Configurations of gambling change and harm: qualitative findings from the Swedish longitudinal gambling study (Swelogs)

Abstract

Background: Gambling participation and problems change over time and are influenced by a variety of individual and contextual factors. However, gambling research has only to a small extent studied gamblers’ own perceptions of transitions in and out of problem gambling.

Method: Qualitative telephone interviews were made with 40 gamblers who had repeatedly participated in the Swelogs Swedish Longitudinal Gambling Study. The framework approach was used for analyses, resulting in a multiple-linkage typology.

Results: Our analyses revealed four configurations of gambling: (a) stable low frequency with no or minor harm, (b) decreasing high frequency with occasional harm, (c) fluctuating with moderate harm, and (d) increasing high frequency with substantial harm. Natural recovery and return to previous levels of gambling intensity were common. Change occurred either gradually, as a result of adjustment to altered personal circumstances, or drastically as a consequence of determined decisions to change. Personal and contextual factors such as psychological well-being, supportive relationships, and meaningful leisure activities played a part in overcoming harmful gambling and keeping gambling on a non-problematic level. Gambling advertising was commonly perceived as aggressive and triggering.

Conclusions: The experience of harm is highly subjective, which should be taken into account when developing preventive measures. Considering the fluid character of gambling problems, help and support should be easily accessible and diversified. To repeatedly be interviewed about gambling and its consequences can contribute to increased reflection on, and awareness of, one’s own behaviours and the societal impacts of gambling.

Keywords:

• Gambling
• problem gambling
• harm
• advertising
• qualitative interviews

Introduction

It is commonly known that gambling behaviours and problems tend to change over time (LaPlante et al. 2008; el-Guebaly et al. 2015). In Sweden, about 2% of the population were, in 2008/2009, ‘moderate risk’ and ‘problem gamblers’, scoring at least three points on the Problem Gambling Severity Index (PGSI, Ferris and Wynne 2001), while another 5% were ‘low risk’ gamblers (PGSI 1–2 points) (Public Health Agency of Sweden 2016). However, many people move in and out of problematic gambling. While the prevalence of problem and moderate risk gambling remained stable in a follow-up study about one year later (2009/2010), about three-fourths of previous PGSI 3 + gamblers had been replaced by new ones.

Knowledge of factors relevant for change in gambling behaviours and problems are mainly derived from quantitative studies. For example, increased gambling has been found to be related to positive life changes in family function and relationships, as well as to stressful events and psychological problems (el-Guebaly et al. 2015). This shows that people tend to gamble both to enhance positive feelings and to escape negative sentiments (Stewart and Zack 2008). Availability of gambling (St-Pierre et al. 2014; Welte et al. 2016), cognitive distortions (Cunningham et al. 2014), reaching the legal gambling age (Winters et al. 1995), alcohol and drug use, increased income, and becoming unemployed (el-Guebaly et al. 2015) all tend to intensify gambling. Reasons for declining involvement in gambling include its negative consequences (affecting economy, relationships, and psychological well-being), diminished gambling availability, personal maturation, other priorities in life, and having a more negative attitude towards gambling (Cunningham et al. 2009; Suurvali et al. 2010). A large percentage of problem gamblers recover from their gambling problems with time, with or without professional help (Abbott et al. 2004; Slutske 2006).

Of particular interest to this research are results from previous qualitative studies on gambling change. A consistent temporal finding is that gambling participation and problems often fluctuate (White et al. 2001; Kerr et al. 2009; Saugeres et al. 2012; Victorian Responsible Gambling Foundation 2012). The intensity of gambling may steadily increase or decrease over a number of years, or fluctuate in cyclical fashion. Two separate studies have found the same four gambling pathways or ‘gambling careers’: intensification, reduction, stability, and non-linearity (Reith and Dobbie 2013; Kristiansen et al. 2017). Fairly consistent are also qualitative findings regarding factors leading to change in gambling behaviour (White et al. 2001; Anderson et al. 2009; Kerr et al. 2009; Victorian Responsible Gambling Foundation 2012; Reith and Dobbie 2013; Kristiansen et al. 2017). External factors include having more money or less, social contexts, exposure to gambling, changing personal circumstances (work or study situation, family responsibility, demands from partners), and being harmed by gambling, whereas internal factors include the perceived need to gamble to alleviate feelings of stress or dullness, and loss of interest in gambling.

A study similar in methodology to ours – qualitative interviews made with people who in a longitudinal population study had problem gambling (PG) scores suggesting change in PG severity – was part of the Leisure, Lifestyle and Lifecycle Project (LLLP) in Alberta, Canada (Mutti-Packer et al. 2017). The study found that both increased and decreased gambling behaviour was caused by financial, environmental, and internal reasons. However, the study concludes that a considerable number of the participants may not correctly perceive changes in their gambling.

The current qualitative study adds to the existing body of knowledge by exploring configurations of gambling change, reasons for change, and levels of harm. The basic idea of the study was to explore qualitatively the significant extent of change in problem gambling severity observed in the Swelogs quantitative longitudinal study. A novel component in this research is to study how gamblers’ experiences of participating in a longitudinal gambling study have influenced their perceptions and gambling behaviour.

