Gambling addiction and its treatment within the NHS

the Board of Science of the British Medical Association, whose membership for 2006/07 was as follows: Professor Parveen Kumar CBEPresident, BMA Dr Michael Wilks Chair, BMA Representative Body Mr James N Johnson Chair, BMA Council DrDavid PickersgillTreasurer, BMA Sir Charles GeorgeChair, Board of Science Dr P B Maguire Deputy Chair, Board of Science Dr P H DangerZeld Dr G D Dilliway Dr G D Lewis Dr S Minkoff Dr O Moghraby Dr G Rae Dr D M Sinclair Dr A S Thomson Dr D M B Ward Dr D G Wrigley Dr C Spencer-Jones (by invitation) Dr S Chaudhry (Co-optee) Dr E F Coyle (Co-optee) Dr P Steadman (Co-optee) Dr S J Nelson (Deputy member) Approval for publication as a BMA policy report was recommended by BMA Board of Professional Activities on 1 December 2006. Declaration of interest There were no competing interests with any Board member involved in the research and writing of this report.<br><br> For further information about the editorial secretariat or Board members please contact the Science and Education Department which holds a record of all declarations of interest: info.science@bma.org.uk BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionalsiii About the contributing author Professor Mark GrifZths is a Chartered Psychologist and Director of the International Gaming Research Unit (IGRU) at Nottingham Trent University. The IGRU is the UK 9s largest gambling research unit and conducts research in the area of gaming, risk taking and interactive technologies. Professor GrifZths is Europe 9s only Professor of Gambling Studies and has researched and written widely on gambling and gambling addictions.<br><br> He has received seven national and international awards for his gambling research including the US John Rosecrance Research Prize for 8outstanding scholarly contributions to the Zeld of gambling research 9 (1994), the Spanish CELEJ Prize for best paper on gambling (1998), the Canadian International Excellence Award for 8the extraordinary contribution made to problem gambling over many years 9 (2003) and the North American Lifetime Achievement Award For Contributions To The Field Of Youth Gambling 8in recognition of his dedication, leadership, and pioneering contributions to the Zeld of youth gambling 9 (2006). Acknowledgements The association is very grateful for the help provided by the BMA committees and many outside experts and organisations. We would particularly like to thank Dr Gerda Reith, Senior Lecturer, Department of Sociology, Anthropology and Applied Social Sciences, University of Glasgow.<br><br> Abbreviations BGPSBritish Gambling Prevalence Survey DCMSDepartment for Culture, Media and Sport DHDepartment of Health DSMDiagnostic and Statistical Manual of Mental Disorders EGMElectronic Gaming Machine IGRIInternational Gaming Research Unit PGSIProblem Gambling Severity Index RIGTResponsibility in Gambling Trust SOGSSouth Oaks Gambling Screen BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals iv BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionalsv Foreword At the BMA 9s 2006 annual representative meeting a resolution on gambling addiction and its treatment in the NHS was referred to the Board of Science. In addressing this resolution, the Board of Science decided to undertake a review of what services are available in the United Kingdom (UK) for problem gamblers and who provides them, and establish what (if any) treatment and prevention services are available on the NHS for gambling addiction in order to raise awareness of the problem in the UK. The report is aimed at healthcare professionals, policy makers and service providers, and makes recommendations for tackling this growing problem in the UK.<br><br> The forthcoming implementation of the Gambling Act 2005 will have important implications for gambling in the UK, potentially facilitating an increase in problem gambling. It is therefore important for healthcare professionals, policy makers and service providers to be aware of these developments in order to respond appropriately to a likely increase in demand for gambling addiction treatment. Professor Sir Charles George Chair, Board of Science The Board of Science, a standing committee of the BMA, provides an interface between the medical profession, the government and the public.<br><br> The board produces numerous reports containing policies for national action by government and other organisations, with speciZc recommendations affecting the medical and allied professions. BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals vi BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionalsvii Contents Introduction .........................................................................................................1 Problem gambling ................................................................................................2 DeGnition of gambling.......................................................................................................... ..2 DeGnition of terms.............................................................................................................<br><br> .....3 Social context................................................................................................................. ........4 ProGling....................................................................................................................... ...........5 Youth gambling.................................................................................................................<br><br> .....7 Pathological features.......................................................................................................... .....9 Consequences and co-morbidities.........................................................................................10 The importance of structural and situational characteristics..................................................12 Support and treatment for problem gambling ........................................................14 Gambling addiction treatment and services..........................................................................14 Accessing treatment 3 referral paths.....................................................................................15 The gaming industryand gambling addiction services..........................................................16 Problem gambling services and the NHS...............................................................................16 Impact of the Gambling Act 2005 on problem gambling ...........................................18 Internet and remote gambling ..............................................................................19 Recommendations ..............................................................................................22 Glossary....................................................................................................................... .............<br><br> 24 Further information ............................................................................................25 Appendix 1: DSM-IV Diagnostic criteria for Pathological Gambling .............................27 Appendix 2: South Oaks Gambling Screen ..............................................................28 Appendix 3: Providers of treatment, support and advice for people with gambling addiction ......................................................................31 Appendix 4: The Gambling Act 2005 ......................................................................36 References .........................................................................................................39 BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals viii Introduction On 18 October 2004 a Gambling Bill was introduced into Parliament. Following consideration by the House of Commons and the House of Lords, it received Royal Assent on 7 April 2005, and became the Gambling Act 2005. The initial target for full implementation of the Act is 1 September 2007.