The contemporary landscape of psychoactive substance regulation is characterized by a striking policy paradox. On one hand there is the gradual liberalization and mainstreaming of the cannabis market (the “Green Wave”), propelled by principles such as human rights, harm reduction, criminal justice reform, social equity, and economic efficiency. This coincides with a neo-prohibitionist tightening of regulations against non-combustible, harm reduction nicotine products (the “Nicotine Freeze”). This manuscript interrogates the toxicological, sociological, and bioethical inconsistencies driving this divergence. Decoupling the active compounds (THC and nicotine) from their traditional combustible delivery systems reveals a stark regulatory asymmetry. Toxicologically, while the primary harms of both substances appear to stem from combustion, state policies heavily restrict lower-risk, non-combustible nicotine alternatives while facilitating access to smokeable and edible cannabis. Neurocognitively, nicotine functions as a non-intoxicating stimulant with potential cognitive benefits, whereas cannabis, particularly sustained and heavy use, carries risks of cognitive impairment and psychosis. Furthermore, a glaring double standard exists regarding youth protection: the “gateway theory” and flavor bans are aggressively weaponized to prohibit nicotine alternatives, while cannabis products become progressively more palatable and include potentially youth-appealing flavored products with minimal precautionary resistance. Therefore, from a toxicological and public health perspective, these regulatory double standards indicate that the current treatment of nicotine versus cannabis repeats historical prohibition paradigms, which, despite toxicological arguments, were driven primarily by political ideology and prejudice rather than objective evidence. Sociologically, the strict prohibition of nicotine products ignores the “Iron Law of Prohibition,” inadvertently fostering unregulated black markets—a historical lesson policymakers readily accept regarding cannabis. Bioethically, cannabis legalization is championed under the banner of “cognitive liberty” and adult autonomy, whereas nicotine regulation has regressed into “hard paternalism,” infantilizing consumers and denying smokers’ access to life-saving substitutes. Current regulatory frameworks are no longer neutral; they enforce a moral hierarchy that protects the pursuit of cannabis while punishing the management of functional nicotine dependence. The foundational arguments that characterize the current trend of cannabis legalization are systematically ignored in the case of harm reduction nicotine products. To optimize public health outcomes, regulators must resolve this paradox by abandoning selective paternalism and applying a consistent, risk-proportionate harm-reduction paradigm to all psychoactive substances.
The volatile illicit drug supply continues to drive overdose and severe health harms among people who use drugs (PWUD). Community-based drug checking services (DCS) are a proactive harm reduction strategy; however, research on these services has relied on cross-sectional data, without examining participants’ engagement and drug samples over time. We conducted a quantitative panel drug checking study in the United States. Between March and November 2025, 57 PWUD were recruited from a syringe services program providing DCS with Fourier-transform infrared spectroscopy (FTIR) in Minnesota. Participants completed a baseline survey and up to seven weekly follow-up surveys, each paired with a drug sample for testing. We assessed retention, compared participant expectations with drug checking results, and measured within-person drug source change as the proportion of person-periods in which participants reported that the submitted sample came from the same source as the prior week. Participants demonstrated sustained engagement, with 65
Women who use drugs (WWUD) face substantial barriers to accessing medications for opioid use disorder (MOUD), including buprenorphine. As part of a formative evaluation to co-design a community-based intervention for MOUD delivery, we explored multi-stakeholder perspectives on the acceptability and delivery of buprenorphine for WWUD. We conducted qualitative interviews with 16 WWUD (who reported lifetime history of injection drug use) and 5 healthcare and harm reduction professionals (HHRP) who work closely with WWUD. Interviews asked open-ended questions about attitudes and beliefs towards buprenorphine, experience receiving (WWUD) or facilitating receipt (HHRP) of buprenorphine, and barriers to using buprenorphine in the future. Interviews were audio-recorded, professionally-transcribed, and coded using Rapid Assessment Process. Two coders generated templated coding summaries of each transcript, which were placed into a matrix and iteratively reviewed to identify cross-cutting themes. Qualitative learnings were finalized with the investigative team and confirmed with community advisors. Among 16 WWUD participants, 12 (75
