Perceived Problems With Adolescent Online Gaming: National Differences and Correlations With Substance Use

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Perceived problems with adolescent online

gaming: National differences and correlations


with substance use

Journal of Behavioral JULIAN STRIZEK1p , JOSEFINE ATZENDORF2,


Addictions LUDWIG KRAUS3,4,5, KARIN MONSHOUWER6,
ALEXANDRA PUHM1 and ALFRED UHL1,7
9 (2020) 3, 629–641
DOI:
1
10.1556/2006.2020.00061 Austrian Public Health Institute, Vienna, Austria
© 2020 The Author(s) 2
Munich Center for the Economics of Aging (MEA), Max-Planck-Institute for Social Law and Social
Policy, Munich, Germany
3
Institut f€
ur Therapieforschung, Munich, Germany
4
Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
5
Institute of Psychology, ELTE E€
otv€
os Lorand University, Budapest, Hungary
FULL-LENGTH REPORT 6
Trimbos Institute, Utrecht, The Netherlands
7
Sigmund-Freud Privat-Universit€at, Wien, Austria

Received: February 1, 2019 • Revised manuscript received: July 2, 2020 • Accepted: August 26, 2020
Published online: October 6, 2020

ABSTRACT
Background: Not much is known about the correlation between gaming problems and substance use
across different countries. This paper presents cross-national analyses of different gaming indicators
and their relationship to substance use. Methods: Based on data from the 2015 ESPAD study, differences
in the relationship between gaming and substance use across 35 countries were analysed using multi-level
logistic regression, using substance use as an individual level predictor, economic wealth as a country-level
predictor and a combined problem gaming indicator as the outcome. Results: Multi-level logistic re-
gressions revealed significant correlations between individual substance use and gaming problems, which
varied across countries and were moderated by economic wealth. Students who used alcohol, tobacco or
cannabis and who lived in high-income countries had a smaller risk of scoring positively on a combined
problem gaming indicator than students who used alcohol, tobacco or cannabis and who lived in less
prosperous countries. Discussion: Different gaming indicators varied substantially across countries, with
self-perceived gaming problems being more common in countries with a low prevalence of gaming.
Significant cross-level effects demonstrate the need to take the societal context into account when the
relationship between problem gaming and substance use is analysed. Prevention measures need to take the
fact into account that patterns of substance use among problem gamers vary across countries.

KEYWORDS
online gaming, substance use, ESPAD, cross-level effect

INTRODUCTION
Over the past few decades, video games have become a widespread social phenomenon and
*Corresponding author.
E-mail: julian.strizek@goeg.at
part of a booming gaming industry (Kuss, 2013). In line with a general growing scientific
interest in behavioural addictions (Billieux, Schimmenti, Khazaal, Maurage, & Heeren, 2015),
more and more attention has been paid to problem gaming in recent years, with a special
focus on certain types of games played on the Internet (e.g. MMORPGs, so-called “massively
multiplayer online role-playing games”). The game mechanics of MMORPGs share all of the
630 Journal of Behavioral Addictions 9 (2020) 3, 629–641