<br><br> It has been recognised that the introduction of this new legislation may have important implications for public health through changing patterns of gambling and hence rates of problem gambling (GrifZths, 2004). It is important that healthcare professionals are aware of these developments in order that they may respond appropriately to a potential increase in demand for gambling addiction treatment. Gambling is a popular activity and recent national surveys into gambling participation (including the National Lottery), show that over 70 per cent of adults gamble annually (Sproston, Erens & Orford, 2000; Creigh-Tyte & Lepper, 2004).<br><br> Gambling also makes a signiZcant contribution to the economy: in the year ending 31 March 2004 gambling expenditure was estimated at £8.875bn, which corresponds to 0.8 per cent of the UK GDP (Ward, 2004). This expenditure was used to pay £1.3bn in gambling-related duties (approximately 0.3% of total government revenues), and around £1.3bn in good causes contributions. The gaming machine sector is the most proZtable branch of the industry (accounting for some 70% of government revenue) (Ward, 2004).<br><br> Although most people gamble occasionally for fun and pleasure, gambling brings with it inherent risks of personal and social harm. According to research commissioned by GamCare (a non-government organisation (NGO) that provides treatment, education and research on problem gambling) and conducted by an independent research company, the National Centre for Social Research, there are approximately 300,000 problem gamblers in the UK which equates to just under 1 per cent of the adult population (Sproston et al, 2000). Problem gambling can negatively affect signiZcant areas of a person 9s life, including their physical and mental health, employment, Znances and interpersonal relationships (eg family members, Znancial dependents) (GrifZths, 2004).<br><br> There are signiZcant co-morbidities with problem gambling, including depression, alcoholism, and obsessive-compulsive behaviours. These co-morbidities may exacerbate, or be exacerbated by, problem gambling. Availability of opportunities to gamble and the incidence of problem gambling within a community are known to be linked (GrifZths, 2003a; Abbott & Volberg, in press).<br><br> A review of the accessibility and availability of gambling addiction services, as well as raising awareness among general practitioners (GPs) and other healthcare workers of these services and other relevant treatments, is therefore essential as the target date for full implementation of the Gambling Act 2005 draws near. BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals1 Problem gambling DeHnition of gambling Gambling is a diverse concept that incorporates a range of activities undertaken in a variety of settings. It includes differing sets of behaviours and perceptions among participants and observers (Abbott & Volberg, 1999).<br><br> Predominantly, gambling has an economic meaning and usually refers to risking (or wagering) money or valuables on the outcome of a game, contest, or other event in the hope of winning additional money or material goods. The activity varies on several dimensions, including what is being wagered, how much is being wagered, the expected outcome, and the predictability of the event. For some things such as lotteries, most slot machines and bingo, the results are random and unpredictable.<br><br> For other things, such as sports betting and horse racing, there is some predictability to the outcome and the use of skills and knowledge (eg recent form, environmental factors) can give a person an advantage over other gamblers. Some of the UK 9s most common types of of[ine commercial forms of gambling are summarised in box 1. Box 1: A summary of the most common forms of ofIine commercial gambling in the UK Type of gamblingBrief description The National Lottery National lottery game where players pick six out of 49 numbers to be drawn bi-weekly for the chance to win a large prize.<br><br> Tickets can be bought from a wide variety of outlets including supermarkets, newsagents or petrol stations. Bingo Agame of chance where randomly selected numbers are drawn and players match those numbers to those appearing on pre-bought cards. The Zrst person to have a card where the drawn numbers form aspeciZed patternis the winner.Usually played in bingo halls but can be played in amusement arcades and other settings (eg church hall).<br><br> Cardgames Gambling while playing cardgames either privately (eg with friends) or in commercial settings (eg poker,bridge, blackjack)(eg land-based casino) in an attempt to win money. Sports betting Wagering of money for example on horse races, greyhound races or football matches. Usually in a betting shop in an attempt to win money.<br><br> Non-sports betting Wagering of money on a non-sporting event (such as who will be evicted from the 8Big Brother 9 house) usually done in a betting shop in an attempt to win money. Scratchcards Instant win games whereplayers typically try to match a number of winning symbols to win prizes. These can be bought in the same types of outlet as the National Lottery.<br><br> Roulette Game in which players try to predict where a spinning ball will land on a 36-numbered wheel. This game can be played with a real roulette wheel (eg in a casino) or on electronic gaming machines (eg in a betting shop). Gaming machines These are stand-alone electronic gaming machines that come in a variety of guises.<br><br> These include (eg fruit machines, Zxed many different types of 8fruit machine 9 (typically played in amusement arcades, family leisure odds betting terminals)centres, casinos, etc) and Zxed odds betting terminals (FOBTs) typically played in betting shops. Football pools Weekly game in which players try to predict which football games will end in a score draw for the chance of winning a big prize. Game is typically played via door-to-door agents.<br><br> Spread betting Relatively new form of gambling whereplayers try to predict the 8spread 9 of a particular sporting activity, such as the number of runs scored in a cricket match or the exact time of the Zrst goal in a football match, in an attempt to win money. Players use a spread betting agency (a type of specialised bookmaker). (Notes on box 1: [1] Most of these forms of gambling can now be done via other gambling channels including the internet, intera ctive television and/or mobile phone.<br><br> [2] There are other types of gambling such as dice (casino-based 8craps 9), keno (a fast draw lottery game) and video lot tery terminal machines. However, these are either unavailable or very rare in the UK. [3] Technically, activities such as speculation on the stock market or day trading are types of gambling but these are not typically viewed as commercial forms of gambling and they are not taxed in the same way.<br><br> BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals 2 As can be seen from box 1, gambling is commonly undertaken in a variety of environments including those dedicated primarily to gambling (eg betting shops, casinos, bingo halls, amusement arcades), those where gambling is peripheral to other activities (eg social clubs, pubs, sports venues), and those environments where gambling is just one of many things that can be done (eg supermarkets, post ofZces or petrol stations). In addition, most types of gambling can now be engaged in remotely via the internet, interactive television and/or mobile phone. This includes playing roulette or slot machines at an online casino, the buying of lottery tickets using a mobile phone or betting on a horse race using interactive television.