Journal of Gambling Studies

https://doi.org/10.1007/s10899-019-09831-6

ORIGINAL PAPER

Gambling Problem Trajectories and Associated Individuals

Risk Factors: A Three‑Year Follow‑Up Study Among Poker
Players

Magali Dufour1,4   · Adèle Morvannou2,4 · Natacha Brunelle3 · Sylvia Kairouz2 ·

Émélie Laverdière4 · Louise Nadeau5 · Djamal Berbiche4 · Élise Roy4,6

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Despite the popularity in poker-related activities in recent years, few studies have focused
on the evolution of gambling habits of poker players over a long period of time. The aim
of this study is to examine factors influencing trajectories of poker players. The results
are based on data collected at a four-time measurement of a prospective cohort study con-
ducted in Quebec (n = 304 poker players). A latent class growth analysis was performed
to identify trajectories based on the Problem Gambling Severity Index score. Multinomial
multivariable logistic regression analyses were conducted to determine the correlates of
gambling trajectories. Over the 3 years of the study, three gambling problem trajectories
were identified, comprising one decreasing trajectory (1st: non-problematic—diminishing),
one stable trajectory (2nd: low risk—stable), and one increasing trajectory (3th: problem
gamblers—increasing). Internet as the main poker form and number of game played were
associated with at-risk trajectories. Depression symptoms were significant predictors of the
third trajectory whereas impulsivity predicted the second trajectory. This study shows that
the risk is remaining low over years for the vast majority of poker players. However, the
vulnerable poker players at the beginning of the study remain on a problematic increas-
ing trajectory. It is therefore important to prioritize individuals in the third trajectory for
interventions.

Keywords  Poker · Gambling problems · Trajectories · Prospective cohort study · Internet

gambling

Introduction

Poker, a complex game comprising mathematics, psychology, skills, and luck, has a place
all on its own among gambling activities (MacKay et  al. 2014; Siler 2010). Despite the
decrease in participants over the last few years, poker has turned into a multi-million-dollar

* Magali Dufour
dufour.magali@uqam.ca
Extended author information available on the last page of the article

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 Journal of Gambling Studies

industry (Fiedler and Wilcke 2012) and remains one of the most popular gambling activi-
ties worldwide (Kairouz et al. 2014).
During the last 10 years, some 30 studies of poker players have been conducted (Bar-
rault and Varescon 2013a; Dufour et al. 2015; Kairouz et al. 2016; Laakasuo et al. 2015;
Zaman et  al. 2014). For the most part, these studies used a cross-sectional design and
looked at online poker. These studies have allowed researchers to draw up portraits of poker
players (Barrault and Varescon 2013a; Dufour et al. 2015; Hopley et al. 2012), to describe
their gambling motivations and passions (Bradley and Schroeder 2009; Brochu et al. 2015;
Dufour et al. 2012; Hopley and Nicki 2010; Mitrovic and Brown 2009; Morvannou et al.
2017; Smith et al. 2012; Wood et al. 2007), and to determine both the prevalence of their
gambling problems and the associated risk factors (Brosowski et  al. 2012; Hopley et  al.
2012; O’Leary and Carroll 2013; Smith et al. 2015). These studies indicate that poker play-
ers are usually young, highly educated men (Bjerg 2010; Hopley et al. 2012), who none-
theless do not seem to constitute a homogeneous group (Dufour et al. 2015). A significant
proportion of poker players, between 7.9 and 17.2% are considered to have gambling prob-
lems (Barrault and Varescon 2013a; Kairouz et  al. 2014). Moreover, several risk factors
associated with gambling problems in poker players are mentioned, such as gambling in
several types of activities (Brosowski et al. 2012), playing frequently, playing on the Inter-
net (Kairouz et al. 2012), being impulsive (Barrault and Varescon 2013a; Hopley and Nicki
2010), and having erroneous beliefs (Barrault and Varescon 2013b). Furthermore, gam-
bling problems among poker players are also linked to problems managing and identifying
emotions such as anxiety and depression (Hopley and Nicki 2010; Mitrovic and Brown
2009; Shead et al. 2008).
Though these studies of poker players seem to indicate that this population is at risk of
having gambling problems, their transversal nature does not allow to follow their various
trajectories. Indeed, there has only been one longitudinal study that has specifically looked
at poker players (LaPlante et al. 2009). This 2-year-long prospective study, carried out with
3445 online poker players, was based on behavioural data collected through transactions
conducted on the BWin Internet site. Despite the absence of measure for gambling prob-
lems, the authors were able to draw up two profiles for the poker players: (i) those (95%)
who adjusted their gambling behaviour according to losses incurred; (ii) those (5%) who
continued to gamble intensely whatever their losses (Laplante et al. 2009). While interest-
ing, this study did not make it possible to document factors associated with gambling prob-
lems. However, evaluating these aspects would make it possible to identify the risk factors
associated with both the positive and negative evolutions of gambling problems.
Whereas several variables seem to influence the gamblers’ behaviors, in particular men-
tal health problems, erroneous belief, types of game (see Dowling et al. 2017; Johansson
et  al. 2009; Scholes-Balog and Hemphill 2012 for review), to our knowledge, no studies
have as yet documented whether these same variables specifically apply to poker players’
trajectories. The aim of this study was thus to document, over a 3-year period, changes in
the severity of gambling problems in poker players and the factors associated therein.

