their results in the coming months. “We’re going to be riding on this issue for years,” he said.

Early signs from Nower’s research in New Jersey suggest that people who engage in sports betting appear to develop gambling problems at particularly high rates and are at higher risk for mental health and substance use problems compared with other kinds of gamblers. About 14% of sports bettors reported thoughts of suicide and 10% said they had made a suicide attempt, she and colleagues found in one New Jersey study.

“Risk-takers who like action can get really involved in sports wagering,” Nower said. “Because of gambling on mobile phones and tablets, there’s no real way to keep children from gambling on their parents’, friends’, or siblings’ accounts. And they’re being bombarded with all these advertisements. This is a recipe for problems among a lot of young people.”

It takes time for a gambling problem to develop, and simple steps can interrupt the progression for many people, Kraus said. That might include placing a limit on how much they are going to spend or setting an alarm to remind them how long they have been gambling.

Education before people try gambling would help, Derevensky said, and plenty of prevention programs exist, including interactive video games designed by his group. But kids do not often get access to them. Teachers are not monitoring lunch tables for gambling activity, Nower said. And administrators are not screening for problems. Derevensky recommends that parents talk with kids about loot boxes and other gambling games and explain the powerful psychological phenomena that make them appealing.

“We educate our kids in our school systems about alcohol use, drug use, drinking and driving, and unprotected sex,” Derevensky said. “It’s very difficult to find jurisdictions and school boards that have gambling prevention programs.”

Further reading

Sports betting around the world: A systematic review Etuk, R., et al., Journal of Behavioral Addictions , 2022

The migration between gaming and gambling: Our current knowledge Derevensky, J. L., et al., Pediatric Research and Child Health , 2021

The intergenerational transmission of gambling and other addictive behaviors: Implications of the mediating effects of cross-addiction frequency and problems Nower, L., et al., Addictive Behaviors , 2022

National Problem Gambling Helpline

Gamblers Anonymous

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Online Gambling-Related Harm: Findings from the Study on the Prevalence, Behavior and Characteristics of Gamblers in Spain

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Online gambling has grown into a global social and economic phenomenon. It is, however, regarded as a risky practice, as it may be connected to the development of gambling-related disorders. Literature has shown a growing interest to determine the direction of the relationship between online gambling participation and gambling-related harm, as it raises some endogeneity concerns. This paper aims to contribute to the study of this relationship. Using data from the prevalence study of gambling users in Spain, a two-stage approach with instrumental variables is proposed to address these endogeneity concerns. An ordered probit model is then estimated to explore the correlation between online gambling participation, the intensity of participation, and the risk of developing some kind of gambling-related harm. Findings showed that online gambling had a significant impact on the odds of experiencing a gambling disorder, which worsened as online gambling participation increased.

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Díaz, A., Pérez, L. Online Gambling-Related Harm: Findings from the Study on the Prevalence, Behavior and Characteristics of Gamblers in Spain. J Gambl Stud 37 , 599–607 (2021). https://doi.org/10.1007/s10899-020-09966-x

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Public health effects of gambling – debate on a conceptual model

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Gambling for money is a popular leisure time activity in most countries, which has major social and economic impacts not only affecting the gambler, but his/her significant others, and the society. Gambling impact studies can help researchers and policymakers compare the health and social costs and benefits of different gambling policies and can be used when considering which gambling policies will reduce or increase costs or benefits the most. In a public health approach, the impacts of gambling, negative and positive, are assessed across the entire severity spectrum of the activity. Although some studies have created basic principles for conducting impact studies, a theoretical model is currently lacking. The aim of this debate is to review complementing and contrasting views on the effects of gambling to create a conceptual model, where a public health perspective is applied.

The effects of gambling can be structuralized using a conceptual model, where impacts are divided into negative and positive; costs and benefits. Costs and benefits are categorized into three classes: financial, labor and health, and well-being. These classes manifest in personal, interpersonal, and societal levels. Individual impacts cause effects on a personal level to gamblers themselves. External impacts influence the interpersonal and society/community levels and concern other people. The temporal level refers to the development, severity and scope of the gambling impact. These include general impacts, impacts of problem gambling and long-term impacts of gambling.

Conclusions

The conceptual model offers a base on which to start building common methodology for assessing the impact of gambling on the society. While measuring monetary impacts is not always straightforward, the main issue is how to measure the social impacts, which are typically ignored in calculations, as are personal and interpersonal impacts. The reviewed empirical work largely concentrated on the costs of gambling, especially costs on the community level. The Model can be used to identify areas where research is scarce. Filling the gaps in knowledge is essential in forming a balanced evidence base on the impacts of gambling. Ideally, this evidence could be the starting point in formulating public policies on gambling.

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Gambling can be defined as betting money on an outcome of uncertain results to win money. All forms of gambling, even those typically considered to be more skill-based, like poker and sports betting, contain an element of luck [ 1 ]. Another common characteristic of gambling is that it is a zero-sum game: when one player wins, the other must lose [ 2 ]. Gambling is a popular leisure time activity in most countries, and the vast majority of adults have engaged in some gambling activity at least once in their life, and between 40 and 80% have participated in some form of gambling in the last 12 months [ 3 ]. For most individuals, gambling is a form of entertainment [ 4 , 5 ]. For some consumers, the motivation for gambling is influenced by social interactions because gambling venues offer social settings to meet people [ 6 , 7 ], whereas others are mainly motivated by the dream of winning money [ 8 ]. By contrast, some use gambling to escape their problems, and this is especially common among problem gamblers [ 9 ].

Gambling is typically viewed as a continuum, with most people gambling only occasionally or not at all and some gambling more frequently. Along this continuum, people can experience negative financial and social consequences, although harms tend to be more common among frequent gamblers [ 10 ]. Based on harms experienced because of gambling, gamblers are usually divided to recreational, at-risk, and problem and pathological gamblers [ 11 , 12 ]. Problem and pathological gamblers are usually called problematic gamblers. Pathological gambling is a disorder included in both diagnostic manuals: International Classification of Disorders [ 13 ] and Diagnostic and Statistical Manual [ 14 ]. Prevalence of problem and pathological gambling varies between countries, but it is estimated that among adult population 1 to 4% are problem gamblers [ 15 ], whereas prevalence estimates of pathological gambling range from 0.1 to 0.8% [ 16 ]. There are, however, much more people suffering from gambling-related harms.

Harms caused by gambling can co-occur with other difficult situations in life, usually intensifying along with crises and continuing even after the problematic behavior comes to an end [ 17 , 18 ]. Gambling-related harm can affect multiple domains of life [ 17 ], including financial [ 19 , 20 ] and health problems [ 21 , 22 ], psychological and emotional distress [ 23 , 24 ], and impaired social and cultural relationships [ 25 , 26 , 27 ]. They have an influence on multiple levels: gambling-related harms restrict the gambler and their family, friends, workplace, community, and society [ 17 , 18 , 28 , 29 ]. Because of these significant influences on society and the population’s overall health, gambling is a critical public health issue [ 30 , 31 ].

The impacts of gambling on societies is positive and negative and depends on a number of factors, including what type of gambling environments and games are available, how long gambling has been possible, whether gambling revenues are derived locally or outside the jurisdiction, and the effectiveness of gambling policy [ 32 , 33 , 34 , 35 ]. Overall, there are several main purposes for conducting impact studies on gambling. First, to demonstrate that gambling has major social and economic impacts. Impact studies can also help researchers and policymakers compare the impact of different health and social problems and benefits; for example, gambling impacts can be weighed against alcohol impacts. Additionally, impact studies can be used when considering which gambling policies will reduce or increase costs or benefits the most [ 36 ].

Different approaches have been used to study the impacts of gambling. Research into the socioeconomic impacts of gambling can be conducted from a cost of illness perspective, commonly used in alcohol and drug research; however, this approach neglects the benefit side [ 37 ]. Economic cost–benefit analysis (CBA) measures changes in well-being in common units (dollars) [ 38 ] and attempts to discover whether increased gambling opportunities are positive for society [ 39 ]. In this approach, monetary value is also assigned to intangible harms (harms not necessarily monetary in nature, e.g., the pain and suffering of problem gambler), and harms are known to affect others in addition to the gamblers themselves. This approach, however, has been criticized because an arbitrary monetary value is applied to these intangible harms [ 37 , 40 ]. Anielski and Braaten [ 39 ] also examined the impacts of gambling by using an approach they called full cost–benefit accounting, which attempts to overcome the obstacles of CBA. However, like Williams, Rehm and Stevens [ 32 ] stated, figures obtained by this approach are not reliable and somewhat arbitrary, and it is not clear how the monetary values for some variables are created. Anielski and Braaten [ 39 ] also described many other approaches to study gambling impacts.

In a public health approach, the impacts of gambling, negative and positive, are assessed across the entire severity spectrum of the activity [ 41 ]. According to the literature, harms can occur also among those classified as nonproblem gamblers [ 42 ]; however, examining only problem or pathological gambling and its impacts on society is still common in economic costing studies [ 43 ]. When concentrating solely on problematic gambling, only the tip of the iceberg is observed and gambling harms and its costs to society are underestimated [ 42 ]. Additionally, in a public health approach, the positive effects associated with gambling are recognized [ 17 ]. In the economic literature, gambling revenues and positive impacts on public services have been observed [ 32 ], but fewer studies have examined the positive impacts of gambling on gamblers or their significant others. In a public health approach, the negative impacts of gambling can be assessed by health-related quality of life (HRQL) weights, known as disability weights (DW), which measure the per-person burden of health state on quality of life [ 44 , 45 ]. DWs have been used to measure intangible social costs of gamblers, but could be also used to discover gambling harms that affect a gambler’s social network. Some studies have attempted to quantify the benefits of gambling by “consumer surplus,” which is the difference between what people would be willing to pay for a product or service versus what they pay [ 32 ]. In Australia, the estimated consumer surplus for gambling is AUS$8–$11 billion per year [ 2 ]. However, using this arbitrary monetary amount to quantify something that is clearly nonmonetary creates similar problems when trying to place a monetary value on the “social” impacts of gambling [ 32 ].

Since the expansion of the gambling market, the question of gambling impacts has piqued researchers and policymakers interest [ 37 ]. Despite increased interest in gambling impacts, no consensus has been reached regarding the appropriate theoretical and methodological approach to studying them [ 32 ]. A theoretical model is still lacking, although some studies have created basic principles for conducting socioeconomic impact studies. Based on Anielski and Braatan’s socioeconomic impact of gambling (SEIG) framework [ 39 ], Williams et al. [ 32 ] proposed a simpler categorization of impacts. By doing this, Williams et al. ignored that impacts can be evaluated on different levels, like the individual, family, household, community, regional, and national levels.

Several limitations of earlier gambling impact studies have been highlighted [ 37 , 40 ], but one major concern has been how to capture and quantify the social impacts [ 32 , 46 ]. While quantifying the economic impacts is reasonably straightforward (e.g., costs of treating problem gamblers or of preventing problem gambling), this is not the case for social impacts (e.g., invisible costs like the impacts of emotional stress and relationship problems caused by gambling), which cover the major negative impacts from gambling and cannot be evaluated in monetary terms [ 42 ].

