Abstract
Background:
Online gambling and sports betting have recently been legalized and expanded in North America. We aimed to evaluate long-term changes in the frequency of gambling-related helpline contacts in the province of Ontario following the launch of a government-operated online gambling platform (PlayOLG) in January 2015 and the expansion of private online gambling, including single-event sports betting, in April 2022.
Methods:
We conducted an interrupted time-series analysis of contacts with Ontario’s free 24-hour mental health and addictions helpline (ConnexOntario) between January 2012 and September 2025. We used segmented linear regression to compare immediate, gradual, and overall changes in monthly rates of gambling-related contacts after gambling expansion in January 2015 and April 2022 overall and by age and gender subgroups.
Results:
Over 13 years, ConnexOntario received 745 716 contacts, including 37 087 (5.0%, mean age 39 yr, 68.2% men) related to gambling. The mean monthly rate of gambling-related contacts per 1 000 000 individuals aged 15 years and older was stable over time before the launch of PlayOLG (13.4); the rate increased after Play-OLG’s launch (17.0) and further increased following privatization (26.2). Compared with the scenario in which PlayOLG never launched, the estimated effect was 9.3 (95% confidence interval [CI] 1.04 to 17.5) additional monthly contacts per million individuals aged 15 years and older in February 2022 (an approximately 80.7% increase). Compared with the scenario in which neither PlayOLG nor private online gambling was allowed, the estimated effect was 20.8 (95% CI 8.5 to 33.2) additional monthly contacts per million individuals aged 15 years and older in September 2025 (an approximately 198.3% increase). Increases in gambling-related contacts occurred almost exclusively in adolescent boys and men aged 15 to 44 years. Compared with no private online gambling, and no private online gambling or PlayOLG, gambling-related contacts in adolescent boys and men aged 15 to 24 years were estimated to have increased by 144% and 337.8%, respectively.
Interpretation:
The introduction of online gambling and subsequent privatization with single-event sports betting were each associated with substantial increases in gambling-related helpline contacts, specifically in adolescent boys and young men, suggesting increased gambling problems, care-seeking, or both. This underscores the need to strengthen preventive measures and treatment access.
Over the past decade, gambling regulation in North America has shifted toward increasing liberalization.1 In 2018, the US supreme court removed federal restrictions on sports betting, leading to rapid expansion across multiple states.2 In Canada, federal legislation amending the criminal code passed in 2021 legalized single-event sports betting, allowing provinces and territories to choose how to regulate sports betting within their jurisdictions.3 Although the expansion of gambling availability in North America, coupled with high-volume advertising and promotion,4 has raised concerns that market liberalization may exacerbate gambling-related harms,5, 6, few studies have evaluated changes in gambling-related harms following gambling liberalization.7
Gambling can be addictive and is associated with adverse outcomes, including depression, anxiety, financial hardship, relationship disruption, and suicidality.8 In 2018, an estimated 64.5% of Canadians reported past-year gambling (most participated in lotteries or raffles), and 1.6% of past-year gamblers were at moderate or severe risk of a gambling disorder.9 A substantial proportion of harms from gambling occur in individuals for whom gambling is not severe enough to meet criteria for a gambling disorder. Further, gambling causes harm not just to gamblers but also to their families, communities, and society at large.8 Global evidence links increases in the availability of gambling to increased gambling participation and harms, at least in the short term. Reviews support a dose–response relationship between gambling advertising exposure and more favourable gambling attitudes, intention to gamble, and actual gambling.10
Several policy changes in Ontario, Canada’s most populous province, present an opportunity to evaluate gambling liberalization. In January 2015, the Government of Ontario began offering online gambling through a government-run online platform, Play-OLG, with online lottery, casino, and instant games.11 In April 2022, Ontario expanded online gambling, allowing private companies to offer legal online gambling services, including sports betting. Under this expanded model, private companies can apply for licences to provide and advertise online betting and casino products. In 2023/24, 49 private operators, including some of the largest multinational gambling corporations in the world, offered 80 gaming and betting sites, with total wagers of $63 billion from more than 2.1 million active player accounts.12 We sought to evaluate long-term changes in the frequency of gambling-related helpline contacts in Ontario after the liberalization of online gambling, overall and by age and gender.
Methods
We conducted a repeated cross-sectional study with an interrupted time-series design to examine changes in helpline contacts for gambling-related problems following liberalization of online gambling in Ontario. We obtained monthly counts of total and gambling-related contacts to ConnexOntario from January 2012 to September 2025.
