Introduction

Problem gambling, also referred to as gambling disorder, is a significant public health concern with profound and far-reaching consequences. Characterized by persistent and recurrent problematic gambling behavior, it disrupts personal, family, and social functioning, often leading to severe emotional, financial, and societal repercussions (American Psychiatric Association, 2013) ^[1] . While direct financial harms such as monetary losses are frequently discussed, the broader spectrum of secondary and tertiary harms warrants equal attention. These include family breakdowns, debts and financial ruin, social alienation, associated mental health issues, and their potential to create cascading negative effects that amplify the initial harm (Langham et al., 2016) ^[2].

Understanding these interconnected harms is essential for developing comprehensive strategies to mitigate the damage caused by problem gambling. Central to this effort is the concept of playing informed—equipping individuals with the knowledge and tools to gamble responsibly. Playing informed minimizes not only the immediate harms such as financial losses but also the secondary and tertiary harms by fostering awareness of the risks, encouraging healthy gambling practices, and breaking the chain of adverse outcomes. Evidence suggests that informed gambling behaviors, such as setting limits and recognizing risky patterns, significantly reduce harm and interrupt the potential for cascading consequences (Gainsbury et al., 2015 ^[3]; Wohl et al., 2017 ^[4]). The current review synthesizes current research on these cascading harms in relation to the critical role of informed gambling in the reduction of these harms, while pointing out interdisciplinary connections that might contribute to this research for crystallizing an adequate conceptual and theoretical framework.

Financial harms and their ripple effects

Financial harm is the most immediate and apparent consequence of problem gambling. Gambling losses often lead to severe economic instability. The study by Langham et al. (2016) ^[2] identified financial strain as a primary harm that frequently catalyzes additional harms, such as housing insecurity and diminished access to essential resources like food and healthcare.

Debt accumulation, in particular, has been shown to escalate stress levels, contributing to mental health issues such as anxiety and depression (Dowling et al., 2016 ^[5]; Hakansson & Widinghoff, 2020 ^[6]; Swanton & Gainsbury, 2020 ^[7]). Research also indicates that individuals experiencing financial harm from gambling are at increased risk of engaging in illegal activities, such as theft or fraud, to fund their gambling (Blaszczynski & Nower, 2002 ^[8]).

Most of researchers have talked about debts as a primary harm of problem gambling, but we would suggest qualifying it as secondary harm, because is causally subsequent to big financial loss and implies the action of borrowing money. A theoretical argument related to the topic of our review is that the role of playing informed in minimizing the harms produced by debts can be investigated in more depth if making the distinction between the gambler’s risk of losing their money by gambling and their risk of not being able to pay their debts.

Family and relationship strains

Problem gambling places a significant burden on family members, often leading to marital conflicts, separation, or divorce. Research by Kalischuk et al. (2006) ^[9] highlights the emotional and psychological toll on family members, who frequently experience feelings of betrayal, financial stress, and social isolation. Partners of problem gamblers often report a decline in their mental health, including symptoms of anxiety and depression (Dowling et al., 2016 ^[5]).

Children of problem gamblers are particularly vulnerable, with studies indicating higher risks of emotional neglect, academic challenges, and developing behavioral issues (Dowling et al., 2018 ^[10]). In addition, research by Jacobs et al. (2000) ^[11] emphasizes the intergenerational transmission of gambling behaviors, suggesting that children exposed to problematic gambling environments are more likely to develop gambling issues themselves.

The family harms have the highest potential to occur in cascade. Therefore a topic deserving more attention is that of the gambler’s family getting involved in the awareness of the problematic gambler, by delivering them the information necessary for a responsible play, if the gambler cannot do that by themselves or has any difficulty in assimilating that information.

Social and community-level harms

Social harms stemming from problem gambling extend beyond the individual and family to the broader community. Individuals with gambling problems often experience stigma and social exclusion, which can erode their support networks. This isolation exacerbates the difficulty of seeking help, perpetuating the cycle of harm (Hing et al., 2016 ^[12]; Reith & Dobbie, 2012 ^[13]).

At the community level, problem gambling contributes to increased demand for social services, law enforcement, and healthcare, creating a financial burden on society. Abbott et al. (2018 ^[14]) noted that communities with higher rates of gambling disorders often experience elevated crime rates and diminished social cohesion. Additionally, gambling-related harms can strain public health resources, diverting attention from other pressing societal issues.

Cascading and interconnected harms

The harms associated with problem gambling are rarely isolated; they often interact in complex ways, creating a cascade of adverse outcomes. For instance, financial stress can exacerbate mental health issues and negative emotional states, which in turn strain relationships and social connections. The financial loss may cause borrowing money and implicitly debts, which reinforce the financial stress with its associated consequences. This interconnectedness highlights the need for a holistic approach to prevention and intervention.

