The relationship between the price and demand of alcohol, tobacco, unhealthy food, sugar-sweetened beverages, and gambling: an umbrella review of systematic reviews.

BACKGROUND: The WHO highlight alcohol, tobacco, unhealthy food, and sugar-sweetened beverage (SSB) taxes as one of the most effective policies for preventing and reducing the burden of non-communicable diseases. This umbrella review aimed to identify and summarise evidence from systematic reviews that report the relationship between price and demand or price and disease/death for alcohol, tobacco, unhealthy food, and SSBs. Given the recent recognition as gambling as a public health problem, we also included gambling. METHODS: The protocol for this umbrella review was pre-registered (PROSPERO CRD42023447429). Seven electronic databases were searched between 2000-2023. Eligible systematic reviews were those published in any country, including adults or children, and which quantitatively examined the relationship between alcohol, tobacco, gambling, unhealthy food, or SSB price/tax and demand (sales/consumption) or disease/death. Two researchers undertook screening, eligibility, data extraction, and risk of bias assessment using the ROBIS tool. RESULTS: We identified 50 reviews from 5,185 records, of which 31 reported on unhealthy food or SSBs, nine reported on tobacco, nine on alcohol, and one on multiple outcomes (alcohol, tobacco, unhealthy food, and SSBs). We did not identify any reviews on gambling. Higher prices were consistently associated with lower demand, notwithstanding variation in the size of effect across commodities or populations. Reductions in demand were large enough to be considered meaningful for policy. CONCLUSIONS: Increases in the price of alcohol, tobacco, unhealthy food, and SSBs are consistently associated with decreases in demand. Moreover, increasing taxes can be expected to increase tax revenue. There may be potential in joining up approaches to taxation across the harm-causing commodities.

The identification of Australian low-risk gambling limits: A comparison of gambling-related harm measures.

BACKGROUND AND AIMS: Problem gambling severity and gambling-related harm are closely coupled, but conceptually distinct, constructs. The primary aim was to compare low-risk gambling limits when gambling-related harm was defined using the negative consequence items of the Problem Gambling Severity Index (PGSI-Harm) and the Short Gambling Harms Scale items (SGHS-Harm). A secondary aim was compare low-risk limits derived using a definition of harm in which at least two harms across different domains (e.g. financial and relationship) were endorsed with a definition of harm in which at least two harms from any domain were endorsed. METHODS: Data were collected from dual-frame computer-assisted telephone interviews of 5,000 respondents in the fourth Social and Economic Impact Study (SEIS) of Gambling in Tasmania. Receiver operating characteristic (ROC) curve analyse were conducted to identify low-risk gambling limits. RESULTS: PGSI-Harm and SGHS-Harm definitions produced similar overall limits: 30-37 times per year; AUD$510-$544 per year; expenditure comprising no more than 10.2-10.3% of gross personal income; 400-454 minutes per year; and 2 types of gambling activities per year. Acceptable limits (AUC ≥0.70) were identified for horse/dog racing, keno, and sports/other betting using the PGSI definition; and electronic gaming machines, keno, and bingo using the SGHS definition. The requirement that gamblers endorse two or more harms across different domains had a relatively negligible effect. DISCUSSION AND CONCLUSIONS: Although replications using alternative measures of harm are required, previous PGSI-based limits appear to be robust thresholds that have considerable potential utility in the prevention of gambling-related harm.

The association between gambling and financial, social and health outcomes in big financial data.

Gambling is an ordinary pastime for some people, but is associated with addiction and harmful outcomes for others. Evidence of these harms is limited to small-sample, cross-sectional self-reports, such as prevalence surveys. We examine the association between gambling as a proportion of monthly income and 31 financial, social and health outcomes using anonymous data provided by a UK retail bank, aggregated for up to 6.5 million individuals over up to 7 years. Gambling is associated with higher financial distress and lower financial inclusion and planning, and with negative lifestyle, health, well-being and leisure outcomes. Gambling is associated with higher rates of future unemployment and physical disability and, at the highest levels, with substantially increased mortality. Gambling is persistent over time, growing over the sample period, and has higher negative associations among the heaviest gamblers. Our findings inform the debate over the relationship between gambling and life experiences across the population.

[What's new in addiction medicine]. / Addictions.