ConnexOntario is a free and confidential 24-hour information and referral service for mental health, addictions, and problem gambling, which is funded by the Government of Ontario. Individuals of any age can contact ConnexOntario for themselves or another individual by telephone, live chat, email (introduced in 2012), or text (introduced in 2021). ConnexOntario was first established in 1991 for drug and alcohol concerns and added helplines for gambling and mental health concerns in 1997 and 2005, respectively. In 2018, the 3 helplines were consolidated.
ConnexOntario’s contact information is included in all legal gambling advertising and websites, on all lottery tickets and slot machines, and within responsible gambling centres located in Ontario casinos. In addition, the general (non–gambling specific) ConnexOntario contact information is promoted by community organizations, health system partners, and government mental health campaigns. Trained ConnexOntario responders classify the reason for contact, record demographic information, and note any services or referrals provided, using standardized intake fields. The legal age of gambling in Ontario is 18 years; however, gambling harms can occur in those below the legal age. We included contacts from individuals aged 15 years and older, consistent with World Health Organization surveillance approaches for alcohol.13
We obtained monthly population estimates for Ontario from Statistics Canada.14 We obtained the number of active player accounts and the total online wagers (which exceed net losses, as gambling participants can re-wager winnings) in Canadian dollars per month from iGaming Ontario, the government agency that manages the private market for online gambling. Licensed operators are mandated to report active player accounts and wagers in their operating agreements.
We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines in the reporting of this study.
Observation period
We divided the study into 4 policy periods: before launch of Play-OLG (January 2012 to December 2014: 36 months), after launch of PlayOLG (January 2015 to February 2020: 62 months), COVID-19 pandemic period (March 2020 to March 2022: 25 months), and after establishment of a private market for online gambling including single-event sports gambling (April 2022 to September 2025: 42 months).
Casinos shut down across Ontario on Mar. 16, 2020, by government order owing to the COVID-19 pandemic. Casinos had fluctuating closures and capacity restrictions, with the last restrictions on in-person gambling being lifted in February 2022.15
Outcome measures
The primary outcome was any contact (telephone, text, email, or live message) to ConnexOntario that was identified as being primarily gambling related. The primary concern of a contact is identified by a trained responder according to the contactor’s stated needs and the support sought.
While evidence indicates that only a small proportion of individuals with gambling disorders or gambling harms seek care,16 prior studies have found that helplines are the most common first point of contact and the most used resource for gambling problems.17,18 ConnexOntario contacts for gambling have been previously used in gambling research as indicators of gambling disorders and problems.19
We had 2 secondary outcomes. First, for contactors who identified the type of gambling, we identified 6 categories of gambling types: table games (e.g., poker and blackjack), sports betting, electronic gaming machines (e.g., slots and video lottery terminals), lotteries, online gambling, and other gambling (i.e., stocks, cryptocurrency, bingo, and racing). Collection of information about online gambling began in July 2021.
Second, we examined the outcomes of the contact (no referral, bed-based treatment, counselling and treatment, and non-gambling-related referral). For most referrals, ConnexOntario responders provide contactors with information on how to contact or book an appointment with the relevant service.
Statistical analysis
We obtained the demographic information of service users at the time of contact for gambling-related harms, including age, gender, and type of gambling.
We calculated the counts and rates of gambling-related helpline contacts per 1 000 000 individuals aged 15 years and older and per total helpline contacts for any reason. We summarized helpline contacts across the 4 different policy periods. We used segmented linear regression analyses to examine immediate (intercept) and gradual (slope) changes in the monthly rates of gambling and contacts after the launch of PlayOLG and the launch of the private market. We omitted data from the COVID-19 pandemic period from models owing to the impact of the pandemic on in-person gambling activities.
We accounted for seasonality by including indicators for each month and presented de-seasonalized rates with the season fixed in November. Models were estimated using restricted maximum likelihood and included a first-order autoregressive covariance structure.20 The total effect (combined intercept and slope changes) was estimated by comparing the model-based estimated rate at the end of the study period to the counterfactual rate projected from the pre-policy trend, representing the estimated rate at the end of the study had the policy change not occurred (see Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.251894/tab-related-content, for calculation details).21 We calculated 3 counterfactual scenarios: first, if Play-OLG never launched; second, if privatization never occurred after PlayOLG launched; and third, with neither PlayOLG nor market privatization. We also estimated relative effects by comparing the ratio of the modelled rates with the counterfactual rates. We conducted analyses in SAS 9.4 (SAS Institute) between October and November 2025.
Subgroup analyses
We completed stratified analyses of changes in per capita rates by 8 age and gender strata (ages 15 to 24, 25 to 44, 45 to 64, and ≥ 65 yr for men and women).
Internal control
We compared changes in gambling-related contacts to total contact volume for mental health and addictions. We used total contact volume to control for changes in population-level mental health or awareness of ConnexOntario.