Methods and material

Swelogs research programme

The Swedish longitudinal gambling study Swelogs was a research programme to produce knowledge and methods to prevent gambling problems. The study comprised an epidemiological track (EP) and an in-depth track (ID) where a sub-sample from the EP track was followed for consequences and risk and protective factors (Romild et al. 2014) (see Table 1). With regard to the changeable nature of gambling behaviours, and the importance of taking contextual factors into consideration in understanding individual gambling change, a qualitative component was included into the longitudinal study. The current study was the final in-depth study (ID III).

Table 1. Data collection in Swelogs epidemiological and in-depth tracks.

	2008/2009	2009/2010	2011	2012	2013	2014	2016
Epidemiological track	EP I	EP II		EP III		EP IV
	n = 15 000	n = 8165		n = 7064		n = 7000
	Age 16–84	Age 17–85		Age 19–87		Age 21–89
In-depth track			ID I		ID II		ID III
			n = 2400		n = 2000		n = 40
			Age 18–86		Age 20–88		Age 23–75

Procedure and participants

To recruit participants who were likely to have experienced variations in gambling behaviours and problems, the inclusion criteria were having gambled at least monthly during the past 12 months, having participated in at least three Swelogs EP studies, and having a minimum of a three-point difference in PGSI scores between two data collections in the EP track; a difference of this size has in a Canadian longitudinal study been found to indicate a fairly reliable change in PG severity (Williams et al. 2015, p. 69). Among those who met these criteria, 102 individuals were sampled, of whom women were prioritised because they were in a minority. The goal was to interview 40 gamblers, which was attained after contacting 45 gamblers.

The interview guide was semi-structured, covering current and previous gambling and personal circumstances, negative consequences, and reasons for changes in gambling behaviour and problems; it was inspired by the guide used in the study by Anderson et al. (2009). Telephone interviews lasted for about 30 minutes (10 to 50 minutes), took place between January and August 2016, and were audio recorded. A EUR 25 gift certificate was given as compensation for the time offered.

The interviewers did not have access to data gathered in previous Swelogs studies to avoid bias towards any particular interpretation when asking questions and discussing with the participants. Open-ended and follow-up questions were posed, which facilitated the participants’ own narratives of their gambling and changing personal circumstances. Questions were posed so as not to suggest that the interviewee might have had gambling problems, since this term could have been perceived as stigmatising and suggesting a relatively high degree of harm. The terms used by the interviewers were ‘drawbacks’ and ‘negative consequences’ of gambling.

However, if the respondent did not report any problems, drawbacks, or negative consequences from gambling, the nine PGSI questions were asked with an eight-year frame (2008–2016; ‘During the last eight years have you ever…’) to cover the period of participation in Swelogs. The objective of asking these questions was thus not to retrospectively re-assess PG status, but simply to elicit the recollection of possible harms or problematic gambling behaviour by asking the same questions that were implied by the inclusion criteria, that is, at least three points at the PGSI in at least one previous EP study.

Of the 40 gamblers interviewed, 19 were women and 21 men. The mean age was 37 years (SD = 13). A majority (57.5%) were in employment at the time of the interview and were single (52.5%).

Ethical approval to conduct the study was obtained from the Regional Ethical Review Board in Umeå, Sweden (ref. 2015-456-32Ö).

Analysis

In the thematic analysis, the data was structured according to the framework approach (Gale et al. 2013), which is a widely used systematic procedure for handling and analysing qualitative data. First, the interviews were transcribed verbatim, repeatedly read, and listened to. After each interview the interviewers wrote analytical memos, which were used to construct a coding tree, iteratively updated during the listening and reading process. The qualitative coding platform NVivo (QSR International Pty Ltd. 2012) was used for coding. To increase the coherence of the process, five interviews were coded by the first two authors simultaneously.

Each case was categorised based on the extent of harm, the intensity of gambling seen over time, stability versus change, and pace of change. The categorisations were made by the first two authors and discussed to reach consensus. Using framework matrices, broad themes and categories were identified within and across cases, resulting in four configurations of change and harm. The configurations were constructed on four dimensions – pattern of change, harm level, gambling motives, and factors of importance for change. This multiple-linkage typology approach (Spencer et al. 2014) meant that attitudes and experiences of one individual could belong to more than one typological category. The goal was to grasp variations and patterns in perceptions, experiences, and explanations to provide a nuanced picture of factors influencing changes in gambling behaviours and problems on individual and contextual levels.

Based on the participants’ narratives of negative consequences from gambling during the past eight years, and their answers to the PGSI questions (if asked), a harm level characterisation was made (see below).

Results

Harm levels and patterns of change

In the interviews, the participants were asked for drawbacks and negative consequences from their gambling. Surprisingly, considering the inclusion criteria in the sampling procedure (showing at least a three-point difference in PGSI scores between two EP tracks), 18 of the interviewees did not spontaneously report any negative consequences from their gambling. After having been asked the PGSI questions, eight of them recalled occasional consequences or side effects of gambling that might be considered negative.