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Journal of Gambling Studies

Methods

Study Design

This study is a prospective cohort study conducted from 2008 to 2016 among poker
players in the Province of Quebec, Canada. The study design involves a survey of a con-
venience sample of poker players from 16 regions in Quebec. Players were recruited in
various poker playing places (casinos, bar tournaments, poker room tournaments), and
through adds on websites and newspapers (Dufour et al. 2015). To be eligible, individu-
als had to consider themselves to be a poker player, have bet money on a poker game
in the past year, be at least 18 years old, and speak French or English. After providing
informed consent and contact information, participants completed a 60 min interview-
questionnaire at baseline (T1) and follow-up visits (T2–T3–T4) scheduled at 12-month
intervals. Participants were given a gift certificate of CAD $30 at each interview.

Participants

Due to uncertainty around funding, recruitment was carried out in waves instead of in
a continuous manner. Three recruitment waves took place from 2008 to 2013 approxi-
mately 2 years apart from each other and annual follow-ups were conducted until early
2016. The participants recruited in the first (2008–2016) and second (2011–2016) waves
could complete all measurement time, whereas those from the third (2013–2016) wave
could complete only two follow-up interviews (Table  1). The number of participants
available for analyses thus varied according to the measurement time.
Response rates were calculated at each measurement time and defined as the num-
ber of people who completed the interview over the number of people eligible at that
moment. Of the 304 poker players recruited, all were eligible for the first (T2) and the
second follow-up interview (T3). At T2, 275 individuals completed the first follow-up
for a response rate of 90%. At T3, 232 completed the interview for a response rate of
76%. At T4, only participants from the first and second recruitment wave were eligible
when the study ended. Calculating a retention rate based on the number of participants
recruited at baseline (T1, n = 304) would thus be inaccurate given the three recruitment
times. Consequently, at T4, 167 were eligible and 115 completed this follow-up, giving
a response rate of 69% (115/167).

Table 1  Follow-up of participants, response and retention rate

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Instruments

All data were measured at baseline (T1) and for each follow up time (T2–T3–T4). Gen-
eral sociodemographic information was collected for each participant: sex, age, education,
marital status and economic situation.