The development of research, clinical practice and prevention in addiction medicine is, compared to other disciplines, more influenced by socio-political factors. Research on psychedelics has thus long been hampered by prohibitive policy but has recently been revived thanks to the relaxation of these political positions. The extensive prescription of baclofen for alcohol addiction is mainly the consequence of popular support and has so far not been clearly supported by specific research. The aim of the new Gambling Act was to harmonize the regulatory provisions for lotteries and betting on the one hand and casino gambling on the other, while at the same time opening up the market for online gambling.

Le développement de la recherche, de la pratique clinique et de la prévention en addictologie est davantage influencé par les circonstances sociopolitiques que dans de nombreuses autres disciplines. La recherche sur les psychédéliques a ainsi longtemps été entravée par une politique prohibitive mais a été relancée récemment grâce à l'assouplissement de ces positions politiques. La prescription importante du baclofène pour traiter l'addiction à l'alcool est principalement la conséquence d'un soutien populaire et n'est jusqu'à présent pas clairement appuyée par la recherche spécifique. Le but de la nouvelle loi sur les jeux d'argent était d'harmoniser les dispositifs de régulation concernant les loteries et paris d'une part et les jeux de casinos d'autre part, tout en ouvrant le marché des jeux en ligne.

The societal costs of problem gambling in Sweden.

BACKGROUND: Problem gambling is a public health issue affecting both the gamblers, their families, their employers, and society as a whole. Recent law changes in Sweden oblige local and regional health authorities to invest more in prevention and treatment of problem gambling. The economic consequences of gambling, and thereby the potential economic consequences of policy changes in the area, are unknown, as the cost of problem gambling to society has remained largely unexplored in Sweden and similar settings. METHODS: A prevalence-based cost-of-illness study for Sweden for the year 2018 was conducted. A societal approach was chosen in order to include direct costs (such as health care and legal costs), indirect costs (such as lost productivity due to unemployment), and intangible costs (such as reduced quality of life due to emotional distress). Costs were estimated by combining epidemiological and unit cost data. RESULTS: The societal costs of problem gambling amounted to 1.42 billion euros in 2018, corresponding to 0.30% of the gross domestic product. Direct costs accounted only for 13% of the total costs. Indirect costs accounted for more than half (59%) of the total costs, while intangible costs accounted for 28%. The societal costs were more than twice as high as the tax revenue from gambling in 2018. Direct and indirect costs of problem gambling combined amounted to one third of the equivalent costs of smoking and one sixth of the costs of alcohol consumption in Sweden. CONCLUSIONS: Problem gambling is increasingly recognized as a public health issue. The societal costs of it are not negligible, also in relation to major public health issues of an addictive nature such as smoking and alcohol consumption. Direct costs for prevention and treatment are very low. A stronger focus on prevention and treatment might help to reduce many of the very high indirect and intangible costs in the future.

Inside the decentralised casino: A longitudinal study of actual cryptocurrency gambling transactions.

Decentralised gambling applications are a new way for people to gamble online. Decentralised gambling applications are distinguished from traditional online casinos in that players use cryptocurrency as a stake. Also, rather than being stored on a single centralised server, decentralised gambling applications are stored on a cryptocurrency's blockchain. Previous work in the player behaviour tracking literature has examined the spending profiles of gamblers on traditional online casinos. However, similar work has not taken place in the decentralised gambling domain. The profile of gamblers on decentralised gambling applications are therefore unknown. This paper explores 2,232,741 transactions from 24,234 unique addresses to three such applications operating atop the Ethereum cryptocurrency network over 583 days. We present spending profiles across these applications, providing the first detailed summary of spending behaviours in this technologically advanced domain. We find that the typical player spends approximately $110 equivalent across a median of 6 bets in a single day, although heavily involved bettors spend approximately $100,000 equivalent over a median of 644 bets across 35 days. Our findings suggest that the average decentralised gambling application player spends less than in other online casinos overall, but that the most heavily involved players in this new domain spend substantially more. This study also demonstrates the use of these applications as a research platform, specifically for large scale longitudinal in-vivo data analysis.

The development and implementation of electronic gambling machine policy: a qualitative study of local government policy makers.

