The 11th edition of the International Classification of Diseases (ICD-11; World Health Organization, 2019), defines gambling disorder (GD) as a pattern of gambling behavior characterized by impaired control over gambling, increased priority given to gambling over other activities to the extent that gambling takes precedence over other interests and daily activities, and continued escalation of gambling despite presence of negative consequences. The 4th and 5th editions of the Diagnostic and Statistical Manual (DSM-IV and DSM-5, respectively) classified GD as an impulse control disorder, and further included gambling disorder as a stand-alone entity in the category of disorders due to addictive behaviors that can be offline and online (Brand, 2022; American Psychiatric Association, 2013; Awo et al., 2022; Abe et al., 2021). These classifications require that social, medical, public and mental health service providers begin to address GD in the same way and manner as substance-related addictions since they are both explained by similar underlying factors.
According to the Interaction of Person-Affect-Cognition-Execution (I-PACE) model of behavioral addictions (Brand et al., 2019), GD is triggered and maintained by the interaction of an individual’s environment (availability/accessibility and affordability of gambling costs), person (mood, rewarding experience), cognition (thinking about gambling), and consequences/outcome of past actions (decision and responses to reward/triggers). Brand (2022) summarized the driving factors to online GD) as the “feels better” path which includes both positive (e.., pleasure, reward) and negative (e.., reduction of stress and negative mood) reinforcement experiences and related cravings and desires, and the “must do” path that majorly occurs towards the later stages of addiction development, including seemingly habitual and compulsive behaviors such as automatic responses to environmental cues and stimuli, and maladaptive persistence of GD despite being aware of its negative consequences.
Available systematic review of national surveys from 2000–2015 (Yu et al., 2023; Choliz and Choliz, 2016) found wide variations in GD rates for different countries; worldwide ranged from 0.12–5.8%, 0.12–3.4% in Europe. In Nigeria, evidences show that 1 in every 5 male and 1 in every 12 female youths have high to severe GD rating leading to elevated burden of mental harm (e,g., anxiety, stress, depression and in some instances suicidal deaths) (Akpunne et al., 2022). This report underscores the need to understand the underlying factors that drive GD including the environment (quality of life), person (escape outcome expectancies and craving) in order to optimize its prevention, treatment and policy.
Quality of life and GD
The world Health Organization (WHO, 1993) defines quality of life (QoL) as a person’s perception of his/her position in life in the context of the prevailing culture and values in relation to his/her goals, expectations, standards and concerns. Defining and measuring QoL in the context of gambling has often involved the use of instruments that assess four areas including physical, well-being, psychological state and social relations (Bonfils et al., 2022; Moore et al., 2024). Some other studies support the effective use of health-related Qols (HRQoL) in assessing the relationship of gambling with interpersonal relationships, physical state, financial concerns, medical care and satisfactions with life (Bonfils et al., 2019). Bonfils and his colleagues argued that, despite being self-report and subjective measures, the HRQoL measures may not necessarily explore the complete spectrum of individual’s concerns over QoL of GD and may not capture the individual’s subjectivity.
Specifically, gambling-anchored QoL tend to best capture QoL among gamblers as it has been widely reported that GD was associated with gamblers’ impaired QoL including family, financial, legal and social problems (McCormack and Griffiths, 2011). Despite emerging research evidences indicating a strong link between GQoL and GD, little or nothing is known about the psychological mechanisms that may help maintain the GQoL-GD association. One view is that GD manifests through efforts to eke a living, boost economic status, and improve QoL. However, any perceived or actual improvement due to resources gained from gambling stakes maybe short-lived (Bonfils et al., 2019) as the gained resources are highly likely to staked back. Sequentially, the GQoL-GD relationship may develop through the accumulation of the negative effects of gambling, which themselves could be a source of reduced quality of life, which could trigger continued gambling frequency to improve income, thus, creating a vicious cycle (Bruneau et al., 2016). These findings reiterate the need to explore avenues to prevent GD including GQoL as a criterion. GQoL is therefore, not QoL reduced by gambling, but all possible areas of life affected by GD in a comprehensive and subjective meaning. Drawing on these evidential reports, we predicted that:
Hypothesis 1
GQoL will be negatively associated with GD.