Ethics approval
The use of the data in this study was exempt from research ethics board review as the data were deidentified and publicly available on request from ConnexOntario.
Results
A total of 745 716 helpline contacts occurred during the study period, of which 37 087 (5.0%) were gambling related. The following characteristics reflect the person with a gambling-related problem, even in cases when someone else contacted ConnexOntario on their behalf. The mean age of individuals with gambling-related concerns was 39 years, and 68.2% of contacts were from men. Over the study period, 72.3% of gambling-related contacts were by telephone, 21.1% were via online live chat, and the rest were by email or text. Most gambling-related contacts were self-initiated (68.5%), 21.7% of contacts came from family members, and the rest came from friends or health care professionals. The specific type of gambling was recorded for 22 922 (61.8%) of contacts, with the most common types being electronic gaming machines (45.6%), table games (25.0%), and sports gambling (12.4%). Between April 2022 and September 2025, 76.0% of gambling-related contacts were for online gambling. Most contacts were referred for additional gambling-specific care, including counselling and treatment (61.6%), family support (7.8%), or admission to a treatment facility (4.8%) (Table 1).
Table 1:
Characteristics of gambling-related helpline contacts to ConnexOntario*
| Characteristic | No. (%) of contacts† | ||||
|---|---|---|---|---|---|
| Whole study (Jan. 2012 to Sept. 2025) | Before launch of PlayOLG (Jan. 2012 to Dec. 2014) | Launch of PlayOLG (Jan. 2015 to Feb. 2020) | COVID-19 pandemic (Mar. 2020 to Mar. 2022) | After policy (Apr. 2022 to Sept. 2025) | |
| Total contacts | 37 087 | 5456 | 12 566 | 4198 | 14 867 |
| Gender | |||||
| Men | 25 281 (68.2) | 3442 (63.1) | 8104 (64.5) | 2984 (71.1) | 10 751 (72.3) |
| Women | 10 004 (27.0) | 1997 (36.6) | 3759 (29.9) | 1050 (25.0) | 3198 (21.5) |
| Nonbinary | 54 (0.1) | 0 (0.0) | 0 (0.0) | 6 (0.1) | 48 (0.3) |
| Not identified | 1748 (4.7) | 17 (0.3) | 703 (5.6) | 158 (3.8) | 870 (5.9) |
| Age, yr | |||||
| Mean | 39 | 43 | 42 | 38 | 37 |
| 15–24 | 5763 (15.5) | 567 (10.4) | 1479 (11.8) | 739 (17.6) | 2978 (20.0) |
| 25–44 | 16 234 (43.8) | 2328 (42.7) | 5005 (39.8) | 1925 (45.9) | 6976 (46.9) |
| 45–64 | 10 162 (27.4) | 1997 (36.6) | 4074 (32.4) | 1097 (26.1) | 2994 (20.1) |
| ≥ 65 | 2260 (6.1) | 519 (9.5) | 899 (7.2) | 189 (4.5) | 653 (4.4) |
| Not identified | 2668 (7.2) | 45 (0.8) | 1109 (8.8) | 248 (5.9) | 1266 (8.5) |
| Type of gambling | |||||
| General gambling disorder | 4818 (13.0) | 31 (0.6) | 1652 (13.1) | 1112 (26.5) | 2023 (13.6) |
| Specific type identified | 22 922 (61.8) | 4677 (85.7) | 7176 (57.1) | 1438 (34.3) | 9631 (64.8) |
| Not identified | 9317 (25.1) | 748 (13.7) | 3732 (29.7) | 1642 (39.1) | 3195 (21.5) |
| Did not provide | 30 (0.1) | 0 (0.0) | 6 (0.0) | 6 (0.1) | 18 (0.1) |
| Type of gambling in those identified‡ | |||||
| Any (online or non-online) | n = 22 922 | n = 4677 | n = 7176 | n = 1438 | n = 9631 |
| EGMs§ | 10 460 (45.7) | 2934 (62.7) | 4292 (59.8) | 436 (30.3) | 2940 (30.5) |
| Lottery and scratch cards | 1674 (7.3) | 481 (10.3) | 720 (10.0) | 227 (15.8) | 358 (3.7) |
| Table games§ | 5721 (25.0) | 1339 (28.6) | 2118 (29.5) | 341 (23.7) | 2207 (22.9) |
| Sports betting | 2837 (12.4) | 353 (7.5) | 581 (8.1) | 199 (13.8) | 1748 (18.1) |
| Other§ | 1158 (5.1) | 299 (6.4) | 473 (6.6) | 92 (6.4) | 307 (3.2) |
| Online specific¶ | n = 22 922 | n = 1438 | n = 9631 | ||
| Any online gambling | 7613 (33.2) | NC | NC | 290 (20.2) | 7323 (76.0) |
| EGMs§ | 1558 (6.8) | NC | NC | 0 (0.0) | 1558 (16.2) |
| Table games§ | 1145 (5.0) | NC | NC | 0 (0.0) | 1145 (11.9) |
| Sports betting | 1215 (5.3) | NC | NC | 0 (0.0) | 1215 (12.6) |
| Outcome of contact | |||||
| No referral | 7566 (20.4) | 47 (0.9) | 3283 (26.1) | 1133 (27.0) | 3103 (20.9) |
| Counselling and treatment | 22 853 (61.6) | 3511 (64.4) | 7292 (58.0) | 2212 (52.7) | 9838 (66.2) |
| Bed-based treatment | 1791 (4.8) | 221 (4.1) | 393 (3.1) | 170 (4.0) | 1007 (6.8) |
| Family support | 2908 (7.8) | 86 (1.6) | 284 (2.3) | 230 (5.5) | 2308 (15.5) |
| Non-gambling-related services | 5201 (14.0) | 572 (10.5) | 1537 (12.2) | 786 (18.7) | 2306 (15.5) |
| Other | 2033 (5.5) | 1186 (21.7) | 94 (0.8) | 145 (3.5) | 608 (4.1) |
Note: EGM = electronic gaming machine, NC = not collected.
