Introduction

Gambling has been defined as any activity that involves an element of risk, whereby money or something of sentimental or monetary value could be won or lost [1]. Gambling behavior may best be conceptualized as a dynamic continuum ranging from social and recreational gambling to pathological gambling [2, 3]. Pathological gambling is characterized by continuous or periodic loss of control over gambling, irrational thinking, distorted cognitions and a preoccupation with gambling activities as well as with obtaining money to gamble. This behavior persists despite adverse consequences on the person and his/her family, while there is remarked inability on the part of the player to stop gambling [4]. The definition of pathological gambling in adolescents is not different from that of adults; although marked interest has been recently expressed for formulating a separate definition for this population sub-group [5].

Adolescence is defined as the developmental process that begins with the biological and physiological changes of puberty and ends with the acquisition of self- and sexual-identity, as well as a sense of independence; achieved through the symbolic separation of adolescents from their parents [6]. This fundamental transition from the dependence of youth to the independence of adulthood is characterized by novelty-seeking and proneness to risk-taking; features that enable adolescents to adapt to different circumstances, but also render them more vulnerable to harm and addictions [7]. In this context, adolescents explore novel areas and experiment with adult habits, including gambling activities, and therefore constitute a high-risk population group in terms of manifesting gambling-related problems [2, 3].

Today’s youth worldwide is among the first generations to be exposed throughout their entire lives to an environment, where gambling is widely accepted, legalized in most cases, easily accessible, socially accepted, advertised and favored by state policies [8, 9]. Nonetheless, for a substantial proportion of adolescents, gambling involvement may rapidly turn from a leisure activity into a major health problem with disruptive consequences [8]. Consistent with this, the epidemiology of gambling involvement in adolescents has come to the forefront of attention. According to the low in Greece (4002/2011 ΦΕΚ 180/Α/22-08-2011), people under 18 years old are not allowed to reach places where gambling activities take place. The age of legalized gambling is above 18 years.

Regarding the epidemiology of problem gambling among adolescents, considerable variability in the prevalence rates of the disorder has been recorded among studies, probably due to the heterogeneity in terminology and methods employed, i.e., diversity in sampling procedures and screening instruments as well as due to cultural differences, varying forms of available gambling products and inconsistency in social settings [10]. However, most studies arrive at a similar conclusion, suggesting a higher prevalence of problem gambling among adolescents than adults with pertinent rates being almost three times greater than those in the adult population [2]. In particular, meta-analytical studies have revealed that 4.4–7.4% of youth meet the diagnostic criteria for pathological gambling, whereas 9.9–14.2% of adolescents exhibit some subclinical gambling-related problems [11, 12]. Gambling participation across European countries has also consistently shown that gambling is part of the life experiences of adolescents and that problem gambling is also present [13, 14]. Some examples of studies for problem gambling across European countries are, Romania: problem gambling: 6.8% (lifetime prevalence); Germany: problem gambling: 2.96% (past-year prevalence); Great Britain: 5.4% (past-year prevalence); other study in Great Britain: 3.5% (past-year prevalence); Italy: problem gambling: 2.6% (lifetime prevalence); Spain: SOGS-RA: problem gambling: 4.6% (past-year prevalence) [15,16,17,18,19,20].

Studies have demonstrated that if gambling opportunities are presented to adolescents, the majority of them will participate to a large degree in these activities, but only a minority is susceptible in developing a gambling problem. In Greece, in spite of a proliferation of clinical observations that problem gambling is present; there is a dearth of evidence-based epidemiological data. To date, the only findings that exist with regard to adolescents’ involvement with gambling activities stem from small-scale studies assessing Internet addictive behaviors, conducted by the Adolescent Health Unit of the Second Department of Pediatrics, University of Athens [21]. Specifically, the study has documented that 15.1% of the sample was involved with internet gambling at least once in lifetime, resulting in marked psychosocial maladaptation, especially in the form of emotional and social difficulties [22]. Nonetheless, the aforementioned studies did not examine the prevalence of pathological gambling and its correlates in adolescents. The necessity of conducting such an epidemiological study in Greece becomes even more imperative nowadays, in light of the pervasiveness of the financial crisis in the country, with a documented negative impact on the mental health of the population [23,24,25]. Congruent with these, the present study has set out the following research objectives:

  1. 1.

    To estimate 1-year prevalence of problem gambling in adolescents in Athens area

  2. 2.

    To identify the socio-demographic variables associated with problem gambling.

Methods

Sample

A total of 2141 students was recruited from a representative sample of 51 schools (44 public schools and 7 private ones) in the greater Athens area. For the selection of schools, the procedure was implemented consisting of two stages: (1) stratification in terms of geographical region and (2) selection of a random sample schools, within each stratum. Consistent with this, the first stage of sampling procedure produced the following five strata: Centre of Athens, Northern and Eastern suburbs, Central and Western suburbs, Central and Eastern suburbs and Piraeus. In the second stage of sampling, within each stratum, a random sample of public and private schools was selected from the pertinent list of the Ministry of Education. In each school unit, a random sample of classrooms was chosen.