Even though the interviewees could experience controlled gambling in recent times, the harm level categorisation was based on occurrence of negative consequences at any time in the last eight years (see Table 2). No harm meant that the gambler could not recall any negative consequences or loss of control, even when prompted by the PGSI questions; 10 of the interviewed belonged to this category. Low harm meant that occasional marginal consequences were reported (such as self-recrimination due to over-investment of time and money in gambling, occasional chase of losses), which was the case for 14 interviewees. Five interviewees were categorised as harm gamblers, with repeated marginal consequences or occasional but substantial consequences. Substantial harm meant that the participants stated repeated loss of control over time or money spent on gambling and negative consequences for the gamblers or someone close to them, and that they would thus have scored as problem gamblers. Eleven interviewees were categorised as belonging to the substantial harm category. Each interviewee was also categorised into one of the following patterns of change according to their overall gambling behaviour during the last eight-year period: stable (n = 13), decreasing (n = 13), fluctuating (n = 9), and increasing (n = 5).

Table 2. Harm levels and pattern of change.

	N	%
Harm level
No harm	10	25.0
Low harm	14	35.0
Harm	5	12.5
Substantial harm	11	27.5
Pattern of change
A. Stable	13	32.5
B. Decreasing	13	32.5
C. Fluctuating	9	22.5
D. Increasing	5	12.5

Configurations of change and harm

In this section, gambling change is described according to four configurations (A–D). Each configuration is based on a synthesis of narratives of the characteristics of the pattern of change, harm level, and factors influential for increasing or decreasing the involvement in gambling. The gambling behaviour of a specific individual in the study need not have been characterised by a single configuration over the eight years. The configurations refer to distinct and coherent periods of time, which can be eight full years but also less, as when one configuration is followed by another.

A. Stable, low-frequency gambling with no or minor harm. Characteristic for the stable configuration was controlled, planned, and regular gambling on lotteries or sports games for small amounts of money. Because gambling was habitual and a tradition, sometimes in the form of a monthly subscription to lotteries, it was easier to continue than to quit. Gambling also served a social purpose together with friends, family, and colleagues, for example on cruises and holidays, and at sports events. The excitement of gambling and the contribution to good causes in charity lotteries played a certain role, but gambling was not crucially important in the interviewee’s life.

The majority of those interviewed in this category did not report any negative consequences from gambling. Consequences mentioned were minor and inconsequential, such as having occasionally gambled more than intended, and regretting or feeling ashamed over gambling. Concerned significant others had in some cases made fun of the interviewees’ gambling habits.

Naturally, the stable gambling configuration had few factors relating to change. Some interviewees mentioned aspects of importance for their gambling frequency or the amounts spent, such as the opportunity in the moment, where buying lottery tickets in the local supermarket was given as an example. Availability thus had some relevance. Sometimes, gambling decreased during a period if the interviewee, for example, had forgotten to renew the lottery subscription. Gambling took place in secure environments; electronic gaming machines (EGMs) in unknown bars were avoided as well as gambling online for reasons of not wanting to start a new habit, preferring to hold an actual lottery ticket in the hand, or being unaccustomed to using computers in general. In some cases, the gambling was pure enjoyment for the moment, while in other cases it was driven by a hope to improve one’s economic situation and to afford a holiday abroad, to get a driving licence or buying things for the household. The chance of winning motivated the gambling, even though the interviewees were aware of the low probabilities.

I do not buy lottery tickets because I think that I will win, rather I am a realist. I understand that the chances are extremely low. (IP 30)

Gambling advertising and offers were influential, as well as the wish to increase excitement when watching a football game. The gambling was sometimes perceived as a waste of money and causing irritation. Setting up a budget meant becoming aware of the money spent on gambling and keeping it within reasonable limits. Even though small amounts were spent, a high awareness of the risks associated with gambling was evident, which increased the tendency to keep involvement on a low level.

B. High-frequency gambling with occasional harm, decreasing. Configuration B gambling was characterised by high frequency, having a substantial impact during a period of life, but decreasing with maturation into adulthood. For people in this category, the driving force was often related to the challenge of calculating probabilities and learning the rules of the game. Social motives and the excitement and pleasure of winning were also mentioned. Some reported having begun to play live poker or participate in sports betting with older peers, and thereafter having a period of increased gambling when they were aged 18–25, with substantial economic losses. Significant others could have objected to the time and money spent on gambling. Losses had caused frustration and irritation, but no substantial psychological harm.

Becoming of legal age to gamble typically increased the interest and participation in gambling, and participants described this as an opportunity to try out various forms or modes of gambling without really being able to handle the games. Having plenty of money to spend on gambling and other leisure activities had been influential in younger years, for example as a result of living in the parents’ house and having a part-time job.

Alcohol was associated with higher risk-taking when gambling. It had made the participants reckless and lose clear judgement, while some interviewees also described the intoxication as dulling the gambling experience. Gambling often took place with friends, with drinking and gambling combined at a nightclub. Drinking alcohol alone while gambling online was uncommon. To gamble with friends was described as more triggering, and friends encouraged each other to take greater risks.