<br><br> In these remote types of gambling, players use their credit cards, debit cards or other electronic forms of money to deposit funds in order to gamble (GrifZths, 2005a). Concerns surrounding remote gambling will be examined later in this report. DeHnition of terms In the UK, the term 8problem gambling 9 has been used by many researchers, bodies, and organisations, to describe gambling that compromises, disrupts or damages family, employment, personal or recreational pursuits (Budd Commission, 2001; Sproston et al, 2000; GrifZths, 2004; Responsibility in Gambling Trust).<br><br> The two most widely used screening instruments worldwide are the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) for pathological gambling (American Psychiatric Association, 1994), and the South Oaks Gambling Screen (SOGS) (Lesieur & Blume, 1987). Both screening instruments were used to measure problem gambling in the British Gambling Prevalence Survey (BGPS). Further, these two screening tools are the most widely used by UK researchers and other UK service providers in patient consultations (eg GamCare ).<br><br> The screens are based on instruments used for diagnostic purposes in clinical settings, and are designed for use in the general population (Sproston et al, 2000). Thereis some disagreement in the literature as to the terminology used, as well as the most appropriate screens to diagnose and measure the phenomenon. Researchers internationally are beginning to reach a consensus over a view of problem gambling that moves away from earlier, often heavily DSM-based clinical deZnitions.<br><br> For instance, early conceptions of 8pathological gambling 9 were of a discrete 8disease entity 9 comprising a chronic, progressive mental illness, which only complete abstinence could hope to manage. More recent thinking regards problem gambling as behaviour that exists on a continuum, with extreme, pathological presentation at one end, very minor problems at the other, and a range of more or less disruptive behaviours in between. Moreover, this behaviour is something that is mutable.<br><br> Research suggests it can change over time as individuals move in and out of problematic status and is often subject to natural remission (Hayer, Meyer & GrifZths, 2005). Put more simply, gamblers can often move back to non-problematic recreational playing after spells of even quite serious problems. This conception Zts in with an emphasis on more general public health, with a focus on the social, personal and physical 8harms 9 that gambling problems can create among various sectors of the population, rather than a more narrow focus on the psychological and/or psychiatric problems of a minority of 8pathological 9 individuals.<br><br> Such a focus tends also to widen the net to encompass a range of problematic behaviours that can affect much larger sections of the population. The screening tools that are currently used to diagnose the existence and severity of problem gambling re[ect this change of focus. There have been criticisms of both the DSM-IV and the SOGS.<br><br> In part, these criticisms stem from an acknowledgment that both screens were designed for use in clinical settings, and not among the general population, within which large numbers of individuals with varying degrees of problems reside. A range of alternative screening instruments have been developed, and these are increasingly being used internationally (Abbott, Volberg, Bellringer & Reith, 2004). One such screening tool is the Problem Gambling Severity Index (PGSI), BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals3 which was developed in Canada and has been used in the UK, the USA and Australia.<br><br> This screen will replace the SOGS in the upcoming BGPS. This survey will provide comprehensive data on the prevalence and distribution of problem gambling in this country. It will therefore be useful for practitioners to have some understanding of the types of screening tools it will use, as well as the different orientations that lie behind them.<br><br> A 8harm based 9 conception of problem gambling has implications for policy and treatment. Given that the most severe cases of pathological gambling are one of the most difZcult disorders to treat (Volberg, 1996), and given that, at various points in their lives, members of the general population may experience some degree of gambling-related harms, it becomes important to provide intervention strategies that can prevent this potential group developing more serious problems. To this end, public health education and awareness-raising initiatives come to the fore, and these are recognised internationally as the most cost-effective way of dealing with problem gambling in the long term (Shaffer, Hall & Vander Bilt, 1999; Abbott et al, 2004; National Gambling Impact Study Commission, 1999).<br><br> Such strategies have been successfully deployed in countries such as Australia, New Zealand and Canada. There is a multitude of terms used to refer to individuals who experience difZculties related to their gambling. These re[ect the differing aims and emphases among various stakeholders concerned with treating patients, studying the phenomenon, and in[uencing public policy in relation to gambling legislation.<br><br> Besides 8problem 9 gambling, terms include (but are not limited to) 8pathological 9, 8addictive 9, 8excessive 9, 8dependent 9, 8compulsive 9, 8impulsive 9, 8disordered 9, and 8at-risk 9 (GrifZths & Delfabbro, 2001; GrifZths, 2006). Terms are also employed to re[ect more precisely the differing severities of addiction. For example, 8moderate 9 can refer to a lesser level of problem, and 8serious problem gambling 9 to the more severe end of the spectrum.<br><br> Although thereis no absolute agreement, commonly 8problem gambling 9 is used as a general term to indicate all of the patterns of disruptive or damaging gambling behaviour. This report follows this precedent, employing the use of the term 8problem gambling 9 to refer to the broad spectrum of gambling-related problems. Problem gambling must be distinguished from social gambling and professional gambling.<br><br> Social gambling typically occurs with friends or colleagues and lasts for a limited period of time, with predetermined acceptable losses. There are also those who gamble alone in a non-problematic way without any social component. In professional gambling, risks are limited and discipline is central.<br><br> Some individuals can experience problems associated with their gambling, such as loss of control and short-term chasing behaviour (whereby the individual attempts to recoup their losses), that do not meet the full criteria for pathological gambling (American Psychiatric Association, 1994). Social context Research into gambling practices, the prevalence of problem gambling, and the socio-demographic variables associated with gambling and problem gambling, has not been considered part of mainstream health research agendas until quite recently. The BGPS (Sproston et al, 2000) was the Zrst nationally representative survey of its kind conducted in Britain.<br><br> The extent of gambling activity, as measured in the survey, revealed gambling to be a popular activity in Britain. In the year covered by the survey, gambling was engaged in by almost three-quarters of the population (72%), with the most popular gambling activity being the National Lottery Draw (ie Lotto). Two- thirds of the population bought a National Lottery ticket in the year covered by the survey (65%), while the next most popular gambling activity was the purchase of scratchcards (22%), followed by playing fruit machines (14%), horse race gambling (13%), football pools (9%) and bingo (7%).<br><br> For a large number of people (39% of those who purchased National Lottery tickets), the National BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals 4 Lottery Lotto game was the only gambling activity they participated in. The BGPS also found that men were more likely than women to gamble (76% of men and 68% of women gambled in the year covered by the survey), and tended to stake more money on gambling activities. The gambling activities men and women participated in were also varied.