Our national survey, based on a large, representative sample of Italian adults, found that the prevalence of gambling habit decreased during COVID-19 lockdown in Italy, while, among gamblers, the intensity of gambling significantly increased in the same time period, leading to an overall decrease in gambling activity (considering both prevalence and intensity) by 29%. In particular, the national regulation banning many types of land-based games resulted in a fall by 76% of the prevalence of traditional gambling. Even online gamblers declined by 20% during lockdown, but a non-negligible portion of Italian adults (i.e., 4%) reported a worsening in their total gambling activity during lockdown (e.g., an increase in intensity or a start of the habit).

Persons with behavioral addictions experienced greater reactivity to environmental cues compared to the general population (Starcke, Antons, Trotzke, & Brand, 2018). Those subjects trigger conditioned emotional reactions and provide the basis for explaining the variations in craving and the strength of the withdrawal syndrome with varying environmental exposure. The use of a substance or a behavior leads to the desired effect, thus determining an operative conditioning which leads to increase the use (Drummond, 2001). Conversely, a reduction in stimuli leads to a reduction in craving and addictive behavior. For this reason, we considered the possibility that the reduction of traditional gambling due to the lockdown reduced the incentives, consequently decreasing the craving for pathological gambling.

Despite some specific types of traditional gambling games were banned during COVID-19 lockdown, the non-zero prevalence of use of such games during lockdown might reveal a misclassification of games among participants and/or could suggest that a non-negligible portion of subjects have been involved in some forms of informal or illegal land-based gambling during lockdown. A less marked decrease in the online gambling prevalence from prior to during lockdown can be justified by confinement at home and social distancing. Confinement indeed have induced people to increase their interaction and activities online, including, possibly, playing gambling. Moreover, some other subjects who used to play traditional gambling in pre-lockdown might have decided to switch to online gambling during stay-at-home orders.

Few studies so far have analyzed the effects of COVID-19 lockdown on gambling habits. A cross-sectional online study conducted on 2016 subjects from the general adult population in Sweden within the same time frame of our study showed that, in line with our study, a small proportion of study participants (i.e., 4%) reported an increase in gambling activity and that the worsening group was characterized by severe gambling addiction (Hakansson, 2020). It is although worth to mention that in Sweden there was no lockdown due to COVID-19 pandemic, therefore a comparison with the results of our study on the Italian population are to be considered with caution. Another online survey was conducted between late March and mid May 2020 on 764 Australian adults, predominantly males and former gamblers, with the aim of investigating the impact of COVID-19 lockdown on their gambling behavior. Preliminary results showed that approximately 11% of study participants increased their gambling activity during lockdown (The University of Sidney, 2020).

In our study, gambling behaviors before the lockdown were associated with being young and male. These results are in line with a recent literature review on gambling disorder (Potenza et al., 2019), and with a study conducted in Italy on a representative sample of 4,773 adults aged from 18 to 94 years (Cavalera et al., 2018).

In our study we observed that worsening in gambling behavior, either by starting or increasing intensity of gambling, was associated with young age. This can be explained with the prolonged period of isolation that might have induced young people to consider online gambling as a valid recreational activity at home. Similarly, the Swedish web survey has identified that being a young man and spending more time at home were associated with an increase in gambling activity (Hakansson, 2020).

We observed that survey participants having or having had an addiction were more likely to both play gambling before lockdown and worsen gambling activity during the lockdown. In line with current available literature, being a smoker (Latvala et al., 2019; Pacifici et al., 2019), or a cannabis user (Pacifici et al., 2019; Xian, Giddens, Scherrer, Eisen, & Potenza, 2014), or being affected by alcohol use disorder (Pacifici et al., 2019; Potenza et al., 2019), were all associated with being a gambler before lockdown. We also observed that electronic cigarette and HTP use were associated with being a gambler before lockdown. The addictive behaviors mentioned above were also associated with increasing the intensity of gambling during lockdown. It is particularly interesting to point out that cannabis was the only addictive behavior associated with starting gambling during the confinement period.