elements suspected of increasing gaming time excessively, to the societal effects of when gaming is classified as being
including narrative features, game rewards and socialisation problematic. It is very likely that all factors are relevant. In
features (Nagygy€ orgy, 2013), and may lead to problem all countries the prevalence of problem gaming is much
gaming. higher in boys than in girls (Van Rooij et al., 2014).
As a result of the growing body of research on problem
gaming, the diagnosis of “Internet Gaming Disorder” (IGD) Association between gaming and substance use
was included in the annex of DSM-5 (emerging measures
In line with Problem-Behaviour Theory (Jessor, 1987),
and models that need further research) for the first time
problem gaming might be a symptom of general problem
(Petry & O'Brien, 2013) and “Gaming Disorder” (GD) was
behaviour, like problematic substance use and problem
added to the ICD-11 (WHO, 2018). Even though there is
drinking. This hypothesis is supported by empirical findings
some evidence that IGD and GD share similarities with
suggesting that addictive behaviours often co-occur (Kotyuk
substance use disorders, more information on the aetiology
et al., 2020), presumably because some individuals are more
and progression of IGD/GD is needed. Consequently, the
vulnerable to addictive behaviours than others due to dif-
debate as to whether it is justified to label these behaviours
ferences in genetic or psychological predispositions like
an “addiction” is controversial (Griffiths, Kiraly, Pontes, &
impulsivity (Van Rooij et al., 2014), lack of perseverance
Demetrovics, 2015). The inclusion of gaming disorder in the
(Thomsen et al., 2018), variants of the dopamine receptors
ICD-11 was supported by one group of researchers (Rumpf
(Blum et al., 1996), ADHS (Romo et al., 2018), or other
et al., 2018) and criticised by another (Van Rooij et al.,
mental health problems (Marmet et al., 2019). A common
2018). Since there is no clear consensus on the definition of
aetiology for addictive behaviours is also suggested by the
gaming disorder, some authors prefer the term “problem
Component Model of Addiction (Griffith, 2005) that stresses
gaming”, even though the criteria used are usually quite
common characteristics of different addictions. Skarupova,
similar.  apal (2018) point out that at least some gamers
Blinka, and T
use substances for game-related reasons (e.g. to enhance
Prevalence of gaming and problem gaming enjoyment), suggesting that co-occurring substance use is a
Data on the prevalence of gaming in European adolescents pragmatic choice rather than an indicator of underlying
were obtained from two large international surveys. Results problems. From all these perspectives we would expect a
from the European School Survey Project on Alcohol and positive correlation between substance use and problem
Other Drugs (ESPADs) in 2015 (ESPAD group, 2016a) gaming. On the other hand, common sense tells us that all
indicate that 23% of ESPAD students (born in 1999) re- individuals only have a limited amount of spare time and
ported regular gaming (on 4 out of 7 days). Data from the therefore gaming activities in adolescents may lead to fewer
Health Behaviour in School-aged Children Study in 2014 activities outside their own home, where substance use by
(HBSC) suggest that spending two or more hours on a minors is more likely to happen. From this perspective we
weekday playing games on a computer, smartphone or would expect a negative association between gaming and
games console is a common habit in 11 year olds (37% on substance use.
average), 13 year olds (45% on average) and 15 year olds Recent trend analyses using ESPAD data reveal a pro-
(42% on average) (HBSC, 2016). nounced decrease in alcohol and tobacco use in 15- to 16-
Griffiths et al. (2015) concluded that the prevalence of year-old students over the last few years in Europe (ESPAD
problem gaming varies considerably across different cultures Group, 2016; Kraus et al., 2018), indicating a more general
and samples, ranging from less than 0.2% in Germany to decrease in adolescents’ substance use (Pennay et al., 2018).
34% in Taiwan. The comparability of problem gaming An increasing use of digital media may be one driving force
prevalence estimates is impeded by the use of different scales behind this decline in youth drinking in Western societies,
being applied to assess problem gaming and a lack of although this hypothesis has not yet been tested (Kraus et al.,
consensus on the dimensions included in these scales 2018). In the present paper, we used an explorative analysis
(among them mood alteration, compulsive use, distraction, to assess the association between gaming and substance use
loneliness/depression, withdrawal, time management, toler- in general.
ance and others) (Jia & Jia, 2009). Ambiguity also arises
from the fact that some scales assess gaming in general while
Aim of the study
others focus specifically on online gaming and still others Making use of the comparable methodology of the European
include any Internet activities (Bischof, Bischof, Besser, & School Survey Project on Alcohol and other Drugs
Rumpf, 2016). (ESPADs), the aim of this paper was (1) to provide
Population prevalence rates in South-East Asia usually descriptive information on gaming activity and indicators of
exceed prevalence rates in Western countries by far. Results problem gaming across European countries, (2) to assess the
from Western countries, including Europe, report rates relationship between problem gaming and substance use
ranging from below 1% to up to 12%. The large differences (alcohol, tobacco, cannabis) and (3) to test the effect of
in the prevalence of self-reported problem gaming may be economic wealth on the relationship between problem
due to differences in gaming behaviour, access to games or gaming and substance use.
Journal of Behavioral Addictions 9 (2020) 3, 629–641 631

METHODS study by Marmet, Notari, and Gmel (2015), a screening


instrument for problem gaming was only used with in-
dividuals with an AGT of 1 hour or more per day. In line
Participants
with this research, the AGT was dichotomised using a
Data were taken from the 2015 ESPAD study, a cross-na- threshold of 1 hour per day as a precondition for problem
tional survey performed in 35 European countries repre- gaming.
senting student populations who turned 16 in 2015. The A problem gaming index (PGI) as a proxy for measuring
countries collected data on students in accordance with problem gaming was computed by combining the PPS and
consistent methodological guidelines using an anonymous the AGT. The PGI was coded 1 if the AGT was 1 hour or
self-administered questionnaire completed on a voluntary more per day and if the PPS had a positive score; it was
basis in classroom settings. Details on sampling and survey coded 0 if at least one of the two conditions was not fulfilled.
methodology as well as further information can be found In other words, 1 hour or more of gaming time per day was
elsewhere (ESPAD Group, 2016b). defined as the lower threshold for problem gaming.
All data were weighted if weights were provided in the
national datasets. The data from Portugal and Belgium Substance use (individual-level indicators). Substance use
(Flanders) were not used for the analyses because perceived variables were re-coded into dichotomous variables,
gaming problems were not included while the data from including alcohol use in the last 30 days (yes/no), smoking
Ireland were not included in the multi-level analyses because cigarettes in the last 30 days (yes/no) and lifetime cannabis
class membership was missed out. Sample sizes by gender use (yes/no). Different timeframes for prevalence estimates
for all countries are provided in Table 6 in the Appendix. were used to avoid too low a prevalence rate.

