Racial Associations Between Gambling and Suicidal Behaviors Among Black and White Adolescents and Young Adults

Abstract

Purpose of Review

Suicide is the second leading cause of death among Black youth ages 10–19 years. Between 1991 and 2017, rates of suicide among Black youth have been increasing faster than rates among any other race/ethnic group. There are many factors that may explain this increase, with gambling being suggested as one such potential risk factor. This review examines the association between gambling and suicide behaviors, and how these associations may vary between Black and White youth and young adults. The current review examines these associations using data from the Missouri Family Study (MOFAM).

Recent Findings

Recent findings have revealed distinct patterns of substance use initiation and gambling behaviors between Black youth and White youth. While strong links between gambling and suicide behaviors have also been reported, whether the associations were consistent across race/ethnicity groups was not investigated, nor in these cross-sectional analyses was it possible to determine whether the gambling behaviors preceded or followed suicidality. Thus, there is a need to investigate whether there are differences in the associations of gambling and suicide behaviors at the race/ethnicity level in tandem with data that examine the sequence of the behaviors. The current report focuses on racial/ethnic differences using data that allow for sequencing the occurrence of the behaviors via the age of first gambling experience, and of first suicidal symptom, to better distinguish the nature of the association.

Summary

The current findings revealed that gambling initiation predicted suicide ideation among Black youth, while no significant association was found among White youth. This is of major public health concern, given the rising rates of suicide among Black youth, and the increased availability of gambling. The report did not find a link between gambling and suicide attempts. Culturally tailored interventions should be considered among schools, families, and clinicians/providers, to highlight the risk of adolescent gambling, particularly among Black youth.

Introduction

Gambling is a popular activity that has become part of the life experience of most young people despite its illegality in youth [1, 2] and has been found to be one of the most frequently reported problematic behaviors [2]. Recent studies have found prevalence rates of gambling and problem gambling [3] to be higher among adolescents in comparison to adults [4], and a recent review found that 4 to 8 percent of adolescents experience significant gambling-related problems [5]. Factors such as mental health disorders, substance use, and adverse childhood experiences are some key factors that are associated with problem gambling [6–8]. Problem gambling is known to be associated with a host of adverse consequences including poor academic performance, economic hardship, difficult peer relationships and social exclusion, drug and alcohol use, legal problems, and suicidal thoughts and behavior [9–13]. Furthermore, those who do not necessarily meet diagnostic criteria for gambling disorder but gamble excessively are prone to a variety of physical and psychological harms [14, 15].

Of growing concern is the high prevalence of suicidal behaviors in relation to gambling [16–20]. Suicide continues to be a major public health problem in the USA as the age adjusted rate in 2018 was at the highest since 1941 [21]. The suicide rate has risen an average of 1.5% a year since 1999. At this rate, this increase would mean a doubling of the suicide rate from 2000 to 2050 in the USA [22]. Youth are highly vulnerable to suicidal behaviors, and suicide is one of the leading causes of death in late childhood and adolescence worldwide [23], and is the second leading cause of death among America’s youth [24]. In a study of 8500 secondary school students in New Zealand, Rossen et al. (2016) reported a positive association between unhealthy gambling and suicide attempts [25]. In a study of 7th to 12th graders from Ontario, problem gamblers reported a 17-fold increase in suicide attempts [26]. Nower et al. (2007) examined three studies of middle and high schoolers from Canada, and found higher rates of suicidality among problem and pathological gamblers as compared to non-gamblers and social gamblers. Over a lifetime, approximately 17 to 24% of those who meet criteria for gambling disorder will attempt suicide [27, 28] and 80% of those calling a gambling helpline reported suicidal ideation [29]. Using data from the Iowa Gambling Study, Black and colleagues (2014) reported that problem gamblers had an 11-fold risk of lifetime suicide ideation versus controls. In a recent report from Great Britain, Wardle and McManus (2021) found problem gambling to be associated with suicide attempts in both young men and young women [30••].