<br><br> Men were more likely to play football pools and fruit machines, bet on horse and dog races, and to make private bets with friends, while women were more likely to play bingo, and tended to participate in a lesser number of gambling activities overall (Sproston et al, 2000). There are also cultural variations in the prevalence and type of gambling activities. For instance, in other cultures there is greater participation in games like PaiGow 1 and dice, or betting on cockZghts.<br><br> The type of gambling activity engaged in also differs according to social class. Although gambling is popular among people of all social classes, people in social class I are more likely to go to casinos (5%) than play bingo (3%), while the opposite is true among people in social class V, who have a participation rate of 20 per cent in bingo, and only 1 per cent in casinos. Income is a factor in gambling participation, with people living in low-income households (under £10,400) being the least likely to gamble.<br><br> In general, participation in gambling activities tends to increase along with household income until around the level of £36,000, after which participation rates level off and decline slightly (Sproston et al, 2000). However, it must be noted that those in the lower classes spending the same amount on gambling as those in higher social classes will be spending a disproportionately higher amount of disposable income on gambling. Examination of prevalence and socio-demographic variables associated with problem gambling undertaken in the BGPS revealed that between 0.6 per cent and 0.8 per cent (275,000 to 370,000 people) of the population aged 16 and over were problem gamblers (Sproston et al, 2000).<br><br> In comparison to other countries (such as Australia, the USA, New Zealand and Spain which have problem gambling rates of 2.3, 1.1, 1.2 and 1.4% respectively), the number of problem gamblers in Britain is 3 based on the 2000 prevalence survey 3 relatively low (Sproston et al, 2000). ProHling The BGPS revealed that there were a number of socio-demographic factors statistically associated with problem gambling. These included being male, having a parent who was or who has been a problem gambler, being separated or divorced and having a low income.<br><br> Low income is one of the most consistent factors associated with problem gambling worldwide. This may be both a cause and an effect. Being on a low income may be a reason to gamble in the Zrst place (ie to try to win money).<br><br> Additionally, gambling may lead to low income as a result of consistent losing. In Britain, people in the lowest income categories are three times more likely to be classed a problem gambler than average (Sproston et al, 2000). Although many people on low incomes may not spend more on gambling, in absolute terms, than those on higher wages, they do spend a much greater proportion of their incomes than these groups.<br><br> The links with general 8disadvantage 9 should also be noted. Research shows that those who experience unemployment, poor health and housing, and low educational qualiZcations have signiZcantly higher rates of problem gambling than the general population (GrifZths & Delfabbro, 2001; GrifZths, 2006). BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals5 1PaiGow is a Chinese gambling game that is played with Chinese domino tiles.<br><br> http://www.paigow.com The American Psychiatric Association (1994) claims that approximately one third of problem gamblers are women. In the USA this loosely corroborates the results of the BGPS that showed that approximately 1.3 per cent of men and 0.5 per cent of women in Britain could be classiZed as problem gamblers (Sposton et al, 2000). Results of the BGPS also showed that the prevalence of problem gambling decreased with age.<br><br> For instance, the prevalence of problem gambling was 1.7 per cent among people aged between 16 and 24, but only 0.1 per cent among the oldest age group. Further, the prevalence was highest among men and women aged between 16 and 24 (2.3% and 1.1% respectively). The types of games played also impact on the development of gambling problems.<br><br> This has consequences for understanding the risk factors involved in the disorder, as well as the demographic proZle of those individuals who are most susceptible. For instance, certain features of games are strongly associated with problem gambling. These include games that have a high event frequency (ie that are fast and allow for continual staking), that involve an element of skill or perceived skill, and that create 8near misses 9 (ie the illusion of having almost won) (GrifZths, 1999).<br><br> Size of jackpot and stakes, probability of winning (or perceived probability of winning), and the possibility of using credit to play are also associated with higher levels of problematic play (Parke & GrifZths, 2006; in press). Games that meet these criteria include electronic gaming machines (EGMs) and casino table games. According to the BGPS, the most problematic type of gambling in Britain is associated with games in a casino (8.7% of people who gambled on this activity in the past year were problem gamblers according to the SOGS, and 5.6% according to the DSM-IV).<br><br> Groups most likely to experience problems with casino-based gambling were single, unemployed males, aged under 30. Other subgroups include slightly older single males, aged over 40, often retired, who are also more likely to be of Chinese ethnicity (Fisher,2000), and adolescent males who have problems particularly with fruit machines (GrifZths, 1995; 2002). The problem of adolescent gambling will be examined in more detail later in this report.<br><br> The BGPS also indicated that other types of gambling activities were engaged in by problem gamblers. These included betting on events with a bookmaker (SOGS 8.1%; DSM-IV 5.8%), and betting on dog races (SOGS 7.2%; DSM-IV 3.7%). Problem gamblers were less likely to participate in the National Lottery (1.2% of people who gambled on this activity in the past year were problem gamblers according to the SOGS; 0.7% according to the DSM-IV), or playing scratchcards (SOGS 1.7%; DSM-IV 1.5%).<br><br> In addition, problem gambling prevalence was associated with the number of gambling activities undertaken, with the prevalence of problem gambling tending to increase with the number of gambling activities participated in. As noted above, for a large number of people, the National Lottery was the only gambling activity they engaged in, and problem gambling prevalence among people who limit their gambling to activities such as the National Lottery and scratchcards was very low at 0.1 per cent. As might be expected, problem gambling was associated with higher expenditure on gambling activities.<br><br> Internationally, as in almost every other country worldwide, the greatest problems are, to a very considerable degree, associated with non-casino EGMs such as arcade 8fruit machines 9 (GrifZths, 1999; Parke & GrifZths, 2006). It has been found that as EGMs spread, they tend to displace almost every other type of gambling as well as the problems that are associated with them. EGMs are the fastest-growing sector of the gaming economy, currently accounting for some 70 per cent ofrevenue.<br><br> Australia 9s particularly high rates of problem gambling are almost entirely accounted for by its high density of these non-casino machines. It is likely that Britain 9s relatively lower rates of problems associated with EGMs is explained by its current legislative environment, which limits BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals 6 the numbers of machines in what are relatively regulated venues. This situation will change however, as the Gambling Act 2005 comes into force, allowing larger numbers of higher stakes machines into casinos, bingo halls and other gambling venues.