Measures Economic wealth (macro-level indicator). At a macro-level,


the gross domestic product (GDP) per capita for 2015 was
retrieved from an external data source (World Bank, 2018).
Gaming indicators (outcome measures). Time loss is one of GDP per capita is the gross domestic product divided by the
the most important negative effects of excessive gaming. A mid-year population; it was aggregated for each country.
greater amount of time spent on gaming is considered a
necessary condition for problem gaming, although this is not Statistical analyses
a sufficient indicator for problem gaming on its own (King,
Haagsma, Delfabbro, Gradisar, & Griffiths, 2013). Gender differences were calculated as gender ratios, with a
A three-item scale of perceived gaming problems (sub- value above 1 indicating that boys were more likely to play
sequently referred to as the perceived problems scale 5 PPS) games than girls (which is the case in all countries). Further
developed by Holstein et al. (2014) was used in all but two descriptive information on a country level is provided by
participating countries. In contrast to other scales assessing odds ratios (ORs), which were calculated to assess the risk
gaming addiction, the present scale does not use any of the relation between problem gaming and substance use. For the
DSM-5 criteria but three items self-assessing the amount of bivariate analyses, the PGI was used because the combina-
time spent gaming (“I think I spend way too much time tion of self-assessment (PPS) and minimum gaming time
playing computer games”), the individual’s mood when not (AGT) was considered less prone to being confounded by
gaming (“I get in a bad mood when I cannot spend time on either cultural or economic factors than the PPS or the AGT
computer games”) and parents’ perception of time spent alone. Due to the fact that only a very small proportion of
gaming (“My parents tell me I spend way too much time on girls scored positively on the PGI, all bivariate analyses were
computer gaming”). According to the authors, a score of 2 run for boys only. These descriptive analyses were not
or 3 (counting only the responses “strongly agree” and controlled for potential cluster effects and thus no signifi-
“agree”) indicates gaming problems. The scale showed a cance levels or confidence intervals were calculated.
high level of face validity and an acceptable level of internal Regression analyses are based on the assumption that
consistency in a sample of Danish students (Holstein et al., residuals are independent from each other (Field, 2013),
2014). which might not be true for nested data. In our data, stu-
In the ESPAD survey, time spent on online gaming is dents (Level 1) were nested within school classes (Level 2)
assessed by (1) the number of days in the last week playing which were nested within countries (Level 3). To test the
online games and (2) the number of hours on a typical day effects between substance use, the PGI and economic wealth
playing online games. These two items were combined to for significance, a three-level logistic regression analysis was
compute an average duration of time spent gaming per day performed to account for the hierarchical structure of the
(average gaming time 5 AGT). In contrast to symptom- data, resulting in corrected standard errors (Raudenbush &
based screening tools, there are no consistent thresholds to Bryk, 2002; Hox, 2010). The Median Odds Ratio (MOR) was
distinguish between periodic gaming, regular gaming and used to measure the effect of heterogeneity between school
problem gaming when using the AGT. Holstein et al. (2014) classes and countries. The MOR can be conceptualised as the
provided evidence that an AGT of 1 hour or more per day median increased risk if one individual moved from a cluster
already increased the risk of a positive score on the PPS. In a with a lower risk to a cluster with a higher risk (Merlo et al.,
632 Journal of Behavioral Addictions 9 (2020) 3, 629–641

2006). In our study, a MOR equal to one indicates no dif- did not converge when random slopes were assumed. To
ferences between classes and countries in the risk of scoring compensate for multiple testing, the alpha level of 0.05 was
positively on the PGI for students using alcohol, tobacco or divided by three and set to 0.017 after the analyses (Bon-
cannabis. By contrast, a MOR greater than one indicates ferroni correction). Descriptive analyses were performed
cluster effects and that cluster membership is relevant for using SPSS 23 (IBM Corp., Armonk, NY) and multilevel
understanding variations in the probability of a positive logistic regression models were performed using Stata 14
score on the PGI. The Akaike Information Criterion (AIC) (Stata Corp LP, College Station, TX). Cases with missing
was used to assess the fit of the model. A smaller value of the data were deleted list wise.
AIC indicates that a certain model has a reduced mean
squared error and is therefore more precise in its predictions Ethics
(Vrieze, 2012).
According to the ESPAD methodology, the students were
In accordance with the literature on multi-level logistic
informed that answering the questionnaire was voluntary
regression (Sommet & Morselli, 2017), we used a step-wise
and that responses to survey questions were confidential and
approach: In the first step, no predictors were included in
anonymous. In addition, all surveys complied with the
the model in order to estimate whether the PGI varied be-
relevant national laws, regulations and guidelines concern-
tween school classes and countries (intercept-only model).
ing research ethics (ESPAD Group, 2016b).
Different levels of the PGI across school classes and coun-
tries were indicated by significant variance components.
Next, predictors at the individual level (substance con-
sumption) and at the macro-level (GDP) were included as
RESULTS
fixed effects with random intercepts in order to estimate the
direct associations between the predictors and the outcome Prevalence of problem gaming indicators across
measure without taking variations between school classes European countries
and countries into account (fixed predictors with random-
Overall, the prevalence of students scoring positively on
intercept model). In a third step, random slopes were
the PPS and the number of students with an AGT of at
included in the model in order to assess whether the asso-
least 1 h per day were rather similar at 20.3 and 21.0%,
ciations between individual-level predictors and outcome
measures varied between school classes and countries respectively (Table 1). However, on a country level the two
(random-intercept and random-slope model). Different as- indicators varied substantially. The proportion of students
sociations between the PGI and the predictors across school with a positive score on the PPS ranged from 13% in
classes and countries were indicated by significant variance Germany (Bavaria) and Liechtenstein to 31.8% in Latvia
components. Finally, cross-level interactions between indi- (SD 5 5.5 across countries) while the proportion of stu-
vidual-level and macro-level variables were included in or- dents with an AGT exceeding 1 hour per day ranged from
der to assess whether the different associations between the almost 13% in Albania, Macedonia and Georgia to 38.4%
PGI and substance consumption across the countries could in Denmark (SD 5 6.2 across countries). Countries tended
be explained by economic wealth (random-intercept and to have a high score either on the PPS (notably South
random-slope model with cross-level interaction). Signifi- Eastern European countries) or on the AGT (notably
cant regression coefficients indicated a significant effect for Northern European countries) while only very few coun-
the cross-level interactions. Furthermore, a decreasing value tries tended to score high on both scales (notably Baltic
of the AIC indicated a better fit of the model compared to countries) (cf. Fig. 1).
the intercept-only model. Based on the PGI, differences in the prevalence of
Similar to the bivariate analyses, only male students were problem gaming were smaller (SD 5 2.2), ranging from
included in the multilevel logistic regression. GDP was reco- 4.8% in Ukraine to 13.6% in Latvia. The total prevalence of
ded into three categories based on the terciles of the distri- the PGI was 8.5%, with male students being 9 times more
bution of GDP on country level. The least wealthy group of likely to score positively on the PGI than female students.
countries (GDP per capita <$13,000) was coded 1 and consists Gender differences can also be observed for the two single
of the Republic of Moldova, Ukraine, Georgia, Albania, FYR indicators, with a more pronounced gender ratio in favour
of Macedonia, Montenegro, Bulgaria, Romania, Croatia, of male students for gaming time (male students were 6.7
Hungary and Poland. The middle group of countries ($13,000 times more likely to play more than 1 h per day on
< $40,000) was coded 2 and consists of Latvia, Lithuania, the average) than for perceived gaming problems (male stu-
Slovak Republic, Estonia, the Czech Republic, Greece, dents were 3.1 times more likely to self-report game-
Slovenia, Cyprus, Malta, Italy and France. The wealthiest related problems).
group of countries (GPD per capita >$40,000) was coded 3
and consists of Germany (Bavaria), Finland, Austria, the Bivariate analyses between the PGI and substance use
Netherlands, the Faroe Islands, Sweden, Iceland, Denmark, in male students
Norway and Liechtenstein (countries in all three groups are
arranged in order of GDP per capita). The associations between problem gaming and substance
Separate models were run for alcohol, tobacco and use indicators, i.e. whether male students who fulfil the
cannabis use since a model with all three level-1 predictors criteria for the PGI have a higher likelihood of using a
Journal of Behavioral Addictions 9 (2020) 3, 629–641 633