Gambling Activity and Gambling Problems

The players main poker gambling form (i.e., Internet vs. landbased) was determined by
participants in their answer to one of these two following statements: ‘I mostly or exclu-
sively play poker on the Internet’ or ‘I mostly or exclusively play land-based poker’.
The number of games played (excluding poker) could range from 0 to 16 and was
defined as the number of games played at least once during the last year among the fol-
lowing gambling activities: (1) lotto tickets, (2) instant prizes or scratch-and-win, (3) raf-
fle tickets, draws, or fundraisers, (4) horse track races, (5) bingo, (6) slot machines at the
casino, (7) black jack at the casino, (8) roulette at the casino, (9) keno at the casino, (10)
video lotteries in bars, (11) sports betting, (12) betting on card or board games with family
or friends, (13) betting in card games in a non-regulated gaming room, (14) betting during
pool, bowling, and dart games, (15) betting on video games, and (16) trading stocks.
Severity of gambling problems was evaluated using the Problem Gambling Severity
Index (PGSI) (Ferris and Wynne 2001), a 9-item subscale with scores ranging from 0 to
27. The PGSI distinguished four categories of gamblers: (0) no risk; (1–2) low risk; (3–7)
moderate risk; and (8–27) problem gamblers. Internal consistency in this study was good
(Cronbach’s α: 0.78)

Co‑variables

Co-variables associated with the main outcome were selected based on the literature and
were all treated as continuous variables except for at-risk alcohol and drug use.
The Beck Anxiety Inventory (BAI) (Beck et al. 1988) is a 21-item scale that assesses
the intensity of affective, cognitive, and somatic symptoms of anxiety in the past week. The
validated French version has excellent methodological qualities (Freeston et al. 1994). At
baseline, Cronbach’s value was 0.87.
The Beck Depression Inventory (BDI), a 21-item test, evaluates the main symptoms of
depression in the past week (Beck et al. 1996). The French version has good methodologi-
cal qualities (Bourque and Beaudette 1982) (Cronbach’s α: 0.86).
The DEBA-Alcohol and DEBA-Drugs questionnaires (Dépistage-évaluation du besoin
d’aide-alcool ou drogue) (Tremblay et al. 2001) were used to assess the severity of alcohol
and drug use as well as addiction to these substances during the last year. They showed
good validity and reliability indices (Tremblay et al. 2001).
The Eysenck Impulsiveness Questionnaire (EIQ) assessed impulsivity with 43 items
(Eysenck and Eysenck 1977) and was validated through a process of translation into
French followed by a back-translation into English (Jacques et al. 1997). Internal consist-
ency in our study was acceptable as Cronbach’s α was greater than or equal to 0.6 (Hume
et al. 2006; Norman and Streiner 1994).
Illusion of control was assessed by the Inventaire des croyances liées aux jeux
(ICROLJ), an inventory of eleven gambling-related beliefs, was developed in French by
Ladouceur et al. (2005). Internal consistency in our study was good (0.84).

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Data Analysis

All the participants were included in the analysis. Descriptive statistics were used to
characterize the study population in terms of demographic characteristics and gambling
participation at baseline (T1). This included frequency distributions for categorical vari-
ables and means with standard deviations (SD) for continuous variables.
The main outcome of interest is the gambling problem severity that was evaluated
using the PGSI. In order to assess whether changes occurred regarding the severity of
gambling problems over the 3 years of follow-up, analyses of the trajectories were con-
ducted. Using the PGSI continuous scores, a Latent Class Growth Analysis (LCGA) was
performed using the PROC TRAJ procedure of SAS (Jones et  al. 2001). The number
of trajectories to be retained in the final models was identified by allowing three to six
trajectories to be fitted to the data with linear, quadratic, and cubic temporal trends. The
choice of the optimal model was based on the Bayesian information criterion (BIC), the
Akaike information criterion (AIC) and the sample-size adjusted Bayesian information
criterion (SSABIC). In the Proc Traj procedure, the BIC and AIC values in the output
were negative; the best fit model was the one with the lowest information criteria. An
entropy closest to 1 also reflect a better fit and the different class solutions were finally
judged based on clinical significance.
Multinomial multivariable logistic regression analyses were conducted to determine
the correlates of gambling trajectories as measured at baseline. All variables with an
alpha level of < 0.10 in univariate analysis were included in the multivariable model.
Following the backward procedure, significant variables with p values < 0.05 (Wald’s
test) were kept in the final models. SAS 9.3 software was used to perform the analysis.

Ethics

Ethical approval was provided by the ethical boards of the Lettres et sciences humaines
at the Université de Sherbrooke and the Université du Québec à Trois Rivières.