OBJECTIVE: To understand how policies developed by Local Government Authorities (LGAs) to address electronic gambling machine (EGM) harm are developed and implemented. METHODS: Semi-structured interviews were conducted with 16 participants from 15 LGAs in metropolitan Melbourne who worked in a role associated or aligned with gambling. An inductive thematic analysis was used to interpret the data. RESULTS: Three key themes emerged. First, participants described a shift from addiction frameworks to public health policy responses to EGMs, which was driven by increasing EGM losses and the harms caused by EGMs to communities. Second, there was the role of stakeholder groups in the policy-making process, including the challenges associated with engaging the community. Finally, there were barriers and facilitators to policy development and implementation. Barriers included a lack of financial resources and legislative boundaries imposed by the State Government. Facilitators included whole-of-LGA approaches, supportive councillors and collaborative efforts. Conclusions and implications for public health: LGAs have made shifts towards public health responses to EGM harm. Initiatives to further support policy development and implementation could include imposing a levy on EGM losses to directly support public health prevention activities and implementing robust state-based regulatory frameworks that support LGA responses to EGM harm.

[The gambling industry: a public health perspective.] / El negocio de los juegos de azar: una perspectiva desde la salud pública.

OBJECTIVE: Gambling may cause a variety of problems, both health and social, to the player, his family and his environment; Problems can be more serious for those who gamble more frequently or bet more money. Beyond the mental health gambling disorder and considering other harms derived from gambling, it is possible to develop a public health approach to the issue, including both prevention and harm reduction aspects. In recent decades gambling availability has expanded, with attempts at regulation. The objective of this paper is to provide basic information about gambling in Spain, stratifying data by Autonomous Communities (AC), from a public health perspective. METHODS: A descriptive study of some aspects of gambling in Spain was carried out. The data for amounts gambled by participants, gross gaming revenue of the industry, and establishments or machines licensed for the year 2017 were extracted from the available systematic sources. Aggregated data were tabulated and stratified by AC for those presential gambling categories with the greatest compulsive gambling potential and relevant business volume. Crude results and ratios per 100,000 inhabitants were calculated. RESULTS: Up to 41,826.8 million euros were spent gambling throughout Spain in 2017, a figure that exceeds 3.5% of the Gross Domestic Product, and the largest segment was online gambling in its various modalities (32%), followed by the national lottery and similar traditional games (27%). The supply of gambling venues (74.9 establishments per million inhabitants) was assessed by AC, showing large differences among them: their density in the region of Murcia is tenfold that of Catalonia. Gambling machines that can be installed in hospitality establishments (B machines) showed a density of 43.4 per 1,000 inhabitants, with greater homogeneity across AC than gambling premises. Regional data on the amounts spent in casinos, bingo cards, and sports betting show no homogeneous patterns. CONCLUSIONS: The volume of money spent on gambling in Spain is very important, and online gambling has become the largest business segment. The most traditional game modes and probably with less addictive potential such as lotteries and draws continue to have a relevant presence. The availability of presential gambling shows wide heterogeneity among AC, especially for licensed gambling establishments, whose density is ten times greater in the community with more supply compared to the one with less. The data by AC of some game modalities suggest that availability may be a relevant factor for gambling, but not the only one.