Erroneous beliefs about gambling contribute to the development and maintenance of problem gambling and represent an important public health concern. Norsk Tipping (NT), the state-owned gambling operator in Norway, initiated the Spillepuls project to develop and evaluate preventive interventions for its online customers. This study evaluated an educational intervention that addressed gambling-specific misconceptions among users of NT’s online casino platform. The intervention compared different formats (video versus quiz), delivery modes (voluntary versus mandatory), and timing (pregame versus during play), against a non-intervention control group. The outcome measures comprised gambling behaviour and use of responsible gambling (RG) measures. The data were collected by NT as part of their routine operations. The experiment took place between May 2022 and January 2023. During this period, NT randomly assigned 18,981 new online casino customers to one of three conditions (Video, Quiz, or Control) on their third day of play. Customers allocated to the Video and Quiz conditions were subsequently randomized to one of three delivery modes: voluntary before gameplay, mandatory before gameplay, or mandatory during gameplay. No significant differences in gambling behaviour or uptake of RG measures were observed between the intervention groups and the control group. However, comparisons across the six intervention conditions revealed clear differences in engagement. Mandatory pregame delivery produced the highest completion rates, with a small but significant difference between the video and quiz formats (99.8
The principle “Nothing about us without us” underscores the ethical imperative to involve people with lived and living expertise in shaping harm reduction praxis. While the United States Veterans Health Administration (VHA) has expanded harm reduction initiatives, such as syringe services and naloxone distribution, over the past four years, Veterans with lived and living expertise (VWLLE) have not been meaningfully integrated into policy and program design. In response, VHA clinicians and advocates established the Harm Reduction Veteran Engagement Board (HR-VEB), a peer-supported initiative that positions VWLLE as partners in harm-reduction reforms. This perspective emphasizes structural barriers faced by Veterans who use drugs, highlights the leadership and work of HR-VEB members, and outlines policy and practice recommendations for designing more equitable care. Through the voices and work of Veterans, we argue that peer-led harm reduction is both evidence-based and a matter of social justice.
This study aimed to assess the comprehensiveness of existing policies, strategies, and research regarding harm reduction services for refugees and displaced populations in Lebanon, evaluating service availability, access barriers, and policy gaps to inform targeted and evidence-based interventions and improve health outcomes for this vulnerable group. A systematic review was conducted to examine substance use and harm reduction among refugees in accordance with PRISMA guidelines. The study protocol was registered in PROSPERO. PubMed, EMBASE, and Google Scholar databases were searched using free-text words and MeSH terms, including substance use, drug use, harm reduction, hepatitis C virus (HCV) screening, hepatitis B virus (HBV) screening, refugees, treatment access, and displaced population. Grey literature from the Lebanese Ministry of Public Health, World Health Organization, and other global reports was reviewed separately and included in the PRISMA flowchart, alongside peer-reviewed studies. The risk for bias in included research papers was evaluated using the Joanna Briggs Institute Critical Appraisal Tools. A total of 387 papers (369 peer-reviewed studies and 18 grey literature reports on harm reduction and substance use) were retrieved, and 29 were included in the review after screening and full-text evaluation (17peer reviewed articles and 12 grey literature reports). The results revealed a lack of structured harm reduction policies specifically targeting refugees. The identified barriers include legal restrictions, stigma, and poor integration of harm reduction services into healthcare programs. Of the 12 grey literature documents, only four mentioned harm reduction provision, and none offered a comprehensive strategy to enhance access for this vulnerable group. Many studies were general and lacked focused insights into substance use or harm reduction in refugee settings. The findings suggest that current policies require adaptation, as they inadequately address the specific vulnerabilities and barriers faced by refugee populations. Priority actions include adapting policies to refugee contexts, expanding mobile harm reduction clinics to improve accessibility, and integrating HCV screening into refugee healthcare services. Further targeted research is urgently required to characterize substance use patterns among refugees and develop evidence-informed interventions.