Results

A total of 304 poker players were recruited and were not statistically different at p < 0.05
from the 115 participants who completed all follow-ups (T2–T3–T4) with respect to
general sociodemographic characteristics (i.e., sex, age, salary) and gambling or mental
health characteristics (i.e., number of games played, main poker form, gambling prob-
lem severity, at-risk alcohol or drug use). Since the final sample was not different from
the recruited participants, there was no imputation for missing data due to the method of
recruitment.

Study Participants’ Characteristics at Baseline

Of the 304 poker players who completed the baseline interview (T1), the majority
were men (88.2%) and were born in Canada (95.1%). The mean age was 32.5  years
old (SD = 11.5) and 44.1% were single (Table  2). Concerning gambling habits at T1,

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Table 2  Study participants’ characteristics at baseline (T1, n = 304)
All poker players [n (%)] Trajectory 1: non-problem- Trajectory 2: low- Trajectory 3: problem p value (X2-
atic—diminishing path [n risk—stable path [n gambling—increasing path test) [n (%)]

13
(%)] (%)] [n (%)]

Sociodemographic characteristics
Gender
 Male 268 (88.16) 167 (86.08) 89 (91.75) 12 (92.31) 0.3303
 Female 36 (11.84) 27 (13.92) 8 (8.25) 1 (7.69)
Age†,a 32.53 (11.50) 33.20 (12.16) 31.60 (9.55) 31.92 (14.73) 0.5235‡
Nationality
 Canadian born 289 (95.07) 186 (95.88) 90 (92.78) 13 (100.00) 0.0586β
 Others 15 (4.93) 8 (4.12) 7 (7.22) 0 (0.00)
Marital status
 Married or in common-law relationships 169 (55.59) 115 (59.28) 50 (51.55) 4 (30.77) 0.0839
 Divorced, separated, single or widowed 135 (44.41) 79 (40.72) 47 (48.45) 9 (69.23)
Last level of education completed
 Elementary level completed 9 (2.96) 7 (3.61) 2 (2.06) 0 (0.00) 0.1579β
 High school level completed or higher 295 (97.04) 187 (96.39) 95 (97.94) 13 (100.00)
Annual ­salary†,b 47462.00 (79512.00) 47196.18 (47824.57) 51118.69 (125497.69) 20571.43 (24453.06) 0.0180‡
Gambling behaviors
Main poker form
 Land-based poker 157 (51.64) 112 (57.73) 42 (43.30) 3 (23.08) 0.0073
Internet poker 147 (48.36) 82 (42.27) 55 (56.70) 10 (76.92)
Number of games p­ layed†,c,d 3.90 (2.25) 3.57 (1.95) 4.40 (2.51) 5.15 (3.24) 0.0145‡
Illusion of control 19.09 (16.00) 15.71 (15.82) 25.10 (14.58) 24.69 (14.96) < .0001‡
Mental health
At-risk alcohol or drug ­usec
 Yes 120 (39.47) 69 (64.43) 42 (56.70) 9 (30.77) 0.0359
Journal of Gambling Studies
 Table 2  (continued)
All poker players [n (%)] Trajectory 1: non-problem- Trajectory 2: low- Trajectory 3: problem p value (X2-
atic—diminishing path [n risk—stable path [n gambling—increasing path test) [n (%)]
(%)] (%)] [n (%)]

 No 184 (60.53) 125 (35.57) 55 (43.30) 4 (69.23)

Anxiety†,e 3.68 (5.82) 2.51 (5.06) 5.57 (6.08) 7.15 (9.10) < .0001‡
Depression†,e 3.01 (4.80) 2.07 (3.93) 4.18 (4.88) 8.38 (9.26) < .0001‡
Journal of Gambling Studies

Impulsivity† 12.19 (11.43) 9.31 (10.54) 16.91 (10.87) 20.00 (13.77) < .0001‡
Total 304 (100.00) 194 (63.82) 97 (31.91) 13 (4.28) –
†
 Mean (SD)
‡
 Test de Kruskal-Wallisce
β
 Fisher test
a
 Years
b
 CAD $
c
 Past 12 months
d
 Excluding poker
e
 Past week