Different types of money were described by the interviewees. Some had considered ‘bonus money’ or ‘gambling cash’ to be eligible for spending, irrespective of the balance of overall wins or losses. Others had more strict rules on how much to spend, a more or less adjustable limit. Gambling online was experienced as associated with greater risk, because the money tended to be perceived as just figures on the computer screen, not ‘real’ money.

Some forms of gambling were said to be more, or less, triggering than others, depending on the interviewees’ preferences, motives, and interests. Some said that coming out ahead in poker had become more difficult in recent years because of tougher competition, which made them lose interest in the game. Some individuals changed from one gambling form to another, depending on their personal circumstances and availability (e.g. from casino gambling to online gambling; from live poker to sports betting).

Friends or colleagues who had more extensive gambling habits than the interviewees themselves could have either a normalising or a deterrent effect on an individual’s gambling. Having an acquaintance with substantial gambling problems increased risk awareness and put more attention to setting and keeping gambling within reasonable limits. Even though gambling was not that extensive, the risk of ‘becoming addicted’ or ‘getting caught’ was evident in the narratives.

Several interviewees said they had overestimated the number and size of their wins. In retrospect, the gambling could be regarded as not worth the time and money spent, described as difficult to comprehend in the midst of an active gambling period.

In relation to the time spent and the long period of losses, it was not worth it. But I don’t know, when you are gambling you cannot see clearly. Now when I have quit gambling I have a different view. (IP 16)

Gambling had often changed its character over the years, from a social to a solitary pastime. Meeting a new partner or having a new circle of friends was cited as decisive for less interest in gambling. Socialising in bars or nightclubs with casino gambling and sports betting was replaced with dinners at home with partners. Nonetheless, even though the gambling was less frequent, gambling episodes could involve more money spent – thus in a way maintaining the overall dose of gambling.

The narrative of maturation was central for those interviewees with a decreasing gambling configuration. Becoming older and wiser, and living a more stable life with family responsibilities, was decisive.

The reason for decline [in gambling] was mainly that I grew older and became more responsible maybe. Knowing that you cannot gamble when you have little money. Well, growing up sort of. (IP 6)

The gambling belonged to a youthful lifestyle with nightclubs, alcohol, comradeship, and risk-taking. When friends scattered, and the need for creating a stable future with education, work, and family became imminent, gambling lost much of its appeal. Money was rather spent on other, more important things in the new personal circumstances. Becoming a parent and having to face the future as a family provider were influential.

Maturation was also described as getting a wiser and a more rational view of the probabilities of gambling games and the value of money. Previous notions of betting and staking on the basis of hunches and a sense of flow now appeared to have been naïve. This realistic outlook removed much of the appeal of gambling.

C. Periodic gambling with moderate harm, fluctuating pattern. Configuration C – fluctuating gambling – was characterised by periodic negative consequences from gambling. As described by one of the interviewees:

Many turns, up and down. Sometimes I’ve been totally crazy and sometimes I’ve been able to refrain from it. Yes, a real roller coaster I would call it, depending on circumstances in life. Relationships and family and such. (IP 28)

In difficult and stressful times, gambling became more frequent. In good times – without economic worries, with psychological well-being, having meaningful employment or studies, and living in a harmonious relationship – the drive to gamble was weak. Thus, gambling had the function of mood regulation; it was a coping strategy to temporarily escape hardships and feel better. The negative consequences were to varying degrees economic (losses, debts, and loans), psychological (self-reproach, anxiety, depression, insomnia), and social (isolation, strained or broken relationships with partners or friends).

Personality traits – with or without formal diagnoses – that had a bearing on the intensity of gambling were a risk-taking personality, impulsivity, or being depressive with low self-esteem and negative self-image.

The fluctuating pattern was related to shifting opportunities to gamble. Some work conditions tended to increase gambling – such as working nights at stressful jobs and then having the need to wind down in front of the computer, or itinerant and unsupervised work with money, time, and opportunity to gamble together with colleagues. Several interviewees described that they had been close to losing control over gambling. Somewhat paradoxically, buying lottery tickets became for some a way to handle concerns about the economy, enforced by the dream of becoming economically independent.

Gambling preferences, the level of risk-taking, spending limits, and the number of games engaged in were influenced by the self-perceived appeal of the game, advertising, bonus and rake-back offers, and sudden hunches. Some perceived online casinos as especially risky, which prompted the decision to not participate in this form of gambling. As described by one of the interviewed:

Sometimes I fall back but then I get the feeling “it’s enough” and I can stop it. But sure, I get that I am on a slippery slope. So that’s why I avoid online poker. Because I feel it is the most noxious so to say. (IP 8)

Some interviewees had, without having thought much about it, gambled less and less. Others had made a determined decision to cut down on gambling or quit altogether. In these latter cases, the strength and occasion to change had suddenly appeared; some described it as an awakening and a turning point. A decisive factor was realising the full extent of the negative consequences. The burden of all gambling losses was felt so heavy that gambling lost its appeal.