Table 1. Scores of the gaming indicators PPS, AGT and PGI by country
PPS (2–3 pts) AGT (1 h þ) PGI
Total prevalence Gender ratio Total prevalence Gender ratio Total prevalence Gender ratio
(%) (m:f) (%) (m:f) (%) (m:f)
Albania 27.6 2.1 12.7 3.1 7.5 3.7
Austria 14.8 5.8 22.5 7.9 9.1 14.9
Bulgaria 29.8 2.2 22.9 4.8 10.6 5.2
Croatia 21.8 3.1 20.5 6.9 9.9 8.3
Cyprus 23.8 2.2 20.8 5.0 9.3 5.5
Czech Republic 16.8 5.8 25.3 7.3 11.0 10.6
Denmark 14.2 5.6 38.4 2.7 10.1 7.7
Estonia 17.4 4.9 32.4 8.7 12.9 12.3
Faroe Islands 26.4 4.6 26.5 16.1 14.6 73.5
Finland 14.1 5.3 26.1 11.4 9.1 14.2
France 17.8 4.1 22.4 8.3 9.3 10.9
FYR of Macedonia 29.3 1.8 12.8 5.0 6.9 5.2
Germany (Bavaria) 12.9 7.0 24.8 7.0 9.4 9.3
Georgia 23.9 3.6 12.5 14.7 7.7 25.7
Greece 17.1 4.1 15.7 12.9 7.7 14.7
Hungary 17.6 4.6 20.3 5.5 8.8 7.9
Iceland 12.9 4.8 23.0 14.4 6.8 17.8
Ireland 16.2 5.7 19.0 8.7 8.4 16.1
Italy 22.9 2.4 16.1 3.2 7.1 4.7
Latvia 31.8 1.7 28.7 6.3 13.6 11.1
Liechtenstein 12.7 6.9 22.6 27.5 6.3 23.1
Lithuania 25.1 2.7 29.3 4.4 11.4 7.4
Malta 23.7 3.4 22.9 5.4 11.8 8.3
Moldova, 28.9 1.8 14.0 9.2 6.3 9.4
Republic of
Montenegro 26.2 2.7 14.6 6.6 8.1 6.9
Netherlands 16.0 4.0 30.0 7.2 10.0 11.2
Norway 14.3 4.8 28.2 10.6 8.4 16.1
Poland 15.4 4.1 22.4 7.5 8.5 9.3
Romania 26.7 2.1 19.4 6.1 8.2 8.7
Slovak Republic 21.2 3.8 20.9 4.2 8.9 7.9
Slovenia 18.8 4.7 16.6 9.2 7.8 9.4
Sweden 20.3 3.3 32.4 11.1 12.7 13.2
Ukraine 16.9 2.1 15.9 6.3 4.8 3.6
Total 20.3 3.1 21.0 6.7 8.5 8.9
Notes: PPS 5 perceived problems scale; AGT 5 average gaming time; PGI 5 problem gaming indicator.

Fig. 1. Heat maps based on the prevalence of the PPS (left), the AGT (middle) and the PGI. PPS 5 perceived problems scale. PPS 5
perceived problems scale; AGT 5 average gaming time; PGO 5 problem gaming indicator; dark blue indicates high values, light blue
indicates low values, Source: 2015 ESPAD Survey
634 Journal of Behavioral Addictions 9 (2020) 3, 629–641