Instrument

The research instrument consisted of the following sub-sections:

Socio-demographic variables Students were enquired with respect to their gender, age, nationality, living arrangement (both parents, one parent, neither parents), parental family status, last years school grade, parental involvement with gambling activities, pocket money from parents, type of school (public, private), weekly hours in extracurricular activities, weekly hours in tutorial activities.

Gambling involvement For investigating gambling involvement in adolescents, the DSM-IV-MR-J questionnaire was employed. This is a self-report measure tapping gambling involvement in adolescents. The Cronbach alpha value of the DSM-IV-MR-J was equal to 0.78, indicating acceptable internal consistency [5]. The checklist entails 12 items (9 categories) which tap the pertinent DSM-IV criteria for problem gambling in adolescents. The majority of items are rated on a four-point scale: (a) never, (b) once or twice, (c) sometimes and (d) often. However, answers are transformed into binary responses (presence–absence of the criterion). A positive answer to more than four categories corresponds to the presence of problem gambling in the adolescent.

The instrument assesses a number of important variables related to problem gambling: progression and preoccupation, tolerance, withdrawal and loss of control, escape, chasing, lies and deception, illegal activities and family/school disruption.

The particular instrument has been extensively used in studies exploring problem gambling in adolescents [11].

The instrument was translated and back translated in Greek by bilingual mental health professionals. A group of experts comprising psychiatrists, epidemiologists, child psychiatrists and psychologists read through the questionnaire and revised its content in accordance to the Greek culture. Finally, a group of 20 adolescents commented on the comprehensibility and clarity of the items.

Procedure

Data were collected in the form of a self-report questionnaire during one, pre-arranged, school period. To enter the classroom, the pertinent permission was attained by the Ministry of Education. Informed consent was obtained from both parents and students prior to participation in the study. Members of the research team visited each school to inform the School Principal, the staff and the Parents’ Association about the project. In agreement with the School Principal they entered the classrooms and introduced themselves and the study to the students, in an interactive manner, while distributing the informed consent forms. One week after the first visit, members of the research team visited the classrooms for the second time to administer the questionnaires to the students who had previously provided a signed informed consent for participation by their parents.

Statistical analysis

Quantitative variables are expressed as mean values (SD) or as median values (interquartile range). Categorical variables are expressed as absolute and relative frequencies. Univariate and multiple logistic regression analyses were used to find which factors were associated with the presence of problem gambling. Unadjusted and adjusted odds ratios with 95% confidence intervals were computed from the results of the logistic regression analyses. All p values reported are two-tailed. Statistical significance was set at 0.05 and analyses were conducted using SPSS statistical software (version 19.0).

Results

Sample consisted of 2141 adolescents (45.4% males and 54.6% females). 31.7% of the total sample aged from 13 to 14 years and 38.3% aged 16–17 years. Sample characteristics are presented in Table 1. The majority of the participants (87.0%) were Greek and most of the adolescents (80.5%) lived with both parents. Parental gambling was referred in 24.4% of the sample and 78.5% of the adolescents had pocket money from their parents. 90.3% of the participants attended a public school and 9.7% attended a private school. Problem gambling according to DSM was identified in 5.6% of the sample.

Table 1 Sample characteristics
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Results from univariate and multiple analyses of sample characteristics with the presence of pathological gambling are presented in Table 2. Univariate analyses showed that non-Greek participants (p < 0.001), males adolescents living without their parents and those that their parents are gambling were more likely to be pathological gamblers (p < 0.001). Also, pathological gamblers had a greater weekly pocket money (p < 0.001) and spend more hours on extracurricular activities in univariate analysis (p = 0.031). Additionally, a greater proportion of pathological gamblers was found in adolescents with low grades at school (p < 0.001) and in those who in the last month there was a time when they had no food in their family (p < 0.001).

Table 2 Results from univariate logistic regression analysis with dependent variable the presence of problem gambling
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When multiple logistic regression analysis was conducted with dependent variable the presence of pathological gambling (Table 3), it was found that nationality, sex, living without parents, having parents that gamble, last year’s grade, Weekly pocket money and no having food in their family were independently associated with pathological gambling. Specifically, Greek participants were less likely for being pathological gamblers (p = 0.034). Being a male (p < 0.001) and living without parents (p < 0.05) had a positive relationship with pathological gambling. Adolescents with high grade at last school year (18.1–20) were less likely to be pathological gamblers as compared with those having very low grade at last school year (0–9.9) p < 0.05. The increased weekly pocket money is positively associated with pathological gambling (p = 0.008). Also, adolescents who in the last month there was a time when they had no food in their family were more likely to be pathological gamblers (p < 0.001).