Individuals can contact ConnexOntario for themselves or another person. Characteristics reflect the person with gambling-related problems even when the contactor is another person.
Unless stated otherwise.
Sums to more than 100%, as individuals can indicate more than 1 response
Examples of EGMs include slot machines and video lottery gaming terminals. Examples of table games include poker and blackjack. “Other” includes bingo, racing, cryptocurrency, and stock trading.
Before July 2021, ConnexOntario did not ask about whether gambling activities were online. Questions about online gambling and type were added in July 2021.
Overall changes
The mean monthly rate of gambling-related contacts per million individuals was 13.4 in the period before the launch of PlayOLG, increased to 17.0 following the launch of PlayOLG, declined to 13.4 during the COVID-19 pandemic period, and increased to 26.2 after privatization of online gambling. This represents a 95.5% relative increase from the period before the launch of PlayOLG to the period after privatization (Table 2).
Table 2:
Total and gambling-related contacts in Ontario by policy period between January 2012 and September 2025
| Characteristic (population at risk in 2022) | Whole study (Jan. 2012 to Sept. 2025) | Before launch of PlayOLG (Jan. 2012 to Dec. 2014) | Launch of PlayOLG (Jan. 2015 to Feb. 2020) | COVID-19 pandemic (Mar. 2020 to Mar. 2022) | Private market expansion (Apr. 2022 to Sept. 2025) | Relative change in mean monthly rates private market v. pre-PlayOLG, % | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. (%)contacts* | Mean monthly rate per 1 000 000 | No. (%)events | Mean monthly rate per 1 000 000* | No. (%)events | Mean monthly rate per 1 000 000 | No. (%)events | Mean monthly rate per 1 000 000 | No. (%)events | Mean monthly rate per 1 000 000 | ||
| Overall contacts (12 840 379) | |||||||||||
| Total contacts | 745 716 | 370.9 | 114 017 | 280.3 | 361 844 | 491.3 | 107 403 | 342.8 | 162 452 | 287.8 | 2.7 |
| Gambling | 37 087 | 18.1 | 5456 | 13.4 | 12 566 | 17.0 | 4198 | 13.4 | 14 867 | 26.2 | 95.5 |
| (5.0) | (4.8) | (3.5) | (3.9) | (9.2) | |||||||
| Gambling-related contacts by age and gender † | |||||||||||
| Adolescent boys and men; age, yr | |||||||||||
| 15–24, n = 982 566 | 4666 (12.6) | 28.1 | 462 (8.5) | 13.8 | 1120 (8.9) | 18.9 | 527 (12.6) | 22.0 | 2557 (17.2) | 57.5 | 316.7 |
| 25–44 n = 2 163 342 | 12 138 (32.7) | 35.4 | 1670 (30.6) | 26.1 | 3657 (29.1) | 31.3 | 1414 (33.7) | 27.3 | 5397 (36.3) | 54.4 | 108.4 |
| 45–64 n = 1 929 084 | 6218 (16.8) | 19.6 | 1053 (19.3) | 15.5 | 2471 (19.7) | 20.6 | 788 (18.8) | 16.3 | 1906 (12.8) | 23.6 | 52.3 |
| ≥ 65 n = 1 258 356 | 1081 (2.9) | 5.9 | 233 (4.3) | 7.1 | 411 (3.3) | 6.3 | 101 (2.4) | 3.3 | 336 (2.3) | 6.0 | −4.0 |
| Adolescent girls and women; age, yr | |||||||||||
| 15–24 n = 902 126 | 708 (1.9) | 4.7 | 94 (1.7) | 3.0 | 232 (1.9) | 4.3 | 131 (3.1) | 5.9 | 251 (1.7) | 6.3 | 110.0 |
| 25–44 n = 2 087 085 | 3782 (10.2) | 11.4 | 655 (12.0) | 9.9 | 1260 (10.0) | 10.7 | 461 (11.0) | 9.1 | 1406 (9.5) | 14.9 | 50.5 |
| 45–64 n = 2 012 741 | 3821 (10.3) | 11.7 | 939 (17.2) | 13.5 | 1552 (12.4) | 12.6 | 295 (7.0) | 5.9 | 1035 (7.0) | 12.2 | −9.6 |
| ≥ 65 n = 1 504 979 | 1144 (3.1) | 5.3 | 284 (5.2) | 7.0 | 470 (3.7) | 5.9 | 86 (2.1) | 2.4 | 304 (2.0) | 4.6 | −34.3 |
Percentage for overall contacts is of total contacts; percentage for gambling-related contacts is of total gambling-related contacts.