Thus, studies have mostly ignored social impacts, choosing to measure only the economic costs or benefits that are quite easily quantifiable. This approach, however, presents a very biased view of the situation. There are no established ways to define the social impacts of gambling. Based on Williams et al. [ 32 ] social impacts are costs or benefits that are nonmonetary in nature. Walker and Barnett [ 40 ] stated that social costs must aggregate societal real wealth, that is, cause harm to someone in the society and benefit no one. They also defined that social cost must be social, rather than personal.

According to these definitions, when a gambler becomes ill because of excessive gambling, their suffering should not be counted as a social cost as long as someone in society gains from this excessive gambling and gamblers do not demand any treatment that would cause costs to society. In our study, rather speaking of social impacts, we use the term nonmonetary impacts (i.e., nonmonetary costs and nonmonetary benefits). Costs and benefits refer to overall negative or positive gambling impacts and not only those with monetary value. We also state that impacts should be examined at the societal, individual, and interpersonal levels.

Compared with existing models, this model combines aspects from costing studies [ 32 , 39 ] and from gambling harm literature [ 18 , 33 , 34 , 35 ] making the present model more comprehensive and up to date. The Model emphasizes the public health perspective, which is somewhat different from the one in costing studies. It covers both positive and negative effects of gambling and examines costs and benefits on individual, interpersonal and community/society levels. The model includes a temporal dimension, which refers to the development and severity of gambling behavior. From the public health perspective, it is not presumed that costs and benefits result only from problem gambling; instead we are interested in the whole spectrum of gambling behavior. Costs and benefits can be general, come from problem gambling and/or can have long term effects. In summary, a common and comparable methodology for evaluating the impacts of gambling is necessary [ 32 , 37 ], and none has been created. Studies have usually concentrated on impacts of problem gambling while ignoring the entire continuum of gambling. Additionally, the emphasis has been on economic costs, whereas most gambling costs are “social.” The benefits of gambling are usually examined at the societal level (e.g., government revenue), and the influence of gambling on gamblers and their significant others are ignored. This debate argues for a conceptual theoretical model based on the gambling impacts literature, where a public health perspective is applied.

Structure of the public health impacts of gambling (PHIGam) model

Gambling impacts can be observed at the personal, interpersonal, and community/society levels (Fig.  1 ). Personal level refers to the gamblers themselves and interpersonal level to people close to the gambler: friends, family and work colleagues. Impacts can be individual or external. Individual impacts induce effects on a personal level to the gambler. External impacts influence the interpersonal and society/community levels and concern those who are not necessarily gamblers themselves. Gambling creates costs and benefits that others must pay for or can exploit. For example, gambler’s increased debt and financial strain affects family members’ lives, and the effects escalating into bankruptcy and homelessness can also be observed on the community level. Thus, it is of utmost importance that impacts are examined on multiple levels. In the model, impacts can be divided into negative and positive. However, impacts can simultaneously be both negative and positive. For example, gambling is linked to increased criminality [ 44 ] but can also decrease illegal gambling [ 45 ]. Similarly, tourism revenues are positive [ 46 ] but on the other hand tourism can increase crime [ 47 ].

The structure of the Public Health Impacts of Gambling (PHIGam) model

In the model, benefits (Fig.  2 ) and costs (Fig.  3 ) are categorized into three classes: financial, labor and health, and well-being. These classes manifest on personal, interpersonal, and societal levels. Financial impacts, for example, include gambling revenues, tourism, impacts on other industries, and infrastructure cost or value change. On the personal and interpersonal levels, financial impacts can be changes in financial situations. Overall, financial impacts contribute to economic activity and economic growth. Labor impacts include gambling effects on work, such as changes in productivity, absenteeism, reduced performance, inability to work, job gains and losses, and unemployment. Health and well-being impacts include the effects that gambling has on physical, psychological, and social health and well-being.

The positive impacts of gambling on personal, interpersonal and community levels

The negative impacts of gambling on personal, interpersonal and community levels

Temporal level refers to the development, severity and scope of the gambling impact. These include general impacts, impacts of problem gambling and long-term impacts of gambling. General impacts usually result from non-problematic (recreational and at-risk gamblers) gambling. For example, gambling can be a leisure time option that takes time and money from other activities. Impacts of problem gambling are severe consequences that materialize on personal, interpersonal and community/society levels. For example, a problem gambler who uses a lot of money on gambling and falls into bankruptcy influences his/her family’s financial situation and the society by creating cost (e.g. social care cost). These long-term effects of problem gambling can materialize even if the person no longer gambles; it can create a change in the life course of an individual, and even pass between generations [ 18 ]. On the positive side at society/community level, money spent on gambling increases gambling revenues, which in turn can have positive long-term effects when partly directed to beneficial causes, e.g. public services or environmental protection.

Personal and interpersonal level costs are mostly nonmonetary in nature, including invisible individual and external costs that are general, costs of problem gambling and long-term cost. Some of these invisible costs can turn into visible at the society/community level, for example, when gambler’s family members seek help or treatment. Most of the time, however, these costs remain unrecognized. Society/community level external impacts are mostly monetary and are general costs/benefits, costs/benefits related to problem gambling and long-term cost/benefits.

Personal level impacts

Financial impacts.

Financial harms are common, especially among problem gamblers. A survey conducted in Queensland showed that 83% of problem gamblers had experienced gambling-related financial problems [ 47 ]. Another study observed that 34% of problem gamblers reported having severe financial difficulties, compared with 23% of at-risk gamblers and 10% of nongamblers [ 48 ]. In Finland, almost 8% of the population had experienced some sort of financial harms because of their gambling [ 49 , 50 ], and among treatment-seeking gamblers, the percentage was 87% [ 50 , 51 ]. Financial problems can range from escalating harms, such as diminishing savings and borrowing money, to major harms, such as bankruptcy or loss of all valuable possessions [ 17 ]. A study conducted among casino visitors observed that 65% of the “problem” players had to turn to others to relieve a desperate financial situation because of their gambling, whereas none of the “social” players had to do so. In addition, 52% of the “problem” players had sold possessions to pay gambling-related debts, compared with 2% of the “social” players [ 52 ]. Among treatment-seeking Finnish gamblers, common financial harm included late payment of bills (66%) and turning to income support benefits provided by nongovernmental organizations (32%) [ 50 ].

Financial harms have also been observed to be more common in deprived areas [ 53 ] and lower socioeconomic groups [ 19 , 54 ]. Notably, indigenous people are vulnerable to financial problems [ 55 , 56 ]. Financial risks may also be elevated among problem gamblers with psychotic disorders, because one study showed their increased need for financial assistance [ 24 ]. However, causality between financial losses and gambling is not always simple. Factors like ill-health may effect both gambling and poverty, and poverty may lead to problematic gambling and vice versa. However, it is clear, that gambling can intensify poverty [ 57 ].

Gambling-related debt develops when borrowed money is spent on gambling [ 58 ]. Estimations of average current debt per problem gambler have ranged between USD 2500 to greater than USD 53,000 [ 2 , 32 , 59 , 60 ]. For problem gamblers, debts are common, because they were three times as likely to report being in debt compared with nongamblers [ 48 ]. Among Finnish treatment-seeking gamblers, 45% had debt problems at one time [ 50 ]. Further, the more severe the gambling problem the higher the amount of debt [ 61 ].

There is also evidence that some games create more debt than others, because treatment-seeking pathological gamblers playing electronic gaming machines had a higher current and lifetime debt than players of scratch tickets and lotteries [ 62 ]. Similar results have been found among treatment-seeking male internet gamblers: patients who bet online had higher debt levels compared with offline gamblers [ 63 ]. One study observed that 44% of gamblers regarded as heavy consumers had sometimes taken high-interest instant loans for gambling, and this was more common among female respondents than males [ 64 ]. Research has also shown that gambling is a significant contributing factor to indebtedness [ 65 ] and often a reason to continue playing [ 66 ].

The most serious forms of financial harms because of gambling include bankruptcy and homelessness. These extreme consequences are commonly observed at the point of help-seeking [ 67 ]. It is estimated that 10 to 20% of problem gamblers declare bankruptcy [ 20 , 61 , 68 ]. Gamblers who declared bankruptcy were more likely to have more financial, work-related, marital, and legal problems; reported higher rates of depressive and substance use disorders; and were more likely to be daily smokers [ 68 ]. Several studies conducted with individuals who are homeless have observed co-occurring problematic gambling [ 69 , 70 , 71 , 72 , 73 , 74 ]. Studies have estimated that an average of 12 to 39% of people who are homeless reported having gambling problems [ 69 , 71 , 74 ]. However, similar to other gambling comorbidities, the causal nature of this relationship is difficult to resolve [ 75 ]. Gambling may be a risk factor for homelessness: it is often cited as a reason for a lack of housing [ 67 , 75 ], and 82% of problem gamblers indicated that gambling preceded their homelessness [ 74 ].

While the negative financial consequences of gambling are evident, studies have also observed positive financial impacts. For example, in Macao, people working in gambling and related industries earn a higher salary [ 76 ], and their nominal wage has increased as a result of casino liberalization [ 77 ]. Further, a few studies have shown that for some (especially poker players), although a minority, gambling is a significant income source [ 78 , 79 , 80 ].

Labor impacts

Although studies have observed that gambling often has a positive effect on employment at the community level [ 81 , 82 ], only a few studies have examined the positive labor impacts at the personal level and all have considered professional poker players, which represent a minority of people and gamblers.

Problem gambling can affect employment in many ways. Gambling during work causes productivity losses, absenteeism, impaired working relationships [ 50 , 83 ], and termination of employment [ 84 ]. It was observed that almost 40% of problem gamblers reported that gambling had affected their job performance [ 47 ], and 61% reported missing work to gamble [ 83 ]. Among Finnish treatment-seeking gamblers, 43% evaluated that their work performance got worse due to tiredness or distraction, and among those who gambled within the last 12 months, 1% had used work time to gamble and 0.6% stated that their work performance had decreased [ 50 ]. Almost 60% of those experiencing problems with gambling were out of paid work for more than one month and approximately 30% had received some sort of social benefit within the previous year [ 30 ]. However, lack of work may not necessarily be because of gambling, although the literature has indicated that problem gamblers were more likely to report poorer work performance. In some cases, problem gambling may lead to criminal acts in the workplace, like embezzlement and stealing goods like office supplies [ 85 ].

Employment has critical financial and interpersonal impacts because employment is the primary or major source of household income. Reduced performance in work life can have short- and long-term effects on the life of the individual and their family. Employment also causes effects at the community and societal levels.

Health and well-being impacts

Notably, self-reported health decreased with the increasing risk of problem gambling: 57% of nongamblers and 54% of recreational gamblers reported their general health to be good or excellent, whereas 44% of low-risk gamblers, 36% of moderate-risk gamblers, and only 22% of problem gamblers reported good or excellent general health [ 30 ]. However, among gamblers aged 65 years and older, it was observed that past-year gamblers reported more often good or excellent well-being compared with nongamblers [ 86 ]. Similarly, another study found that gambling contributed independently and significantly to perceived wellness among older Australians [ 87 ]. Among older adults, recreational gambling may offer possibilities for increased socialization, community activity, and travel [ 10 , 88 ], which may have positive effects on health [ 89 ].