OBJETIVO: Participar en juegos de azar puede causar problemas diversos, tanto sanitarios como sociales, que afectan a la persona jugadora, a su familia y a su entorno. Éstos pueden ser más graves para las personas que juegan con mayor frecuencia o que se juegan más dinero. Más allá del trastorno por juego reconocido en la salud mental, y teniendo en cuenta que de las apuestas se derivan otros daños sociales, es posible desarrollar un enfoque de salud pública sobre el juego, contemplando tanto aspectos de prevención como de reducción de daños. En las últimas décadas ha proliferado la oferta de juegos de azar, con algunos intentos de regulación. El objetivo de este trabajo fue aportar información básica sobre la oferta actual de juego en España, desagregando los datos según comunidades autónomas (CCAA), desde una perspectiva de salud pública. METODOS: Se realizó un estudio descriptivo de algunos aspectos de la oferta de juego en España. Los datos de importes jugados, los márgenes estimados de los operadores y establecimientos, o las máquinas licenciadas para el año 2017 se extrajeron de las fuentes sistemáticas consolidadas sobre el juego en España. Se tabularon datos agregados, y se desglosaron por CCAA para las categorías de juego presencial con mayor potencial de juego compulsivo y por volumen relevante de negocio. Se calcularon resultados brutos y razones por 100.000 habitantes. RESULTADOS: En 2017 se jugaron un total de 41.826,8 millones de euros en toda España, cifra que supera el 3,5% del Producto Interior Bruto, y el mayor segmento de negocio fue el juego online en sus diversas modalidades (32%), seguido de los juegos tradicionales como la Lotería Nacional y otros similares (27%). Se valoró la oferta de locales de juego (74,9 locales por millón de habitantes), con grandes diferencias entre CCAA: la región de Murcia tuvo una densidad diez veces mayor que Cataluña. Las máquinas B que pueden instalarse en establecimientos de hostelería presentaron una densidad de 43,4 por 1.000 habitantes, con mayor homogeneidad entre CCAA que los locales de juego. Los datos territorializados de gasto en casinos, cartones de bingo y apuestas deportivas mostraron patrones no concordantes. CONCLUSIONES: El volumen de dinero gastado en juegos de azar en España es muy importante, y el juego online se ha convertido en el mayor segmento de negocio. Las modalidades de juego más tradicionales, y probablemente con menos potencial adictivo, como son las loterías y sorteos, siguen teniendo una presencia muy relevante. La oferta de juego presencial muestra cierta heterogeneidad entre CCAA, especialmente por lo que respecta a los salones de juego. Los datos territorializados de algunas modalidades de juego sugieren que la oferta puede ser un factor condicionante del juego, aunque no el único.

The Conceptual Framework of Harmful Gambling: A revised framework for understanding gambling harm.

BACKGROUND AND AIMS: The Conceptual Framework of Harmful Gambling moves beyond a symptoms-based view of harm and addresses a broad set of factors related to the risks and effects of gambling harmfully at the individual, family, and community levels. Coauthored by international research experts and informed by multiple stakeholders, Gambling Research Exchange (GREO) facilitated the framework development in 2013 and retains responsibility for regular updates and mobilization. This review article presents information about the revised version of the Conceptual Framework of Harmful Gambling completed in late 2018. METHODS: We describe eight interrelated factors depicted in the framework that represent major themes in gambling ranging from the specific (gambling environment, exposure, gambling types, and treatment resources) to the general (cultural, social, psychological, and biological influences). After outlining the framework development and collaborative process, we highlight new topics for the recent update that reflect changes in the gambling landscape and prominent discourses in the scientific community. Some of these topics include social and economic impacts of gambling, and a new model of understanding gambling related harm. DISCUSSION AND CONCLUSIONS: We address the relevance of the CFHG to the gambling and behavioral addictions research community. Harm-based frameworks have been undertaken in other areas of addiction that can both inform and be informed by a model dedicated to harmful gambling. Further, the framework brings a multi-disciplinary perspective to bear on antecedents and factors that co-occur with harmful gambling.

Stakeholder interests in gambling revenue: an obstacle to public health interventions?

OBJECTIVES: This article explores the financial interests that are behind gambling revenue and their relative importance. Identifying these interests is crucial to further analysis on how they may impact gambling policy and public health interventions. STUDY DESIGN: The analysis focuses on the spending structures of ten European gambling operators derived from their income statements to identify where money from gambling is further directed and who are the main financial stakeholders (SHs). METHODS: Gambling companies' income statements were categorised based on four types of SHs: states, earmarked contributions, operators, and cost-dependants. The sums directed to these groups are compared with company gross gambling revenue (GGR). RESULTS: Overall, the main financial SHs behind gambling appear to be states and earmarked beneficiaries. State budgets and earmarked contributions account for an average of 50 percent of the GGR of gambling companies, whereas about one-third is directed to cost-dependants. The most significant cost-dependant groups that can be identified are the distribution network and providers of materials. Results also show variance between companies depending on institutional contexts. CONCLUSIONS: The importance of states and earmarked causes as significant beneficiaries of European gambling companies is confirmed by the analysis. The results also show that cost-dependants are an important financial SH in gambling. The implications on public health of a wide network of SHs in gambling revenue are discussed.

Role of Gambling in Payback Failure in Consumer Credit-Data from a Large Body of Material Regarding Consumer Loan Recipients in Sweden.