Dowling et al. (2016 ^[5]) proposed a conceptual framework that categorizes gambling-related harms into three levels: personal, interpersonal, and societal. Understanding these levels can help policymakers and practitioners design targeted strategies to address the root causes and mitigate the cascading effects of problem gambling. Moreover, Browne et al. (2016 ^[15]) emphasized the importance of quantifying and mapping these harms to better understand their breadth and interconnections.

Unmitigated gambling-related harms can lead to further negative outcomes, such as chronic mental health conditions, substance abuse, and even suicidal ideation. The compounded nature of these harms underscores the urgency of early intervention. For example, Kessler et al. (2008 ^[16]) found a strong correlation between gambling disorders and comorbid psychiatric conditions, with individuals often entering a vicious cycle of gambling to cope with mental health challenges, thereby exacerbating their situation.

The role of informed gambling in harm minimization

A crucial strategy for minimizing the harms of gambling is promoting informed gambling practices. Playing informed involves understanding the risks, setting limits, and being aware of the odds and potential consequences of gambling activities. This proactive approach significantly reduces the likelihood of cascading harms by encouraging responsible behaviors that address the root causes of excessive gambling (Gainsbury et al., 2015 ^[3]).

Educational initiatives play a central role in fostering informed gambling. Programs aimed at teaching individuals about the mechanics of gambling, the risks of addiction, and effective harm-minimization strategies have shown promise in reducing harm (Hing et al., 2016 ^[12]). For example, public awareness campaigns that emphasize the randomness of gambling outcomes and dispel myths about "winning strategies" help to correct misconceptions that fuel problematic behaviors (Williams et al., 2012 ^[17]).

Moreover, digital tools and resources, such as gambling calculators and self-monitoring apps, empower individuals to make informed decisions. A study by Wohl et al. (2017 ^[4]) found that individuals who used such tools reported better control over their gambling behaviors and experienced fewer harms. Importantly, these tools help disrupt the cascading effects by addressing issues early, before they escalate into more significant problems.

Promoting informed gambling also extends to creating environments that support responsible behaviors. For example, integrating harm-minimization features into gambling platforms, such as mandatory break times and transparent information about odds, has been shown to help individuals manage their gambling more effectively (Auer & Griffiths, 2013 ^[18]). Policy measures, such as mandatory spending limits and self-exclusion programs, further enhance the protective environment for gamblers (Harris & Griffiths, 2017 ^[19]).

A crucial component of the informed play is knowing in advance how the gambling games actually work and what would be the objective expectations in regard to their outcomes and wins. This pertains to the inner design of the games and implicitly to its mathematical dimension. Research on harms have not given sufficient attention to this dimension (Bărboianu, 2013 ^[20]), which is essential for making the distinction between playing informed as acquiring the necessary information and playing informed as acquiring and understanding that information, submitting to the more general distinction between information and knowledge. In this framework, the mathematical dimension of games and gambling is responsible for understanding the odds and what the objective expectations one should have from gambling are. Most of gambling cognitive distortions (misconceptions, fallacies, and irrational beliefs) are related to the mathematical dimension of gambling and stem from a poor understanding of it (Bărboianu, 2022 ^[21]).

Exploring in more depth the mathematical dimension of gambling relative to gambling harms may prove fruitful in the respect that an informed play focused on this dimension may prevent many of the immediate harms and reduce the potential of such harms to develop cascading (subsequent) harms ^[22]. This is also in the vein of the cognitive-developmental model of educational programs that started to crystallize in recent years, as a model focused on educating about the nature of gambling rather than on its associated harms (Keen & al. 2017 ^[23]). Such an approach would be able to employ more effectively in the research the distinction between the immediate and the subsequent gambling harms, as associating more tightly each harm with a component of the informed play.

Conclusions

The harms associated with problem gambling are multifaceted and interconnected, spanning financial, familial, social, and community dimensions. These harms often cascade, leading to further negative outcomes that perpetuate the cycle of gambling-related distress.

Promoting informed gambling practices is a critical component of harm reduction. Educational initiatives, technological tools, and community support programs can equip individuals with the knowledge and resources needed to make responsible choices. Policymakers and stakeholders should also prioritize integrating harm minimization strategies into broader public health frameworks to address the complex nature of gambling-related harms.

Future research should continue to explore the interconnectedness of these harms and evaluate the effectiveness of various prevention and intervention strategies.

By our review we suggest that research should setup a clearer taxonomy of the gambling harms and revise what harms are immediate and what are subsequent. A focus should be given to the mathematical dimension of gambling in relation to gambling cognitive distortions, while making stronger associations between these distortions and each type of harm. In general, the conceptual framework of the research on gambling harms should be refined to incorporate more distinctions and accommodate interdisciplinary research.