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Table 3  Fit statistics from the Model Fit statistics

LCGA​
AIC BIC SSABIC Entropy

3-Class − 1477.85 − 1505.73 − 1447.44 0.925

4-Class − 1470.84 − 1508.01 − 1430.29 0.916
5-Class − 1467.85 − 1514.31 − 1417.17 0.916
6- Class − 1468.45 − 1524.20 − 1407.63 0.904

Fig. 1  Gambling problem trajectories over 3 years according to the PGSI score

an approximately equal proportion of players were mainly playing land-based poker

(51.6%) vs. Internet poker (48.4%). On average, they had bet at 3.9 different gambling
activities in the last year and the mean score of illusion of control was 19.1 (SD = 16.0).

Gambling Problem Trajectories

The different class solution resulting from the LCGA are presented in Table 3. Based on
the selected criteria, the 3-class model (BIC = − 1505.73; AIC = − 1477.85, entropy 0.925)
was selected over the four to six class. The main reason was the higher entropy, lower AIC,
BIC and SSABIC values. This model also provided the most coherent and clinically sig-
nificant picture of the evolution of gambling problems severity over time with a sufficient
number of participant in each class (referred as ‘trajectories’ in this study) compared to
other class solutions.
Three gambling problem trajectories were identified over 3 years using the continu-
ous score of the PGSI (Fig.  1), comprising one decreasing trajectory (1st: non-problem-
atic—diminishing; 62.4%), one stable trajectory (2nd: low risk—stable; 33.0%), and one

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Journal of Gambling Studies

increasing trajectory (3th: problem gamblers—increasing; 4.6%). The first trajectory com-
prised players without gambling problems who showed no risk during follow-ups. The sec-
ond trajectory presented a low risk of problem gambling that remains stable over 3 years.
There were a small number of individuals in the third trajectory that was characterize by
players with a gambling problem at baseline that continued to increase over 3 years.

Predictors of Gambling Problem Trajectories

In univariate analysis, all gambling behaviors (i.e., Internet as the main poker form, num-
ber of games played, and illusion of control) and mental health problems (i.e., at-risk alco-
hol or drug use, anxiety, depression, and impulsivity) were significant predictors (p < 0.05)
associated with at least one at-risk trajectory (Table 4).
In multivariable analysis, Internet as the main form of poker and number of games
played increased the odds of following either second or third trajectories as compared to
the first (Table  5). Indeed, participants belonging to the second (low risk—stable) and
third (problem gambling—increasing) trajectories were more likely to play mostly on the
Internet (2nd AOR = 2.21, 95% CI 1.27–3.85; 3rd AOR = 6.91, 95% CI 1.62–29.49) and to
take part in a higher number of gambling activities (2nd AOR = 1.24, 95% CI 1.09–1.40;
3rd AOR = 1.59, 95% CI 1.19–2.11) compared to the first trajectory (non-problematic—
diminishing). Furthermore, participants on the second trajectory were more likely to report
impulsive symptoms (AOR = 1.05, 95 % CI 1.02–1.08 vs. 1st). Finally, participants on the
third trajectory were significantly more likely to report depression compared to those in
the first (AOR = 1.16, 95% CI 1.05–1.29) and second (AOR = 1.11, 95% CI 1.01–1.22)
trajectories.