<br><br> All of this indicates that attention should be focused on EGMs as a source of risk. The spread of EGMs also impacts on the demographic groups who experience problems with gambling. Until very recently, such problems were predominantly found in males, but as EGMs proliferate, women are increasingly presenting in greater numbers, so that in some countries (eg the USA), the numbers are almost equal.<br><br> This trend has been described as a 8feminisation 9 of problem gambling (Volberg, 2001). These types of games appear to be particularly attractive to recent migrants, who are also at high risk of developing gambling problems. 2 It has been suggested that Zrst generation migrants may not be sufZciently socially, culturally or even Znancially adapted to their new environment to protect them from the potential risks of excessive gambling (Productivity Commission, 1999; Shaffer, LaBrie & LaPlante, 2004).<br><br> Many are therefore vulnerable to the development of problems. This highlights the need for healthcare professionals to be awareof the speciZc groups 3 increasingly, women and new migrants, as well as young males and adolescents 3 who may present with gambling problems which may or may not be masked by other symptoms. Variations in gambling preferences are thought to result from both differences in accessibility and motivation.<br><br> Older people tend to choose activities that minimise the need for complex decision- making or concentration (eg bingo, slot machines), whereas gender differences have been attributed to a number of factors, including variations in sex-role socialisation, cultural differences and theories of motivation (GrifZths, 2006). Variations in motivation are also frequently observed among people who participate in the same gambling activity. For example, slot machine players may gamble to win money,for enjoyment and excitement, to socialise and to escape negative feelings (GrifZths, 1995).<br><br> Some people gamble for one reason only, whereas others gamble for a variety of reasons. A further complexity is that people 9s motivations for gambling have a strong temporal dimension; that is, they do not remain stable over time. As people progress from social to regular and Znally to excessive gambling, there are often signiZcant changes in their reasons for gambling.<br><br> Whereas a person might have initially gambled to obtain enjoyment, excitement and socialisation, the progression to problem gambling is almost always accompanied by an increased preoccupation with winning money and chasing losses. Youth gambling Adolescent gambling is a cause for concern in the UK and is related to other delinquent behaviours. For instance, in one study of over 4,500 adolescents, gambling was highly correlated with other potentially addictive activities such as illicit drug taking and alcohol abuse (GrifZths & Sutherland, 1998).<br><br> Another study by Yeoman and GrifZths (1996) demonstrated that around 4 per cent of all juvenile crime in one UK city was slot machine-related, based on over 1,850 arrests in a one-year period. It has also been noted that adolescents may be more susceptible to problem gambling than adults. For instance, in the UK, a number of studies have consistently highlighted a Zgure of up to 5 to 6 per cent of pathological gamblers among adolescent fruit machine gamblers (see GrifZths, [2002; 2003b] for an overview of these studies).<br><br> This Zgure is at least two to three times higher than that identiZed in adult populations. On this evidence, young people are clearly BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals7 2Research as to whether this applies to all migrant groups is not available. Most of this Zeld has been dominated by studies of Hispanic migration in the USA and studies of indigenous groups in Australia and New Zealand, but there have not yet been cross-cultural comparisons.<br><br> more vulnerable to the negative consequences of gambling than adults. Atypical Znding of many adolescent gambling studies has been that problem gambling appears to be aprimarily male phenomenon. It also appears that adults may to some extent be fostering adolescent gambling.<br><br> For example, a strong correlation has been found between adolescent gambling and parental gambling (Wood & GrifZths, 1998; 2004). This is particularly worrying because a number of studies have shown that individuals who gamble as adolescents, are then more likely to become problem gamblers as adults (GrifZths, 2003b). Similarly, many studies have indicated a strong link between adult problem gamblers and later problem gambling among their children (GrifZths, 2003b).<br><br> Other factors that have been linked with adolescent problem gambling include working class youth culture, delinquency, alcohol and substance abuse, poor school performance, theft and truancy (GrifZths, 1995; Yeoman & GrifZths, 1996; GrifZths & Sutherland, 1998). The main form of problem gambling among adolescents has been the playing of fruit machines. There is little doubt that fruit machines are potentially 8addictive 9 and there is now a large body of research worldwide supporting this.<br><br> Most research on fruit machine gambling in youth has been undertaken in the UK where they are legally available to children of any age. The most recent wave of the UK tracking study carried out by MORI and the International Gaming Research Unit (IGRU) (2006) found that fruit machines were the most popular form of adolescent gambling with 54 per cent of their sample of 8,017 adolescent participants. The MORI/IGRUsurvey also found that: " 17 per cent of adolescents are regular fruit machine players (playing at least once a week) " 3.5 per cent of adolescents are probable pathological gamblers and/or have severe gambling- related difZculties.<br><br> All studies have reported that boys play on fruit machines more than girls and that as fruit machine playing becomes moreregular it is more likely to be a predominantly male activity. Research has also indicated that very few female adolescents have gambling problems on fruit machines. Research suggests that irregular ( 8social 9) gamblers play for different reasons than the excessive ( 8pathological 9) gamblers.<br><br> Social gamblers usually play for fun and entertainment (as a form of play), because their friends or parents do (ie it is a social activity), for the possibility of winning money, because it provides a challenge, because of ease of availability and there is little else to do, and/or for excitement (the 8buzz 9). Pathological gamblers appear to play for other reasons such as mood modiZcation and as a means of escape. As already highlighted, young males seem to be particularly susceptible to fruit machine addiction with a small but signiZcant minority of adolescents in the UK experiencing problems with their fruit machine playing at any one time.<br><br> Like other potentially addictive behaviours, fruit machine addiction causes the individual to engage in negative behaviours. This includes truanting in order to play the machines, stealing to fund machine playing, getting into trouble with teachers and/or parents over their machine playing, borrowing or the using of lunch money to play the machines, poor schoolwork, and in some cases aggressive behaviour(GrifZths, 2003b). These behaviours are not much different from those experienced by other types of adolescent problem gambling.<br><br> In addition, fruit machine addicts also display bona Zde signs of addiction including withdrawal effects, tolerance, mood modiZcation, con[ict and relapse. BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals 8 It is clear that for some adolescents, gambling can cause many negative detrimental effects in their life. Education can be severely affected and they may acquire a criminal record as most problem gamblers have to resort to illegal behaviour to feed their addiction.