Significance
Problem gambling1,2 and tobacco smoking3,4 are highly comorbid5,6 in North America. Indeed, studies show that tobacco dependence is the most common comorbid disorder among problem gamblers, with prevalence rates ranging from 41% to 60%.7,8,9,10,11 According to the World Health Organization, tobacco use kills up to 50% of its users – translating into nearly six million deaths annually.12 Tobacco use is also linked to several chronic health conditions, including cancers, respiratory problems, and cardiovascular diseases.12 Given their high rates of smoking (relative to the general population)7,8,9, problem gamblers are thus disproportionately affected by the increased morbidity and mortality from tobacco use. Moreover, research to date shows that co-occurring tobacco use compounds gambling-related harms. Problem gamblers who smoke have more severe gambling pathology13, experience stronger gambling urges14, are more likely to have other mental disorders13, tend to bet larger sums of money and spend more time in gambling activities15, and have greater financial problems.16 Based on this, it has been suggested that daily smoking, a central trigger for gambling and related cravings, may undermine the treatment of problem gambling.5 Accordingly, a priority needs to be placed on integrating the treatment of tobacco smoking into evidence-based interventions for problem gambling. In this study, we aim to design and test a novel online pilot study for comorbid problem gambling and tobacco use.
The proposed open label pilot intervention will draw on strategies from Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI) – both evidence-based psychotherapies for problem gambling17,18,19 and smoking.20,21 A main strength is that this pilot study will be integrated – meaning that it will use treatments for both problem gambling and tobacco smoking to target the functional relations between each behaviour within the same treatment. This is in contrast to limited traditional approaches, which include treating these problems either one at a time, or simultaneously by two different professionals. The online platform also offers key advantages relative to in-person modalities. First, some provinces across Canada (e.g., Manitoba and Saskatchewan) and states in the United States have significant rural spread, meaning that communities are dispersed throughout the area with little access to major cities. This poses huge challenges for providing equal access to mental health care services for all citizens. In fact, statistics suggest that people living in remote communities struggle most with addictive behaviours and mental health issues but have limited access to treatment facilities.22 Thus, we will be better able to reach these people with an online treatment. Second, many problem gamblers do not seek traditional forms of treatment due to stigma.23 Problem gamblers may be more willing to try online interventions due to anonymity and reduced shame.24 This integrated intervention has the potential to have positive impacts on the health of adult North Americans who struggle with problem gambling and tobacco use.
Evidence for the Association between Problem Gambling and Tobacco Smoking
Based on the epidemiological literature showing very high prevalence rates of tobacco smoking among problem gamblers, researchers have begun to examine the potential reasons for this association. While we still do not know the exact mechanisms underlying the problem gambling-tobacco use comorbidity, neurobiological studies suggest that both addictive behaviours are mediated by similar reward circuits in the brain.5 Specifically, neurobiological work shows that drugs of abuse, including nicotine, increase transmission of dopamine in mesocorticolimbic regions.25,26 This effect is thought to underlie the reinforcing properties of substance use. Similarly, data suggest that gambling is also associated with increased activity in dopaminergic rich areas of the mesocorticolimbic circuit. For example, in a double-blinded laboratory study27, it was shown that administration of amphetamine (a potent dopamine agonist or releaser) increased motivation to gamble among individuals with gambling problems. Taken together, tobacco use and problem gambling appear to act on similar neural pathways that underlie addictive, reward-driven behaviours.
Functionally, research shows that nicotine may enhance or augment the reinforcing value of other addictive behaviours.5,28 Nicotine has been shown to lead to increased self-administration of alcohol in male smokers29; increased cravings in cocaine-dependent smokers30; and increased self-administration of methadone in opioid-dependent smokers.31 Compared to alcohol and other drugs, very little neurobiological work has been done to show direct functional effects of nicotine on the reinforcing qualities of gambling. Indirect evidence for nicotine’s effects on gambling behaviour, however, comes from studies examining the impact of monetary reward on dopaminergic transmission in the brain. Overall, this work shows that when individuals receive uncertain or variable monetary rewards (i.e., those that cannot be predicted by any regularity), they show increased dopaminergic activity in the very same regions associated with tobacco use.32,33 In comparison, when monetary rewards are certain or predictable, there is no increased dopaminergic transmission in these brain regions. Given that uncertain or variable reinforcement is hallmark of gambling, one could predict that co-occurring tobacco use could promote or reinforce gambling and gambling-seeking behaviours over time (via nicotine’s effects on dopaminergic brain regions in the mesocorticolimbic pathway).