The health impacts of gambling are related to significant increases in distress [ 2 ]. Emotional or psychological distress can be experiences of guilt, anxiety, helplessness, shame, stigma, grief, and self-hatred [ 50 , 90 ]. It is estimated that 4–6% of those who gambled within the last 12 months had experienced feelings of guilt [ 30 , 50 ]. Among people experiencing high stress or anxiety, physical changes in an individual’s biochemistry have been noted [ 91 ]. Frequent exposure to stress affects an individual’s health outcomes [ 91 ], because it has been shown that gambling is associated with heart conditions, high blood pressure, headaches, weight loss, stomach disorders, cardiac arrest, arthritis, indigestion, tachycardia, angina, cirrhosis, and other liver diseases [ 22 , 66 , 92 ]. Notably, problem gamblers were more likely to avoid regular exercise and less likely to seek health care compared with controls [ 93 ].

In addition to a lack of regular exercise, problem gamblers had a higher body mass index and were more likely to be classified as obese [ 93 , 94 ]. They were also more likely to engage in unhealthy lifestyle behaviors, such as watching more than 20 h of television per week, excessive alcohol consumption, and smoking [ 93 ]. Other studies have shown strong associations between gambling and substance use: At-risk and problem gamblers had higher rates of tobacco, alcohol, and drug use [ 30 ]. Substance use disorders co-occur commonly with problem gambling, because one study showed 28 and 17% of gamblers suffer from alcohol and drug use disorders, respectively [ 23 ]. By contrast, 15% of those seeking treatment for alcohol and drug use disorders met the lifetime criteria for problem gambling, and 11% of the current criteria for problem gambling [ 95 ]. Smoking is also common among problematic gamblers [ 96 ]. Further, problem gamblers were significantly more likely to have smoked more than 100 cigarettes in their lifetime and be current smokers compared with recreational gamblers [ 30 ]. Additionally, it has been noticed that among problematic gamblers, 50 to 60% suffered from nicotine dependence [ 23 , 97 ].

Many studies have shown that problematic gambling is associated with mental health disorders [ 23 , 24 , 88 ]. In New Zealand, 46% of problem gamblers had psychological disorders [ 30 ]. Among problematic gamblers, almost 38% had mood disorders and 37% had anxiety disorders [ 23 ]. Additionally, substance use has been shown to co-occur with gambling and mental health problems [ 43 , 97 , 98 , 99 ]. The causality of these health consequences is not clear because gambling can cause negative health outcomes, but is also a coping mechanism to escape physical, emotional, and substance use problems. However, a longitudinal study observed that at-risk and problem gambling predicted future incidents of major depressive disorder, alcohol dependence, and drug use [ 100 ].

The gambling literature has also focused on mortality because of suicide [ 101 , 102 ]. Notably, problematic gamblers have higher rates of suicidal thoughts, suicide attempts, and completed suicides [ 103 , 104 , 105 , 106 ]. In Finland, 5% of treatment-seeking problem gamblers had attempted suicide, whereas it was 0.1% among the population sample [ 50 ]. Studies have also shown a positive correlation among suicidal ideation, suicide attempts, and gambling severity [ 103 , 107 , 108 ]. Heightened risk for gambling-related suicidality is found among youth experiencing gambling problems [ 109 , 110 ]. A link between gambling and suicide may be explained by excessive debts and escalation of family, legal, and mental and substance-related problems [ 20 , 108 ]. Notably, the interaction between suicide and gambling is complex, and it would be an oversimplification to assert that gambling causes suicides [ 17 ].

The literature also demonstrates the positive effects of gambling. Especially among older adults, recreational gamblers reported better physical and mental health functioning than did older nongamblers [ 94 ]. Further, it was proposed that the psychological benefits of gambling may reinforce and enhance seniors’ self-concepts [ 6 ]. Additionally, it was stated that among lower socioeconomic groups, gaining pleasure from the hope of a small win and the possibility of making a choice on the use of scarce resources may be important in helping maintain optimism in the face of difficult life circumstances [ 111 ]. One of the most obvious positive impacts of gambling is its entertainment value and usefulness as an additional leisure option [ 112 ]. Although most adults have engaged in gambling activities, only a minority report that gambling is a very important leisure activity for them or that it has replaced other leisure activities [ 113 ].

Interpersonal level impacts

Gambling affects more people than just the gambler, because an estimate indicates that one person’s gambling problem typically affects 5 to 10 people [ 2 ]. Thus, the percentage of people whose lives are negatively impacted by problem gambling may be 3 or 4 times as high than the problem gambling prevalence in the general population [ 114 , 115 ]. In New Zealand, approximately 30% of adults said they knew at least one person who has/had a problem with gambling, and approximately 8% experienced that someone else’s gambling had affected them personally [ 30 ]. Partners and children who share finances with a gambler often experience greater levels of harm [ 116 ]. Most commonly reported harms by partners were financial impacts, like increased debt and financial strain [ 29 , 117 ]. Financial problems can also cause partners to go without daily household items and quality food, cause problems with payments and loss of utilities [ 118 ], and further cause the inability to afford medication or treatment [ 119 ]. Additionally, partners commonly take loans for someone else’s gambling debts [ 120 ]. Children can experience deprivation of essential items and insecurity of material needs [ 121 , 122 ].

In Australia, 84% of the concerned significant others (CSOs) of people with problem gambling reported that their partners’ gambling had negative impacts on their own employment. Participants with an Asian cultural background had significantly higher employment impacts than their non-Asian counterparts. This was the case also for participants with prior counseling experience [ 116 ]. In Sweden, female CSOs reported more sick leave days and months of absence from work because of illness, and male CSOs reported more fear of losing employment and work problems [ 120 ].

Financial difficulties can lead to relationship problems, which is common. CSOs experienced a great deal of relationship distress [ 123 ], and 96% reported that gambling had negative impacts on their relationships [ 116 ]. Among problem gamblers, separation and divorce were more common [ 25 , 115 , 124 ]. In Finland, among the population sample, only 0.1% had experienced separation or ending a relationship because of gambling, whereas among treatment-seeking problem gamblers the it was 10% [ 50 ]. Conflict, loss of trust due to dishonesty, concealment of the gambling problem, and need to take responsibility for family and household matters can drive couples to separation or divorce [ 117 ].

It is not uncommon that significant others end up as victims of a crime [ 18 ]. Petty theft from family members and illicit lending are relative common forms of interpersonal harm. Violence associated with gambling is an extreme form of interpersonal harm. It was observed that pathological gambling increased the odds of perpetrating dating violence, severe marital violence, and severe child abuse even when adjusted for mental disorders [ 125 ]. Pathological gambling has also been observed to be associated with homicide in the family [ 105 , 126 ]. Additionally, among problem gamblers, 63% had been victims or perpetrated intimate partner violence (IPV) [ 127 ]. Further, 38% of problem gamblers had experienced physical IPV, and 37% were perpetrators of physical IPV [ 128 ]. Additionally, in Asian countries and Asian communities living abroad, high rates of problem gambling and family violence have been observed [ 129 , 130 ]. Among help-seeking CSOs, 20% were victims of violence, 11% were perpetrators, and 26% were both victims and perpetrators [ 131 ]. In Finland 2% of suspected gambling related crimes were intimate partnership violence resulted from gambling problems [ 132 ]. This, however, constitute only a small amount of the total partnership violence.

Experiencing isolation and self-blame is common among significant others. Some spouses attempt to conceal partners’ gambling [ 117 ]. They felt that the gamblers did not spend sufficient time with them, and they had withdrawn from social life due to their inability to pay for social activities [ 118 ]. Thus, CSOs commonly experience isolation and loneliness [ 120 , 133 ]. Self-blame is another identified pervasive harm, and spouses often feel that they should have been able to prevent their partner from gambling [ 117 ].

Gambling is also linked to increased possibilities for social actions [ 6 , 7 ]. Seniors highlighted the social aspects of their casino visits: they liked having a place to meet and socialize with others [ 134 ]. Gambling is also common pastime activity among families [ 135 ]; however, this is not necessarily a positive thing because the majority of young people are introduced to gambling by their parents [ 136 ].

CSOs experienced poorer physical and mental health than the general population [ 120 , 133 , 137 ]. Symptoms of depression and emotional distress and feelings of melancholy were common [ 116 , 120 ] as were physical symptoms, like headaches, insomnia, high blood pressure, panic attacks, and feelings of tiredness or exhaustion [ 138 ]. CSOs also had problems with their own gambling behavior [ 139 ] and with other addictions [ 120 , 137 ], like risky alcohol consumption for males and daily smoking for females [ 133 ].

Children of problem gamblers have an elevated risk of gambling problems [ 140 ]. Further, health risk behaviors, such as smoking tobacco, drinking alcohol, and drug abuse are common [ 141 ]. These children also have higher a risk for physical and mental health problems and suicide attempts [ 122 , 142 , 143 ]. The effects of parental gambling on children’s overall well-being can be significant, and children can suffer long-term effects because of neglect and uninvolved parenting [ 121 ]. Additionally, children whose parents are employed by casinos can suffer from neglect because they are often left at home without much care and can lose contact with their parents [ 76 ].

Community/society level impacts

The introduction of gambling has been associated with increased government revenue and overall economic growth [ 76 , 77 , 113 , 144 ]. Governments earn revenue from gambling through several means: the taxation of gambling venues and operations, becoming directly involved in the provision of gambling and receiving its revenue, or by government controlled monopolies, which can deliver various forms of gambling and taxation of gambling winnings [ 32 ]. Other studies have observed that gambling does not impact government revenue, and in some cases the impacts have been negative [ 145 , 146 ]. When new forms of gambling have significant negative impacts on other forms of gambling and states continue to benefit from revenues from the new forms, the net revenues may not change. These revenues can be used for public services, but also to avoid raising taxes and reduce government debt [ 147 ].

Some forms of gambling are provided by charitable and community organizations, and these profits are used for their own operation, or the governments’ gambling revenues are earmarked for these groups [ 32 ]. However, this scenario can make communities and organizations dependent on gambling revenues [ 148 ]. Gambling can also have negative impacts on public services, for example, new forms of gambling in the community can negatively affect charitable gambling revenue through direct competition [ 149 ].

Another positive impact of gambling has been increased personal incomes and decreased poverty rates [ 81 , 150 , 151 ]. This was especially observed in Native American communities in the United States [ 81 , 150 ]. Casino development has also led to an increase in entertainment and recreation facilities, restaurants, shopping places, and bars as well as public performances and exhibitions [ 151 ].

The construction of a new gambling venues can increase the physical assets and wealth of a local community [ 113 , 152 ], especially when infrastructure improvements and construction of complementary businesses (e.g., hotels, restaurants) occur [ 32 , 76 , 151 ]. Notably, increased infrastructural value is not associated with all types of gambling but primarily with those that involve the construction of new venues like casinos [ 152 , 153 ]. The introduction of machine gaming to Queensland clubs and hotels increased infrastructure value when clubs constructed new building projects and facility improvements [ 154 ]. These infrastructure improvements also attract a large number of tourists [ 151 ].