The critical life event of becoming a parent was important for spending much less time on gambling. There was the wish to be a role model for the children and take on family responsibilities. Comments, criticism, or ultimatums from concerned significant others could be eye-opening experiences, as when children had been upset over the poor state of the family economy, or partners had become aware of the misuse of family savings. As expressed by one of the interviewees:

It was an eye-opener. She [my daughter] was going out and asked for money, but I said I did not have any. She screamed “of course you don’t when everything goes to your gambling.” Then it hit me/…/I can’t be a good role model like that. I have to show her it is possible to succeed in life without winning the lottery. (IP 26)

Shame and guilt were reoccurring themes in these interviews. There was an unwillingness to share the downsides of gambling with close ones for fear of the consequences when the true extent of gambling was revealed and for the embarrassment of failing to keep gambling under control. There was also relief when the truth was out there and comfort of support that in many cases came when all cards were on the table.

Previous periods of gambling problems in life, prior to 2008 when the longitudinal Swelogs study started, could have been influential for the interviewee’s attitudes towards gambling and patterns of change during the study period. The recollection of harmful gambling in younger years clearly had a deterrent effect.

Strategies used for limiting or quitting gambling included engaging in new leisure activities or resuming previous ones, setting firm spending limits – alone or in agreement with and help from friends and family – or self-excluding from the services of gambling companies.

D. High-frequency gambling with substantial harm, increasing. Harmful gambling (configuration D) was characterised by an overall increase in gambling participation over a period of years. Gambling was central in the individual’s life and typically had the function of providing escape from everyday troubles.

After my divorce I was totally absent-minded. I have comforted myself with gambling. It becomes a way of living. (IP 27)

Dramatic life events, such as the death of a loved one, one’s own health problems, and breaking up of a relationship were described as decisive for initiating high-frequency gambling. Loneliness, unemployment, and problems with social relations were also reported as reasons for gambling taking precedence in life. Economic, psychological, relational, and social harms all appeared to a varying extent in the narratives, as well as the tendency of the activity to change its characteristics from amusement to compulsion.

It used to be for fun, now it is more of a need [to gamble]./…/Stressed, worried that there is not enough money… (IP 35)

Winning a substantial amount of money (or having friends doing so) was described as influential for increased gambling; there was a desire to repeat previous wins and again experience the tremendous feeling. Big wins could give rise to a feeling of being ‘immortal’ and override more rational thoughts about limiting the gambling. Bets were often increased for a period after a substantial win. Losing money that had been won was not felt to be as bad as losing money earned by work.

Strategies on how to refrain from chasing losses were described. Despite awareness of erroneous perceptions of gambling, the interviewees told us about having chosen particular venues, occasions to bet, and procedures (e.g. a sense of flow) to increase the chances of winning. A need to gamble with larger amounts of money to get the same feeling of excitement was reported, as well as an awareness of gambling psychology (i.e. behavioural conditioning) and the risks of becoming addicted. Some significant others had tried to make the gamblers change their habits, providing vital support to keep up the motivation to abstain.

Overview of the four configurations of gambling change and harm

Table 3 gives an overview of the factors in the four configurations of gambling change and harm. A distinction is made between individual and contextual factors. Some factors were influential for both decreasing and increasing the intensity of gambling. For example, low money access could constrain gambling (configurations A and B) but also intensify it, because the gambler hoped that a gambling win would solve economic problems. Similarly, important life events could have both an increasing influence (configurations C and D) and a decreasing (configuration B) impact.

Table 3. Overview of configurations of gambling change and harm.

Configuration	A. Low-frequency gambling with no or minor harm	B. High-frequency gambling with occasional harm	C. Periodic gambling withmoderate harm	D. High-frequency gambling withsubstantial harm
Intensity of gambling	Stable	Decreasing	Fluctuating	Increasing
Gambling motives	Excitement Tradition/Habit Social function Chance of winning Charity	Excitement Challenge Chance of winning Social function	Chance of winning Cope with/escape from everyday problems	Excitement Challenge Chance of winning Cope with/escape from everyday problems
Factors increasing gambling Individual level	Erroneous perceptions of gambling High money access	Interest in gambling High money access Alcohol Becoming of legal age to gamble Time to gamble Erroneous perceptions of gambling	Low/high money access Personality traits Ill health Time to gamble Erroneous perceptions of gambling	Low/high money access Personality traits Ill health Alcohol Erroneous perceptions of gambling
Contextual level	Gambling among friends and family Gambling advertising Easy access to gambling	Gambling among friends and family Easy access to gambling Gambling advertising	Gambling among friends and family Important life events Gambling advertising Easy access to gambling Itinerant work or inconvenient working hours Lack of supportive network and meaningful employment	Big wins Gambling advertising Important life events Lack of supportive network and meaningful employment
Factors decreasing gambling Individual level	Low money access Risk awareness Lost interest in gambling Correct perceptions of gambling	Less time for gambling Low money access Risk awareness Own rules and strategies Maturation Negative consequences Turning points Lost interest in gambling Correct perceptions of gambling	Low/high money access Own rules and strategies Responsible gambling tools Improved health Negative consequences Turning points Correct perceptions of gambling Lessons learned from previous destructive gambling habits	Low/high money access Correct perceptions of gambling
Contextual level	No gambling among friends and family Low access to gambling	No gambling among friends and family Meeting new partner/friends Work/study/family responsibilities Important life events Criticism, demands and support from significant others Low access to gambling Leisure activities	Meaningful employment Important life events Criticism, demands and support from significant others Support/treatment from professionals or self-help groups Leisure activities	Meaningful employment Criticism, demands and support from significant others Support/treatment from professionals or self-help groups