Indebtedness is associated with poor health outcomes, and problem gambling may contribute to indebtedness through consumer credits related to gambling expenses. The assessment of consumers' applications for loans may be an opportunity to detect and prevent further problem gambling. The present study analyzed a number of variables including gambling-related transactions and their association with payback failure in 48,197 loans to 20,750 individuals in Sweden. Sums and frequency of gambling deposits or withdrawals generally did not predict failure to pay back loans. Instead, having a loan defaulted at some time was associated with a baseline pattern describing a theoretical loss-of-control gambling pattern (short-term intense gambling), with a higher ratio of gambling deposits or withdrawals per occasion, and with several instances of gambling in close association with a loan. While several group differences were modest, signs of rapid, short-term and intense gambling, rather than gambling itself, may identify risk of payback failure and risk of indebtedness. Implications for early problem-gambling detection and prevention, such as by gambling operators and financial institutes, are discussed and may promote better public health in relation to gambling indebtedness.

Evaluating for Differences by Race/Ethnicity in the Association Between Income and Gambling Disorder.

Multiple studies show an increased prevalence of gambling disorder among African Americans compared to whites. However, few studies take an analytic approach to understanding differences in risk factors by race/ethnicity. Income is inversely associated with gambling disorder; we hypothesized that this association would vary by race/ethnicity. The main objective was to evaluate whether the association between income and gambling disorder varies by race/ethnicity. With data from the baseline visit of a prospective cohort study, Prevention and Etiology of Gambling Addiction Study in the United States, we used multivariable logistic regression analysis to determine whether the association between income and gambling disorder varies by race/ethnicity. 1164 participants were included in the final analyses. Measures included: demographics (age, sex, race/ethnicity, education, employment, annual household income), veteran status, marital status, homelessness, smoking, substance abuse, alcohol abuse, marijuana use, and lifetime gambling disorder diagnosis as derived from Alcohol Use Disorder and Associated Disabilities Interview Schedule. There was no evidence of effect modification by race/ethnicity in the association between income and gambling disorder (global p value = 0.17). Income was associated with increased odds of gambling disorder, but only for those with low income (< $15,000; OR 2.27, 95% CI 1.46, 3.53). There was no evidence that the effect of income on gambling disorder varies by race/ethnicity. For all race/ethnicities combined, low income was associated with significantly increased odds of gambling disorder (OR 2.27, 95% CI 1.46, 3.53). Further research is needed to better understand racial/ethnic differences in gambling disorder.

Making EGMs Accountable: Can an Informative and Dynamic Interface Help Players Self-regulate?

Electronic gaming machines (EGMs) are recognised as one of the most harmful gambling forms, because they promote high-speed repetitive gambling and automatically reinvest winnings. These features, amongst others, make it difficult for EGM gamblers to keep track of their play. Tools to assist gamblers exist, but have limited effectiveness because they require user registration and manual activation, leading to low uptake. The present study aimed to evaluate the effect of a more informative interface (including removal of automatic reinvestment of winnings) and pop-up messages on gambling behaviour, and on player experience. A total of 213 Australian participants, recruited through social media, played a simulated online EGM. The experiment was a two (standard vs. informative interface) × two (pop-ups absent vs. present) between-subjects design. The informative interface: promoted keeping track of spins played; increased accurate estimation of amount spent (as did pop-up messages) and time played; and provided game usage figures which acted as cues to quit play. Once the initial deposit (but not winnings) was expended, informative interface users could opt to reinvest their winnings, although many opted to exit at that point. No difference in total spending or dissociation was observed between experimental groups. Informative interface users reported no reduction in enjoyment. Pop-up messages reduced enjoyment with the standard interface, but increased enjoyment when paired with an informative interface. These findings indicate that a more informative interface and pop-up messages may be useful in reducing the harmful nature of EGMs.

What's the Message? A Content Analysis of Emails and Texts Received from Wagering Operators During Sports and Racing Events.

Previous research has established direct messages (such as emails and text messages) are a widely seen form of advertising and are highly influential on sports betting and race betting behaviour. Nevertheless, few studies have examined the specific content of these messages, and whether their content is related to account-holders' betting behaviour. The current study used an ecological momentary assessment design to examine direct messages received from wagering operators during the week around major Australian sports and racing events. Respondents completed a baseline survey followed by short daily surveys over a period of 1 week during peak betting periods, and provided the research team with the emails and text messages they received from wagering operators during this time. A sample of 102 sports and 110 race bettors provided a total of 931 messages. These messages subsequently underwent a content analysis to extract key features that were promoted, including inducements, incentives, and bet type. The analysis found the messages were saturated with inducements to bet, however no relationships were identified between the content of messages and the gambling risk status or betting frequency of participants. The most common types of incentives offered included bonus bets, rewards points, better odds/winnings, and reduced risk. Frequently promoted inducements included bonus or better winnings, refund/stake back offers, and match your stake/deposit. Given the influences of inducements on increasing betting expenditure and impulsive betting identified through previous research, taken together with the findings of the current study, direct messages may contribute to experiencing gambling-related harm. These findings have important implications for consumer education and the regulation of direct messages.