Complementing neurobiological studies, behavioural research demonstrates that nicotine may alter reward-related cognitive processes that increase risk for problem gambling.5 To illustrate, nicotine may enhance the salience of short-term rewards from gambling, while detracting focus from gambling’s longer-term negative outcomes. This notion is supported by work showing that heavy smokers engage in risky decision making on the Iowa Gambling Task, with response patterns showing preference for short-term gains at the expense of long-term losses.34 Heavy smokers also show steeper discounting of future rewards relative to non-smokers35, suggesting that nicotine may reinforce impulsive behaviour – like gambling – where the goal is immediate reward. It is possible that tobacco smoking (via nicotine’s effects on learning and reward systems in the brain) strengthens problem gambling, making this behaviour difficult to extinguish especially when repeatedly paired with cigarette use. This may account for the increased clinical severity in heavy smoking (relative to non-smoking) problem gamblers. Moreover, some studies demonstrate that nicotine may enhance cognitive processes, like attention and executive control.36 These momentary effects may be highly desirable to problem gamblers, as they may experience a greater ability to focus and shift attention during gambling episodes (after smoking).
Finally, the literature on cross-cue reactivity shows that tobacco use and problem gambling may become powerful reciprocal triggers for each behaviour.37 That is, through repeated co-occurrence, stimuli associated with smoking are believed to become conditioned stimuli for gambling and vice versa. For example, over time, smoking cues can come to elicit strong urges to gamble, and conversely, gambling cues can come to promote cravings for tobacco use. While this is a relatively understudied research area, recent data show that gamblers who smoke had greater cross-cue reactivity (compared to gambling and smoking only control groups).37 Results suggested that smoking gamblers had increased physiological arousal and greater subjective desire to smoke, irrespective of whether cues were smoking- or gambling-related.37 Accordingly, if tobacco use potentiates gambling – and vice versa – then it would be very challenging for a person to reduce either behaviour in isolation.
Existing Evidence-based Treatments for Problem Gambling
Existing evidence-based treatment protocols for problem gambling generally combine strategies from two main psychological intervention frameworks: CBT and MI.17,38 CBT is a structured and goal-oriented treatment, where individuals acquire skills to reduce problem gambling through modifying thoughts and behaviours in response to internal (e.g., negative emotions) and external (e.g., gambling cues) triggers. During CBT, individuals with gambling problems strengthen coping skills by completing various exercises both in-session and at home between sessions. Complementing CBT, MI strategies are used in gambling treatment to elicit and motivate positive change. MI is a patient-centered and collaborative approach, where the goal is to help patients resolve ambivalence about change and get them to move in a direction that is consistent with personal values. MI is typically a prelude to CBT, but also a style that a therapist can return to if barriers are encountered during CBT. The weight of the evidence demonstrates that the combination of CBT and MI has synergistic beneficial effects on gambling and smoking behaviours during treatment.17,18,19,21,38 By increasing motivation for change using MI, individuals with problem gambling may be more willing to engage in the effortful activities of CBT (e.g., homework), which in turn, are essential for building better coping skills. Integrated MI may also help to clarify a problem gambler’s core values in CBT by creating discrepancy between current and desired behaviour. Thus, from a theoretical perspective, CBT and MI naturally complement each other in the treatment of problem gambling. Supporting this, a recent meta-analysis showed that CBT/MI treatments reduce problem gambling symptoms with medium effect sizes,17 and online CBT treatments reduce problem gambling amount, frequency, and urges.39
Despite CBT/MI’s effectiveness for reducing gambling, there are notable problems with existing approaches. First and foremost, while CBT/MI approaches have been shown to be helpful, effect sizes on short- and long-term gambling outcomes are modest.17 This suggests that there is a great deal of room to improve interventions for gambling. Second, dropout rates in problem gambling treatment studies are substantial. Specifically, it has been estimated that 14% to 50% of individuals with problem gambling drop out of active treatment, with the average being about 30% across studies.40,41 This suggests that a large portion of treatment-seeking individuals with problem gambling do not complete this efficacious psychological intervention. Third, individuals with problem gambling show marked problems with treatment adherence, as evidenced by poor homework completion and low session attendance.42 Additionally, comprehensive self-guided treatments are shown to be as effective as face-to-face treatments for problem gambling.43 Adherence may be especially poor among the 50% to 70%44 of problem gamblers with co-occurring substance use problems. In turn, poor treatment adherence predicts poor responses to intervention.42,45 Finally, similar to people with tobacco use disorders,46 relapse rates among treated problem gamblers remain very high.47 As a whole, these issues suggest that we need to find effective ways to augment CBT/MI to improve clinical outcomes for problem gambling.