Table 2. Bivariate associations between the PGI and substance use The results in Table 2 show inconsistent patterns for the
indicators (male students only) bivariate associations between gaming and substance use
ORs of indicators. Across countries, problem gaming is not
ORs of scoring consistently associated with a higher or a lower level of
scoring positively on ORs of substance use. Positive correlations can be found in some
positively on the PGI and scoring countries while they are negative in others.
the PGI and smoking positively on
alcohol use in cigarettes in the PGI and Testing for significant effects of individual-level and
the last 30 the last 30 lifetime
days days cannabis use country-level predictors using multi-level logistic
regression
Albania 1.9 1.4 1.5
Austria 0.6 0.7 0.7
Bulgaria 0.9 0.9 1.3 Intercept-only model. The variance component for the
Croatia 1.1 0.9 0.8 intercept-only model of the PGI was statistically significant
Cyprus 1.3 0.7 0.9 (not shown in Table 3), indicating that prevalence rates of
Czech 0.7 0.8 1.0 the PGI differed between school classes and countries (MOR
Republic 5 1.7, AIC 5 34795.78).
Denmark 0.8 0.4 0.4
Estonia 0.8 0.8 0.8 Fixed predictors with random intercepts. At the individual
Faroe Islands 0.9 1.4 1.2 level, alcohol consumption was not significantly associated
Finland 0.7 0.5 0.7 with the PGI (Table 3). The consumption of cannabis (OR 5
France 0.8 0.6 0.7 0.88; 95%-KI 5 [0.81; 0.97]) and smoking (OR 5 0.77; 95%-
FYR 2.1 1.1 1.4
KI 5 [0.70; 0.85]) were significantly associated with a lower
Macedonia
Germany 0.7 0.6 0.6
chance of scoring positively on the PGI (Tables 4 and 5). At
(Bavaria) the macro-level, the direct effect of GDP was not signifi-
Georgia 2.8 0.8 1.0 cantly associated with the PGI (AICAlcohol 5 34323.49;
Greece 0.8 0.9 0.9 AICSmoking 5 34649.52, AICCannabis5 34595.12).
Hungary 0.9 0.6 0.7
Iceland 0.7 0.4 0.7 Random-intercept and random-slope model. The variance
Ireland 0.7 0.7 1.0 components showed that the associations between the PGI
Italy 1.2 1.1 0.9 and smoking and the consumption of cannabis varied
Latvia 0.6 0.3 0.5 among school classes and countries (Tables 4 and 5). Smaller
Liechtenstein 0.2 0.7 0.5 values of the AIC indicate that precision increased compared
Lithuania 1.2 0.9 0.8 to the models with fixed predictors (AICAlcohol 5 34286.35;
Malta 0.9 0.9 0.8 AICSmoking 5 34638.68, AICCannabis5 34594.56). The MORs
Moldova, 1.0 1.1 0.8 were greater than one for all substances, indicating strong
Republic of
country-level differences regarding the associations between
Montenegro 1.2 1.0 1.0
Netherlands 0.9 0.7 0.8
substance consumption and gaming problems (MORAlcohol
Norway 0.8 1.0 1.0 51.29, MORSmoking 5 1.61, MORCannabis 51.48).
Poland 1.0 0.7 0.9
Romania 1.0 0.9 1.1
Random-intercept and random-slope model with cross-
Slovak 1.3 0.4 1.1 level interaction. There was a statistically significant cross-
Republic interaction between GDP and substance use on the PGI. With
Slovenia 1.0 0.9 1.2 regard to alcohol, as alcohol consumption changes from
Sweden 0.7 0.6 0.7 abstinence (0) to consumption (1) in combination with living
Ukraine 1.0 0.8 1.2 in the wealthiest group of ESPAD countries, the change in the
Total 0.9 0.8 0.9 odds of scoring positively on the PGI is 0.57 compared to the
Source: 2015 ESPAD survey. least wealthy group of countries (reference). In other words,
for students living in the wealthiest group of ESPAD coun-
particular substance in the selected timeframe, are displayed tries, alcohol consumption was less likely to contribute to the
in Table 2. The differences in ORs across countries were PGI. The odds ratios for the cross-interaction of the second
higher for alcohol use than for smoking cigarettes or group of countries did not show any statistically significant
cannabis use. The ORs for the PGI and alcohol use within effect after correcting the alpha value (Bonferroni).
the last 30 days ranged from 0.2 in Liechtenstein and 0.6 in Similar to the model with alcohol as an individual pre-
Austria to 2.8 in Georgia. The ORs for the PGI and cigarette dictor, significant cross-interaction also existed for the
use in the last 30 days ranged from 0.4 in Iceland and the wealthiest group of countries for cannabis (OR 5 0.67; 95%-
Slovak Republic to 1.4 in Albania and the Faroe Islands. CI 5 [0.54; 0.84]) and for tobacco use (OR 5 0.69; 95%-C 5
Finally, the ORs for the PGI and cannabis use ranged from I [0.56; 0.84]. Again, for the second group of countries the
0.5 in Liechtenstein and Lithuania to 1.5 in Albania. cross-interaction effects were not statistically significant.
Journal of Behavioral Addictions 9 (2020) 3, 629–641 635

Table 3. Results of multilevel analyses predicting the associations between the PGI and alcohol consumption (male students only)
Random-intercept and
Fixed predictors with Random-intercept and random-slope model with
random intercepts ICC 0.27, random-slope model ICC cross-level interaction ICC
AIC 34323.49 0.27, AIC 34286.35 0.27, AIC 34273.07
Fixed effects OR 95%-CI OR 95%-CI OR 95%-CI
* *
Intercept 0.15* [0.12; 0.18] 0.14 [0.11; 0.17] 0.13 [0.11; 0.16]
Aggr. GDP – –
1#GDP Ref. Ref. Ref.
2#GDP 0.97 [0.43; 2.17] 1.08 [0.47; 2.45] 1.11 [0.49; 2.54]
3#GDP 0.86 [0.34; 2.18] 1.03 [0.39; 2.70] 1.12 [0.44; 2.86]
Alcohol consumption 0.96 [0.86; 1.07] 0.93 [0.82; 1.06] 1.19 [0.96; 1.49]
Interaction with 1#GDP Ref.
Interaction with 2#GDP 0.77 [0.60; 0.99]
Interaction with 3#GDP 0.57* [0.44; 0.73]
Random effects Var. (SE) 95%-CI Var. (SE) 95%-CI Var. (SE) 95%-CI
Intercept 0.21 (0.04) [0.14; 0.31] 0.19 (0.04) [0.13; 0.27] 0.19 (0.03) [0.13; 0.27]
Alcohol consumption – 0.07 (0.05) [0.02; 0.30] 0.07 (0.50) [0.02; 0.31]
Note: Ref. 5 Reference; Aggr. 5 aggregated; OR 5 odds ratio; 95%-CI 5 95% confidence interval; SEs 5 robust standard errors; Var. 5
variance component.
*
P < 0.017.