National and regional studies have found that Black youth and adults are highly vulnerable to problem gambling [31, 32••, 33]. A nationally representative adolescent sample found higher rates (24%) of heavy gambling among Black youth compared to White youth (15%) [31]. In one of the first nationally representative studies of gambling in the USA, Welte and colleagues reported that Black males with low socioeconomic status were more likely to have gambled frequently than their non-Black male counterparts [34]. Substance misuse may also be a contributing factor to gambling among Blacks. Using data from Survey of Gambling in the USA (SOGUS2) from 2011–2013, Barnes et el. (2017) found that (49.8%) of Black adults who drank 2 or more drinks a day were frequent gamblers as compared with 9.3% of Black adults who did not drink at that level [34]. One recent report examined the reciprocal relationship between substance use and gambling initiation, and found distinct race and gender associations. Werner and colleagues (2020), using data from the Missouri Family Study, reported that cannabis initiation among Black males and White females predicted an increased hazard of gambling initiation, while gambling initiation increased the hazard of cannabis initiation, only among Black males [32••]. The same report found that gambling initiation age <15 predicted alcohol initiation among Black females, Black males, and White males, but not White females. However, Werner et al. (2020) did not consider suicidality in their study, which is a main focus of the current investigation and very timely as suicide rates in adolescents increase. In the present report, we have extended the analysis of gambling behaviors specifically to the relationship with suicidality, using the same data source as in the Werner report.

Factors such as neighborhood disadvantage [35, 36], access to lottery outlets, as well as readily available gambling activities such as dice and craps are highly common and problematic among Black participants. In comparison to White gamblers, Black gamblers are faced with a disproportionate level of adverse consequences including loss of control, financial problems, illegal behaviors, and interference with daily activities associated with gambling [37]. In addition to increased vulnerability to gambling problems, Black youth are also burdened with increases in suicide rates. Historically, Black youth have had significantly lower suicide rates than White youth; however, that gap has narrowed considerably [38]. A recent study using data from the Youth Risk Behavior Study (YRBS) found a 73% increase in suicide attempts among Black youth from 2001–2017, while rates in White youth had reduced by 7.5%. In fact, suicide data from 2001–2015 revealed that black youth aged 5–12 had a 82% higher incidence of completed suicide than White youth [38]. The suicide death rate among Black youth has been rising faster than any other ethnic group, and is the second leading cause of death among Black youth. Other factors including racism, economic adversities, lack of insurance coverage, and culturally unacceptable behavioral health care [39] may also contribute to these soaring rates.

As the rising suicide rates among Black youth are of urgent public health concern, it is important to identify high-risk pathways, such as gambling, which have been overlooked. As gambling continues to become normative, socially acceptable, and widely available, it is more important than ever to examine its downstream risk. While prior research has found associations between gambling and suicide behaviors, most studies to date have employed a cross-sectional approach, with limited investigation of temporal relationships. To our knowledge, no study has examined the effect of gambling initiation and its impact for subsequent suicidal behaviors and how these associations may vary by race. The age that one begins to gamble has potential to influence their trajectory. Early onset of gambling is associated with negative outcomes including gambling problems later in life, substance use problems, and a host of adverse outcomes [31, 40, 41]. As shared risk is evident in gambling and suicide behaviors, it is essential to consider timing of these events. In the current study, we investigate the association between gambling and suicide ideation and attempt, using survival models, and its relationship with race in a Missouri sample of Black and White youth and young adults.

Methods

The analytic sample consists of a sub-sample Black (55.6%) and White (44.4%) participants who completed the gambling questionnaire from the multi-wave Missouri Family Study (MOFAM; N=1349), which was oversampled for Black families. MOFAM is a longitudinal high-risk family study designed to study the effects of paternal alcohol use disorder on development of offspring alcohol involvement and other outcomes. Researchers used Missouri state birth records between 2003 and 2009 to identify families with offspring aged 13, 15, 17, or 19 years and with at least one additional full sibling. Screening interviews with mothers were administered to provide an initial designation of family risk that was based on her report of the father as an excessive drinker (high risk) or not (low risk). The family risk level that was assigned at screening was refined using information reported by the mother at her full interview. Among families classified as high risk at screening, those in which the fathers met criteria for AUD by mother’s report at her full interview were designated “true high risk.” Among families that at screening were low risk, those where mothers did not report AUD in fathers were considered “true low risk.” Other families were designated as “misclassified” and analyzed as a separate category. Very high risk was defined by matching males with two or more DUI citations on state driving records to offspring birth records. Misclassified included false positives and false negatives. False positives consisted of high-risk families in which mothers reported excessive drinking for the father, and at full interview, did not report that the father met alcohol abuse or dependence criteria. False negatives are low-risk families where mothers did not report excessive drinking by the father, and at full interview, but reported that the father met criteria for alcohol abuse or dependence [42, 43]. Final familial risk level was used in the analyses to account for ascertainment strategy. Permission was granted from biological mothers to recruit offspring for interviews; offspring who themselves consented to participate were interviewed.