Does Gambling Identity Predict Unique Variance in Negative Gambling-Related Outcomes: An Examination of Direct and Interactive Associations.

Research from other addiction-related domains have reported identity-related constructs to be positively associated with substance use-related outcomes (e.g., frequency, quantity, and/or problems). Moreover, substance use identity has also been found to be predictive of unique variance in substance use-related outcomes. Given the similarities between substance use and behavioral addictions, it may also be the case that gambling identity is predictive of unique variance in negative gambling-related outcomes (e.g., frequency, expenditure, and gambling problem severity). The current study was conducted to examine whether gambling identity was predictive of negative gambling-related outcomes above and beyond the variance explained by other known risk factors of problem gambling (e.g., motives, social norms, and protective behavioral strategy [PBS] use). Moreover, gambling identity was examined as a moderator of the relationship between known risk factors of problem gambling and negative gambling-related outcomes. The current online study consisted of 270 U.S. participants who were predominantly male (90%), White (82%) and 33 years of age. The results from the negative binomial regression analyses indicated that gambling identity was predictive of unique variance in all of the negative gambling-related outcomes assessed. Moreover, gambling identity was found to moderate the relationship between motives, social norms, and PBS use in the prediction of negative gambling-related outcomes. Taken together, the results from the current study replicate and extend the extant body of gambling research and are used to highlight the importance of assessing gambling identity in future studies.

The Winners and the Losers: Tax Incidence of Gambling in Finland.

Gambling markets have grown rapidly for the last few decades. As a result, gambling is also a very important and common source of tax income for many governments these days. This raises a question about the overall fairness of the gambling taxation systems. In this paper, we aim to study the tax incidence of gambling in Finland. First, we analyse who are the expected payers of the gambling taxes and second, who are expected to be the receivers of the gambling-tax based contributions. In the first part of the study, we analyse the demographic incidence of gambling taxation by using the Finnish gambling 2015 population survey combined with registry based variables. Our data contains 3776 individuals. In the second part of the study, we use data of county level gambling-taxation based contributions to different organisations to analyse how the gambling expenditures are distributed back to citizens in a form of public spending. This study shows that different socio-demographic factors have diverse association with the decisions whether or how much to gamble. The results also suggest that more disadvantaged, i.e. lower income, less educated and rural area living, individuals are expected to be the "losers" of the Finnish gambling taxation system. In other words, the Finnish gambling system is found to be regressive by nature.

Adolescent Gambling, Gambling Expenditure and Gambling-Related Harms in Finland, 2011-2017.

Existing literature on recent trends in adolescent gambling is scarce. The rapidly changing landscape of gambling, together with the generally applied legal age limits, calls for the continuous monitoring of gambling also among the adolescent population. In Finland, the legal gambling age is 18. We examined changes in adolescents' gambling, gambling expenditure and gambling-related harms from 2011 to 2017. Comparable cross-sectional biennial survey data were collected in 2011, 2013, 2015 and 2017 among 12-18-year-olds (N = 18,857). The main measures were self-reported six-month gambling, average weekly gambling expenditure (€) and harms due to gambling. Data were analyzed using cross-tabulations, χ2-tests and linear regression analysis. A significant decline in gambling among minors (aged 12-16-year-olds) was found (ß = - 0.253), while no significant changes were observed among 18-year-olds (who are not targeted by the law). The mean gambling expenditure also declined from 2011 to 2017. Adolescent gamblers experienced significantly less (p = .003) gambling-related harms in 2017 (7.4%) compared to 2011 (13.5%). Adolescent gambling and its related negative consequences have become less prevalent in Finland between 2011 and 2017. Further monitoring is necessary to ascertain whether the positive direction will continue. Also, empirical analyses providing evidence of reasons for the observed trend are warranted.