Sum of age and gender not equal to total number of gambling contacts, as not all contactors identified age or gender.
Figure 1A illustrates changes in the mean monthly wagers in Canadian dollars per individual and active player counts per 100 000 individuals in Ontario from private online gambling websites between April 2022 and August 2025. Total monthly wagers (which exceed net losses, as winnings can be bet again) increased by 654% from $1.08 billion in April 2022 to $8.1 billion in August 2025 ($84.00 to $633.90 monthly per Ontario resident), and active player accounts per 100 000 individuals aged 15 years and older increased by 239.2% (2157.3 to 7316.4).
Figure. 1:
(A) Total monthly wagers in billion Canadian dollars and active player counts per 100 000 individuals from private online gambling websites in Ontario between April 2022 and August 2025. Active player accounts are defined as accounts that made at least 1 wager in the month, and individuals can have more than 1 active player account. Total online wagers exceed net gambling losses as gambling participants frequently re-wager winnings, so that the same initial money may be bet repeatedly over a period. (B) Monthly rate of gambling-related contacts per 1 000 000 individuals aged 15 years and older between January 2012 and September 2025. The first dashed line indicates the launch of PlayOLG, the second dashed line indicates the start of the COVID-19 pandemic in Ontario, and the third dashed line indicates the launch of Ontario’s private gambling market. Dots represent observed monthly values, and the line represents the model fit with shading showing 95% confidence intervals. Models are adjusted for seasonality with season fixed to November.
Figure 1B shows changes in the monthly rates of gambling-related contacts between January 2012 and September 2025. Before the launch of PlayOLG, gambling-related contacts were stable (monthly slope of −0.02, 95% confidence interval [CI] −0.12 to 0.08). No immediate changes in gambling-related contacts occurred after either policy change. However, rates of gambling-related contacts per 1 000 000 individuals began increasing by an additional 0.13 (95% CI 0.09 to 0.18) contacts per month after the launch of PlayOLG and further accelerated, increasing by an additional 0.25 (95% CI 0.17 to 0.33) contacts per month after privatization. Across 3 counterfactual scenarios, all analyses found significant increases in gambling-related contacts after Ontario’s online gambling policy changes. First, compared with a scenario in which PlayOLG was not launched, an estimated 9.3 (95% CI 1.04 to 17.5) additional monthly contacts per million individuals occurred, an approximate 80.7% increase, in February 2020. Second, compared with a scenario without privatization of online gambling after the launch of playOLG (trend from January 2015 to February 2020 projected forward), an estimated 4.9 (95% CI 1.0 to 8.9) additional monthly contacts per million individuals occurred, an approximate 18.7% increase in contacts, in September 2025. Finally, compared with a scenario without PlayOLG or the subsequent establishment of the private market (trend from January 2012 to December 2014 projected forward), an estimated 20.8 (95% CI 8.5 to 33.2) additional monthly contacts per million individuals occurred, an approximate 198.3% increase, in September 2025. See Table 3 for all model coefficients.