Overall, 450 Black youth and 317 White youth were enrolled in the study over 6 years. Three of the intake years had three waves of data, collected at 2-year intervals; the remainder had one to two waves. Offspring were assessed via telephone by an interview that was adapted from the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA), a reliable and valid instrument [44, 45].

Outcome Variable

Suicidal thoughts and Behavior

Two primary outcomes were assessed including (1) suicide ideation and (2) suicide attempt. Participants were asked “Have you ever thought about taking your own life?” and then were asked to report age of first event. To assess attempt, participants were asked “Have you ever made a suicide attempt?” and also reported the age of first attempt. In cases where age of suicide ideation or attempt was reported at more than one assessment wave, the age of first report was used.

Gambling Initiation

To assess gambling behaviors, the Gambling Assessment Module (GAM-IV-S) was used [46]. Participants were queried on the following question, “Have you ever gambled or bet 5 or more times in your lifetime that includes gambling, betting, and playing games for money or for something else of value at a casino, on the computer, at the track, on the street, at home, or any other place?” Gambling initiation was based on age first gambled. In instances where age of gambling initiation was reported at more than one assessment wave, age of first report was used.

Lifetime Psychosocial, Alcohol Use, and Psychiatric risk Factors

We selected covariates that are known to be associated with suicidal behaviors and gambling. Models included time-varying major depressive disorder (MDD), childhood sexual abuse, and alcohol initiation. MDD was based on meeting DSM–IV–TR lifetime criteria for five or more major depressive symptoms during the same 2-week period with age of onset defined as the age when full criteria were first met [47]. Childhood sexual abuse was coded positive if rape or sexual molestation or forced sexual intercourse was endorsed before the age of 16. Alcohol use was based on first age of having first full alcohol drink, including beer, wine, wine coolers, champagne, or hard liquor like vodka, gin, or whiskey. Age of first report was used for all time-varying variables across all interviews. Time-varying variables were counted as “risk factors” only if they occurred either prior to or at the same age as the outcome [48].

Sociodemographic and Familial Level Covariates

We included several measures as controls in the association including family risk status, offspring age at last interview, household income, and parental education. Family risk status was coded as very high risk, true high risk, misclassified, and true low risk [referent]. Overall household income based on mother’s report of household income and coded high (>$75,000), middle ($24,000–$74,999) [referent], and low income (<=$23,999). Parental highest education level was coded as less than high school education, high school only (referent), some college, and college degree or more, and coded separately for the mother and father.

Data Analysis

We conducted data management in SAS 9.4 [49] and all data analyses using Stata Version 14 [50]. We performed analyses of descriptive statistics by race. Chi-square tests were used to assess differences by race (Table 1). Cox proportional hazards (PH) regression analyses were conducted (Table 2) to determine associations of gambling initiation separately for (1) suicide ideation and (2) suicide attempt. Interaction terms between gambling with both gender and race were tested. In cases where interactions were reported (p<.10), data were stratified [51, 52]. The survival analysis method was used as it accounts for the possibility that participants may not have passed through the period of risk, and is particularly applicable for adolescents and young adults. Variables for which ages of first occurrence were obtained were coded as time-varying; that is, they were considered risk factors only if their occurrence was before or at the same time as the outcome being studied. Variables treated in this manner included alcohol use, MDD, and childhood sexual abuse. Cox PH regression analyses considers the possibility that participants may experience the event of interest (e.g., suicidal behaviors) in the future. Under this approach, data up until the time of censoring (most recent interview) is used in the calculation of hazard ratios. Violations of the PH assumption that risk remains constant over time were tested with the Grambsch and Therneau test of the Schoenfeld residuals [53]. If violations were observed, they were resolved by splitting the period of risk and estimating hazards ratios for each risk period based on developmental milestones or graphical analyses to observe where hazard rates differed. When hazards violations were resolved, the hazards ratios for the defined risk periods were tested to ensure that these were distinct.

Table 1.