Intimate partner violence (IPV) and substance use are closely linked and pose significant risks during the perinatal period. American Indian and Alaska Native (AI/AN) women experience disproportionately high rates of IPV and inequities related to perinatal substance use outcomes, yet research is limited regarding timing of IPV exposure and how it relates to perinatal substance use. This study examined associations between IPV exposure before and during pregnancy and patterns of alcohol use and cigarette smoking across the perinatal and postpartum periods among AI/AN women. We analyzed pregnancy risk assessment monitoring system (PRAMS) data from 2016 to 2022 in a cross-sectional design. IPV exposure was categorized as occurring before pregnancy, during pregnancy, or both. Outcomes included alcohol use frequency, heavy drinking (≥ 8 drinks per week), and cigarette smoking before pregnancy, during pregnancy, and postpartum. Survey-weighted ordinal logistic and logistic regression models were used, adjusting for sociodemographic and pregnancy-related factors. Predicted probabilities were calculated. Exploratory analyses examined associations between partner race and IPV. AI/AN women reported higher prevalence of IPV before and during pregnancy (p < 0.001). In adjusted models, IPV before pregnancy was not associated with alcohol use frequency but was associated with higher odds of heavy drinking (aOR = 1.75, 95
Gender-based violence (GBV) and substance use are closely linked in the lives of trans women and travestis. However, mainstream harm reduction frameworks rarely address these issues or focus on community-based practices that emerge in response. In Brazil, trans women and travestis—who are disproportionately Black, engaged in sex work and exposed to lethal violence—navigate health systems marked by transphobia, racism, and the dismantling of harm reduction policies. This study examines how GBV and substance use intersect in their lives, and the role of peer-led harm reduction practices as technologies of care and life-sustaining strategies. This article draws on two multisited ethnographic studies conducted in Brazil between 2018 and 2023. The first (2018–2020) examined suffering, self-care, and community-based support among trans women and travestis in Rio de Janeiro, combining life history and semi-structured interviews. The second (2022–2023) explored sex work, violence, resistance, and practices of care among cis and trans women sex workers, through participant observation, semi-structured interviews, and rodas de conversa (collective conversation circles). The two studies were placed in dialogue and analysed using thematic analysis supported by the Framework Method, through an intersectional and socio-anthropological lens. Four interrelated themes emerged: (1) GBV was enacted across families, schools, health services, labour markets, and sex work spaces, producing cumulative trajectories of exclusion shaped by racism, cisnormativity, and class inequality; (2) substance use was inseparable from trauma, social suffering, and the labour conditions of sex work—embedded in an economy of survival rather than reducible to individual pathology; (3) despite structural exclusion, participants generated situated harm reduction practices—peer-led outreach, informal knowledge networks, collective care, and mutual protection—functioning as counter-hegemonic forms of health knowledge; (4) participants re-signified marginality as a site of agency, transforming exclusion into professional expertise, chosen kinship, and political activism. This study advances a conception of harm reduction that is intersectional, decolonial, and politically grounded. It demonstrates that GBV is not peripheral to substance use but constitutive of it, and that lived experience-generated knowledge, forged in structural oppression, is a legitimate foundation for harm reduction practices. These findings call for frameworks that move beyond individual risk reduction toward a social determination of health perspective—locating harm in intersecting systems of racism, transphobia, patriarchy, and criminalisation of sex work. Trans women and travestis must be recognised not only as populations exposed to harm, but as producers of care, knowledge, and political claims whose expertise is indispensable to advancing harm reduction theory and practice.
LGBTQA+ people are at greater risk of using cannabis at earlier ages, in greater frequencies and quantities and over longer periods of time compared with their cisgendered, heterosexual peers. Prescribed medicinal cannabis is becoming increasingly commonly utilised in Australia to treat a variety of conditions including pain, mental health diagnoses and sleep. There is currently little research looking into the motivations and experiences of LGBTQA+ people accessing medical cannabis (MC) through healthcare providers. To explore differences in patterns, reasons for using, and experiences of accessing medicinal cannabis between LGBTQA+ people and their cisgender, heterosexual peers. We utilised data collected from an online anonymous cross-sectional survey of individuals (CAMS-22 survey), consisting of adult Australians who had utilised cannabis to treat a medical condition in the previous year. Participants were asked questions about their gender and sexuality, demographic characteristics, patterns and characteristics of MC use, conditions treated, and accessibility to and satisfaction of treatment. Of the 3107 respondents included in these analyses, 2332 (77.3
