Mortality in alcohol-related diseases in Sweden during 1971-80 in relation to occupation, marital status and citizenship in 1970

Employment Status and Alcohol-Attributable Mortality Risk-A Systematic Review and Meta-Analysis

Being unemployed has been linked to various health burdens. In particular, there appears to be an association between unemployment and alcohol-attributable deaths. However, risk estimates presented in a previous review were based on only two studies. Thus, we estimated updated sex-stratified alcohol-attributable mortality risks for unemployed compared with employed individuals. A systematic literature search was conducted in August 2020 using the following databases: Embase, MEDLINE, PsycINFO, and Web of Science. The relative risk (RR) of dying from an alcohol-attributable cause of death for unemployed compared with employed individuals was summarized using sex-stratified random-effects DerSimonian-Laird meta-analyses. A total of 10 studies were identified, comprising about 14.4 million women and 19.0 million men, among whom there were about 3147 and 17,815 alcohol-attributable deaths, respectively. The pooled RRs were 3.64 (95% confidence interval (CI): 2.04–6.66) and 4.93 (95% CI 3.45–7.05) for women and men, respectively. The findings of our quantitative synthesis provide evidence that being unemployed is associated with an over three-fold higher risk of alcohol-attributable mortality compared with being employed. Consequently, a global public health strategy connecting brief interventions and specialized care with social services assisting those currently unemployed is needed.

Birth order and alcohol-related mortality by ethnic origin and national context: Within-family comparisons for Finland and Sweden

BACKGROUND

Previous studies have found that birth order is an important predictor of later life health, including hospitalisation for alcohol use. We examine the relationship between birth order and alcohol-related mortality in two national contexts, within native families who differ on ethnic origin.

METHODS

We study the association between birth order and alcohol-related mortality after age 17, using Finnish register data for cohorts born 1953-1999 and Swedish register data for cohorts born 1940-1999. We apply Cox proportional hazard models and use sibling fixed effects that eliminate confounding by factors shared by siblings. We separate full-sibling groups by ethnic origin, which for Finland means mother's and father's Finnish or Swedish ethnolinguistic affiliation. For Sweden, we distinguish native-born according to whether one or both parents were born in Sweden or Finland.

RESULTS

We find a positive correlation between birth order and alcohol-related mortality, but only for ethnic Finns in Finland and primarily men. Within these sibling groups, second-borns have an alcohol-related mortality risk that is 9% higher than that of first-borns, third-borns 19 % higher, fourth-borns 22 % higher, and fifth- or higher-borns 47 % higher. No such birth order associations can be found for any of the other ethnic groups analysed in Finland or Sweden.

CONCLUSIONS

Our findings suggest that cultural-related behaviours typical for ethnic groups, and the national context in which they are studied, are relevant for whether any association between birth order and alcohol-related mortality can be observed. Differences in the social interplay within the family may be an important factor.

Alcohol-related mortality by ethnic origin of natives: a prospective cohort study based on multigenerational population register data from Finland and Sweden

OBJECTIVES

The aim was to assess alcohol-related mortality of persons with mixed and uniform ethnic origins in two national contexts.

SETTING

Data were from the multigenerational population registers of the total population of Finland and Sweden observed from 1971 to 2017. Study persons were men and women of ethnic Finnish and Swedish background, born in their country of residence.

PARTICIPANTS

Persons were born between 1953 and 1999. In Finland, ethnic origin was assessed through own, mother's and father's Finnish or Swedish ethnolinguistic affiliation. Data on Sweden included persons born in Sweden, with mother and father born in Sweden or Finland. A total of 2 997 867 and 4 148 794 persons were included in the Finnish and Swedish data, respectively. The total number of alcohol-related deaths by main cause was 13 204 and 3336. Cox regressions were used to examine associations.

OUTCOME MEASURES

For the period 1971-2017, we studied alcohol as the main cause of death. For the period 1996-2017, we observed if alcohol was the main or contributing cause of death. Parallel analyses were performed for all-cause mortality.