Models for all substances with cross-level interaction countries. There is a consensus that a certain amount of
revealed smaller values for the AIC (AICAlcohol 5 34273.07; gaming time is a precondition for gaming problems but an
AICSmoking 5 34634.55; AICCannabis 5 34585.4), indicating insufficient stand-alone indicator for problem gaming on an
increased precision compared to the model without cross- individual level. Using a minimum gaming time of 1 hour
level interaction. per day as a threshold for a perceived problem scale (PPS),
combining the AGT with the PPS has a considerable effect
on prevalence estimates for gaming problems compared to
DISCUSSION using the PPS without any minimum threshold (8.5 vs.
20.3% in the ESPAD sample).
Our analyses revealed that gaming time and perceived In line with the vast majority of research in this area,
problems were very unevenly distributed across ESPAD male students scored much higher on any gaming indicator

Table 4. Results of multilevel analyses predicting the associations between the PGI and smoking (male students only)
Random-intercept and
Fixed predictors with Random-intercept and random-slope model with
random intercepts ICC 0.27, random-slope model ICC cross-level interaction ICC
AIC 34649.52 0.27, AIC 34638.68 0.27 AIC 34634.55
Fixed effects OR 95%-CI OR 95%-CI OR 95%-CI
* * *
Intercept 0.15 [0.13; 0.18] 0.15 [0.13; 0.18] 0.15 [0.13; 0.18]
Aggr. GDP – –
1#GDP Ref. Ref. Ref.
2#GDP 0.97 [0.43; 2.18] 0.98 [0.43; 2.23] 1.00 [0.44; 2.28]
3#GDP 0.86 [0.34; 2.18] 0.88 [0.34; 2.25] 0.91 [0.35; 2.34]
Smoking 0.77* [0.70; 0.85] 0.70* [0.60; 0.81] 0.81* [0.71; 0.93]
Interaction with 1#GDP Ref.
Interaction with 2#GDP 0.85 [0.67; 1.07]
Interaction with 3#GDP 0.69* [0.56; 0.84]
Random effects Var. (SE) 95%-CI Var. (SE) 95%-CI Var. (SE) 95%-CI
Intercept 0.20 (0.04) [0.13; 0.30] 0.19 (0.04) [0.13; 0.29] 0.19 (0.04) [0.13; 0.29]
Smoking – 0.25 (0.14) [0.08; 0.75] 0.25 (0.14) [0.08; 0.75]
Notes: Ref. 5 Reference; Aggr. 5 aggregated; OR 5 odds ratio; 95%-CI 5 95% confidence interval; SEs 5 robust standard errors; Var. 5
variance component.
*
P < 0.017.
636 Journal of Behavioral Addictions 9 (2020) 3, 629–641

Table 5. Results of multilevel analyses predicting the associations between the PGI and cannabis use (male students only)
Random-intercept and
Fixed predictors with Random-intercept and random-slope model with
random intercepts ICC 0.27, random-slope model ICC cross-level interaction ICC
AIC 34595.12 0.27, AIC 34594.56 0.27 AIC 34585.4
Fixed effects OR 95%-CI OR 95%-CI OR 95%-CI
* * *
Intercept 0.15 [0.13; 0.18] 0.15 [0.13; 0.17] 0.15 [0.12; 0.17]
Aggr. GDP – –
1#GDP Ref. Ref. Ref.
2#GDP 0.98 [0.44; 2.21] 0.99 [0.44; 2.22] 1.00 [0.44; 2.26]
3#GDP 0.88 [0.34; 2.23] 0.89 [0.35; 2.27] 0.93 [0.36; 2.38]
Cannabis 0.88* [0.80; 0.96] 0.82* [0.72; 0.95] 0.96 [0.82; 1.12]
Interaction with 1#GDP Ref.
Interaction with 2#GDP 0.88 [0.73; 1.05]
Interaction with 3#GDP 0.67* [0.54; 0.84]
Random effects Var. (SE) 95%-CI Var. (SE) 95%-CI Var. (SE) 95%-CI
Intercept 0.20 (0.04) [0.13; 0.30] 0.19 (0.04) [0.13; 0.29] 0.19 (0.04) [0.13; 0.29]
Cannabis – 0.17 (0.18) [0.02; 1.32] 0.16 (0.17) [0.02; 1.32]
Notes: Ref. 5 Reference; Aggr. 5 aggregated; OR 5 odds ratio; 95%-CI 5 95% confidence interval; SEs 5 robust standard errors; Var. 5
variance component.
*
P < 0.017.