Table 3:
Changes in rates of monthly gambling-related contacts following the launch of PlayOLG and subsequent expansion to private gambling in Ontario, Canada, overall and by age and gender
| Variable | Change in monthly contacts per 1 000 000 individuals (95% CI) | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Overall | Age 15–24 yr | Age 25–44 yr | Age 45–64 yr | Age ≥ 65 yr | |||||
| Adolescent boys and men | Adolescent girls and women | Men | Women | Men | Women | Men | Women | ||
| Before launch of PlayOLG | |||||||||
| Intercept Jan. 2012 | 13.72 | 13.00 | 3.02 | 27.05 | 9.41 | 15.61 | 14.56 | 8.14 | 7.92 |
| Monthly trend | −0.02 (−0.12 to 0.08) | 0.04 (−0.21 to 0.3) | 0.00 (−0.11 to 0.1) | −0.06 (−0.32 to 0.19) | 0.03 (−0.07 to 0.13) | −0.02 (−0.18 to 0.15) | −0.06 (−0.16 to 0.04) | −0.06 (−0.13 to 0.02) | −0.05 (−0.14 to 0.03) |
| Launch of PlayOLG (Jan. 2015) | |||||||||
| Immediate change | −0.53 (−3.02 to 1.96) | −2.27 (−8.81 to 4.28) | 0.96 (−1.75 to 3.68) | −1.9 (−8.41 to 4.6) | −0.7 (−3.23 to 1.82) | −5.16 (−9.35 to −0.97) | 1.32 (−1.33 to 3.97) | 0.01 (−1.98 to 2) | 0.47 (−1.8 to 2.74) |
| Change in monthly trend from prior period | 0.16 (0.05 to 0.27) | 0.17 (−0.11 to 0.44) | 0.02 (−0.1 to 0.13) | 0.33 (0.04 to 0.61) | 0.01 (−0.1 to 0.11) | 0.36 (0.18 to 0.54) | 0.02 (−0.09 to 0.13) | 0.06 (−0.02 to 0.15) | 0.04 (−0.06 to 0.13) |
| Monthly trend | 0.13 (0.09 to 0.18) | 0.21 (0.1 to 0.32) | 0.01 (−0.03 to 0.06) | 0.26 (0.15 to 0.38) | 0.03 (−0.01 to 0.08) | 0.34 (0.27 to 0.42) | −0.04 (−0.08 to 0.01) | 0 (−0.03 to 0.04) | −0.02 (−0.06 to 0.02) |
| Privatization of online gambling (Apr. 2022) | |||||||||
| Immediate change | 0.03 (−2.39 to 2.45) | 5.63 (−0.64 to 11.9) | −0.29 (−2.9 to 2.32) | 5.96 (−0.33 to 12.25) | 1.85 (−0.57 to 4.27) | −11.21 (−15.25 to −7.16) | −0.53 (−3.07 to 2.01) | −0.95 (−2.86 to 0.95) | −0.43 (−2.61 to 1.74) |
| Change in monthly trend from prior period | 0.12 (0.02 to 0.21) | 1.03 (0.81 to 1.26) | 0.07 (−0.02 to 0.17) | 0.16 (−0.08 to 0.4) | 0.03 (−0.06 to 0.12) | −0.18 (−0.33 to −0.03) | 0.1 (0.01 to 0.19) | 0.02 (−0.04 to 0.09) | 0 (−0.08 to 0.08) |
| Monthly trend | 0.25 (0.17 to 0.33) | 1.24 (1.05 to 1.44) | 0.09 (0 to 0.17) | 0.43 (0.22 to 0.63) | 0.06 (−0.01 to 0.14) | 0.16 (0.03 to 0.29) | 0.06 (−0.02 to 0.14) | 0.03 (−0.03 to 0.09) | −0.02 (−0.08 to 0.05) |
| Model rates compared with counterfactual predictions in absence of policy changes | |||||||||
| No PlayOLG: rate in Feb. 2020 compared with counterfactual | 9.3 (1.0 to 17.5) | 8.1 (−12.5 to 28.7) | 2.1 (−6.6 to 10.7) | 18.3 (−2.7 to 39.3) | −0.4 (−8.3 to 7.6) | 17.1 (3.6 to 30.6) | 2.6 (−5.7 to 11.0) | 3.8 (−2.4 to 10.1) | 2.7 (−4.4 to 9.9) |
| Counterfactual is the value in Feb. 2020 if the trend between Jan. 2012 and Dec. 2014 continued. | |||||||||
| No private market with single-event sports gambling: rate in Sept. 2025 compared with counterfactual | 4.9 (1.0 to 8.9) | 49.1 (39.6 to 58.6) | 2.8 (−1.2 to 6.8) | 12.7 (2.8 to 22.7) | 3.1 (−0.6 to 6.8) | −18.8 (−25.2 to −12.4) | 3.6 (−0.3 to 7.5) | 0.1 (−2.8 to 2.9) | −0.3 (−3.6 to 3.0) |
| Counterfactual is the value in Sept. 2025 if the trend between Dec. 2015 and Feb. 2020 continued. | |||||||||
| No PlayOLG or private market with single-event sports gambling: rate in Sept. 2025 compared with counterfactual | 20.8 (8.5 to 33.2) | 64.2 (33.0 to 95.4) | 5.6 (−7.4 to 18.6) | 44.7 (13.1 to 76.3) | 3.0 (−9.1 to 15.0) | 13.3 (−7.0 to 33.6) | 7.1 (−5.5 to 19.8) | 6.5 (−3.0 to 16.0) | 3.9 (−6.9 to 14.8) |
| Counterfactual is the value in Sept. 2025 if the trend between Jan. 2012 and Dec. 2014 continued. | |||||||||
Note: CI = confidence interval.