<br><br> Gambling is an adult activity and the government should consider legislation that restricts gambling to adults only. Recommendations " All adolescent gambling should be taken as seriously as adult problem gambling. " There should be a review of slot machine gambling to assess whether it should be restricted to those over 18 years of age.<br><br> " Education and prevention programmes should be targeted at children and adolescents along with other potentially addictive and harmful behaviours (eg smoking, drinking, and drug taking). Pathological features Though many people engage in gambling as a form of recreation and enjoyment, or even as a means to gain an income, for some, gambling is associated with difZculties of varying severity and duration. Some regular gamblers persist in gambling even after repeated losses and develop signiZcant, debilitating problems that typically result in harm to others close to them and in the wider community (Abbott & Volberg, 1999).<br><br> In 1980, pathological gambling was recognised as a mental disorder in the DSM-III under the section 8Disorders of Impulse Control 9 along with other illnesses such as kleptomania and pyromania (American Psychiatric Association, 1980). Adopting a medical model of pathological gambling in this way displaced the old image that the gambler was a sinner or a criminal. In diagnosing the pathological gambler,the DSM-III stated that the individual was chronically and progressively unable to resist impulses to gamble and that gambling compromised, disrupted or damaged family, personal, and vocational pursuits.<br><br> The behaviour increased under times of stress and associated features included lying to obtain money, committing crimes (eg forgery, embezzlement or fraud), and concealment from others of the extent of the individual 9s gambling activities. In addition, the DSM-III stated that to be a pathological gambler, the gambling must not be due to antisocial personality disorder. These criteria were criticised for (i) a middle class bias, ie the criminal offences like embezzlement and income tax evasion were 8middle class 9 offences, (ii) lack of recognition that many compulsive gamblers are self-employed and (iii) exclusion of individuals with antisocial personality disorder (Lesieur, 1988).<br><br> Lesieur recommended the same custom be followed for pathological gamblers as for substance abusers and alcoholics in the past (ie allow for simultaneous diagnosis with no exclusions). The new criteria (DSM-III-R, American Psychiatric Association, 1987) were subsequently changed to take on board the criticisms and modelled extensively on substance abuse disorders due to the growing acceptance of gambling as a bona Zde addictive behaviour. In 1989, however, Rosenthal conducted an analysis of the use of the DSM-III-Rcriteria by treatment professionals.<br><br> It was reported that there was some dissatisfaction with the new criteria and that there was some preference for a compromise between the DSM-III and the DSM-III-R. As a consequence, the criteria were changed for DSM-IV. The updated DSM-IV consists of 10 diagnostic criteria (see appendix 1).<br><br> A 8problem gambler 9 is diagnosed when three or more of criteria A1-A10 are met, and a score of Zve or more indicates a 8probable pathological gambler. 9 The diagnosis is not made if the gambling behaviour is better BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals9 accounted for by a manic episode (criterion B) (American Psychiatric Association, 1994). Problems with gambling may also occur in individuals with antisocial personality disorder and it is possible for an individual to be diagnosed with both pathological gambling and manic episode gambling behaviour if criteria for both disorders are met (American Psychiatric Association, 1994). According to the American Psychiatric Association (1994) DSM-IV: 8Pathological gambling typically begins in early adolescence in males and later in life in females.<br><br> Although a few individuals are chooked d with their very Zrst bet, for most the course is more insidious. There may be years of social gambling followed by an abrupt onset that may be precipitated by greater exposure to gambling or by a stressor. The gambling pattern may be regular or episodic, and the course of the disorder is typically chronic.<br><br> There is generally a progression in the frequency of gambling, the amount wagered, and the preoccupation with gambling and obtaining money with which to gamble. The urge to gamble and gambling activity generally increase during periods of stress or depression. 9(p617). SOGS is based on the DSM-III criteria for pathological gambling and is at present the most widely used screening instrument for problem gambling internationally.<br><br> It consists of 20 questions on gambling behaviour from which a total score (ranging from 0 to 20) of positive responses is calculated. A score of three to four indicates a 8problem gambler 9 and Zve or more indicates a 8probable pathological gambler 9 (see appendix 2). Consequences and co-morbidities Problem gambling is often co-morbid with other behavioural and psychological disorders, which can exacerbate, or be exacerbated by,problem gambling.<br><br> Some of the psychological difZculties a problem gambler may experience include anxiety, depression, guilt, suicidal ideation and actual suicide attempts (Daghestani et al, 1996; GrifZths, 2004). Problem gamblers may also suffer irrational distortions in their thinking (eg denial, superstitions, overconZdence, or a sense of power or control) (GrifZths, 1994a). Increased rates of attention-deZcit hyperactivity disorder (ADHD), substance abuse or dependence, antisocial, narcissistic, and borderline personality disorders have also been reported in pathological gamblers (American Psychiatric Association, 1994; GrifZths, 1994b).<br><br> There is also some evidence that co-morbidities may differ among demographic subgroups and gambling types. For instance, young male slot machine gamblers are more likely to abuse solvents (GrifZths, 1994c). There is frequently a link with alcohol or drugs as a way of coping with anxiety or depression caused by gambling problems, and, conversely, alcohol may trigger the desire to gamble (GrifZths, Parke & Wood, 2002).<br><br> According to the DSM-IV, pathological gamblers tend to be highly competitive, energetic, restless, easily bored, and believe money is the cause of, and solution to, all their problems (see also Parke, GrifZths & Irwing, 2004). According to the American Psychiatric Association, pathological gamblers may also be overly concerned with the approval of others and may be extravagantly generous. Further, when not gambling, they may be workaholics or 8binge 9 workers who wait until they are up against deadlines before really working hard.<br><br> Pathological gamblers may also be prone to stress-related physical illnesses including insomnia, hypertension, heart disease, stomach problems (eg peptic ulcer disease) and migraine (Daghestani et al, 1996; Abbot & Volberg, 2000; GrifZths, Scarfe & Bellringer, 2001; GrifZths, 2004). Like other addictive behaviours, while engaged in gambling, the body produces increased levels of endorphins (the body 9s own morphine- like substance), and other 8feel good 9 chemicals like noradrenaline and serotonin (GrifZths, 2006). Many of these negative physical effects may stem from the body 9s own neuro-adaptation processes.<br><br> BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals 10 Health-related problems due to problem gambling can also result from withdrawal effects. Rosenthal and Lesieur (1992) found that at least 65 per cent of problem gamblers reported at least one physical side-effect during withdrawal including insomnia, headaches, upset stomach, loss of appetite, physical weakness, heart racing, muscle aches, breathing difZculty and/or chills. Their results were also compared to the withdrawal effects from a substance-dependent control group.