Gambling is a very popular form of entertainment and socialization in the US and is generally considered a safe form of recreational activity. There is some evidence of associations between positive health outcomes, as well as poor behavioral and mental health conditions with gambling. However, the relationship between recreational gambling and risk health behaviors has been under researched and thus poorly understood. The 2011 Massachusetts Expanded Gaming Act provides the impetus to understand gambling related problems prior to the introduction of new gambling opportunities. The objectives of the study are twofold: (1) examine associations between recreational gambling and, behavioral and mental health disorders, (2) provide a description of health care services used and costs associated with pathological gambling and co-occurring substance use and mental health disorders. Study data was derived from the 2008 and 2013 Massachusetts Behavioral Risk Factor Surveillance System (BRFSS) as well as the All Payers Claim Data from 2009 to 2013. This study finds significant associations between recreational gambling and co-occurring behavioral and mental health conditions which include nicotine use, alcohol abuse and poor mental health status. These findings persist with increasing risk when gambling is dissected by frequency which suggests that the overall assessment of gambling participation tends to obscure related health risks. Further, individuals with pathological gambling are important consumers of health care; they utilize a variety of use a variety of health care services and health care institutions. Approximately $1.9 million (in 2013 dollars) was spent from 2009 –June 30, 2013 on patients with pathological gambling and co-occurring substance abuse and mental health disorders. Total average expenditure was estimated at $491.0 (in 2013 dollars). Study findings provide critical baseline information on the risk factors of co-occurring conditions associated with recreational gambling as well as health care utilization patterns and costs associated with pathological gambling prior to gambling expansion in Massachusetts. These findings have significant public health implications for the need for increased surveillance of gambling related problems.