Subgroup differences and changes over time
Mean monthly rates of gambling contacts per million individuals were highest in adolescent boys and men aged 15 to 24 years (28.1 per million) and 25 to 44 years (35.4 per million) (Table 2). During the period of Ontario’s private gambling market, adolescent boys and men aged 15 to 44 years were responsible for 60.3% of total gambling-related contacts, 69.6% of online gambling-related contacts, and 88.9% of sports gambling contacts.
Increases in gambling-related contacts were much greater in men than women and most pronounced in adolescent boys and young men. The mean monthly rate of gambling contacts per million individuals increased from before the launch of PlayOLG to after privatization of online gambling by 316.7% in adolescent boys and men aged 15 to 24 years (13.8 to 57.4) and 108.4% in men aged 25 to 44 years (26.1 to 54.4) (Table 2).
Figure 2 shows changes in monthly gambling-related contacts by age and gender. The launch of PlayOLG was associated with significant increases over time in monthly gambling-related contacts among men aged 25 to 44 and 45 to 64 years. Privatization of online gambling was associated with significant increases in gambling-related contacts in adolescent boys and men aged 15 to 24 and 25 to 44 years. Compared with the 2 scenarios of (a) no privatization of online gambling after the launch of PlayOLG and (b) no launch of PlayOLG or subsequent privatization, we found an estimated 49.1 (95% CI 39.6 to 58.6, approximate 144% increase) and 64.2 (95% CI 33.0 to 95.4, approximate 337.8% increase) additional monthly contacts per million individuals aged 15 to 24 years in September 2025. See Table 3 for all model coefficients.
Figure 2:
Monthly rate of gambling-related contacts per 1 000 000 individuals of different age categories between January 2012 and September 2025. The first dashed line indicates the launch of PlayOLG, the second dashed line indicates the start of the COVID-19 pandemic in Ontario, and the third dashed line indicates the launch of Ontario’s private gambling market. Dots represent observed monthly values, and the line represents the model fit with shading showing 95% confidence intervals. Models are adjusted for seasonality with season fixed to November.
Internal control
The proportion of total contacts that were gambling-related increased from 4.8% before the launch of PlayOLG to 9.2% after online gambling privatization (Table 2). In our analyses of the proportion of total ConnexOntario contacts that were gambling related, we found significant increases after the privatization of online gambling, with an estimated additional 6.9% (95% CI 4.1% to 9.8%) of total contacts to the helpline that were gambling related in September 2025, compared with a scenario without privatization of online gambling after the launch of PlayOLG (Appendix 1).
Interpretation
We found that the expansion of Ontario’s online gambling market was associated with substantial increases in contacts to Ontario’s mental health and addictions helpline for gambling-related problems. Both the launch of the government-operated PlayOLG platform in 2015 and the introduction of a competitive private online gambling market in 2022 were followed by large increases in contacts. These findings suggest large increases in problematic gambling, changes in help-seeking for gambling, or both.
Despite the potential health impacts of gambling liberalization, limited research has evaluated the effects. A prior study found increases in gambling-related helpline contacts to ConnexOntario in the first 9 months after the launch of private online gambling in Ontario, but did not examine long-term trends.22 A US study found that online searches for gambling addiction increased more than expected after sports gambling was legalized, particularly in states where online sports gambling platforms were made available.2 The current findings provide evidence that the expansion of the online gambling market was associated with ongoing increases in gambling-related helpline contacts. Increases occurred exclusively in adolescent boys and men aged 15 to 44 years, consistent with evidence that this group is at the highest risk of online gambling-related harms,23,24 and frequently targeted by gambling and sports-betting marketing.25 Several factors may have contributed to increases in gambling-related helpline contacts, including the introduction of new (single-event sports betting) and higher-risk gambling products (in-play betting), increased gambling accessibility through expansion of online platforms, and intensified marketing and promotion. Further research, including comparing changes in Ontario to regions that did not undergo privatization, is indicated to determine the relative contribution of each of these factors.