<br><br> They concluded that problem gamblers experienced more physical withdrawal effects when attempting to stop than the substance-dependent group. Interpersonal problems suffered by problem gamblers include con[ict with family, friends and colleagues, and breakdown of relationships, often culminating in separation or divorce (GrifZths, 2004; 2006). The children of problem gamblers also suffer a range of problems, and tend to do less well at school (Jacobs, Marston, Singer et al, 1989; Lesieur & Rothschild, 1989).<br><br> School- and work-related problems include poor work performance, abuse of leave time and job loss (GrifZths, 2002). Financial consequences include reliance on family and friends, substantial debt, unpaid creditors and bankruptcy (GrifZths, 2006). Finally, there may be legal problems as a result of criminal behaviour undertaken to obtain money to gamble or pay gambling debts (GrifZths, 2005b; 2006).<br><br> The families of problem gamblers can also experience substantial physical and psychological difZculties (GrifZths & Delfabbo, 2001; GrifZths, 2006). High levels of substance misuse and some other mental health disorders among problem gamblers highlight the importance of screening for gambling problems among participants in alcohol and drug treatment facilities, mental health centres and outpatient clinics, as well as probation services and prisons. Unfortunately, beyond programmes that provide specialised problem gambling services, few counselling professionals screen for gambling problems among their clients.<br><br> Even when a gambling problem is identiZed, non-specialist professionals are often uncertain about the appropriate referrals to make or what treatments to recommend (Abbott et al, 2004). There is clearly a need for education and training in the diagnosis, appropriate referral and effective treatment of gambling problems. Given the co-morbidity of alcoholism with gambling addiction, the recent introduction of 24-hour licensing may have an impact on the prevalence of gambling addiction.<br><br> It is important that post- evaluative studies undertaken by the Department for Culture, Media and Sport (DCMS) to monitor the impact of the introduction of 24-hour licensing consider any potential impact this will have on levels of gambling addiction. Recommendations " Brief screening for gambling problems among participants in alcohol and drug treatment facilities, mental health centres and outpatient clinics, as well as probation services and prisons should be routine. " The need for education and training in the diagnosis, appropriate referral and effective treatment of gambling problems must be addressed within GP training.<br><br> " Research into the effect 24-hour licensing laws have had on gambling problems as part of its post-evaluations and measurement of future effects must be conducted. BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals11 The importance of structural and situational characteristics Gambling is a multifaceted rather than unitary phenomenon. Consequently, many factors may come into play in various ways and at different levels of analysis (eg biological, social or psychological).<br><br> Theories may be complementary rather than mutually exclusive, which suggests that limitations of individual theories might be overcome through the combination of ideas from different perspectives. This has often been discussed in terms of recommendations for an 8eclectic 9 approach to gamblingor a distinction between proximal and distal in[uences upon gambling (Walker, 1992). For the most part however, such discussions have been descriptive rather than analytical and, so far, few attempts have been made to explain why an adherence to a singular perspective is untenable.<br><br> Put very simply, there are many different factors involved in how and why people develop gambling problems. Central to the latest thinking is that no single level of analysis is considered sufZcient to explain either the aetiology or maintenance of gambling behaviour. Moreover, this view asserts that all research is context-bound and should be analysed from a combined, or biopsychosocial, perspective (GrifZths, 2005c).<br><br> Variations in the motivations and characteristics of gamblers and in gambling activities themselves mean that Zndings obtained in one context areunlikely to be relevant or valid in another. Another factor central to understanding gambling behaviour is the structure of gambling activities. GrifZths (1993; 1995; 1999) has shown that gambling activities vary considerably in their structural characteristics, such as the probability of winning, the amount of gambler involvement, the use of the near wins, the amount of skill that can be applied, the length of the interval between stake and outcome, and the magnitude of potential winnings.<br><br> Structural variations are also observed within certain classes of activities such as slot machines, where differences in reinforcement frequency, colours, sound effects and machines 9 features can in[uence the proZtability and attractiveness of machines signiZcantly (GrifZths & Parke, 2003; Parke & GrifZths, 2006, in press). Each of these structural features may (and almost certainly does) have implications for gamblers 9 motivations and the potential 8addictiveness 9 of gambling activities. For example, skilful activities that offer players the opportunity to use complex systems, study the odds and apply skill and concentration, appeal to many gamblers because their actions can in[uence the outcomes.<br><br> Such characteristics attract people who enjoy a challenge when gambling. They may also contribute to excessive gambling if people overestimate the effectiveness of their gambling systems and strategies. Chantal and Vallerand (1996) have argued that people who gamble on these activities (eg racing punters) tend to be more intrinsically motivated than lottery gamblers in that they gamble for self-determination (ie to display their competence and to improve their performance).<br><br> People who gamble on chance activities, such as lotteries, usually do so for external reasons (ie to win money or escape from problems). This Znding was conZrmed by Loughnan, Pierce and Sagris (1997) in their clinical survey of problem gamblers. Here, racing punters emphasised the importance of skill and control considerably more than slot machine players.<br><br> Although many slot machine players also overestimate the amount of skill involved in their gambling, other motivational factors (such as the desire to escape worries or to relax) tend to predominate. Thus, excessive gambling on slot machines may be more likely to result from people becoming conditioned to the tranquilising effect brought about by playing rather than just the pursuit of money. Another vital structural characteristic of gambling is the continuity of the activity; namely, the length of the interval between stake and outcome.<br><br> In nearly all studies, it has been found that continuous activities (eg racing, slot machines, casino games) with a more rapid play-rate are more likely to be associated with gambling problems (GrifZths, 1999). The ability to make repeated BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals 12 stakes in short time intervals increases the amount of money that can be lost and also increases the likelihood that gamblers will be unable to control spending. Such problems are rarely observed in non-continuous activities, such as weekly or bi-weekly lotteries, in which gambling is undertaken less frequently and where outcomes are often unknown for days.