Who finances these new gambling venues is important whether these investments can be viewed as cost or benefits; when financed partly or wholly by governments rather than by private developers, investment is construed as more of a “cost,” although the wealth of the local community increases [ 32 ]. The costs of public transportation and the required police and fire protection are borne by governments, and the maintenance of roads, electricity, and water supply are usually a government responsibility too [ 155 , 156 ].

Gambling can also impact other industries. Positive impacts have been observed especially in communities where casinos are located in tourist areas offering other entertainment and sightseeing opportunities and where the casinos’ clients are outside the immediate area and require overnight stays [ 76 , 157 , 158 , 159 ]. The most common business sectors that benefit from gambling are hotels, restaurants, and other types of entertainment [ 160 , 161 ]. In addition to the community level, gambling introduction has been shown to increase overall business revenue on a state-wide level [ 146 , 162 ]. However, some studies have not demonstrated that gambling has significant impacts (either positive or negative) on other industries [ 113 , 163 ]. Notably, negative impacts as a result of gambling introduction have been reported in the recreational/amusement sectors [ 164 ] and for retail businesses [ 165 ]. Small ventures are especially likely to have problems with hiring and retaining staff due to the casino expansion, inflation, and increases in shop rents and operating costs [ 76 , 151 ].

The introduction of a new form of gambling often has positive effects on employment [ 81 , 82 ]. Gambling that attracts visitors and brings money to a community has potential positive benefits for other business sectors and further employment [ 76 , 166 ]. This phenomenon is particularly true for the hospitality industry [ 155 ]. Employment growth in different types of jobs has helped Macao diversify its economy toward healthier economic development, and foreign investments in casinos have upgraded the city’s international status [ 76 ]. Additionally, employment gains were reported for casinos [ 82 ]. Automated forms of gambling like electronic gaming machines have only minor impacts on employment [ 32 ]. Further, most gambling industry employment is low skilled and low paid; however, a large majority of new gambling employees tend to come from similar low-skilled and low-wage sectors [ 32 , 113 ]. In Macao, many sectors have reported difficulties recruiting and maintaining staff because people are eager to work for the casino hotels to earn a higher salary [ 76 ]. When staff comes from outside the local area, the employment benefits of gambling to a local area can be minimal [ 32 ]. In Macao, the government and casino operators chose to import migrant workers to employ a sufficiently skilled workforce [ 77 ]. Further, when a situation is examined on a larger than local scope, employment gains of gambling have been minimal or nonexistent [ 2 , 167 ].

Studies have also found work-related costs because of problem gambling. It is estimated that community cost due to productivity losses varies between US$ 6 million to $39 million [ 168 ]. A study conducted in Victoria Australia estimated that productivity loss in the workplace was $323 million [ 42 ]. The total cost to the employer of gambling-related staff replacement was $34.6 million, and the unemployment benefit payments $10.8 million. Absenteeism due to gambling problems cost Victoria an estimated $46 million, and the total cost of gambling-related crime was in 2014–15 $22.5 million. The total cost of fatality by suicide due to gambling problems was estimated to be $28.6 million [ 42 ].

Governments are typically responsible for regulating gambling operations. Regulations and administration procedures are required to secure functions of the industry and maintain social stability [ 46 ]. Thus, increased gambling supply comes with increased regulation costs [ 168 ]. In a society where gambling is legal, anyone could suffer from gambling harms. Thus, resources are required to prevent this phenomenon from occurring. A certain amount of public resources also must be allocated to gambling-related professional training and research [ 46 ]. One of the major costs of gambling problems borne by governments is the funding for gambling regulations, research, and treatment services, and it is estimated that in 2014–15 the Victorian Government spent at least $52 million on these services [ 42 ].

Government revenues are also used to improve public services (e.g., health, education, culture, social security) [ 152 , 153 , 169 ]. In Macao, as a result of casino introduction, more social welfare and benefits have been given to the local people. Additionally, the free education period was prolonged and free medical care and bus transportation for those above 65 years old was offered [ 76 ]. Further, public expenditures on environmental protection increased [ 151 ]. Additionally, in North American Aboriginal communities, improvements in living conditions and public health have occurred [ 150 , 158 ]. Enhanced cultural identity has also been reported after casino openings [ 158 ]. However, some studies have highlighted how gambling changes traditional Aboriginal culture, values, and beliefs [ 170 , 171 ], and increasing materialism has also raised some concerns [ 76 , 171 ]. In Macao, earning money from the casino business was regarded as easier and faster than having a higher education. This phenomenon diminished interest of young people in studying and increased the school drop-out rate [ 76 ].

Gambling brings social problems and leads to increased demand for social services [ 76 ]. Studies have shown that increased availability of gambling is associated with increased problem gambling rates [ 155 , 172 ]. A positive relationship has even been observed between casino proximity and problem gambling [ 173 ]. Increased gambling opportunities are also associated with increases in social inequality. Higher-income households spend on average much more on gambling, but poorer households lose a higher proportion of their income on gambling [ 174 , 175 ]. In Germany, the lowest income quintile spent an average of 12% of their net income on gambling, compared with only 2% in the highest quintile. Overall, 50% of gambling turnover was borne by 12.6% of all gamblers [ 176 ]. In Finland 50% of gambling turnover come from just 5% of all gamblers [ 177 ].

Gambling can have negative effects on quality of life: the introduction of new casinos has increased traffic and cause noise and pollution [ 76 , 149 , 151 ]. Further, casinos can take over areas originally designed for residential and public facilities and conquer green and leisure spaces intended for locals [ 76 ]. One study found that quality of life change from gambling is either very modest or negative [ 178 ]. Gambling can also increase criminality in several ways [ 32 ]. Firstly, by increasing the number of problem gamblers, because problem gamblers are more likely to commit crimes than the general population [ 110 , 179 ]. Secondly, increasing opportunities for illegal activity and creating venues that sell alcohol and potentially affect alcohol-related offences [ 32 ]. The introduction of casinos has been associated with increased violent crime [ 180 ] and rates of driving while intoxicated [ 181 ]. And thirdly, by increasing the overall number of visitors to the area, because increases in population and tourism contribute to increased crime rates [ 182 ]. It is estimated that pathological and problem gambling accounts for $1000 in excess lifetime police costs per person [ 2 ]. Study conducted in Sweden proposed that the total court costs for criminal cases caused by gambling would be approximately between $3 and $72 per problem gambler [ 183 ]. Cost to the prison system associated with people who are problem gamblers was estimated to be between $51 and $243 million per year [ 184 ]. Notably, gambling can decrease the rate of illegal gambling [ 113 ].

Property and other living prices have increased faster than average salaries as a result of casino gambling [ 76 ]. Further, some studies have shown declines in social capital because of casino introduction [ 27 ] and increases in social disorganization and social deprivation [ 185 ]. Additionally, the negative consequences of gambling have been linked with social integration, a sense of connectedness, and reduced social isolation [ 186 , 187 ]. Gambling is also seen as a community activity that brings people together [ 188 ].

The conceptual model developed in this article offers a base on which to start building common methodology for assessing the impact of gambling on the society – a target explicated by, e.g. Walker [ 37 ] and Williams and others [ 32 ]. In the discussion about the best methodological and theoretical approaches for analyzing the impacts of gambling, the main issue is how to measure the social impacts. Most of the social impacts are nonmonetary by nature and are often difficult to measure and thus ignored in calculations. Similarly, personal and interpersonal impacts have often been excluded from calculation, largely for the same reason as social impacts. Except for the most obvious positive impact of gambling, namely, gambling revenues for communities, studies have often concentrated on the negative side of gambling impacts. The central focus has been on problem gambling; thus, many gambling harms have been ignored although gambling-related harms also occur among those who are not problem gamblers and nongamblers within harms reach, such as significant others and the wider community. These methodological deficiencies are common in the gambling impacts literature and cause a significant bias in current knowledge.

As mentioned earlier, gambling causes external impacts that affect more people than just the gambler. Financial, labor, and health and well-being impacts have been observed at the individual, interpersonal, and community/society levels. For example, gamblers’ increased debt and financial strain affect family members’ lives, and the effects of escalating into bankruptcy and homelessness are also observed in the community. Thus, it is of utmost importance that impacts are examined on separate levels. Additionally, these impacts can have long-term effects and create a change in the life course of an individual, and even pass between generations. Key methodological challenges relate to what portion of impacts are the effects of gambling and how these should be measured. We faced similar methodological challenges when examining the interpersonal and community/society level impacts. Community/society level impacts that are nonmonetary, such as quality of life, social cohesion, and other attributes of social capital, have had less emphasis in studies. These studies have been primarily conducted in North America, and the majority of analyses concerns casino impacts.

Although the PHIGam model attempts to be as universal as possible, it is important to note the context in which gambling takes place is critical when examining gambling impacts. Opening a casino in an area where gambling opportunities have been limited has a greater impact than in area where gambling has been widely available. In the “adaptation hypothesis” [ 189 , 190 ], it is argued that the negative effects of gambling are higher when gambling or new games are newly introduced in community but tend to diminish over time. However, a more recent study has shown that overall rates of harm stabilized when participation continued to fall and for some groups participation reduced but harms increased [ 191 ]. Thus, it is suggested that “adaptation hypothesis” over-simplifies the situation [ 191 , 192 ]. Financial harms of gambling have been shown to be more common among deprived areas, whereas in Macao, the nominal wages of people working in gambling and related industries has increased because of casino liberalization. Additionally, the type of gambling presented affects impacts because it was shown that some games create more debt than others. Finally, it is important to understand how revenues are derived and disbursed.

The debate leading to the formation of the model on Public Health Impacts of Gambling utilized existing theoretical and empirical literature to form a structure that can be used to locate individual pieces of research. As shown in the Figures, empirical work has largely concentrated on the costs of gambling, especially costs on the community level. The Figures can be used to identify areas where research is scarce: for example, no research was found analyzing financial or labor benefits to the significant others of gamblers. Filling the gaps in knowledge is essential in forming a balanced evidence base on the impacts of gambling. Ideally, this evidence could be the starting point in formulating public policies on gambling.

Availability of data and materials

Not applicable.

Abbreviations

Cost–benefit analysis

Concerned significant other

Disability weight

Health-related quality of life

Intimate partner violence

Public Health Impacts of Gambling

Socioeconomic impact of gambling

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Latvala, T., Lintonen, T. & Konu, A. Public health effects of gambling – debate on a conceptual model. BMC Public Health 19 , 1077 (2019). https://doi.org/10.1186/s12889-019-7391-z

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What Is Responsible Gambling? An Interview with Jennifer Shatley

An expert from UNLV's International Gaming Institute explains how it differs from problem gambling.

Setting limits — in both time and money — can help ensure gambling remains a fun activity. (Josh Hawkins/UNLV Photo Services)

From the Archives

Please note that this article is more than three years old and details may have changed since the publish date.