These findings have several implications for policy and practice, given that gambling-related contacts increased after the introduction of online gambling through a government-run agency and rose further following market privatization. Ontario is currently the only province in Canada with privatized online gambling, and the findings caution against both increasing online access to gambling and privatization of such markets in other jurisdictions.25 Furthermore, the findings may support restrictions on particularly harmful types of online gambling that are associated with greater gambling intensity and risk of addiction and harms.26,27 These include online slots and electronic gambling machines, single-event sports betting with live or “inplay” or micro-betting during games, which allow rapid repeat wagers and shorten the delay between bets and outcomes.26,27 Policy-makers may wish to place limits on gambling marketing that can normalize gambling, which is often targeted at high-risk groups and is well documented to have proliferated in North America.7,28 Improving harm-reduction measures, including a single province-wide registry for individuals with gambling disorders to self-exclude themselves from gambling (presently, individuals must self-exclude from each private operator) are indicated.29 Finally, health system planners could increase access to gambling-related care.27
To date, most discussions on the legalization of online gambling have emphasized expanding consumer choice, generating government revenue, and curbing illegal gambling.30–32 While gambling is increasingly recognized as an important driver of health and social harms, it continues to not receive proportionate consideration within mental health and addiction prevention strategies and health-system planning relative to the scale and severity of associated harms. The current findings underscore the need to treat gambling as a health issue rather than solely a matter of recreation or revenue generation. Gambling should be addressed within broader mental health and addiction policy frameworks, alongside targeted regulatory measures to prevent and mitigate gambling-related harms.
Limitations
The ConnexOntario contact information appears on all legal gambling websites and advertising in Ontario, and part of the observed changes may reflect better use of the ConnexOntario helpline because of greater exposure as people switch from illegal to legal gambling, rather than actual increases in gambling-related harms. However, importantly, ConnexOntario contact volume did not increase over the study period, suggesting that general increases in ConnexOntario use do not explain the current findings.
Despite standardized training, ConnexOntario responders do not make diagnoses, and gambling-related contacts may be subject to under- or overreporting because of misclassification. However, ConnexOntario’s processes for identifying the primary cause of the contact have not changed over the study period.
Helpline contacts underestimate the total burden of gambling-related harms as most individuals with gambling disorders or harms do not seek care, and contacts do not capture the broader harms to individuals, families, and communities.16 However, help-seeking for gambling through helplines likely represents changes in broader harms.16,33
We were unable to account for repeat contacts by the same individual, and part of the observed increases could be explained by intensifying use of the helpline.
Our net effect estimates for each policy period depend on the assumption of linear trends for both the counterfactual projection and the fitted model. If trends are nonlinear (e.g., plateauing at the end of the study), the net effects estimate may be inaccurate, and longer-term follow-up is indicated to understand the full effect of liberalization
Finally, we excluded pandemic-period data to avoid bias from reduced helpline contacts, which requires the assumption that prepandemic trends would continue. Importantly, gambling-related contacts during the liberalization period exceeded prepandemic levels, and the findings are not explained by a postpandemic return to normal.
Conclusion
The rapid expansion and privatization of online gambling, including single-event sports betting, in Ontario were respectively associated with marked increases in gambling-related helpline contacts, specifically among adolescent boys and young men. These findings suggest a population-level rise in gambling problems, help-seeking behaviour, or a combination, coinciding with the widespread availability and marketing of online betting. Gambling is an underrecognized determinant of health, and these results highlight the urgent need for stronger prevention measures, including restrictions on advertising, limitations on gambling types known to be most addictive, and greater access to treatment.
Supplementary Information
Acknowledgement
The authors greatly appreciate the help from Kirc Cobb at Connex-Ontario, who provided the requested data and details about ConnexOntario.
Footnotes
Competing interests: None declared.
This article has been peer reviewed.
Contributors: Daniel Myran and Robert Talarico had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Ryan Forrest and Daniel Myran conceived and designed the study; were responsible for acquisition, analysis, or interpretation of data; drafted the manuscript; provided administrative, technical, or material support; and supervised the project. Anosha Waqar contributed to the analysis and interpretation of data. Daniel Myran and Robert Talarico performed the statistical analysis. Daniel Myran obtained funding. All authors critically reviewed the manuscript for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Funding: This study was supported by funds from North York General Hospital. Daniel Myran receives salary support as the Cheesbrough Chair in Family and Community Medicine, North York General Hospital, and as a clinician investigator from the University of Toronto Department of Family and Community Medicine. The opinions, results, and conclusions of the authors are independent of the funding supports.
Data sharing: The data used in this study were provided by ConnexOntario. The data can be made available to any individual or organization that contacts ConnexOntario through its Data & Report Service (https://connexontario.ca/data-and-report-service-lp/). We accessed the data through a general inquiry to Connex-Ontario, submitting a list of requested data elements.
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