Discussion

This is the first study to evaluate gambling severity trajectories among poker players. The
aim of this study was to examine the changes in the severity of gambling problems over a
3-year period and the factors associated therein. Over this period, three paths were iden-
tified indicating the heterogeneous nature of gambling problem trajectories among poker
players. The diversity of the trajectories was in line with previous findings from longitudi-
nal studies of gamblers in the general population who participated in various types of gam-
bling activities (Currie et al. 2012; Edgerton et al. 2015; Luce et al. 2016; Svensson and
Romild 2011; Williams et al. 2015). In this study, the majority of poker players reported
either a low risk, stable trajectory (2nd, 33.0%), or a diminishing, non-problematic trajec-
tory (1st, 62.4%) over the 3 years. This result corroborates studies of trajectories that have
shown that most non-problematic gamblers do not develop problems over the years (Edger-
ton et al. 2015; el-Guebaly et al. 2015; Luce et al. 2016; Reith 2015; Williams et al. 2015)
and that the risk decreases for most low risk gamblers (Abbott et al. 2004). The low risk of
gambling problems observed over several years for the majority of players is re-ensuring
despite the fact, in the years 2000, the craze for poker, also called “pokermania,” alerted
public health officials to the risks of this activity (Mitrovic and Brown 2009). It seems that
the simple fact of playing poker did not necessarily seem to lead to an increase in the risk
of developing gambling problems at least for this short 3-year observation period. It is pos-
sible that gambling problems may develop over a longer period of time and has not been
measured in this study.

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Table 4  Multinomial univariate logistic regression analyses: gambling behaviour and mental health predictors of gambling trajectories
Trajectory 2: low-risk—stable path versus Trajectory 3: problem gambling—increasing Trajectory 3: problem gambling—increasing
Trajectory 1: non-problematic—diminishing path versus Trajectory 1: non-problematic— path versus Trajectory 2: low-risk—stable path
path diminishing path
OR (95% CI)

Gambling behaviors
Internet as main poker form
Number of games p­ layeda,b
Illusion of control
Mental health
At-risk alcohol or drug ­usea
Anxietyc
Depressionc
Impulsivity
1.79 (1.09–2.93)* 4.55 (1.21–17.06)* 2.55 (0.66–9.83)
1.19 (1.06–1.33)** 1.36 (1.07–1.73)* 1.15 (0.90–1.46)
1.04 (1.02–1.06)*** 1.04 (1.00–1.08)† 1.00 (0.96–1.04)
1.38 (0.84–2.28) 4.08 (1.21–13.72)* 2.95 (0.85–10.23)†
1.11 (1.05–1.16)*** 1.13 (1.05–1.22)** 1.03 (0.96–1.10)
1.11 (1.05–1.17)*** 1.21 (1.11–1.33)*** 1.10 (1.01–1.19)*
1.06 (1.04–1.09)*** 1.09 (1.03–1.16)** 1.03 (0.97–1.09)

OR Odds Ratio, CI Confidence Interval

Wald’s test: †p < 0.10; *p < 0.05; **p < 0.01; ***p < 0.001
a
 Past 12 months
b
 Excluding poker
c
 Past week
Journal of Gambling Studies
 Journal of Gambling Studies

Table 5  Multinomial multivariable logistic regression analyses: predictors of gambling problem trajectories

Trajectory 2: low-risk—stable path versus Trajectory 3: problem gambling—increasing Trajectory 3: problem gambling—increasing
Trajectory 1: non-problematic—diminishing path versus Trajectory 1: non-problematic— path versus Trajectory 2: low-risk—stable Path
path diminishing path
AOR (95% CI)

Internet as main poker form 2.21 (1.27–3.85)** 6.91 (1.62–29.49)** 3.13 (0.74–13.21)
Number of games p­ layeda,b 1.24 (1.09–1.40)*** 1.59 (1.19–2.11)** 1.28 (0.97–1.70)†
Depressionc 1.04 (0.98–1.11) 1.16 (1.05–1.29)** 1.11 (1.01–1.22)*
Impulsivity 1.05 (1.02–1.08)*** 1.05 (0.98–1.12) 1.00 (0.93–1.07)

AOR Adjusted Odds Ratio, CI Confidence Interval

Wald’s test: †p < 0.10; *p < 0.05; **p < 0.01; ***p < 0.001
a
 Past 12 months
b
 Excluding poker
c
 Past week

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 Journal of Gambling Studies