Based on the neurobiological and behavioural literature discussed above, it is highly possible that comorbid tobacco use is a factor that helps to maintain and reinforce problem gambling behaviours – even after treatment engagement. Despite their best efforts in treatment, individuals with problem gambling who smoke (versus those who do not smoke) may have marked difficulty controlling gambling urges, forming new non-gambling related associations, and shifting focus to adaptive future (relative to often maladaptive and immediate) goals in therapy.5,35,36 These difficulties may contribute to commonly observed poor treatment engagement and completion and the modest success of problem gambling treatment among individuals with problem gambling. Unaddressed daily tobacco use may also be a critical factor in high rates of relapse among treated problem gamblers. Very few studies have explored smoking status and its relationship to gambling-related treatment outcomes.48 As noted earlier, tobacco-related cues are powerful conditioned stimuli that elicit strong cravings among problem gamblers.37 It follows that even after treatment, individuals with problem gambling who continue to smoke will have to fight against strong urges resulting from their increased cross-cue sensitivity. Thus, a key augmentation to CBT/MI treatments for problem gambling would be to include content to address co-occurring tobacco use.
Integrated Treatment
Research on integrated addiction treatment is relatively new. This is surprising, given that it is common for individuals to present with more than one addictive behaviour.49 Polysubstance use is associated with greater clinical severity and poorer treatment outcomes.50 Further, poor treatment outcomes has also been observed for gamblers with substance abuse treatment history compared to gamblers without substance abuse treatment history.51 Traditional methods for treating co-occurring addiction/mental disorders are sequential and parallel intervention.49 During a sequential approach, clinicians treat the addiction/disorder viewed as “primary” first, followed by the treatment of the comorbid condition. For example, a person with co-occurring alcohol misuse and problem gambling would likely not be able to work on reducing gambling until they achieve some notable period of abstinence from drinking. Thus, in the sequential model, treatment is provided for one disorder at a time – with the more acute disorder (e.g., alcohol misuse) taking first priority. The sequential model of intervention has been (and still is) the most widely used approach to treating disorder comorbidities. In contrast, the parallel model involves treating co-occurring problems separately by two distinct professionals and/or clinical teams, each with expertise in one of the two problems.52 An example of this approach would be a person seeing a family doctor for management of smoking, while working with a psychologist to reduce gambling. Therefore, in the parallel model, an individual receives support for both issues simultaneously, but from distinct professionals.