Perceptions and experiences of handling gambling problems

The most common view among those who reported substantial negative consequences from gambling was that they did not perceive any need for professional support. They wished, and had the capacity, to handle the situation on their own, or with the help of friends and family. They did not wish to involve outsiders because it was unnecessary or, when it actually would have been favourable, because of the shame it would bring to contact caregivers. Occasional experiences of contacts with telephone helplines or other support services (social services, mutual support groups) were reported. These contacts were appreciated, for example because they increased the awareness of the true probabilities of gambling games, pointed out erroneous beliefs, and gave a feeling of belonging and support when talking to others with similar problems. Others had shared their gambling problems with counsellors, with whom they had had contact for other reasons.

Perceptions and experiences of gambling advertising and responsible gambling tools

Overall the interviewees perceived an increase in the frequency and aggressiveness of gambling advertising in recent years. Some said that advertising had a deterring rather than a stimulating effect. Several interviewees spontaneously gave their support for stricter regulations. Gambling advertising and text message offers from gambling companies were described as triggers for relapse or returning to previous levels of harmful gambling. The strength and capacity to resist the various modes of gambling marketing varied with psychological well-being; getting a tempting offer at the wrong time could initiate a new and intensive gambling episode.

Even though the possibilities to use responsible gambling tools to block and limit engagement and spending in general were experienced as useful, the interviewees had also simply ignored or found ways to circumvent such opportunities when overcome by a strong urge to gamble. As commented by one of the interviewees:

It could be helpful but at the same time, those limits can be changed and bypassed. If there is a gambling problem, you will find another way to gamble your money anyway. (IP 13)

Experiences of participating in a longitudinal gambling study

The interviewees had since 2008 participated in at least three of Swelogs EP track data collections. In these telephone interviews, the participants were asked about gambling behaviour, health, and socioeconomic circumstances, and were screened for gambling problems by means of the PGSI. Postal questionnaires were used when people could not be reached via telephone.

By the end of the qualitative interviews in this in-depth study, the question was asked whether participating in Swelogs had influenced their perceptions of gambling or their gambling behaviour. While some answered that their participation had not had any influence at all, others said that taking part in the study had made them reflect upon their gambling and made them more aware of the drawbacks of gambling in society. A few stressed that an interview in the EP track had been a thought-provoking experience, which had been followed by a reduction in gambling, at least for a period.

Interviewer: Has participating in Swelogs in any way influenced your gambling over the years?

Interviewee: Well, you think about it a lot. And especially right after hanging up the phone you start thinking about it. You have it in the back of your head and it pops up once in a while and make you reflect and get a bigger picture… and then it fades away. (IP 18)

One interviewee said that the answers given to the questions in the EP track (which mostly concerned the past year) depended on the situation at the moment and could thus vary. Others acknowledged not being fully honest about their gambling, playing down the severity of the problem while being in a destructive gambling episode. Some got the feeling from the EP interviews that their gambling was not that problematic because of how they perceived the scaling of the questions.

While some had been slightly annoyed by repeatedly being asked to report on their gambling, which they perceived as neither problematic nor changing, others had found the interviews to be meaningful and interesting; for example, that their experiences could be useful for others.

The opportunity, in the qualitative interviews of this study, to reason about and nuance the answers to the questions posed was generally appreciated. The conversation-like character of the interviews was felt by some to promote a greater degree of reflection than previous interviews (with predominantly fixed response alternatives). A few participants were grateful for having had the opportunity to share thoughts and feelings seldom or never discussed before. In part, these reflections were prompted because, in interviews of a sensitive character, the interviewer always asked for the participant’s feelings of having been interviewed.

Discussion

Main results – the fluidity of gambling and gambling problems

The aim of this study was to qualitatively explore the high degree of change in problem gambling severity observed in the Swelogs EP track. More specifically, we wished to know how gamblers who had participated in the EP track experienced their gambling, the degree of gambling-related harm over time, changes in gambling intensity, and factors contributing to such change. Also, perceptions of participating in a longitudinal survey on gambling and health were of interest.

Similar to the findings of previous qualitative research, gambling and its possible harm was over time a dynamic process influenced by a number of internal and external factors (Anderson et al. 2009; Kerr et al. 2009; Reith and Dobbie 2013; el-Guebaly et al. 2015). Change took place either gradually, because of adjustment to altered personal circumstances, or drastically as a consequence of determined decisions to change.

Among the participants, gambling-related harm ranged from none to severe, the involvement in gambling ranged from low to high, and the change in involvement over time was none (stable), fluctuating, decreasing, and increasing. Our analyses revealed four main configurations of gambling: (a) stable low frequency with no or minor harm, (b) decreasing high frequency with occasional harm, (c) fluctuating with moderate harm, and (d) increasing high frequency with substantial harm. In the lives of the participants, periods characterised by one configuration could be followed by periods marked by another configuration, such as configuration B (decreasing) followed by a period of configuration A (stable).