Descriptive statistics and prevalence by race (N=1349)

	Total (N=1349)	Black participants (n=750)	White participants (n=599)	χ2f
	N (Column %)
Age at last interview, M, (SD)	20.3 (3.9)	20.3 (4.0)	20.3 (3.7)
Lifetime report of gambling	401 (29.7)	241 (32.1)	160 (26.7)	4.68*
Age of gambling onset, M, (SD)	16.9 (3.5)	16.5 (3.5)	17.4 (3.5)
MDD onset, M, (SD)	14.8 (3.9)	14.7 (3.5)	14.9 (4.2)
Age of childhood sexual abuse, M, (SD)	9.5 (3.4)	9.1 (3.3)	10.4 (3.6)
Mean age/SD of first alcohol drink	16.2 (2.7)	16.7 (2.8)	15.7 (2.5)
Gender
Male	647 (48.0)	390 (52.0)	287 (47.9)
Female	702 (52.0)	360 (48.0)	312 (52.1)
Lifetime report of suicide behaviors
Suicide ideation	334 (24.8)	173 (23.1)	161 (26.9)	2.59
Suicide attempt	110 (8.2)	68 (9.1)	42 (7.0)	1.88
Family risk status				45.78***
Very high risk	426 (31.6)	265 (35.3)	161 (37.8)
True high risk	288 (21.4)	168 (22.4)	120 (41.7)
True low risk	486 (36.0)	213 (28.4)	272 (56.0)
Misclassified	149 (11.1)	103 (13.7)	46 (7.7)
Household income				134.83***
>=$75,000	289 (21.6)	93 (12.4)	196 (32.8)
$24,000–74,999	509 (38.0)	254 (33.9)	255 (42.6)
<=23,999	4542 (40.5)	394 (52.5)	148 (24.7)
Mother’s education level				24.61***
College degree or higher	305 (22.7)	138 (18.4)	167 (27.9)
Some college	529 (33.3)	309 (41.2)	220 (36.7)
High school or GED	401 (29.8)	223 (29.7)	178 (29.7)
Less than high school	111 (8.3)	78 (10.4)	33 (5.5)
Father’s education level				57.37***
College or higher	223 (16.5)	81 (10.8)	142 (23.7)
Some college	266 (19.7)	124 (20.7)	142 (18.9)
High school or GED	583 (43.2)	364 (27.0)	219 (37.6)
Less than high school	221 (16.4)	119 (15.9)	102 (17.0)
Unknowna	56 (4.2)	44 (5.9)	12 (2.0)
Offspring major depressive disorderc	233 (17.3)	129 (17.2)	104 (17.4)	.006
Offspring childhood sexual abused	108 (8.0)	74 (9.9)	34 (5.7)	7.94**
Offspring lifetime alcohol usee	1001 (74.2)	523 (69.7)	478 (79.8)	17.62***

Note:

^***=p<.001,

^**=p<.01,

^*=p<.05;

MDD major depressive disorder, M mean, SD standard deviation

^aFather’s education was based on the mother’s interview. In some cases, the mother was unaware of the father’s highest level of education

^bDSM-IV

^cRape, sexual molestation, or forced sexual intercourse were endorsed (age <16)

^dFull standard 12 ounce can or bottle of beer, a glass of wine, a shot of liquor, or any other kind of drink with alcohol in it during baseline interview

^eChi-squared test to assess differences between Black participants and White participants

Table 2.

Cox proportional hazard analyses predicting time to first suicidal ideation and to first suicide attempt (N=1349)

Variable	Suicidal ideation				Suicide attempt
	Black participants (n=750)		White participants (n=599)		Full sample (N=1349)
	HR	95% CI	HR	95% CI	HR	95% CI
Gambling initiation	2.06	[1.39, 3.07] *	0.81	[0.45, 1.45]	0.78	[0.37–1.63]
MDD onset
Age ≤14	7.80	[4.48, 13.57] *	11.12	[6.58, 18.78] *
Age ≥15	3.48	[2.21, 5.48] *	4.08	[2.38, 6.98] *
Age ≤15					12.02	[6.94–20.80] *
Age ≥16					4.47	[2.19–9.11] *
Alcohol initiationa	1.44	[0.99–2.08]	1.66	[1.11, 2.47] *	1.45	[0.94, 2.23]
Childhood sexual abuseb	2.69	[1.89, 3.81] *	1.39	[0.85, 2.28]	2.48	[1.59, 3.85] *
Black race					1.19	[0.76, 1.95]
Male gender	0.71	[0.52, 0.97] *	0.91	[0.64, 1.29]	0.61	[0.38, 0.99] *

Note. All models account for family risk status, household income, mother and father’s educational attainment, and age.