While the majority of gamblers did not develop gambling problems or even decreased
their risk level, it was quite different for a small group of gamblers for whom the risk level
increased during this study. In fact, the group of gamblers from the third trajectory (4.6%)
already had gambling problems when they joined the study, problems which seemed to
become more severe. Severe gambling problems that remain steady or even worsen have
already been studied (Edgerton et al. 2015; el-Guebaly et al. 2015; Luce et al. 2016; Reith,
2015; Williams et al. 2015). Despite the small proportion of gamblers concerned by this
result, it emphasizes the importance of providing help to gamblers who have long-term
gambling problems, since no remission was observed in their cases.
While the cross-sectional studies reported several risk factors associated with gambling
problems such as gambling on the Internet (Kairouz et  al. 2012; Williams et  al. 2015;
Wood et  al. 2012), having erroneous beliefs (Abdollahnejad et  al. 2015; Källmén et  al.
2008; Sévigny and Ladouceur 2003), being impulsive (Gori et al. 2016), having substance-
abuse or mental-health problems (Momper et al. 2010; Quigley et al. 2015), these factors
seemed to play different roles for the poker players in the present study. For instance, play-
ing poker primarily on the Internet was the strongest predictor in the second and third tra-
jectory compared to the first. Moreover, the proportion of participants who played primar-
ily on the Internet was different from one trajectory to another, the proportion increasing
in the more at-risk trajectories. Indeed, 42.3%, 56.7% and 76.9% of the gamblers played
primarily on the Internet in the first (non-problematic), second (low risk) and third (prob-
lem gambling) trajectory respectively. As seen in other studies (Kairouz et al. 2012; Wil-
liams et al. 2015; Wood et al. 2012), the structural characteristics of Internet gambling and
the ability to play simultaneously at several poker tables seemed to be a risk factor in this
cohort of poker players. The association between Internet gambling and at-risk trajectories
emphasizes the importance of providing prevention on online poker sites (Gainsbury et al.
2014; Khazaal et al. 2013; Ladouceur et al. 2017) and the relevance of tools for responsible
gambling (Gainsbury et al. 2014; Wohl et al. 2013, 2017).
In the present study, the number of games played was also identified as a predictive
factor in the two most at-risk trajectories (2nd and 3rd trajectories) compared to the first
and this independently of playing mainly on the Internet. Previous studies of poker players
have also identified the number of gambling activities as contributing to gambling prob-
lems (Brosowski et al. 2012; Morvannou et al. 2017; Williams et al. 2015). Playing a larger
number of gambling activities is a risk factor that should be evaluated in future studies with
poker players.
Regarding mental health, a previous systematic review showed that problems gam-
blers experience high levels of other comorbid mental health disorders, including sub-
stance use, mood, anxiety, and personality disorders (Lorains et  al. 2011). Our study
showed that depression and impulsivity were significantly associated with some at-risk
trajectories, as observed by Williams et al. (2015), whereas at-risk alcohol or drug use
and anxiety did not remain in our final multivariable model. Some studies suggested that
mood disorders often precede gambling problems; conversely, others suggested that it is
a secondary symptom of increasing financial losses due to gambling activities (Lorains
et al. 2011). In addition to financial hardship, gambling can also cause conflicts at work
and with family, all of them increasing the risk of developing comorbid disorders (Par-
hami et al. 2014). It is also possible gamblers in the more at-risk trajectories took part in
gambling activities to overcome the stress, depression, and solitude related to their gam-
bling habits (Reith 2015). More studies are needed to determine the associations, causal
relationships, and reciprocity between mental health disorders and long-term gambling
problems. There is also some controversy regarding the influence of alcohol or drug