These results are similar to those of some previous qualitative studies, in particular the British and Danish studies that found four pathways of gambling: intensification, reduction, stability, and non-linearity (Reith and Dobbie 2013; Kristiansen et al. 2017). The findings tally with the view that PG seldom is a chronic state. Although some problem gamblers suffer substantial and persistent harm over periods of many years, in most cases there is a dynamic relationship between harm and the intensity of gambling: escalation of gambling leads to more harm, which is a state difficult to sustain over time because it causes severe economic, social, and psychological stress and suffering. By own strength or with external help, the gambler cuts down on gambling and the harms are reduced. Whether the cycle is repeated or not depends on factors such as maturation into adulthood, changing circumstances of life, and learning how to avoid gambling excessively. Some of the participants had experienced a ‘turning point’, a well-known phenomenon in addiction research, when an individual reaches an upper limit of harm and suffering, makes a critical decision to change his/her lifestyle, and succeeds in doing this (Koski-Jännes 1998). We have observed, on the level of the individual, processes which are part of the dynamic interplay over time between the availability of and adaption to gambling on the national level, resulting in changes in the prevalence of gambling and PG (Abbott 2017; Abbott et al. 2014; Binde 2014a).

The factors underlying involvement in gambling and change among the participants in this study (Table 3) were, by and large, the same as those identified in previous quantitative and qualitative studies. There was a range of motives for participating in gambling, such as getting excitement, socialising with peers, and coping with everyday problems, which interacted with personality type. The configurations were characterised by different motives, where the chance of winning triggered by advertising was evident in all four configurations. While social aspects of gambling were emphasised by gamblers with stable or decreasing patterns, those with fluctuating or increasing gambling configurations rather stressed the coping function of gambling to escape everyday trouble. In the decreasing, fluctuating and increasing configurations where substantial gambling change occurred, it was evident that the motives were altered or shifting in intensity over time. Similarly to what was found by McGrath and Konkolÿ Thege (2018) there is substantial fluidity in motives for gambling and the reasons for change in motives depends on a variety of factors such as gambling experience and circumstantial life events. On the individual level, factors increasing gambling included erroneous perceptions of gambling and having plenty of money to spend, while on the contextual level such factors included gambling among family and friends, and gambling advertising. Among the factors decreasing gambling were maturation into adulthood, finding other leisure activities than gambling, and support from others to cut down on harmful gambling.

While quantitative studies typically view these factors in isolation and cross-sectionally, qualitative studies reveal their interrelation both in the moment and in the temporal dimension. In our study, these relationships were synthesised in the four configurations of gambling change and harm.

Methodological and conceptual implications

According to some interviewees, participation in the Swelogs longitudinal study – with three to four interviews over a period of eight years – had contributed to a higher awareness of their gambling behaviour and gambling problems in society. Similar results have been reported with respect to other lifestyle issues (MacNeill et al. 2016). The relationship between higher awareness and actual behaviour change is vague, relying on self-reports (Kypri et al. 2011) and in this case also likely to be influenced by recall bias. Nevertheless, longitudinal gambling studies should consider whether participation has an effect on perceptions and behaviours relating to gambling, which would make the study group different from the general population.

A substantial proportion of the interviewees in this study (10 of 40) did not report any gambling harm (even when the PGSI questions had been explicitly asked). This might appear as surprising. One of the inclusion criteria was at least a three-point difference between two EP tracks, which means that all participants had at least at one EP measurement a PGSI score of at least 3. This issue will, however, be thoroughly analysed and discussed in a separate publication. In summary, the result of our interviews indicates that the main reason for some participants’ reporting no harm and no gambling problems was that they, in the EP measurement, were false positives.

All PG screens produce false negatives and false positives, that is, people who have gambling problems but are not detected, and people who have no gambling problems but by the screening instrument are classified as such. When measuring the prevalence of problem gambling, false negatives and false positives by and large cancel each other out (Abbott and Volberg 2006). In our study, the 10 out of 40 participants who did not report any gambling problems at all in the qualitative interviews appear to have been false positives. Because we did not interview people who might have been false negatives (i.e. the thousands of participants in the Swelogs study who had fewer than three points on the PGSI scale), these do not appear in our material, and do not compensate for the false positives. The reasons for being a false positive, according to a PG screen, are many and well-known (Ladouceur et al. 2000). Another reason for discrepancy in results between PG measurement in a population study and qualitative interview assessment, suggested by a Canadian study, is that people due to gambling fallacies, dissonant feelings and mental health problems do not accurately perceive changes in gambling intensity and problems (Mutti-Packer et al. 2017).

However in our study it was clear that a substantial number of the participants had not had any appreciable problems with gambling but nevertheless had scored at least three points on the PGSI. PGSI covers both problematic behaviours (e.g. chasing losses and increased tolerance) and harmful consequences (economic, relational, and health-related). Explanations found in the interviews were that participants had misunderstood the questions or contextualised them in an unintended way. For example, people had made fun of their lottery gambling or they had been disappointed after having gambled without winning much. This is not harm, but interpersonal friction and learning from experience, which are unavoidable consequences of virtually any human activity. The findings from this study thus illustrate the challenges in measuring harm from gambling, which have recently come to the forefront in gambling studies (Browne et al. 2016; Delfabbro and King 2017; Shannon et al. 2017).