^{* =}significant (p < .05). HR hazard ratio; SE standard error; CI confidence interval; MDD major depressive disorder; all variables reported in the table, excluding male gender and race (for outcome of suicide attempt), were coded as time-variant.

^aAge of initiation for one full alcohol drink

^bRape, sexual molestation, or forced sexual intercourse were endorsed (age <16)

Results

Race Differences and Prevalence and Age at First Involvement

In Table 1, descriptive statistics are presented to assess differences of suicide behaviors, gambling, demographic, and other risk factors by race. Compared to their White counterparts, Black participants reported a significant higher prevalence (χ²=4.69; p=.045) of ever gambling (32.3%) versus White participants (29.7%). Black participants reported lower, but not statistically significant levels of suicidal ideation (23.1% v 26.9%), and higher, but not statistically significant prevalence of suicide attempts (9.1% v 7.0%). Black youth also initiated gambling at an earlier age (16.7) in comparison to White participants (17.8).

Gambling Predicting Suicidal Ideation

In Table 2, results are also shown for the Cox proportional hazards regression analyses for the two outcomes of interest, suicidal ideation and suicide attempt. Significant interactions were found between race and gambling (p=.04); therefore, we ran separate models stratified by race for suicidal ideation. Among Black participants, initiating gambling increased the hazard of suicide ideation by 2.06 times (106%) (HR=2.06, 95% CI [1.39, 3.07]), and was consistent across all risk periods. There was no significant association found between gambling and suicide ideation (HR=0.81, 95% CI [0.45, 1.45]) among White participants.

In addition to gambling, childhood sexual abuse (HR=2.69, 95% CI [1.89, 3.81]) along with MDD predicted an increased hazard for among Black youth. Among White youth, alcohol use (HR=1.66, 95% CI [1.11, 2.47]) and MDD were associated with an increased hazard for suicide ideation. Male gender (HR=0.71, 95% CI [0.52, 0.97]) predicted a lower hazard for suicide ideation in Black youth, but was not significantly associated among White youth (HR=0.91, 95% CI [0.64, 1.29]).

Gambling Predicting Suicide Attempt

Table 2 shows the association between gambling and suicide attempt, in a combined model for both race groups. Data were not stratified as significant interactions were not found between race and gambling. Gambling did not predict suicide attempt (HR=0.78, 95% CI [0.37, 1.63]). However, other factors were significantly associated with an increased hazard of suicide attempt. These included childhood sexual abuse (HR=2.48, 95% CI [1.59, 3.85]) and MDD, for which a violation of the PH assumption required modeling different age risk periods that indicated an exceptionally elevated increase in the hazard of suicide attempt at or before age 15 (HR=12.02, 95% CI [6.94, 20.80]), and a somewhat lower but still elevated increase at age 16 or later (HR=4.47, 95% CI [2.19, 9.11]). Male gender (HR=0.61, 95% CI [0.38, 0.99]) predicted a significantly lower hazard of suicide attempt.

Discussion

The current report expands on the previous work by Werner and colleagues (2020) that assessed Black and White differences relative to substance use and gambling initiation. The current report employed a similar approach, however, with a focus on gambling initiation and the onset of suicidal behaviors. The current report found that gambling initiation predicted an increased hazard of suicide ideation among Black participants, but not White participants. These findings are alarming, given the abundance of gambling opportunities and high participation among Black youth. Legalization and increased opportunity for sports betting, lottery games, horse racing, and casinos have made gambling more accessible. Increased availability of gambling has been linked to increased participation and likelihood of developing a gambling disorder [54, 55]. Although youth do not meet the legal age for these venues, the mere presence of these venues may increase awareness and gambling involvement [56], particularly among ethnic minorities [57]. Furthermore, minorities are highly vulnerable due to a number of factors including density of lottery outlets, which are greater in minority neighborhoods [58]. In the current study, Black participants reported a significantly higher prevalence of lifetime gambling in this study, which is also consistent with prior studies on younger populations [29, 30].