<br><br> Consequently, it is important to recognise that the overall social and economic impact of expansion of the gambling industry will be considerably greater if the expanded activities are continuous rather than non-continuous. Other factors central to understanding gambling behaviour are the situational characteristics of gambling activities. These are the factors that often facilitate and encourage people to gamble in the Zrst place (GrifZths & Parke, 2003).<br><br> Situational characteristics are primarily features of the environment (eg accessibility factors such as location of the gambling venue, the number of venues in a speciZed area and possible membership requirements) but can also include internal features of the venue itself (décor, heating, lighting, colour, background music, [oor layout, refreshment facilities) or facilitating factors that may in[uence gambling in the Zrst place (eg advertising, free travel and/or accommodation to the gambling venue, free bets or gambles on particular games) or in[uence continued gambling (eg the placing of a cash dispenser on the casino [oor, free food and/or alcoholic drinks while gambling) (GrifZths & Parke, 2003; Abbott & Volberg, in press). These variables may be important in both the initial decision to gamble and the maintenance of the behaviour. Although many of these situational characteristics are thought to in[uence vulnerable gamblers, there has been very little empirical research into these factors and more research is needed before any deZnitive conclusions can be made about the direct or indirect in[uence on gambling behaviour and whether vulnerable individuals are any more likely to be in[uenced by these particular types of marketing ploys.<br><br> The introduction of super-casinos into the UK will almost certainly see an increase in these types of situational marketing strategies and should also provide an opportunity to research and monitor the potential psychosocial impact. BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals13 Support and treatment for problem gambling 8The majority of health and related professionals who have contact with problem gamblers are probably unaware that they do. Internationally, general population surveys indicate that the great majority of people identiZed as having problems with gambling do not report them to, orreceive assistance from, professionals of any kind. 9 (Abbott et al, 2004, p11) Gambling addiction treatment and services The intervention options for the treatment of problem gambling include, 3 but are not limited to: " counselling " psychotherapy " cognitive-behavioural therapy (CBT) " advisory services " residential care " pharmacotherapy " combinations of these (ie multi-modal treatment).<br><br> There is a very recent move towards surZng the internet as a route for guidance, counselling and treatment (GriifZths & Cooper, 2003; GrifZths, 2005d). Treatment and support is provided from a range of different people (with and without formal medical qualiZcations), including specialist addiction nurses, counsellors, medics, psychologists, and psychiatrists. There are also websites and helplines to access information (eg GamCare )or discuss gambling problems anonymously (eg GamAid ), and local support groups where problem gamblers can meet other people with similar experiences (eg Gamblers Anonymous ).<br><br> Support is also available for friends and family members of problem gamblers (eg Gam Anon ). Many private and charitable organisations throughout the UK provide support and advice for people with gambling problems. Some focus exclusively on the help, counselling and treatment of gambling addiction (eg Gamblers Anonymous , GamCare, Gordon House Association ), while others also work to address common addictive behaviours such as alcohol and drug abuse (eg Aquarius, Addiction Recovery Foundation, Connexions Direct, Priory ).<br><br> The method and style of treatment varies between providers and can range from comprehensive holistic approaches to the treatment of gambling addiction (eg encouraging Ztness, nutrition, alternative therapies and religious counselling), to an abstinence-based approach. Many providers also encourage patients (and sometimes friends and families) to join support groups (eg Gamblers Anonymous and Gam Anon ), while others offer conZdential one-to-one counselling and advice (eg Connexions ). Most are non- proZt making charities to which patients can self-refer and receive free treatment.<br><br> Independent providers that offer residential treatment to gambling addicts are more likely to charge for their services. Some provide both inpatient treatment and day-patient services (eg PROMIS ),and a decision as to the suitability of a particular intervention is made upon admission. For a list of private and charitable organisations that provide support and advice see appendix 3.<br><br> BMA Board of Science Gambling addiction and its treatment within the NHS: A guide for healthcare professionals 14 3GrifZths, 1996; GrifZths & MacDonald, 1999; GrifZths & Delfabbro, 2001; GrifZths, Bellringer, Farrell-Roberts & Freestone, 2001; Hayer et al, 2005. Due to the lack of relevant evaluative research, the efZcacy of various forms of treatment intervention is almost impossible to address. Much of the documentation collected by treatment agencies is incomplete or collected in ways that make comparisons and assessments of efZcacy difZcult.<br><br> As Abbott et al (2004) have noted, with such a weak knowledge base, little is known about which forms of treatment for problem gambling in the UK are most effective, how they might be improved or who might beneZt from them. However, their review did note that individuals who seek help for gambling problems tend to be overwhelmingly male, aged between 18 to 45 years, and whose problems are primarily with on- and off-course betting, and slot machine use. Recommendation " Research into the efZcacy of various approaches to the treatment of gambling addiction needs to be undertaken and should be funded by the Responsibility in Gambling Trust (RIGT).<br><br> Accessing treatment 3 referral paths People suffering from problem gambling can access free or self-funded treatment via a number of routes. Self-referrals :Problem gamblers can self-refer by contacting one of the many available community addiction centres and clinics where they can have an individual consultation before commencing a treatment programme. Some providers will allow individuals to drop in without an appointment.<br><br> See appendix 3 for a list of organisations that can be contacted directly for help and advice. GP referrals :Some GPs have undergone additional training in addiction management and run special clinics within their own surgery. When this is the case, a GP may not necessarily refer someone to another centre.<br><br> Many GPs, however, will refer the person to the local addiction specialist for an assessment and a treatment plan. These units have specialist addiction management psychiatrists and nurses, counsellors, and social workers working with them. Often treatment is provided on a 8shared-care 9 basis.<br><br> This may involve the GP providing certain parts of treatment, for example, appropriate prescriptions and treatment for addiction-related health problems, while the specialist addiction team provides ongoing monitoring and counselling. Where possible, a person is given the choice of where he or she is treated. Some prefer to be looked after in the familiar surroundings of their general practice, and even if the GP is not able to provide the treatment, arrangements can often be made for the person to be seen by the community specialist addiction nurse or counsellor within the general practice.<br><br> Other people however, prefer to be looked after at aspecialist addiction unit because of the anonymity this allows and the fact that everyone is there for the same reason (B

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