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Journal of Gambling Studies

use and erroneous belief on long-term gambling behaviors. Alcohol or drug use were
significant markers of at-risk trajectories in some studies (Edgerton et  al. 2015; Reith
2015; Williams et al. 2015) but not in another (el-Guebaly et al. 2015) as in our study.
These discordant results could be explained by methodological differences between the
studies, especially number and length of follow-ups and characteristics of the gamblers’
samples. With respect to illusion of control, cross-sectional studies reported also diver-
gent data on the association with gambling problems. Indeed, while one study identified
erroneous beliefs as a risk factor in poker players (Barrault and Varescon 2013b), other
studies have called this result into question, particularly due to the role of strategy in
poker (Bjerg 2010; McCormack and Griffiths 2012). In this study, illusion of control
was not predictive of gambling problems trajectories. This result highlights the diffi-
culty of documenting the role of what can be labeled “erroneous beliefs” particularly in
a game where there is some skill involved. The development of questionnaires “at-risk
beliefs” validated with poker players is necessary to understand in depth the influence
of this factor.
This study is not without its limitations. The use of a convenience sampling strategy
may have affected the representativeness of the sample. The education and the aver-
age income are higher than expected in the general population, but this is not surpris-
ing from poker players (Bjerg 2010; Hopley et  al. 2012). The mistrust of poker play-
ers towards researchers may prevented us from having access to the whole community
of players. Despite the substantial effort made to lessen the attrition rate due to study
design, it is possible that some gamblers, especially those whose gambling increased,
did not wish to continue in the study. Moreover, the sample size was also limited in
the third and most at-risk trajectory. Post hoc statistical analyses were performed and
299 participants were needed to detect an effect of the main variable “Playing poker
mainly on the Internet” between trajectories (effect size = 0.1798, statistical power = 0.8,
alpha error probability = 0.05). As our study was conducted among 304 participants and
allowed us to detect a quite weak effect, our study is sufficiently robust to assure reli-
ability of findings. Finally, the results are based on subjective data reported by partici-
pants to measure poker activities. Electronic devices such as computers or a diary to
report regular poker activities would improve the quality of the results.
Despite these limitations, this study makes a meaningful contribution to existing
gambling literature by highlighting the diversity of trajectories among poker players.
While the severity of the gambling problems decreased or remained stable for the large
majority of the gamblers, there was an increase for those who were in distress at the
beginning. These results indicate the importance of continuing to provide prevention for
low risk gamblers. Moreover, for pathological gamblers whose state worsened during
the study, it is important to consider strategies to reach out and help them. The charac-
teristics associated with this group, namely Internet gambling, gambling in several types
of activities, and mental health characteristics, point to different ways in which preven-
tion and dissemination of treatment information could be conducted. Finally, it would
be important to conduct longer studies to ensure that these trajectories continue in the
long term.

Acknowledgements  The authors would like to thank all participants that collaborated in this study and all
members of the research team.

Funding  This study was funded by Fonds de recherche du Québec - Société et Culture (FRQSC) (Grant no.
2012-JU-164313).

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 Journal of Gambling Studies

Compliance with Ethical Standards 

Conflict of interest  The authors declare that they have no conflict of interest.

Ethical Approval  All procedures performed in studies involving human participants were in accordance with
the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki dec-
laration and its later amendments or comparable ethical standards. This research received institutional ethical
boards approvals of the Lettres et sciences humaines at the Université de Sherbrooke (2012-17/Dufour/) and
the Université du Québec à Trois Rivières (CER-12-182-04.04.01).

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Journal of Gambling Studies

Affiliations

Magali Dufour1,4   · Adèle Morvannou2,4 · Natacha Brunelle3 · Sylvia Kairouz2 ·

Émélie Laverdière4 · Louise Nadeau5 · Djamal Berbiche4 · Élise Roy4,6
1
Département de psychologie, Université du Québec à Montréal (UQAM), C.P. 888, succursale
Centre‑ville, Montréal, QC H3C 3P8, Canada
2
Department of Sociology and Anthropology, Concordia University, 1455 De Maisonneuve West,
Montréal, QC H3G 1M8, Canada
3
Psychoeducation Department, Université du Québec à Trois-Rivières (UQTR), 3351 Boulevard
des Forges, C.P. 500, Trois‑Rivières, QC G9A 5H7, Canada
4
Faculty of Medicine and Health Sciences, Université de Sherbrooke, 150 Place Charles‑Le Moyne,
Bureau 200, Longueuil, QC J4K 0A8, Canada
5
Department of Psychology, Université de Montréal, 90, Avenue Vincent d’Indy, Montréal,
QC H2V 2S9, Canada
6
Institut National de Santé Publique du Québec, 190 Boul Crémazie E, Montréal, QC H2P 1E2,
Canada

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