• September 17, 2020
• By Nicole Schultz

Editor's Note:

Sept. 13-19 marks this year’s Responsible Gaming Education week. Those outside the hospitality industry might not know exactly what responsible gambling is — or how it differs from problem gambling.  Jennifer Shatley , who works at UNLV International Gaming Institute as she pursues her doctorate in public policy, is a longtime industry expert and President of the Nevada Council on Problem Gambling . Here she sheds some light on an often misunderstood topic.

What is the difference between responsible gambling and problem gambling?

Responsible gambling is about using gambling for fun and entertainment’s sake. Gambling can become problematic when patrons use it as a source of income or when they gamble with more money than they can afford to lose. 

Responsible gambling programs are really about prevention. They are intended for gambling operators’ entire customer base because the goal is to stop problem gambling behaviors from developing in the first place. 

Ironically, though, responsible gambling programs are often thought to be problem gambling programs. Because of this, casino patrons might ignore responsible gambling programs because they don’t identify themselves as problem gamblers.

That’s a terminology and perception issue that needs to be addressed. We need to determine how to position these programs to make them relevant within the minds of all customers—because that’s who they are for.

What does it mean to gamble responsibly?

Gambling responsibly means taking breaks, not using gambling as a source of income, only gambling with money that you can afford to lose, and setting limits for yourself (both with time and money). Limit-setting is actually easier to do online because a lot of online gambling sites have built-in tools that allow gamblers the ability to set limits directly on the site.

For example, an online casino patron can say, “OK, I only want to gamble for two hours today.” Then, all they have to do is put that time into the site and, after two hours, the site will tell the patron that they’ve reached their daily limit. Oftentimes, online sites also include 24-hour cooling off periods, where players can block themselves from using the platform entirely.

How has responsible gambling changed during the pandemic, if at all?

When we talk about responsible gambling, we always say that gambling is and should be a social activity. You should do it for entertainment and fun. You should do it with friends and family. But what does that look like in the COVID era—now that we have all of these social distancing protocols in place? How does that change how we talk about responsible gambling? Because unless you’re living within the same household of people, you can’t be within six feet of them. So something we need to think about is, “How do we keep gambling a social activity when we have to enforce social distancing and put barriers between people?”

Gambling operators also need to be aware that most of the customers who are returning to casinos have potentially experienced — because of COVID-19 — increased anxiety, loss of income, loss of a loved one, depression, and unemployment. These are all factors that generally contribute to problem gambling, and now most of the customer base is going to have some if not all of these experiences. 

Basically, awareness is still key and the first step to gambling responsibly. 

Are there individuals who might be more at risk of problem gambling behaviors?

It’s a very complicated disorder. There are neurological, biological, psychological, genetic, and other  factors, but there are some factors that might make a person more at risk. 

For instance, children who are raised by a problem gambler are more likely to become problem gamblers themselves. It also typically occurs alongside other mental health struggles, like post-traumatic stress disorder, bipolar disorder, and depression—among others.

What should someone do if they or someone they know struggles with problem gambling?

Call the helpline number: 800-522-4700.  Help is available 24/7, and it’s 100 percent confidential. When you call, you’re going to get specific resources for assistance in your area. They will also give you referrals for financial resources in addition to problem gambling treatment and support resources in your area. And best of all, the helpline is not just for problem gamblers — it’s for their families and loved ones, too. They might receive referrals to GamAnon, which is like Gamblers’ Anonymous but for family members. 

Another idea is to contact the casino or other gambling venue to see if they have self-exclusion programs. These programs allow gamblers to request that their play privileges be restricted. The whole idea behind self-exclusion programs is that the individual recognizes that their behavior is a problem and they play an active role in changing that behavior. Family members can play a role in self-exclusion, too, by encouraging the gambler to seek treatment and offering support.

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Essay on Gambling Addiction

Students are often asked to write an essay on Gambling Addiction in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Gambling Addiction

What is gambling addiction.

Gambling addiction is when someone can’t stop betting money on games, sports, or other chances to win more money. It’s like they need to gamble, just as some people need to eat or drink.

Why People Get Addicted

Signs of problem gambling.

If someone is always thinking about betting, spending too much money on it, or gambling instead of doing important things, they might have a gambling problem.

Getting Help

It’s important to talk to someone if gambling is causing problems. There are groups and people who understand this addiction and can offer help and support to stop.

250 Words Essay on Gambling Addiction

Why it’s a problem.

This addiction is harmful because it can make people lose lots of money, which can lead to big problems like debt or stealing. It can also hurt their relationships with family and friends. People with gambling addiction often feel sad or anxious, and it can be hard for them to do well at school or work.

Signs of Gambling Addiction

Some signs that someone might have a gambling addiction include always thinking about gambling, trying to gamble with more money to win back what they lost, and not being able to stop or cut down on gambling. They might also lie about how much they gamble or become restless when they try to stop.

It’s important for people with gambling addiction to get help. This can include talking to a counselor or joining a support group. Their family and friends can also support them by being understanding and encouraging them to seek help. With the right support, people with gambling addiction can overcome their challenges and live a healthier life.

500 Words Essay on Gambling Addiction

Gambling addiction is a serious problem where a person cannot stop gambling even when it hurts them or their loved ones. It is like being trapped in a room where the only door out seems to be winning a game that is almost impossible to win. This problem is not just about losing money; it affects a person’s whole life, including their relationships, job, and health.

The Signs of Gambling Addiction

To spot gambling addiction, look for signs like thinking about gambling all the time, trying to gamble with more money to win back what was lost, and not being able to cut back or stop. People with this problem often feel restless or irritable when they try to stop gambling. They might keep their gambling a secret, lie about how much they gamble, or use money meant for important things like food or rent to gamble instead.

Why Do People Get Addicted?

The impact on life.

Gambling addiction can turn a person’s life upside down. It can eat up all their money, leaving them in big debt or even without a home. It can break their trust with family and friends, leading to loneliness and broken relationships. People with this addiction might also lose their job because they’re too focused on gambling or they might steal money to keep gambling. Their health can suffer too, with stress causing problems like headaches, stomach aches, and trouble sleeping.

The good news is that people with gambling addiction can get help and turn their lives around. There are special groups where people with this problem can talk to others who understand what they’re going through. Doctors and therapists can also help by talking about the problem and giving advice on how to deal with the urge to gamble. Sometimes, medicine can help with the feelings that make a person want to gamble.

If you’re looking for more, here are essays on other interesting topics:

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The Financial Consequences of Legalized Sports Gambling

30 Pages Posted:

Brett Hollenbeck

University of California, Los Angeles (UCLA) - Anderson School of Management

Poet Larsen

Marshall School of Business - University of Southern California

Davide Proserpio

Date Written: July 23, 2024

Following a 2018 ruling of the U.S. Supreme Court, 38 states have legalized sports gambling. We study how this policy has impacted consumer financial health using the state-by-state rollout of legal sports gambling and a large and comprehensive dataset on consumer financial outcomes.  Our main finding is that overall, consumers' financial health is modestly deteriorating as the average credit score in states that legalize sports gambling decreases by roughly 0.3%. The decline in credit score is associated with changes in indicators of excessive debt. We find a substantial increase in bankruptcy rates, debt collections, debt consolidation loans, and auto loan delinquencies.  We also find that financial institutions respond to the reduced creditworthiness of consumers by restricting access to credit.  These results are stronger for states that allow sports gambling online compared to states that restrict access to in-person betting and larger for young men in low-income counties.  Together, these results indicate that the ease of access to sports gambling is harming consumer financial health by increasing their level of debt.

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University of California, Los Angeles (UCLA) - Anderson School of Management ( email )

110 Westwood Plaza Los Angeles, CA 90095-1481 United States

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Marshall school of business - university of southern california ( email ).

701 Exposition Blvd Los Angeles, CA 90089 United States

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108 Gambling Essay Topic Ideas & Examples

🏆 best gambling topic ideas & essay examples, ⭐ good research topics about gambling, 👍 simple & easy gambling essay titles, ❓ research questions on gambling.