Although still widely used, sequential and parallel approaches are limited as intervention models for comorbid addictive behaviours.52 A sequential approach may be necessary in crisis situations, such as when a person needs hospitalization for alcohol-related seizures. However, in the absence of an emergency warranting the immediate stabilization of one disorder over the other, sequential treatment may impede the treatment of both addictive behaviours.52 Sequential treatment does not consider the interconnectedness of addictive behaviours. To illustrate, a person would likely find it very challenging to reduce gambling if their smoking (a main trigger for gambling) remains untouched in treatment. In turn, this person’s smoking (perhaps as a coping mechanism) would likely be worsened by repeated failed attempts to control gambling. In such a scenario, it would be difficult for this person to make major improvements on either problem. Moreover, in a parallel treatment model, there is often little communication between the professionals independently treating each problem.52 This is problematic because professionals often have different case conceptualizations and treatment recommendations. For example, a physician may emphasize the usefulness of medication over psychotherapy, whereas, the reverse may be true for a psychologist. Hence, it is very common for a person to get conflicting advice and feedback in a parallel treatment approach.52 Furthermore, it is up to the patient to “integrate” distinct treatment approaches, which is likely difficult due to high rates of cognitive impairment among those with problem gambling.53 Finally, another potential problem for the client is the demands of attending two separate treatments (i.e., time, money). The limitations of a parallel approach may lead to adverse patient outcomes, such as frustration, continued mental health challenges, and in the most extreme case, discontinuation of treatment. Overall, attesting to these limitations, the literature shows that sequential and parallel approaches result in poor treatment outcomes in those struggling with addictive behaviours.52
The main advantage to an integrated treatment framework is that it recognizes common etiological mechanisms underlying co-occurring addictive behaviours. Hence, from a common mechanism or “transdisease” approach,54 one can design a treatment that helps individuals achieve notable improvements on more than one addictive disorder at a time. We posit that combined CBT/MI represents a general framework to target co-occurring problem gambling and tobacco use. CBT/MI therapies have been shown to be effective for smoking cessation across many studies55, and these approaches are very similar in content to those used for problem gambling. Overall, CBT/MI therapies help people acquire coping skills to deal with addictive behaviours broadly, including building motivation, improving understanding of triggers (i.e., learning how smoking is a trigger for gambling), avoiding high-risk situations, developing balanced ways of thinking, and creating well-informed relapse prevention plans. Numerous articles support the efficacy of these CBT/MI strategies for the treatment of problem gambling, tobacco use, and addictive behaviours more broadly.17,55 In the gambling literature, approaches aimed at targeting both problem gambling and alcohol use56 or mental health difficulties57 were shown to have no significant difference in outcomes between the separate and integrated treatment interventions; however, a limitation to both trials relied on a more sequential approach to treatment and lacked a stronger integrated component. Given CBT/MI’s emphasis on general coping skill development, we posit that it is an ideal framework for an integrated intervention for co-occurring problem gambling and tobacco use.
The Current Study
This open label pilot study will address a notable gap in the literature on problem gambling treatment. It has been known for a long time that a high proportion of gamblers smoke cigarettes,7,8 and that daily smoking compounds gambling severity.13-16 However, very little work has been done to systematically address the problem of smoking in treatment for problem gambling. In fact, to our knowledge, no existing treatment protocols have integrated content to help problem gamblers reduce smoking. Using a randomized controlled trial (RCT), we will be the first to design, implement, and test a novel online integrated treatment for problem gambling and comorbid smoking. Relative to traditional face-to-face approaches, there are distinct advantages to an online delivery of integrated treatment in North American. First, online interventions would be able to reach adults from rural and Northern communities across North America. We know from health statistics that the highest rates of addictive behaviours and addiction-related deaths exist in these communities.58,59 Second, adults with gambling issues may be more willing to engage in a self-help online intervention (relative to in person). This is because an online modality may be associated with reduced shame and stigma – which are known, persistent barriers to seeking treatment among problem gamblers.24 Finally, online interventions could significantly reduce the burden on mental health care systems in North America. More people with gambling problems would be helped for much less cost relative to hospital treatments. Data show that cost-effective, online psychosocial interventions reduce problem gambling60 and tobacco use61, separately. Therefore, the literature supports the online modality as a means to deliver our proposed integrated pilot study.
Objectives
Informed by the literature, our primary aim will be to examine if integrating treatment of comorbid tobacco smoking improves gambling outcomes among North Americans with problem gambling relative to a focus on problem gambling alone. Our second aim will be to test if reduced smoking explains (or mediates) the beneficial effects of the integrated treatment on gambling. We expect that participants receiving online integrated treatment will show larger reductions in gambling relative to those receiving a control gambling only intervention. We further hypothesize that reductions in smoking will mediate these group differences.