Since their introduction in 2014, heated tobacco products (HTPs) have entered a growing number of countries. However, few studies have systematically compared their affordability with that of cigarettes or examined differences in access across income groups. This study assessed the affordability of HTPs relative to combustible cigarettes with a focus on socioeconomic disparities. Using publicly available data from the World Health Organization, World Bank, and industry sources, we compared retail prices, affordability, and tax shares across 55 countries with complete analytical data. Affordability was measured as the share of GDP per capita required to purchase 100 packs. Income distribution data were used to assess affordability across income quintiles. HTP sticks were more expensive than the most-sold cigarette brand in 23 countries and more expensive than the cheapest cigarette brand in 44 countries. In all 9 lower-middle-income countries and 10 of 16 upper-middle-income countries, HTPs were more expensive than the most-sold cigarette brand; in 24 of 30 high-income countries, they were cheaper. HTPs were not marketed in low-income countries. In lower-middle-income countries, purchasing 100 packs required 7.9
Survivors of sex trafficking often experience co-occurring substance use and face significant barriers to accessing care. Harm reduction offers a nonjudgmental, survivor-centered approach to mitigating health risks associated with substance use and commercial sex. However, limited research has explored how harm reduction is understood and implemented by service providers working with this population. This study aimed to examine service providers’ perspectives on the role, impact, and challenges of harm reduction in supporting survivors of sex trafficking who use substances. This qualitative study employed purposive and snowball sampling to recruit 21 service providers from human trafficking, domestic violence, and other agencies across the southwestern US who serve survivors of sex trafficking. Semi-structured interviews were conducted to explore participants’ experiences with harm reduction strategies, perceived barriers, and relational dynamics in service provision. Interviews were transcribed verbatim and analyzed using thematic analysis, following Braun and Clarke’s six-step process. A constant comparative method was used to refine codes and identify emergent themes. Five major themes were identified: (1) comprehensive harm reduction as a lifesaving strategy, (2) education and health literacy as critical intervention tools, (3) navigating barriers to harm reduction, (4) relational foundations of harm reduction, and (5) ambivalence toward harm reduction as a standalone strategy. Participants described harm reduction as essential to preventing overdose, reducing disease transmission, and fostering engagement through nonjudgmental care. They emphasized the importance of peer-led outreach, trauma-informed education, and holistic support that includes meeting basic needs. However, providers also reported legal and institutional constraints, funding challenges, and public misconceptions that hindered implementation. A minority of participants expressed ambivalence about harm reduction, reflecting ongoing tensions between abstinence-based and non-abstinence approaches. Harm reduction is viewed by providers as a vital, relational, and flexible approach to supporting survivors of sex trafficking who use substances. Findings highlight the need for policy reform, increased investment in peer-led and trauma-informed models, and broader cultural shifts to reduce stigma. Future research should include survivor perspectives and explore harm reduction strategies across diverse geographic and demographic contexts.
Opioid use disorder (OUD) is a major source of morbidity and mortality in the United States. While substantial evidence supports the effectiveness of medications for opioid disorder (MOUD), 80
Abstract Background People with illicit opioid use have a high risk of overdose related morbidity and mortality. A small group of Supersavers (i.e., individuals who have administered naloxone on three or more overdose occasions) carries a substantial burden by managing a high proportion of overdose reversals. Despite their critical role, little is known about how Supersavers’ experiences of repeated overdose reversals, their own overdose risks and its mitigation, or the support needed to sustain their engagement. This study examines Supersavers’ contextual experiences, their views on risks, responsibility, and overdose engagement, and their need for healthcare support. Methods Semi-structured interviews were conducted with thirteen Supersavers recruited from Malmö needle and syringe program. Thematic analysis was conducted whereupon analysis was guided by Bourdieu’s theories on habitus, capital and field and Rhode’s ‘risk environment’ framework. Results Supersavers were deeply committed to helping others and widely recognized for their skills, often having managed multiple overdoses prior to naloxone availability. This responsibility functioned as an embodied readiness to act, reflecting a habitus shaped through repeated exposure and supported by experiential (“street”) capital, including technical skills and peer trust. Access to training and naloxone strengthened this capacity, increasing perceived safety and reducing the physical and emotional burden of overdose reversals. While repeated exposure to overdose contributed to normalization, it also involved cumulative emotional strain, and most participants had not sought professional support despite experiencing multiple traumas. Conclusion These findings show how Supersavers’ practices emerge through the interplay of habitus, capital, and risk environment, where engagement is sustained by responsibility yet shaped by structural constraints. Strengthening harm reduction responses requires not only continued access to naloxone and training, but also accessible, context-sensitive healthcare support that addresses both Supersavers’ own overdose risk and the emotional burden associated with repeated reversals. Trial registration NCT03570099, registered on 26 June 2018.
