Individual vulnerability as core risk factor for gambling disorder: implications for public health and gambling policies
Aim: (1) To argue for a paradigm shift in our understanding of etiopathological processes in gambling disorder (GD), from the traditional SUD derived triad model to a modified concept with a focus on individual vulnerability, and (2) to present implications for better gambling regulations and consumer protection of vulnerable gamblers. Background: In many countries, gambling regulations are based on the traditional triad model of individual, social and substance-related risk factors for GD. Attempts to reduce GD onset and prevalence predominantly rest on limiting access to gambling opportunities and gambling features. This approach is seen as insufficient to protect vulnerable gamblers and questionable for the large group of resilient gamblers showing unproblematic gambling behaviour. Method: Recent findings on characteristics of subjects with GD from clinical and epidemiological studies as well as findings from basic experimental research and cohort studies are summarized. Results: Current evidence strengthens the theoretical framework of a set of vulnerability factors for GD: Impaired cognitive control, increased reward and lower punishment sensitivity, impairments of the dopaminergic system (attentional bias and cue reactivity), lower inhibitory control, increased risk taking and high delay discounting, together with a high rate of comorbid mental disorders. There is increasing evidence that these factors are not only correlates of GD but have a causal relevance. These findings would also explain intercultural low prevalence rates of GD (0, 5 to 2%) in spite of easy and general access to gambling opportunities and high gambling activities in the adult population (around 40 to 80%). Consequently, current gambling supply reduction activities are seen as insufficient to protect vulnerable gamblers and unreasonably paternalistic for resilient gamblers. Conclusions: Implications for improved public health concepts are discussed and a two-step strategy is presented: To implement (1) better consumer protection activities for the large group of resilient gamblers (information, a choice of easy to implement self-limitations, warnings and automatic gambling feedback features) and (2) early detection and support of vulnerable gamblers with a variety of instruments like personal warnings, provider-suggested and provider-initiated temporal limitations of gambling time and stakes, temporal gambling brakes, voluntary and as ultima ratio forced exclusion. These activities require strong public regulation and control agencies. Furthermore, ethical aspects in the context of gambling regulations are discussed, as well as research needs to better understand etiopathological processes and effective protection activities.