• Gambling Benefits and Disadvantages Also in relation to this, the gambling industry offers employment to a myriad of people. This is thus a boost to the economy of the local people.
• Online Gambling Addiction Gambling is an addiction as one becomes dependent on the activity; he cannot do without it, it becomes a necessity to him. Online gambling is more of an addiction than a game to the players.
• Impact of Gambling on the Bahamian Economy Sources from the government of The Bahamas indicate that the first of gambling casinos in the name of the Bahamian Club opened for business from the capital of Nassau towards the close of the 1920s […]
• Gambling as an Acceptable Form of Leisure In leisure one should have the freedom to choose which activity to engage in and at what time to do it. Gambling is considered as a form of leisure activity and one has freedom to […]
• Comorbid Gambling Disorder and Alcohol Dependence The patient was alert and oriented to the event, time, and place and appropriately dressed for the occasion, season, and weather.
• Gambling: Debate Against the Legislation of Gambling More significantly, the Australian government has so far adopted a conciliatory and indulgent attitude towards most kinds of gambling, which has been the main reason for the rampant growth and proliferation of both forms of […]
• Impact of Internet Use, Online Gaming, and Gambling Among College Students The researchers refute the previous works of literature that have analyzed the significance of the Internet, whereby previous studies depict that the Internet plays a significant role in preventing depression ordeals and making people happy.
• History of Gambling in the US and How It Connects With the Current Times It is possible to note that it is in the Americans’ blood from the sides of Native Americans and the Pilgrims to bet.
• Effects of Gambling on Happiness: Research in the Nursing Homes The objective of the study was to determine whether the elderly in the nursing homes would prefer the introduction of gambling as a happiness stimulant.
• The Era of Legalized Gambling Importantly, they build on each other to demonstrate power in taking risk action and actually how legalizations of the practice can influence character integrity. The conclusive speculation is whether there is a changing definition of […]
• Legalization of Casino Gambling in Hong Kong Thus, the problem is in the controversy of the allegedly positive and negative effects of gambling legalization on the social and economic development of Hong Kong.
• The Problem of Gambling in the Modern Society as the Type of Addiction Old people and adolescents, rich and poor, all of them may become the prisoners of this addiction and the only way out may be the treatment, serious psychological treatment, as gambling addiction is the disease […]
• The Psychology of Lottery Gambling This kind of gambling also refers to the expenditure of more currency than was first future and then returning afterward to win the cash lost in the history.
• Gambling, Fraud and Security in Banking By supervising the institutions and banks, there exists openness into the dealings of the banks and this allows investors to get full information about the banks before investing.
• Earmark Gambling Revenue Legislation in Illinois The state of Illinois enacted PA 91-40 in 1999, which has affected the gaming industry. The growth in the revenue from gambling has attracted the attention of lawmakers.
• Jay Cohen’s Gambling Company and American Laws Disregarding the controversy concerning the harmful effects of gambling, one might want to ask the question concerning whether the USA had the right to question the policies of other states, even on such a dubious […]
• Internet Gambling and Its Impact on the Youth However, it is necessary to remember that apart from obvious issues with gambling, it is also associated with higher crime rates and it is inevitable that online gambling will fuel an increase of crime rates […]
• Fantasy Football: Gambling Regulation and Outlawing Taking this into consideration, it can be stated that fantasy football and its other iterations on sites like Draft Kings is not a form of gambling.
• Gambling and Addiction’s Effects on Neuroplasticity It was established further that blood flow from other parts of the body to the brain is changes whenever an individual engages in gambling, which is similar to the intake of cocaine.
• Gambling and Its Effect on Families The second notable effect of gambling on families is that it results in the increased cases of domestic violence. The third notable effect of gambling on the family is that it increases child abuse and […]
• Online Gambling Legalization When asked about the unavoidable passing of a law decriminalizing online gambling in the US, the CEO of Sams Casino stated that the legislation would not have any impact on their trade.
• Casino Gambling Legalization in Texas In spite of the fact that the idea of legalizing casino gambling is often discussed by opponents as the challenge to the community’s social health, Texas should approve the legalization of casino gambling because this […]
• Economic Issues: Casino Gambling Evidence from several surveys suggests that the competition from various states within the US has contributed to the growth and expansion of casinos. The growth and expansion of casinos has been fueled by competition from […]
• Casino Gambling Industry Trends This will make suppliers known to the rest of the companies operating in the industry. The bargaining power of the supplier in the casino gambling industry is also high.
• Gambling Addiction Research Approaches Therefore, it is possible to claim that the disease model is quite a comprehensive approach which covers several possible factors which lead to the development of the disorder.
• Public Policy on Youth Gambling The outcomes of the research would be useful in identifying the program outcomes as well as provide answers to the whys of youth gambling.
• Gambling and Gaming Industry Compulsive gambling Compulsive gambling refers to the inability to control an individual’s urge to engage in gambling activities. Other gambling activities in the state are classified as a misdemeanour.
• Revision of Problem Gambling The reasoning behind the researchers’ decision to focus on the social and financial factors of gambling within the UK is because of the significant increase in gambling-related problems within Britain.
• Positive Aspects of Gambling It is therefore essential for sociologist to understand the positive aspects of gambling and the impact that it has on our lives. However, it is essential to control the level of gambling.
• Argument for Legalization of Gambling in Texas The subject of gambling is that the gambler losses the money offered if the outcome of the event is against him or her or gains the money offered if the event outcome favors the gambler.
• Gambling’s Positive and Negative Effects In some cases such as in lotteries, the financial reward is incidental and secondary because the participants drive is to help raise funds for the course the lottery promotes.
• Gambling in Kentucky: Moral Obligations vs. the Economical Reasons The industries that added to the well-being of the state and its GNP since the day the state was founded and throughout the past century was the coal mining, which contributed to the state’s income […]
• Gambling in Ohio The purpose of this project is to investigate the history of gambling in Ohio, its development in the 1990s, and its impact on ordinary human lives in order to underline the significance of this process […]
• Gambling Projects: Impact on the Cultural Transformations in America The high rates of unemployment and low earning levels may coerce residents to engage in gambling, hoping that they would enrich themselves.
• Gambling in Four Perspectives A gambler faces the challenge of imminent effect of addiction to the effects of gambling every time he continues with the exercise of gambling something that may take long to drop.
• Gambling Discusses Three Causes or Effects of Gambling and Their Impact on Society
• Taking the Risk: Love, Luck, and Gambling in Literature
• Financial Crime and Gambling in a Virtual World
• Management and Information Issues for Industries With Externalities: The Case of Casino Gambling
• Internet Gambling Consumers Industry and Regulation
• Human Resource Management for Gambling Industry
• Youth Gambling Abuse: Issues and Challenges to Counselling
• Differentiate Between Investment Speculation and Gambling
• The Gambling and Its Influence on the Individual and Society
• Assessing the Differential Impacts of Online, Mixed, and Offline Gambling
• Gambling Taxation: Public Equity in the Gambling Business
• Risk and Protective Factors in Problem Gambling: An Examination of Psychological Resilience
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• v.33(45); 2013 Nov 6

Pathological Choice: The Neuroscience of Gambling and Gambling Addiction

1 Department of Psychology, University of Cambridge, Cambridge CB2 3EB, United Kingdom,

Bruno Averbeck

2 Laboratory for Neuropsychology, National Institute of Mental Health, Bethesda, Maryland 20892,

Doris Payer

3 Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, Ontario M5T 1R8, Canada,

Guillaume Sescousse

4 Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, 6525 HP Nijmegen, The Netherlands,

Catharine A. Winstanley

5 Department of Psychology, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada, and

6 State Key Laboratory of Cognitive Neuroscience and Learning, and IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing, China 100875

Author contributions: L.C., B.A., D.P., G.S., C.A.W., and G.X. wrote the paper.

Gambling is pertinent to neuroscience research for at least two reasons. First, gambling is a naturalistic and pervasive example of risky decision making, and thus gambling games can provide a paradigm for the investigation of human choice behavior and “irrationality.” Second, excessive gambling involvement (i.e., pathological gambling) is currently conceptualized as a behavioral addiction, and research on this condition may provide insights into addictive mechanisms in the absence of exogenous drug effects. This article is a summary of topics covered in a Society for Neuroscience minisymposium, focusing on recent advances in understanding the neural basis of gambling behavior, including translational findings in rodents and nonhuman primates, which have begun to delineate neural circuitry and neurochemistry involved.

Gambling is a branch of the entertainment industry where patrons stake an object of value (typically money) on the uncertain prospect of a larger reward (the “jackpot”). Gambling dates back several millennia and remains ubiquitous across human societies, with lifetime gambling participation reported as 78% in the United States ( Kessler et al., 2008 ). As such, gambling games serve as a useful model of risky choice, to the extent that laboratory tasks modeling the choice between two lotteries are regarded as “the fruitfly of behavioral economics” ( Kahneman, 2011 ). In light of the widespread recognition that the expected value of gambling is negative (“the house always wins”), gambling games may shed further light on some of the errors and biases that characterize human decision making. Examining their underlying neural mechanisms is naturally relevant to the emergent discipline of neuroeconomics.

Gambling also has a more insidious side. Pathological gambling was first recognized as a psychiatric disorder in 1980 and was grouped initially in the Impulse Control Disorders. An international program of research over the past decade has revealed multiple similarities between pathological gambling and the substance use disorders, including neurobiological overlap ( Petry, 2006 , Leeman and Potenza, 2012 ). Whereas the comparability with obsessive compulsive disorders was also evaluated, the support for placement on a “compulsive spectrum” was mixed ( Hollander and Wong, 1995 ). This process culminated in the recent reclassification of pathological gambling (now to be called “Gambling Disorder”) into the addictions category of the DSM5 ( Petry et al., 2013 ). This ratification of the so-called “behavioral addictions” is a pivotal step for not only the gambling field, but for addictions research in general.

The current article aims to provide a concise overview of recent developments in our understanding of decision making during gambling and the relevance of these processes to problem gambling (for comprehensive overviews, see van Holst et al., 2010 ; Hodgins et al., 2011 ; Leeman and Potenza, 2012 ). We begin by describing some emerging methods for probing gambling decisions, highlighting translational models, behavioral economic tasks, and cognitive distortions associated with gambling ( Fig. 1 ). We then consider the underlying neural mechanisms, distinguishing neurochemical substrates and neuroanatomy.

Schematic overview showing the emerging methods for modeling gambling decisions and the associated neural circuitry. The list is not intended as comprehensive but highlights the core themes covered in this review.

Models of gambling decisions: translational probes

Given that the calculation of risk versus reward trade-offs is inherent in numerous aspects of real-world choice and foraging behavior, it should be unsurprising that laboratory animals are capable of performing decision-making tasks that resemble gambling. Recent work has aimed to model gambling decisions in rats using operant behavioral tasks derived from the established probes of choice behavior in human neuropsychology and cognitive psychology. One widely used human test is the Iowa Gambling Task ( Bechara et al., 1994 ), which quantifies the deficits in affective decision making seen after injury to the ventromedial prefrontal cortex. In humans, this task involves a series of choices between four decks of cards that offer gains and losses of varying amounts of money. A key challenge in translating the procedure into animals concerns the representation of “loss”; standard reinforcers, such as sugar pellets, are instantly consumed and thus cannot be deducted in the same way as money or points. In the rat Gambling Task ( Zeeb et al., 2009 ), rats choose between four apertures that vary in the probability of delivering a smaller or larger number of sugar pellets, as well as the probability of receiving time-out penalties of varying durations. Like the human version, the two apertures that offer larger rewards are also associated with longer and more frequent time-outs, and most rats learn to avoid these tempting options to maximize their sugar pellet profits over the duration of the task. (The key decision here is probabilistic and the task should not be confused with temporal discounting).

Postacquisition lesions to BLA skewed rats' preference toward the high-risk high-reward options, matching the observation that amygdala damage leads to disadvantageous choice in the Iowa Gambling Task ( Bechara et al., 1999 ; Zeeb and Winstanley, 2011 ). If BLA lesions were made before task acquisition, animals struggled to develop the optimal strategy and correctly discriminate between the options. Lesions to the orbitofrontal cortex (OFC) impaired acquisition of the rodent task in an identical manner but did not affect performance if the lesions were implemented after animals had learned the correct strategy. Such data support the suggestion that the classic disruption of everyday decision making associated with ventromedial prefrontal cortex lesions may stem from a difficulty in learning the optimal strategy, rather than an increase in preference for risky outcomes per se ( Bechara et al., 2000 ; Fellows and Farah, 2005 ). Moreover, the similarity between the effects of BLA and OFC lesions on task acquisition suggested that these two areas work together to promote development of the optimal strategy, a hypothesis recently confirmed using a functional disconnection procedure ( Zeeb and Winstanley, 2013 ). Hence, similar brain regions appear to be involved in guiding decision making under uncertainty in both rats and humans.

Prefrontal connectivity with the striatum is also implicated in choice behavior. Contemporary hypotheses of frontostriatal function emphasize a primary role in either action selection or reinforcement learning, both of which are likely important in substance addiction and behavioral addictions. To differentiate these elements, Seo et al. (2012) trained monkeys on a task in which they had to select rewarding actions using either reinforcement learning or perceptual inference. While the animals performed this task, neural activity was monitored simultaneously in anatomically connected regions of lateral prefrontal cortex (LPFC; caudal area 46) and the dorsal striatum (DS, primarily the anterior caudate nucleus). A larger fraction of LPFC neurons represented selected actions, independent of how they were selected. In the perceptual inference condition, the LPFC representation of the selected action preceded the DS representation of the selected action, whereas in the reinforcement learning condition, both structures represented the actions up to 500 ms before they were executed, with no clear temporal ordering. Additionally, DS more often represented the value of the selected action when it was selected using both perceptual inference and reinforcement learning. Thus, a hypothesis that the DS was important for action selection was not supported, but DS did often represent action values, when driven by either reinforcement learning or perceptual inference. LPFC, by contrast, appears to play a dominant role in representing and selecting actions, particularly when the selection is based on perceptual inference.