These findings are particularly timely, given the current crisis faced by Black youth. Research has confirmed that the risk of suicide for Black youth has extended into younger age groups [36, 55, 56]. The emergence and increased popularity of gambling among Black youth only further exacerbates these risks. Blacks have nearly twice the overall prevalence of disordered gambling than Whites [59], which increases their risk for transitioning from initiation to problem gambling. On a positive note, while gambling initiation predicted suicide ideation, the current study found no association with suicide attempt. However, the power was relatively low, since suicide attempt was a rare event. Factors elevating the hazard of suicide attempt included childhood sexual abuse and MDD, particularly for the hazard of an attempt at age 15 or younger.

Other Risk Factors

In the current study, among White participants, initiating alcohol was observed to elevate the hazard of suicide ideation. Alcohol use has been found to be more prevalent among White youth than Black youth [60, 61]. Prevention efforts towards alcohol use and abuse is critical, to prevent the risk of suicide and premature death [62]. Findings may have differed, had we used cannabis use, which is more common among Black youth [63, 64]. MDD was also associated with an elevated hazard of both suicide ideation and attempts, and particularly at early ages as depression is known to be a strong predictor or both ideation and attempt [65]. Childhood sexual abuse was found to increase the hazard for suicidal ideation among Black, but not White, participants. Suicide ideation is common among Black youth and adults, who are victims of sexual abuse [66, 67].

Strategies for Prevention and Intervention

Coordinated responses across all levels, from providers, and through schools and families can result in a clear and consistent message about risks of gambling, and implementation of culturally appropriate strategies to prevent risks. As Black suicide rates continue to rise, and many individuals who have suicidal ideation do not seek treatment services [65], there is an urgent need for increased access to mental health services, particularly for vulnerable populations.

Suicidal prevention efforts that include education and screening are warranted at regular intervals from adolescence to adulthood, particularly for vulnerable populations. Such efforts may lead youth and emerging adults to seek help before risky behaviors such as gambling become ingrained as avoidance behaviors. These services and heightened educational efforts within the school system may help to ultimately reduce the likelihood of suicidal behavior. It is critically important that educators, school staff, and youth group leaders have professional development and training opportunities available on the risks of gambling, and their implications. Furthermore, parents and caregivers need to be informed and brought into discussions about the risks of gambling and their implications. Parents can be strong partners in reinforcing the messages relayed in school against gambling, and promoting mental health, and suicide prevention.

We must also pay particular clinical attention to culturally appropriate treatment for gambling and its associated disorders [32]. A recent report found an unmet need for gambling treatment and prevention program at the cultural level [57]. The type of games played, the setting, motivation, and other factors may vary at the race/cultural level. For example, games such “tunk,” “the numbers,” dice, and craps are more common among Black populations [68], while problems related to casino slot machines are less common [69]. Further, a recent study found that Black populations endorsed more subsyndromal gambling compared to other racial-ethnic groups, and this appears linked with aspects of compulsivity [70•]. Early detection is essential, particularly for those who may gamble recreationally, but do not necessarily endorse diagnostic criteria for gambling disorders [70•]. Future studies are needed to identify culture-specific factors in gambling practices and pathology that may influence treatment-seeking patterns that will lead to optimal intervention strategies.

Limitations and Conclusion

Findings should be interpreted with certain limitations in mind. First, these findings may not be generalizable to the population-at-large as a high-risk, regional sample from one Midwestern state was used. Second, there is a possibility of recall bias for ages of first suicide ideation, suicide attempt, gambling experience, and alcohol initiation. We can assume that estimates will be relatively accurate, as the study focuses on younger populations and data collection is more proximal to the initiation of these behaviors. Third, due to the low prevalence (4.7% among lifetime gamblers) of problem gambling in the current sample, the relationship between suicidality and problem gambling is not assessed. That said, previous research has suggested that age of gambling, particularly during youth, may be serve as a proxy for subsequent gambling problems [66]. Future studies of a larger size should consider the assessment of problem gambling among youth [71]. Fourth, we did not consider the frequency of specific gambling activities (e.g., slot machine, craps), although those data are available and could be analyzed in future work. In conclusion, the current findings point to the importance of considering race when assessing gambling and suicide behaviors. Culturally responsive targeted interventions for both gambling and suicide prevention should be considered, to prevent potential harm.