Table 3 Results from multiple logistic regression analysis with dependent variable the presence of problem gambling
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Discussion

Prevalence of problem gambling

Results from our study indicate that the prevalence of problem gambling in adolescents in the greater area of Athens is 5.6%. In a meta-analysis by Blinn-Pike and colleagues [26], the estimated proportion of disordered gambling among college students in the studies included was 7.86%. In addition, studies across European countries indicate that Europe appears to be moving towards a more continued expansion of gambling [8]. In line with this, it seems that Greece displays similar levels of problem gambling with that reported for adolescents in the international literature.

Risk factors of problem gambling

In line with the results of the present study, students that reported parental gambling involvement showed higher chances of exhibiting problem gambling behavior. Parents’ engagement into the particular activity is one of the most researched risk factors in the international literature [27].

Our results indicate a significant statistical link between gender and problem gambling. In particular, boys were found to be more likely to suffer from the disorder than girls. This finding has been extensively replicated in the existing literature. Therefore, one might argue that there is strong evidence corroborating elevated prevalence rates of problem gambling in boys, who are 2–4 times more likely to develop the disorder, as compared to girls [28]. Possible explanations for these inter-gender differences are not sufficiently bolstered in the existing international literature. Some studies attribute the phenomenon to genetic factors; while others question this finding [29]. In addition, other researchers have corroborated the influence of hormonal factors in the prevalence of pathological gambling, and more specifically they have underlined the role of testosterone in the emergence of impulsive behavior in boys [30].

The development of the disorder may also be influenced by the different sociocultural pressures boys and girls face. There is some evidence that gambling may be more socially acceptable for men than for women, and as a corollary of this, boys are not as concerned about the social repercussions of such behavior as girls may be [31].

The other important risk factor is the association between school performance and pathological gambling. According to the results of this study, having very good or excellent grades at school protect adolescents from facing gambling problems.

A link between gambling problems and poor school performance has been demonstrated in several studies [36].

It has been also shown that a high proportion of adolescents with gambling problems report having learning disability [32].

Additionally, our results indicate that the odds for pathological gambling increases as the weekly pocket money increases. This particular result was expected because adolescents to gamble need at least some pocket money to spend on gambling. Moreover, in Greece it is a cultural trend for parents to give to their children pocket money.

On the grounds of the present results, there is some indication also about the adverse effects of the financial crisis in the development of problem gambling in adolescents. Adolescents who reported that there was a time where there was not sufficiency food in the household were most likely to exhibit problem gambling than those who had always enough food in the household. These findings are congruent with the literature suggesting that youth living under poverty often resort to gambling [33].

It is noteworthy that problem gamblers often use gambling as a way to escape life adversities. They also display dysfunctional coping styles and avoid reality through gambling [34].

Our results indicate also an association between family conditions and problem gambling. More specifically, adolescents who were living with one or two parents had lower possibility to have gambling problems as compared with those living without parents. There is evidence that family factors are associated with increasing risk for engaging in gambling behaviors [35]. According to the literature, family environment and family relationships are associated with adolescent gambling behavior. In addition, family characteristics such as problems at family structure are associated with increased engagement in risk taking behaviors during adolescence and across the life span [36].

Limitations

The findings of the present study are limited to the region of Athens, and therefore prevalence rates cannot be extrapolated to the rest of the country. The refusal rate was 22% and we did not investigate the types of gambling involvement. Further research should concentrate on exploring the types of gambling involvement. In addition, sampling bias might have occurred in the study design, as only students whose parents consented to taking part in the survey were administered the questionnaire. It is highly likely that parents who are most severely struck by the crisis or parents who are indifferent to the upbringing of their children would not notice the implementation of the study nor consent to their children’s participation. These children are more likely to present symptoms of problem gambling as well. In addition, screening of problem gambling was made through self-report measure and was not cross-validated against clinical assessment.

Conclusion

The current prevalence study constitutes the first research effort to explore gambling involvement in adolescents in Greece. Previous work was restricted to internet gambling involvement as well as internet addiction [19, 20]. The findings of our study indicate that as in most western countries, gambling behavior constitutes also a problem in Greece at the moment. Risk factors for disordered gambling involvement, namely gender, parental involvement, nationality, and academic achievement echo existing evidence in the international literature [5, 32]. Nonetheless, the study provides some indication about the adverse effects of the financial crisis on the mental health of the adolescent population in Greece. Adolescents’ worry about the sufficiency of food in the household showed a clear link with problem gambling, supporting the view that problem gambling may have developed in response to the ubiquitous insecurity characterizing the Greek society during this rough time period. Adolescents experience this insecurity and gamble perhaps in an attempt to control their environment or to provide their families with money. A future study should concentrate on exploring this particular hypothesis. The rates of gambling problems in Greek adolescents accentuate the need for designing and implementing appropriate preventive interventions, especially amid financial crisis.