Young people across the world use opioids and experience drug-related harms yet remain excluded from many opioid-related harm reduction policies and services. In this commentary, we trace our collective advocacy as young people who use opioids and youth harm reduction workers from Canada, Indonesia, Kenya, Mexico, Uganda, and the United States. Specifically, we describe the creation of our Youth RISE cohort in 2023 and our community engagement to strengthen access to harm reduction for young people globally. Over a two-month period, we held weekly online meetings where we exchanged perspectives and experiences with three set thematic discussion topics—needs, challenges, and recommendations—related to youth opioid use and harm reduction within our respective countries. Our work reflects the challenges we have faced confronting entrenched prohibitionist policies and navigating services that stigmatize and control young people who use opioids. Despite these challenges, we share a commitment to advance person-centered harm reduction and push for structural reforms to improve the health and rights of young people who use opioids and other drugs. Recommendations from our work together converge on the need to move beyond punitive approaches toward comprehensive, youth-tailored harm reduction grounded in evidence, equity, and human rights. Specifically, we call for investment in youth-tailored harm reduction programs (e.g., drug-checking, supervised consumption spaces, naloxone), prescribed alternatives, comprehensive drug education, and systemic action to address the stigma and surveillance that come with abstinence-focused approaches to youth opioid use. Beyond this, we argue that meaningful youth engagement is essential to genuinely resourcing youth harm reduction and ensuring that it effectively responds to young people’s diverse and evolving realities of opioid use amid the harms of criminalization and prohibitionist-based drug policies.
Research studies that include adults who smoke conventional combustible tobacco cigarettes (cigarettes) commonly use exhaled carbon monoxide (eCO) as a biomarker of cigarette usage. eCO is regularly used as an inclusion or exclusion criterion. Multiple studies have examined the time course of eCO levels after acute use of cigarettes. Published studies have verified the relationship between the reported number of cigarettes smoked per day (CPD) and eCO levels. One article suggested that collection time of day may induce variations in eCO elimination. Researchers can improve recruitment if there is confidence that collection time does not significantly affect eCO. We analyzed data from eight separate studies conducted between 2019 and 2024 that collected eCO levels from adults who were not abstinent from smoking, after they reported their usual consumption patterns of cigarettes, to determine whether collection time or CPD had a significant effect on eCO levels. Data analyzed included eCO levels, collection times of eCO levels, and reported CPD smoked. In the aggregate data, collection time did not result in significant changes in eCO levels (p = 0.87), as assessed throughout typical clinical hours (08:00 to 18:00). In contrast, and as expected, eCO levels were significantly impacted by CPD (p < 0.001). This finding verifies that screening eCO levels may be obtained throughout the day while minimally impacting eCO levels, allowing for greater flexibility in scheduling individuals for participation in research studies which require evaluation of smoking status.
Abstract Background People who inject drugs (PWID) are at increased risk of infective endocarditis (IE). While opioid injection is a major risk factor for IE, the risk associated with specific prescription opioids, such as hydromorphone, remains unclear and is inconsistently reported, despite a hypothesized pathway whereby the insolubility of controlled-releaseformulations may promote injection equipment reuse and bacterial contamination. Therefore, we estimated and compared the 1-year incidence rates of IE among PWID reporting injection of hydromorphone versus non-hydromorphone opioid medications and versus other opioids/drugs. Methods Baseline questionnaire data on PWID in the Ontario Integrated Supervised Injection Services cohort (November 2018–March 2020) were linked to health administrative databases. IE incidence was calculated over 1-year post-baseline. Participants were followed until first of IE, death, or 1-year censoring. Exposure was self-reported recent (past 6 months) injection of: hydromorphone, non-hydromorphone opioid medications of interest, or other opioids/drugs. Cox regression estimated associations, adjusting for age, gender, ethnicity, injection drug use, and prior injection-related infections. Results Among the 514 participants included, 191 reported recent injection of hydromorphone, 32 non-hydromorphone opioid medications of interest, and 291 other opioids/drugs. IE incidence rates were low across groups: 1.6, 3.3, and 1.8 per 100 person-years. Adjusted hazard ratio comparing recent hydromorphone injection versus non-hydromorphone opioid medications of interest was 0.64 (95% confidence interval (CI) 0.06–6.53); versus other opioids/drugs was 0.82 (95% CI 0.19–3.51). Conclusions In this cohort of PWID, no clear association was found between hydromorphone injection and IE when compared to non-hydromorphone opioid medications or to other opioids/drugs. Due to low event rates and the resulting wide CIs, the findings are limited by low statistical precision. Further research with larger cohorts is warranted to quantify IE risk of specific injected drugs among PWID.