Escape outcome expectancies and GD
According to Caudwell et al. (2024), one common approach to understanding a given action/behavior is to examine the motives and anticipated outcomes derived from engaging in the act. In regards to GD, a range of motives and outcome expectancies have been fingered in literature, including to improve personal income (Hagfors et al., 2022), to socialize (Flack and Morris, 2015), and to escape from poverty and low economic status (Caudwell et al., 2024; Greer et al., 2023). Noted that various gambling specific motives and expectancies are associated with gambling involvement, gambling to escape from low economic status and to improve quality of life appears especially crucial GD (Caudwell et al., 2024). For example, gambling to win money and escape from poor life have been found to account for variations in problem gambling scores over time (Lelonek-Kutela and Bartczuk, 2021: Richardson et al., 2023). As reported by Buchanan et al. (2023), the probability, however unlikely, that engaging in gambling may alleviate financial burden through winning monies was a distinctive feature that differentiated GD from other behavioral addictions. Despite the existence of rich data around the QoL-gambling outcome expectancies-GD association, an arear that have largely remained understudied, especially in the African/Nigerian context is how the perceptions of gambling as a form and source of escape relates to experience of both GQoL and GD. Based on extant research, it is plausible that escape could mediate the GQoL-GD link. For instance, those who are highly preoccupied with gambling thought and imagination about gambling as a means of improving living standard may tend to develop positive views of gambling, and consequently, engage in excessive gambling (thus, leading to GD). On the strength of these evidences in literature, we propose that:
Hypothesis 2
Escape outcome expectancies will be positively associated with GQoL and GD.
Hypothesis 3
Escape outcome expectancies will mediate the association between GQoL and GD.
Gambling craving and GD
Craving plays crucial role in addictive behaviors (Romanszuk et al., 2014; Hasin et al., 2013), and has remained one key criterion for the diagnosis of addictions such as substance use disorder (Tiffany and Wray, 2012) in the DSM-5 (APA, 2013). In the DSM-5, craving is defined as an intense desire or urge for a drug which is usually triggered in a context where the drug was previously used, but can occur independently. Shmulewitz et al. (2021) reports that DSM-5’ 2013 inclusion of craving as a main criterion has demonstrated good validity. Further evidences have shown that craving plays key role in non-substance-related behavioral addictions including GD, and internet gaming disorder (Antons et al., 2020) as they share similar clinical and neurobiliological features with substance use disorders including craving and loss of control (Romanczuk-Seiferth et al., 2014) as individuals suffering from GD tend to make efforts to regain loss with urgent need to keep gambling (Caudwell et al., 2024; APA, 2013). Despite this strong link, more consensus is needed since craving is not yet recognized as a major criterion for GD diagnosis.
The overarching goal of our research is to understand gambling craving as a psychological mechanism that explain the GQoL-escape-GD pathway. The assumption that gambling could be used to escape poor QoL by gaining more resources is often inferred, and is yet to be empirically tested in the Nigeria, to the best of our knowledge. Our study is important as it aims to identify modifiable psychological and personal factors pertaining to GD (Hoffman and Hayes, 2018). Given that GQoL may be considered a precipitating factor in GD, research on GQoL as a potential trigger of GD is non-existent in Nigeria where gambling is rife with its expected increase in GD prevalence (Awo 2023). To address these limitations in research, we investigate the relationships among GQoL, escape outcome expectancies, gambling craving and GD in Nigeria using a moderated mediation model.
Taken together, escape outcome expectancies and craving show promise in explaining the association between GQoL and GD. Again, consistent with past research, gambling craving may weaken or amplify these associations. For example, the experience of GQoL and a thrift toward craving for gambling may interact to influence the GQoL-escape relationship. That is, an individual experiencing poor GQoL may likely develop escape outcome expectancies, and these may affect GD, especially when the individual engages in gambling craving. In contrast, moderation of the escape-GD link would indicate that higher gambling craving scores strengthen the relationship between escape and GD. This, therefore, suggests that gamblers who perceive gambling as a form of escape from poor GQoL could reduce their GD by craving less for gambling as a source of income. The study model is proposed in Fig. 1.
If supported, this conceptualization outlines two key intervention targets. If escape expectancies account for the GQoL-GD association, escape expectancies could be targeted in efforts to facilitate GD behavior change. The moderated mediation component of the model indicates potential for synergy in interventions targeting both escape expectancies and gambling craving simultaneously. We therefore propose that:
Hypothesis 4
Gambling craving will moderate the associations between GQoL, escape outcome expectancies and GD.