Behavioral economic aims to decompose the processes of option valuation into simple components that can be quantified with discrete parameters ( Schonberg et al., 2011 ). Prospect theory (PT) remains the most influential of these accounts because of its ability to describe a range of common behaviors and deviations from normative expected value theory ( Kahneman and Tversky, 1979 ). A central feature of PT is “loss aversion,” referring to the empirical observation that humans (and other species) are more sensitive to losses than to gains. For example, subjects typically reject mixed gambles that offer a 50–50 chance of winning or losing a given amount of money. Loss aversion may be underpinned by value computations in the ventral striatum and amygdala ( Tom et al., 2007 ; De Martino et al., 2010 ) and has been shown to be modulated by thalamic norepinephrine ( Takahashi et al., 2013 ). In addition to this asymmetry between gains and losses, PT describes a value function for gains that is concave, contrasting with a value function for losses that is convex. This disparity accounts for subjects' tendency to be risk averse in the gain domain and risk seeking in the loss domain, which may account for the “loss chasing” behavior that is characteristic of problem gamblers ( Campbell-Meiklejohn et al., 2008 , 2011 ). Although recent work has demonstrated impaired processing of loss information ( Brevers et al., 2012 ) and aversive signals ( Brunborg et al., 2012 ) in pathological gamblers, loss aversion is yet to be formally quantified in pathological gamblers.

PT also posits nonlinearity in probability calibration, whereby small probabilities are overestimated and medium to high probabilities are underestimated, in an inverse S-shaped “probability weighting function.” These subjective distortions are reflected in brain activity profiles observed in the ventral striatum and dorsolateral prefrontal cortex ( Tobler et al., 2008 ; Hsu et al., 2009 ) and also correlate with striatal dopamine D 1 receptor density ( Takahashi et al., 2010 ). Behaviorally, the overestimation of small probabilities may contribute to the attractiveness of gambles, such as a lottery ( Trepel et al., 2005 ). Ligneul et al. (2013) tested this hypothesis in pathological gamblers, calculating “certainty equivalents” across varying levels of objective probability from 0 to 1. As expected, the results revealed elevated risk taking in gamblers compared with nongambling controls; however, this behavior was not linked to a specific distortion of small probabilities but rather to a general overweighting across the entire probability range. Similar approaches using the discounting framework have demonstrated fine alterations of value representations in the ventral striatum in pathological gamblers ( Miedl et al., 2012 ; Peters et al., 2012 ).

In addition to the computational characterization of gambling offered by behavioral economics, psychological models of gambling have additionally highlighted the central role of cognitive distortions during gambling. These distortions refer to how the gambler thinks about randomness, chance, and skill ( Ladouceur and Walker, 1996 ; Clark, 2010 ) and foster an inappropriately high expectation of winning during the game. A number of specific biases have been described, and these cognitions can be effectively targeted as one element of psychotherapy for pathological gambling ( Fortune and Goodie, 2012 ).

Arguably, the most classic distortion is the gambler's fallacy, which is a bias in the processing of random sequences. In this compelling example, the expectancy of a certain event (e.g., heads in a coin flip) becomes less likely after a long series of the same event (e.g., three successive tails). The phenomenon occurs across many situations, including casino gambling ( Sundali and Croson, 2006 ), but also stock investment ( Johnson et al., 2005 ). It is widely viewed as arising from the representativeness heuristic, the belief that a short segment of a random sequence should reflect the overall distribution ( Rabin, 2002 ; Ayton and Fischer, 2004 ). Another archetypal distortion is the “illusion of control,” referring to the interpretation of skill involvement in situations that are governed by chance alone ( Langer, 1975 ; Stefan and David, 2013 ). Illusory control can be fostered by a various psychological features of games, such as the involvement of a choice (e.g., choosing a lottery ticket), instrumental action (e.g., throwing a roulette ball), or apparent competition ( Langer, 1975 ). A recent study using a contingency judgment task from the associative learning literature found that pathological gamblers displayed a greater tendency to overestimate their control of positive outcomes than nongambling participants ( Orgaz et al., 2013 ). Other recent work has considered the impact of “near miss” outcomes, unsuccessful outcomes that are proximal to a major win ( Kassinove and Schare, 2001 ). Using a slot machine task that delivered occasional jackpot wins, near misses (where the reels landed adjacent to a win) were associated with higher self-reported motivations to gamble than full-miss outcomes, despite their objective equivalence as nonwins ( Clark et al., 2009 ). To date, most of the research on these distortions has been in healthy samples; and although questionnaire measures, such as the Gambling Related Cognitions Scale ( Raylu and Oei, 2004 ), indicate a clear increase in the overall propensity toward these erroneous beliefs in pathological gamblers ( Michalczuk et al., 2011 ), there remain few empirical demonstrations that pathological gamblers are oversensitive to specific biases.

Dopamine has been a prime candidate for investigation of neurochemical abnormalities in pathological gamblers, given its established roles in both drug addiction and rewarded behavior. In patients with Parkinson's disease, sudden onset gambling can be observed, alongside other reward-driven behaviors, including compulsive shopping and hypersexuality, as a side effect of dopamine agonist medications ( Ambermoon et al., 2011 ; Voon et al., 2011 ). The most direct approach for quantifying dopamine transmission in human brain is PET imaging of dopamine ligands, of which the most widely studied is [ 11 C]-raclopride, a D 2/3 receptor antagonist that binds predominantly in the striatum. Building upon evidence for robust reductions in striatal dopamine D 2/3 receptor availability in substance users dependent on a number of distinct drugs ( Martinez et al., 2004 ; Volkow et al., 2007 ; Fehr et al., 2008 ), recent studies have used this ligand in pathological gamblers ( Linnet et al., 2011 ; Clark et al., 2012 ; Joutsa et al., 2012 ; Boileau et al., 2013 ). Notably, none of these studies has detected a significant group difference in dopamine D 2/3 binding, although some individual differences have been observed, for example, against trait impulsivity ( Clark et al., 2012 ).

Ongoing work is using alternative PET tracers that offer advantages over [ 11 C]-raclopride. [ 11 C]-(+)-Propyl-hexahydro-naphtho-oxazin (PHNO) is a D 2/3 receptor agonist that binds preferentially to D 3 over D 2 receptors in vivo ( Narendran et al., 2006 ). The D 3 receptor subtype is localized to limbic circuitry and implicated in drug self-administration and relapse behavior in preclinical models ( Heidbreder et al., 2005 ). As a dopamine receptor agonist, [ 11 C]-(+)-PHNO is also more sensitive to displacement by endogenous dopamine than [ 11 C]-raclopride (an antagonist) ( Willeit et al., 2008 ). A recent PET study using [ 11 C]-(+)-PHNO in methamphetamine abusers indicated higher baseline binding in the D 3 -rich substantia nigra and pallidum, coupled with lower binding in the D 2 -rich dorsal striatum ( Boileau et al., 2012 ). Employing a multimodal PET design in pathological gamblers using both [ 11 C]-(+)-PHNO and [ 11 C]-raclopride ( Boileau et al., 2013 ), no group differences were detected, but a positive correlation was observed between gambling severity scores and [ 11 C]-(+)-PHNO binding in substantia nigra, a region where signal is fully attributable to D 3 ( Tziortzi et al., 2011 ). This association suggests that D 3 expression is relevant to symptom severity in problem gambling, and as an addiction phenotype, it may be a useful marker for risk.

Preliminary work has also begun to examine dopamine release in pathological gamblers, with some provocative early findings. The change in [ 11 C]-(+)-PHNO binding was examined after a challenge dose of oral amphetamine (0.4 mg/kg) in pathological gamblers: greater dopamine release was detected in the dorsal (associative) striatum in the pathological gamblers (D. Payer, I. Boileau, D. Lobo, B. Chugani, A. Behzadi, A. Wilson, S. J. Kish, S. Houle, M. Zack, unpublished observations). This result effect is echoed in two further experiments examining task-related changes in [ 11 C]-raclopride binding in pathological gamblers, where higher levels of dopamine release were correlated with greater subjective excitement ( Linnet et al., 2011 ) and gambling severity ( Joutsa et al., 2012 ). Notably, the available data in drug addiction show blunted dopamine release in response to psychostimulant administration ( Volkow et al., 1997 ; Martinez et al., 2007 ). The extent to which these discrepancies reflect etiological differences between substance and behavioral addictions, or the masking of incentive sensitization processes via drug-induced depletion of dopamine stores ( Robinson and Berridge, 2003 ), is a key question in ongoing research.

Rodent models have also provided a means of examining the neurochemistry of gambling, implicating dopamine and serotonin influences. In light of the effects of dopamine agonist medications in Parkinson's disease, it is notable that administration of selective D 2 agonists did not affect choice behavior on the rat Gambling Task ( Zeeb et al., 2009 ). However, whereas the D 2 receptor antagonist eticlopride improved choice of the best option, amphetamine and the 5-HT 1A agonist 8-OH-DPAT were found to impair performance ( Zeeb et al., 2009 ). Selective dopamine antagonists did not block the effects of amphetamine on choice, even though such agents did attenuate amphetamine-induced increases in motor impulsivity ( Zeeb et al., 2013 ). Furthermore, amphetamine's effects were not mimicked by dopamine, 5-HT, or noradrenaline reuptake inhibitors but were reproduced by different combinations of these drugs ( Baarendse et al., 2013 ). Such results imply concurrent regulation of choice behavior on the rat Gambling Task by multiple monoaminergic systems, consistent with human data ( Rogers, 2011 ).

A modified choice procedure in the rodent has been used to assess the sensitivity to stake size, implicating striatal D 2/3 transmission specifically ( Cocker et al., 2012 ). In this task, the rats choose between two options of equivalent value, one of which delivers a guaranteed reward, and the other offers either double that reward or nothing, with 50:50 odds. The reward size varies over the session from 1 to 3 pellets. Whereas some animals are largely indifferent to this “escalation of commitment,” other rats become markedly risk avoidant as the stake increases, increasing their preference for the guaranteed option ( Campbell-Meiklejohn et al., 2012 ; Sescousse and den Ouden, 2013 ). Critically, such a behavioral shift confers no advantage in terms of reward earned and may be considered irrational in a similar vein to the framing effects observed in human choice under risk. PET imaging using 11 C-raclopride revealed that D 2/3 receptor binding in the dorsal striatum correlated significantly with the degree of wager-sensitivity rats exhibited. Moreover, in a key advantage over human PET imaging, it was possible to use autoradiography to confirm that the differences in raclopride binding were the result of lower levels of D 2/3 receptor expression, as opposed to variation in endogenous dopamine levels.

Functional neuroimaging studies have also contributed much to our understanding of appetitive processing in pathological gamblers and provide data that complement the investigations of dopamine transmission ( Schott et al., 2008 ). Several fMRI studies in pathological gamblers have reported blunted neural responses to monetary gains and appetitive cues, primarily in ventral striatum and orbital/lateral PFC ( Reuter et al., 2005 ; de Ruiter et al., 2009 ; Balodis et al., 2012 ). This observation can be interpreted in terms of the reward deficiency hypothesis ( Comings and Blum, 2000 ), consistent with the PET evidence reviewed above indicating reduced dopamine receptor levels in addiction. However, other recent studies have described increased, rather than decreased, responses to monetary rewards in the same population ( Hewig et al., 2010 using EEG; van Holst et al., 2012 using fMRI), prompting ongoing debate about the impact of naturalistic cues and stage of processing (anticipation vs outcome) in these effects ( Leyton and Vezina, 2013 ; Limbrick-Oldfield et al., 2013 ).