in all ESPAD countries. However, the gender ratio for the fact that in many cases, playing computer games will take
PPS was much smaller than for the AGT, indicating that place at home and substance use will often take place away
girls were more likely than boys to perceive their gaming from parental supervision. This association also supports the
behaviour as being problematic. Without in-depth analyses hypothesis that the use of digital media may be one
using a “gold standard” of gaming problem behaviour, it is contributing factor to the decline of substance use in ado-
not possible to conclude whether girls actually need less lescents across some Western European countries (Kraus
gaming time to experience subjective problems or whether et al. 2020; Room et al. 2019). In contrast, in countries with a
this self-evaluation problem scale would need different cut- low GDP per capita, we found a positive association between
off scores for girls and boys. problem gaming and substance use. The fact that we used a
The negative correlation between gaming time and measure for substance use instead of a measure for substance
perceived gaming problems on a country level (despite a use disorders may also explain why our results differ from
positive correlation on an individual level) adds contextual other research suggesting a consistent positive association
information to the findings, i.e. the more widespread gaming between behavioural addiction and substance use disorders.
is in a given country, the lower the number of students who Multi-level logistic regression revealed statistically signifi-
see themselves being at risk of gaming problems (and vice cant cross-level effects between substance use and GDP on the
versa). This result supports the idea that perceived problems PGI. The odds of scoring positively on the PGI differed sta-
might be more strongly related to the social status of tistically significantly between individuals who used alcohol,
gaming, e.g. whether gaming is considered normal or not cannabis or tobacco and lived in the wealthiest group of
according to cultural norms and only weakly related to countries compared to students who used alcohol, cannabis or
actual gaming behaviour. Similar results were found for tobacco and lived in the least wealthy group of countries.
subjective intoxication and levels of per capita consumption Accordingly, use of these substances in the wealthiest coun-
in US trend data (Kerr, Greenfield, & Midanik, 2006). tries was less likely to be associated with problem gaming than
However, with regard to gaming it might be the case that in the least prosperous countries. By contrast, there were no
other symptom scales are more closely related to the actual statistically significant cross-level effects for the second group
problem level. It is, of course, also possible that different of countries and no direct effects of GDP on the PGI in any of
assessments of perceived problems indicate “true” differ- the three models. One possible interpretation is that the effect
ences, since the population of adolescent gamers in one of competing leisure activities requires a rather higher level of
country may be more vulnerable to gaming problems than prosperity because only then do a variety of leisure activities
in other countries. become widely available for all adolescents and not only to
ORs between problem gaming and substance use showed selective subpopulations such as students in urban areas or
an inconsistent pattern across European countries. In high- students living in less traditional families, who might be more
income countries the association tended to be negative. This likely to be involved in both online games and substance use
negative association has some face validity, considering the despite limited spare time.
Journal of Behavioral Addictions 9 (2020) 3, 629–641 637

LIMITATIONS variables in more detail and should also take differences into
account in the characteristics of young people playing online
games across countries.
Several limitations should be considered when interpreting
the results presented in this study. Firstly, it is important to
stress that neither gaming time, perceived problems nor the
combination of both indicators are a valid measure of Funding sources: JS, AP and AU received funding by an in-
gaming disorder with clinical relevance. Neither does any of €
ternal publication grant provided by Gesundheit Osterreich
the substance use indicators included necessarily indicate GmbH. Funding for KM was provided by the Dutch Ministry
problem behaviour. The measure used in the ESPAD study of Health, Welfare and Sport. Funding for LK was provided
is a rather short self-assessment scale; more sophisticated by the Bavarian State Ministry of Finance, Regional Devel-
scales might produce other results. opment and Regional Identity via the Bavarian State Ministry
Secondly, the cross-sectional design of youth surveys like of Public Health and Care Services in the context of the
the ESPAD study does not allow us to distinguish between Bavarian Coordination Centre for Gambling Issues and the
low prevalence and postponed substance use. For countries Swedish program grant “Responding to and Reducing
with ORs on the PGI and substance use below 1, this may be Gambling Problems – Studies in Help-seeking, Measurement,
an indication of postponed substance use rather than a long- Comorbidity and Policy Impacts“ financed by the Swedish
term decline in use. Research Council for Health, Working Life and Welfare
Thirdly, cross-sectional data on behavioural indicators (Forte), grant number 2016–07091.
do not provide information on how problem behaviour may
develop over time. Problem behaviour in general peaks in Authors’ contribution: JS proposed the concept and design of
adolescence and in many cases ceases without intervention the study. Interpretation of data was done by JS, JA, LK, KM,
(Moffitt, 1993). Longitudinal designs may help to provide a AP and AU. All statistical analyses were done by JA and JS
more solid foundation for the temporal evolution of po- in consultation with LK, KM and AU.
tential problem behaviours like gaming and substance use in
adolescents. Conflict of interest: The authors report no financial or other
Fourthly, we did not succeed in computing a model relationship relevant to the subject of this article.
including all three level-1 predictors with random slopes in
one single model in either SPSS or STATA. Problems
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APPENDIX: ADDITIONAL TABLES

Table 6. Number of students per country and sex


Country Male Female Total
Albania 1,216 1,337 2,553
Austria 1,901 1,793 3,694
Bulgaria 1,453 1,469 2,922
Croatia 1,337 1,221 2,558
Cyprus 1,008 1,090 2,098
Czech Republic 1,361 1,412 2,773
Denmark 796 874 1,670
Estonia 1,224 1,228 2,452
Faroe Islands 257 254 511
Finland 1,958 2,091 4,049
France 1,363 1,351 2,714
FYR of Macedonia 1,179 1,249 2,428
Georgia 1,047 919 1,966
Germany (Bavaria) 428 434 862
Greece 1,583 1,619 3,202
Hungary 1,333 1,314 2,647
Iceland 1,312 1,351 2,663
Ireland 749 721 1,470
Italy 2,093 1,966 4,059
Latvia 565 554 1,119
Liechtenstein 143 173 316
Lithuania 1,303 1,270 2,573
Malta 1,665 1,661 3,326
Moldova, Republic of 1,325 1,261 2,586
Montenegro 1,957 1,887 3,844
Netherlands 832 852 1,684
Norway 1,380 1,195 2,575
Poland 1,585 1,704 3,289
Portugal 1,568 1,888 3,456
Romania 1,711 1,789 3,500
Slovak Republic 1,108 1,100 2,208
Slovenia 1,675 1,809 3,484
Sweden 1,263 1,288 2,551
Ukraine 1,170 1,302 2,472
Total 42,848 43,426 86,274
Notes: PPS 5 perceived problems scale; AGT 5 average gaming time; PGI 5 problem gaming indicator; a 5 cannot be calculated since only
boys score positively on the PGI.
Source: 2015 ESPAD survey
640 Journal of Behavioral Addictions 9 (2020) 3, 629–641