Abstract Background Injection opioid use is associated with fatal and non-fatal harms including accidental overdose and infectious diseases. Syringe service programs offer sterile injection equipment and safer injection training to reduce the incidence of injection-related harms. Nevertheless, factors that might reduce adherence to safer injection practices are understudied. This report explores pain as one such factor. Methods People who inject opioids (n = 130) were recruited from a syringe service program for a cross-sectional survey assessing the relationship between fluctuations in pain severity and adherence to safer injection practices over the past 7 days. Results A within-subjects Sign Test analysis revealed participants’ adherence to safer injection practices fluctuated with changes in pain severity. When their pain was at its worst, participants reported they less often engaged in hand washing (Z −5.63, P < .001), cleaning the injection site (Z −5.29, P < .001), and waiting until in a clean safe place to inject (Z −3.94, P < .001). Additionally, they more often reused their own injection equipment (Z −2.55, P = .011), and injected faster, or at a higher dose (Z −2.71, P = .007) when in worse pain. Conclusions This study provides initial evidence that pain is associated with reduced adherence to safer injection practices among people who inject opioids. Although all study participants received training in safer injection practices and cost-free sterile injection equipment, within-subject adherence to safer use practices varied significantly under conditions of best and worst pain.
Abstract Background Stigma experienced by individuals with cannabis use disorder (CUD) has been identified as a significant impediment to their engagement with treatment programs. Therefore, this study aims to investigate the effect of sociodemographic factors and familiarity with cannabis on stigmatizing attributions towards adolescent and adult case vignettes of people affected by CUD. Method A quota sampling web survey in Germany conducted by a professional survey institute including two case vignettes of people with a CUD, applying a 2 × 2 × 2 (age of vignette* age of participant*familiarity with cannabis/CUD) within-subject design. Sociodemographic information, questions about participants’ cannabis use experience, a measure of stigmatizing attitudes, and a short version of the attribution questionnaire. Results A total sample of n = 1603 (50.1% female) participants was recruited, with n = 501 being adolescent participants. Subjective social standing of the whole sample was slightly elevated (Mean social rank (SD) = 5.74 (1.8)). The adolescent case with a CUD was more stigmatized compared to an adult case (F(1, 3196) = 12.77; p < 0.001). Individuals who were more familiar with cannabis use (F(1,3196) = 19.65; p < 0.001) and/or CUD (F(1,3196) = 6.00; p =0 .014) reported fewer stigmatizing attributions. This effect of familiarity was more pronounced for adolescents compared to adults. Conclusions Adults with CUD seem to receive less stigma compared to adolescents with CUD, while stigmatizing attributions are produced less often when people have more contact with cannabis use and CUD. Future studies should aim to systematically test the influence of different characteristics of stigmatizing persons on stigma production in order to offer tailored interventions.
Sports sponsorship by commercial betting providers is an essential source of income for sports entities worldwide. This study examines the formation of betting behavior in sporting events using predictor variables, namely, self-congruence, perceived exposure, subjective norms, goodwill, and involvement, to predict betting intention and actual gambling behavior, comparing linear (PLS-SEM) and nonlinear (artificial neural networks-ANN) methods. Data from 661 Spanish subjects were analyzed. The results of the PLS-SEM model identified subjective norms and self-congruence as the main predictors of betting intention, whereas goodwill showed limited effects. However, the ANN analysis revealed complex patterns not detected by linear methods, where variables such as goodwill acquire greater relative importance when considering complex interactions between variables. The research contributes theoretically by highlighting the need to adopt conceptual frameworks that consider the complex interaction between psychosocial variables, overcoming traditional models that analyze the determinants of gambling behavior in isolation. Additionally, it provides new knowledge about the differentiated and complementary influence of self-congruence, perceived exposure, goodwill, and involvement in predicting gambling behavior, constructs that had not been systematically integrated into a joint predictive model. Methodologically, it contributes by demonstrating that the integration of SEM and ANN approaches improves the robustness and validity of the analysis, offering a more complete view of the factors that influence the intention to gamble. The findings have practical implications for the design of more effective problem gambling prevention strategies and regulations.