In line with available literature, we found a significant relationship between several mental health symptoms and being a gambler before COVID-19 lockdown, including consuming psychotropic drugs (Potenza et al., 2019), reporting a low quality of life (Bonfils et al., 2019), low sleep quality (Parhami et al., 2012), depressive symptoms (Potenza, Xian, Shah, Scherrer, & Eisen, 2005; Quigley et al., 2015) and anxiety symptoms (Bonfils et al., 2019). The same mental health indicators were also associated with increasing gambling activity during lockdown. Moreover, the use of psychotropic drugs before lockdown was also related with starting gambling during lockdown.

The study presents some limitations worth to mention. Firstly, results were obtained via a web-survey. This mode of data collection intrinsically introduces a selection bias towards a portion of population actively using internet, excluding therefore less wealthy subgroups of the population who do not have access to internet or use it less frequently. However, our sample had a distribution by socio-economic characteristics, including income and level of education, similar to those of the general Italian population. Moreover, a web-survey was the best option to reach subjects during the lockdown, given the restrictions in place. Secondly, a response-shift bias might also have affected information provided by the subjects in relation to before and during lockdown. In fact, reported changes in habits within this time frame might reflect individual perceptions of the change, more than real changes in behaviors due to the lockdown. Thirdly, answers provided by study participants on selected topics might have also been affected by the seasonal effect with respect to before (winter season) and during lockdown (spring season). Another limitation worth to mention, is the definition of gambler used, that, even if in accordance with previous literature (Pacifici et al., 2019) does not allow to distinguish occasional gamblers from heavy gamblers. However, in a sensitivity analysis, the changes in prevalence for heavy players were consistent with those for any players. Another limitation is related to mental health indicators: the PHQ-2 and GAD-2 scales used to assess depression and anxiety only represent a first step screening and not a clinical evaluation. However, this was not among the aims of the present survey and the length of the questionnaire did not allow any deeper investigation. More importantly, we did not have the possibility to use a probability sampling methodology which would have better ensured the representativeness of the target population. Finally, as this is a cross-sectional study, it is not possible to establish any causal relationship, although all efforts have been considered to give a longitudinal context to the analyses. Thus, all the possible determinants of changes in gambling habit, including addictive behaviors, referred to a time frame prior the lockdown.

Despite these limitations, to our knowledge this is the first study aimed at analyzing the effect of COVID-19 lockdown on gambling habits on a national representative sample of the adult population. In addition, it is also worth to mention that data were collected in the last weeks of a two month-long home confinement. The section of questions focused on gambling habits during lockdown refers to the same specific time frame nested within the most restrictive period of lockdown ensuring data uniformity and minimizing therefore memory and recall biases.

The COVID-19 pandemic and its response had and will have consequences on all levels of our society, including its psychological wellbeing (Holmes et al., 2020). Although our results show that gambling activity has definitely decreased during lockdown, time spent in gambling has slightly increased. As described in previous studies, increased time spent gambling might be an indicator of the development of gambling disorders (Fong, 2005). It will be relevant therefore to monitor gambling consumption levels in the post lockdown period. Specifically, it would be useful to identify additional indicators which could be easily tracked over time in order to define strategies to support the most vulnerable population and the new potential subjects addicted to gambling. This goal can only be achieved through a transdisciplinary approach which involves epidemiologists, public health researchers and practitioners, mental health experts and policy makers (Lopez-Pelayo et al., 2020). In addition, it is particularly important to consider the well known, here confirmed, strong relationship between mental health and addictive behaviors with gambling. Gambling is highly comorbid with other psychiatric disorders. In this critical period of uncertainty and psychological disorientation, new policies should be adopted to monitor and prevent these mentally vulnerable subgroups of the population from increasing and developing gambling disorders.