Table 7. Scores of gaming indicators PPS, AGT and PGI by country (using 2 h per day as the threshold for the AGT and the PGI)
PPS (2–3 pts) AGT (2h or more) PGI
Total prevalence Gender ratio Total prevalence Gender ratio Total prevalence Gender ratio
(%) (m:f) (%) (m:f) (%) (m:f)
Albania 27.6 2.1 8.3 2.9 5.4 3.1
Austria 14.8 5.8 15.9 12.6 7.3 30.7
Bulgaria 29.8 2.2 17.7 5.5 8.6 5.8
Croatia 21.8 3.1 15.5 7.5 7.9 7.8
Cyprus 23.8 2.2 16.0 6.6 7.7 6.2
Czech Republic 16.8 5.8 18.7 8.6 8.5 10.5
Denmark 14.2 5.6 32.3 2.6 8.7 7.8
Estonia 17.4 4.9 24.0 10.8 10.4 14.1
Faroe Islands 26.4 4.6 19.0 23.6 11.2 56.1
Finland 14.1 5.3 18.1 16.4 7.0 24.2
France 17.8 4.1 15.8 8.9 7.5 11.6
FYR of Macedonia 29.3 1.8 9.6 7.5 5.4 7.5
Germany 12.9 7.0 17.0 7.7 7.5 8.4
(Bavaria)
Georgia 23.9 3.6 9.3 19.2 6.4 21.2
Greece 17.1 4.1 9.7 19.0 5.4 21.0
Hungary 17.6 4.6 14.7 5.5 7.1 7.1
Iceland 12.9 4.8 15.3 18.0 5.2 27.6
Ireland 16.2 5.7 11.8 11.0 5.3 11.7
Italy 22.9 2.4 12.2 3.4 5.7 5.1
Latvia 31.8 1.7 20.9 6.4 10.0 14.2
Liechtenstein 12.7 6.9 15.6 28.5 3.5 a
Lithuania 25.1 2.7 22.8 4.7 9.2 8.0
Malta 23.7 3.4 16.5 7.0 9.4 11.0
Moldova, 28.9 1.8 10.0 10.3 4.7 12.0
Republic of
Montenegro 26.2 2.7 10.8 7.1 6.2 6.5
Netherlands 16.0 4.0 22.1 8.5 8.8 10.6
Norway 14.3 4.8 21.6 13.4 7.3 14.0
Poland 15.4 4.1 16.6 8.3 7.0 9.2
Romania 26.7 2.1 14.5 7.5 6.7 9.1
Slovak Republic 21.2 3.8 16.1 3.9 7.2 7.7
Slovenia 18.8 4.7 11.4 9.7 6.0 10.3
Sweden 20.3 3.3 26.6 15.8 10.8 17.5
Ukraine 16.9 2.1 10.9 7.7 3.5 4.2
Total 20.3 3.1 15.4 7.6 6.7 9.8
Notes: PPS 5 perceived problems scale; AGT 5 average gaming time; PGI 5 problem gaming indicator; a 5 cannot be calculated since only
boys score positively on the PGI;
Source: 2015 ESPAD survey.
Journal of Behavioral Addictions 9 (2020) 3, 629–641 641

Table 8. Bivariate association between the PGI (using 2 h per day as the threshold) and substance use indicators (male students only)
ORs of scoring positively on the
ORs of scoring positively on the PGI PGI and smoking cigarettes in the ORs of scoring positively on the
and alcohol use in the last 30 days last 30 days PGI and lifetime cannabis use
Albania 2.2 1.6 1.3
Austria 0.6 0.7 0.6
Bulgaria 0.9 1.3 0.9
Croatia 1.1 0.9 1.0
Cyprus 1.3 1.0 0.8
Czech Republic 0.8 1.1 1.0
Denmark 0.7 0.3 0.3
Estonia 0.9 0.9 0.8
Faroe Islands 0.8 1.8 1.7
Finland 0.7 0.7 0.6
France 0.7 0.8 0.6
FYR Macedonia 1.9 1.3 1.0
Germany (Bavaria) 0.7 0.6 0.6
Georgia 2.4 0.9 0.6
Greece 0.8 0.9 0.9
Hungary 0.9 0.8 0.6
Iceland 0.7 0.8 0.5
Ireland 0.6 0.8 0.7
Italy 1.1 0.9 1.0
Latvia 0.3 0.4 0.2
Liechtenstein 0.2 0.5 1.0
Lithuania 1.3 0.8 0.9
Malta 0.8 0.8 0.8
Moldova, Republic of 1.0 0.9 1.2
Montenegro 1.3 0.9 1.2
Netherlands 0.8 0.9 0.8
Norway 0.9 1.1 1.2
Poland 1.1 0.9 0.7
Romania 1.0 1.3 1.0
Slovak Republic 1.1 1.2 0.5
Slovenia 1.0 1.3 1.1
Sweden 0.8 0.6 0.7
Ukraine 1.0 1.3 0.9
Total 0.9 0.9 0.8
Source: 2015 ESPAD survey.

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