One means of resolving these discrepancies is to consider the sensitivity to nonmonetary (i.e., nonaddiction related) rewards in gamblers. Using an incentive delay protocol involving both monetary and visual erotic rewards, pathological gamblers showed a markedly decreased response to the erotic cues, compared with monetary cues, in the ventral striatum ( Sescousse et al., 2013 ). This differential response was correlated with the severity of gambling symptoms and accompanied by a similarly reduced behavioral motivation for erotic rewards. Comparable designs indicate blunted brain responses to non–drug-related cues in drug-addicted groups ( Goldstein et al., 2007 ; Wrase et al., 2007 ; Bühler et al., 2010 ). These findings suggest that the key variable of interest may be the differential response to monetary (or drug) rewards versus other (primary) appetitive cues, rather than the response to money or drugs per se.

Experiments on gambling-related cognitive distortions also implicate reward-related circuitry, as well as the interactions with regions responsible for top-down cognitive control. Specifically, the gambler's fallacy appears to arise from an imbalance between cognitive and emotional decision making mechanisms in the brain ( Shiv et al., 2005 ; Xue et al., 2011 ). Using a card guessing task to capture subjects' tendency to predict the break of a streak as it continued (a signal of the gambler's fallacy), enhanced neural responses in left LPFC were observed to outcomes that were followed by a gambler's fallacy switch ( Xue et al., 2012b ). A follow-up experiment applied anodal transcranial direct current stimulation, a procedure known to enhance cortical excitability and cerebral perfusion ( Stagg et al., 2013 ), over the same region. Corroborating the fMRI data, stimulation to left LPFC increased the use of the gambler's fallacy ( Xue et al., 2012b ) and point to a causal role of this region in implementing this suboptimal decision strategy, guided by false world models.

Extending this interpretation in a larger sample of college students ( N = 438), the use of the gambler's fallacy was positively correlated with general intelligence (Raven's matrices) and executive function (2-back working memory and Stroop tasks) but was negatively correlated with affective decision making (Iowa Gambling Task) ( Xue et al., 2012a ). Thus, the gambler's fallacy seems to be associated with (1) weak function in the affective decision making system and (2) strong function in the LPFC cognitive control system ( Xue et al., 2011 , 2012b ).

In contrast to these cortical responses, the robust striatal activations seen in response to monetary wins are not evidently modulated by the psychological context that characterizes these gambling distortions. For example, the striatal responses to winning outcomes did not differ between the first win in a streak, compared with the fourth successive win ( Akitsuki et al., 2003 ). In a study investigating the illusion of control, striatal activity did not differ between choice and no-choice conditions, even though perceived control did enhance subjective confidence ( Kool et al., 2013 ). However, both distortions appear to be coded in higher cortical regions. Using a card guessing game to compare trials where either the subject or computer predicted the location of the winning card, agency affected not only the amount bet but also subjects' “world model” regarding the outcome dependency ( Xue et al., 2013 ). Functional imaging results revealed that the decision-related activation in the lateral and medial PFC was significantly modulated by both agency and previous outcome and that these effects were further predicted by the trait-like disposition to attribute negative events externally. These results suggest that the prefrontal decision making system can be modulated by abstract beliefs and are thus vulnerable to factors, such as false agency and attribution.

Nevertheless, subcortical responses have been observed to near-miss outcomes during a simulated slot machine task. Specifically, these events recruited overlapping neural circuitry to the jackpot wins in the ventral striatum, amygdale, and anterior insula ( Clark et al., 2009 ; Shao et al., 2013 ). Of these responses, the effect in the insula was seen to covary with trait levels of gambling distortions and individual differences in the motivational effect of the near misses ( Clark et al., 2009 ). Administering a behavioral version of the slot machine game to patients with focal brain injury, a group with insula lesions was seen to be insensitive to near misses (i.e., did not show the typical motivational response) and also failed to manifest the gambler's fallacy (L. Clark, B. Studer, J. Bruss, D. Tranel, A. Bechara, unpublished observations). Thus, these results again highlight how gambling cognitions and persistent play are most likely to emerge from an imbalance between bottom-up emotional systems and prefrontal control systems, rather than a disruption in either component in isolation.

In conclusion, studies of cognitive processing during gambling have begun to uncover a wealth of phenomena that are relevant to problematic gambling, and useful as more general models of human decision making. The arsenal of tasks that probe gambling-related decision making can be implemented in other mental health problems associated with decision making disruption, including schizophrenia ( Balzan et al., 2013 ), obsessive compulsive disorder ( Reuven-Magril et al., 2008 ), and suicidal behavior ( Dombrovski et al., 2011 ). The convergence with translational models of choice behavior in nonhuman species carries enormous potential for delineating the neural circuitry. Thus far, the translational work has progressed primarily in the area of value-based decision making, highlighting the roles of prefrontal cortex, striatum, and amygdala, innervating by ascending dopamine and serotonin inputs. Further progress may be achieved by modeling constructs from behavioral economics, and gambling-related cognitive distortions, in nonhuman species. For example, recent data from a rodent slot machine task indicate that rats are susceptible to near-miss outcomes and that erroneous attempts to collect reward on near-miss trials were dramatically increased by the D 2 -receptor agonist quinpirole ( Winstanley et al., 2011 ). Interestingly, these effects appear to be mediated by the D 4 receptor subtype specifically, leading to the exciting possibility that D 4 receptor antagonists may be a useful treatment for compulsive slot machine play (P. Cocker, B. Le Foll, R. Rogers, C. A. Winstanley, unpublished observations).

Studies of patients with pathological gambling are also beginning to provide clues about the mechanisms involved in addiction. One interpretation of the null results from investigations of [ 11 C]-raclopride binding in pathological gamblers is that the robust reductions observed in drug addiction may represent a consequence of long-term drug exposure, rather than a preexisting vulnerability marker ( Groman et al., 2012 ). Over the coming decade, we anticipate a similar program of research for other candidate behavioral addictions, such as excessive online video gaming ( Kim et al., 2011 ; Kühn et al., 2011 ).

L.C. was supported by the Medical Research Council (G1100554). B.A. was supported by the Intramural Research Program of the National Institute of Mental Health. C.A.W. was supported by the Canadian Institutes of Health Research (CIHR), the Canadian Natural Sciences and Engineering Research Council, Parkinson Society Canada, and the Canadian Foundation for Innovation and receives salary support through the Michael Smith Foundation for Health Research and the CIHR New Investigator Award program. G.X. was supported by the Natural Science Foundation of China (31130025). G.S. was supported by The Netherlands Organization for Scientific Research. D.P. was supported by Ontario Problem Gambling Research Centre 2642 and Canadian Institutes of Health Research (CIHR/IRSC 258458). B.A., D.P., G.S., C.A.W., and G.X. are listed alphabetically.

The authors declare no competing financial interests.

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Dolphins Take Familiar Leap of Faith in Extending Tua Tagovailoa

Conor orr | jul 26, 2024.

• Miami Dolphins

When we imagine the NFL like a high school classroom, the assumption is that everyone is crowded around the seats of Sean McVay and Kyle Shanahan, hoping for a glimpse at the test before it’s time to turn it in. 

There’s no doubt that both of these coaches have contributed significantly to the forward momentum of American football. But lost in this discussion is the fact that—before Shanahan and McVay turn in their papers—both will also be looking at what Mike McDaniel has done as well. The NFL is a copycat league but some coaches tend to be copied off more often. 

We bring that up on the heels of Tua Tagovailoa’s contract extension, which he signed Friday, making him the third-highest paid quarterback in the NFL in terms of average annual value, though the practical guarantees have Tagovailoa as the eighth highest-paid passer in the league. 

The Dolphins are, essentially, tied to Tagovailoa for another handful of seasons because Tagovailoa has done so well since McDaniel’s arrival—and the subsequent arrival of Tyreek Hill—that he has pivoted from near castaway to borderline MVP candidate. We bring up the word borderline because, such as a few other quarterbacks who have signed extensions recently and are playing alongside really strong offensive-minded coaches, Tagovailoa leaves us with a pit in our stomachs. It could go well, for sure, but we could be left wondering if, because of extensions such as these, we never truly get to see the offense at its max potential because the team is married to the quarterback it elevated by virtue of its own scheme.  

It’s not an uncommon story, especially lately. Jared Goff joined forces with Detroit Lions offensive coordinator Ben Johnson and showed the world that, along with the best offensive line in football and a top wide receiver, he could be a quarterback worth building around. But is he? And how much better could the Lions be with someone else? We won’t know.  

Two years ago, New York Giants quarterback Daniel Jones joined forces with Brian Daboll and marginally connected with ownership’s fever dream of Jones becoming a franchise quarterback. He earned himself an extension that all but prevented the selection of his successor for at least another year and, by the time the team was close enough to snag a quarterback, there were a few clubs already waiting in line at the top of the draft. How much better could the Giants be with someone else? We’re about to find out. 

Now we have Tagovailoa, who, statistically, carries all the benchmarks of a steadily ascending player. He has gotten better every year. He is experimenting with different ways to adapt his body to the NFL. He has displayed an incredible amount of both physical toughness when he takes a hit and mental toughness as the league’s poster child for most frequently questioned talent.

And, yet, there are these little moments that are impossible to ignore. Whether it’s when Hill is out of the game, or at the end of a long season where the Dolphins’ track team seems to be worn down and the moment is placed squarely on his shoulders, he seems to be lacking that take-it-over magic. When a play is out of structure, there are times when Tagovailoa appears to be treading water. Other times, the Dolphins look like they’d be better off taking a knee. 

The same could be said, in one way or another, about Goff as he entered his final days with the Los Angeles Rams or Jones in the moments preceding Daboll’s arrival. 

We are in a strange moment in NFL history where it seems, minus a few genetic-defying individuals, that the position is creating more existential questions about the health of the league than providing answers. In the place of a legion of 15 really good NFL quarterbacks, we are left with about four or five excellent ones and the rest dependent on consistently inventive schematics, marginal improvements made through advancements in coaching and technology and the whims of their owner and general manager (along with their ability to acquire surrounding talent). 

Miami’s problem is not unique but there’s also no reasonable solution. Next to having one of these genetic-defying quarterbacks, the next best option is to hold on dearly to one good enough (because the dropoff between good enough and horribly bad is far worse than the one from genetic-defying to good enough). Of course, the problem with good enough is that it’s never as good as it can be. And as that problem uniquely pertains to the Dolphins, as good as it can be could be incredibly special. 

My hope, like any sane and feeling individual, is that Tagovailoa continues his rise, proves us all wrong and shows us the outer realm of McDaniels’s play calling and play design capabilities. But in taking so long to get this deal done, it seems Miami’s powers that be have already shown us that they are not entirely sure that will happen. Like the Lions and the Giants before them, the only other course of action is to don the blindfold and jump. 

Conor Orr is a senior writer for Sports Illustrated, where he covers the NFL. He is also the co-host of the MMQB Podcast. Conor has been covering the NFL for more than a decade. His award-winning work has also appeared in The Newark Star-Ledger, NFL.com and NFL Network. He lives in New Jersey with his wife, two children and a loving terrier named Ernie. 

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