Strengths and limitations of the study

The interviewees had participated in the Swelogs longitudinal study and had previously reported negative consequences from gambling and changes in gambling behaviour. This was advantageous, because our study focussed on these issues and because we could ask about the influence of participating in a longitudinal gambling study. However, it also means that the results of this qualitative study are not generalisable to gamblers’ experiences in general.

The accounts of past and present gambling and problems could be affected by recall errors and biases, a desirability bias to appear in a favourable light, and a wish to present a coherent narration of events that in reality might have been more unstructured and driven by factors not fully perceived. However, we gained knowledge of the participants’ own interpretations of experiences and events, allowing us to view nuances and complexities that cannot easily be discerned in quantitative research. When inconsistencies were evident in the participant’s experiences of harms from gambling during the course of the interview, the interviewer asked follow-up questions to clarify. The harm level categorisation was made based on the overall assessment of the whole interview.

Although greater detail in the results could have been achieved with a larger sample, 40 individuals is not unusual for a qualitative study. A series of in-depth interviews with each participant could have given a more detailed insight in gambling changes. Good coherence between our results and those of previous research in this field indicates reliability of data and analysis. We used telephone interviews rather than face-to-face interviews, which limited the possibility to observe body language or emotional expressions. However, the interviewers perceived the interviews as relaxed conversations, in which the vast majority of the participants openly and generously shared their experiences, providing a rich and detailed material. The confidence to talk openly among the participants may have been strengthened by the sense of anonymity when talking over the telephone, thereby making it easier to discuss sensitive issues (Cachia and Millward 2011).

Policy implications

The experience of harm, especially to one’s well-being, is highly subjective, which should be taken into account when formulating preventive measures. Irrespective of the magnitude of reported negative consequences and whether PG is formally diagnosed, individuals who seek help should be offered counselling based on their own experiences of needs and problems.

As gambling problems tend to manifest in a variety of ways and changes in gambling habits tend to follow different paths depending on various contexts and factors, it is reasonable to suggest that help options should be diversified. For some gamblers, internet or telephone support is enough, while others need support from self-help groups or professional treatment.

The interviewees reflected a great deal on their own and others’ gambling habits in the interviews, but typically reported that gambling problems are something shameful and seldom discussed with friends and family. The stigma of gambling problems should be addressed in the provision of support and treatment services by emphasising early intervention, outreach strategies, and public campaigns towards shifting attitudes as well as increasing availability and enhancing self-help tool options which allow anonymity (Hing et al. 2014). Considering the fluid characteristics of gambling problems, support and treatment services should be easily accessible and systematically follow up previous help-seekers.

The interviewees were disturbed by the extent of gambling advertising and advocated harsher restrictions. For some individuals with previous gambling problems, advertising and offers had triggered new gambling episodes. This is in agreement with the results of previous studies (Binde 2014b) and suggests that gambling companies should take care not to promote their products to people who they have reasons to assume are gambling excessively.

Conclusion

The chief objective of this qualitative study was to shed light on the high fluidity of people transitioning in and out of moderate risk and problem gambling – 70% of respondents who one year earlier had scored PGSI 3+ – observed in the Swedish longitudinal gambling study. By investigating gamblers’ own perceptions of gambling change and harm, we found a large number of internal and external factors associated with transitions in and out of excessive gambling. By and large, these were the same as those revealed in previous quantitative and qualitative studies. Our study contributes specifically by showing how these factors covariate in particular configurations of gambling, characterised by harm level and whether gambling is increasing and decreasing. Further research could use this approach to explore such configurations in other jurisdictions and among subgroups of the general population. We also show that some factors can cause both increased and decreased gambling intensity. For example, while some people gamble less when they have less money, there are others who gamble more, because they hope that gambling will solve their economic problems or at least provide some extra spending money. This finding has implications for the interpretation of results from quantitative studies, where such Janus-like qualities of factors of gambling involvement are difficult to discern; their relationship with change might not be noticed at all, because the opposing effects on behaviour cancel each other out.

Acknowledgements

We are grateful to all the gamblers who offered their time to speak with us and contribute to the study.

Disclosure statement

The authors alone are responsible for the content and writing of this article.

Eva Samuelsson has no conflicts of interest to declare in relation to this article. She has no current or past affiliations with the gambling industry.

Kristina Sundqvist has no conflicts of interest to declare in relation to this article. While she has no current or past direct affiliations with the gambling industry, the research for her doctoral thesis was funded by a grant from the Svenska Spel research council, as is her present postdoc research. This research council is associated with and financed by the state-owned gambling company Svenska Spel.

Per Binde has no conflicts of interest to declare in relation to this article. The author has no current or past affiliations with the industry. All his research funding has come from government-funded sources or public health agencies, with the exception of a minor grant for writing a research review, received in 2014 from the Responsible Gambling Trust in the UK, which is an independent national charity funded by donations from gambling companies.

Additional information

Funding

This work was supported by the Public Health Agency of Sweden under Grant 04178-201.