RESULTS

For men in Finland, the hazard rate of alcohol-related mortality of Swedish speakers with uniform Swedish background was 0.44 (95% CI: 0.38 to 0.52) that of Finnish speakers with uniform Finnish background. The corresponding hazard rate for women was 0.40 (95% CI: 0.28 to 0.55). In Sweden, the hazard rate of men with both parents born in Sweden was 0.40 (95% CI: 0.32 to 0.49) that of men with both parents born in Finland. The corresponding hazard rate for women was 0.50 (95% CI: 0.31 to 0.79). In both countries, persons with mixed background had an alcohol-related mortality rate between that of persons with uniform Finnish and Swedish background.

CONCLUSION

The consistent pattern across countries necessitates increased policy attention towards offspring disadvantaged via parental ethnicity to minimise harmful consequences of alcohol consumption across and within ethnic groups.

Divorce and the Onset of Alcohol Use Disorder: A Swedish Population-Based Longitudinal Cohort and Co-Relative Study

OBJECTIVE

The purpose of this study was to clarify the magnitude and nature of the relationship between divorce and risk for alcohol use disorder (AUD).

METHOD

In a population-based Swedish sample of married individuals (N=942,366), the authors examined the association between divorce or widowhood and risk for first registration for AUD. AUD was assessed using medical, criminal, and pharmacy registries.

RESULTS

Divorce was strongly associated with risk for first AUD onset in both men (hazard ratio=5.98, 95% CI=5.65-6.33) and women (hazard ratio=7.29, 95% CI=6.72-7.91). The hazard ratio was estimated for AUD onset given divorce among discordant monozygotic twins to equal 3.45 and 3.62 in men and women, respectively. Divorce was also associated with an AUD recurrence in those with AUD registrations before marriage. Furthermore, widowhood increased risk for AUD in men (hazard ratio=3.85, 95% CI=2.81-5.28) and women (hazard ratio=4.10, 95% CI=2.98-5.64). Among divorced individuals, remarriage was associated with a large decline in AUD in both sexes (men: hazard ratio=0.56, 95% CI=0.52-0.64; women: hazard ratio=0.61, 95% CI=0.55-0.69). Divorce produced a greater increase in first AUD onset in those with a family history of AUD or with prior externalizing behaviors.

CONCLUSIONS

Spousal loss through divorce or bereavement is associated with a large enduring increased AUD risk. This association likely reflects both causal and noncausal processes. That the AUD status of the spouse alters this association highlights the importance of spouse characteristics for the behavioral health consequences of spousal loss. The pronounced elevation in AUD risk following divorce or widowhood, and the protective effect of remarriage against subsequent AUD, speaks to the profound impact of marriage on problematic alcohol use.

Alcohol use disorder and divorce: evidence for a genetic correlation in a population-based Swedish sample

AIMS

We tested the association between alcohol use disorder (AUD) and divorce; estimated the genetic and environmental influences on divorce; estimated how much genetic and environmental influences accounted for covariance between AUD and divorce; and estimated latent genetic and environmental correlations between AUD and divorce. We tested sex differences in these effects.

DESIGN

We identified twin and sibling pairs with AUD and divorce information in Swedish national registers. We described the association between AUD and divorce using tetrachorics and used twin and sibling models to estimate genetic and environmental influences on divorce, on the covariance between AUD and divorce and the latent genetic and environmental correlations between AUD and divorce.

SETTING

Sweden.

PARTICIPANTS

A total of 670 836 individuals (53% male) born 1940-1965.

MEASUREMENTS

Life-time measures of AUD and divorce.

FINDINGS

AUD and divorce were related strongly (males: r_tet  = +0.44, 95% CI = 0.43, 0.45; females r_tet  = +0.37, 95% CI = 0.36, 0.38). Genetic factors accounted for a modest proportion of the variance in divorce (males: 21.3%, 95% CI = 7.6, 28.5; females: 31.0%, 95% CI = 18.8, 37.1). Genetic factors accounted for most of the covariance between AUD and divorce (males: 52.0%, 95% CI = 48.8, 67.9; females: 53.74%, 95% CI = 17.6, 54.5), followed by non-shared environmental factors (males: 45.0%, 95% CI = 37.5, 54.9; females: 41.6%, 95% CI = 40.3, 60.2). Shared environmental factors accounted for a negligible proportion of the covariance (males: 3.0%, 95% CI = -3.0, 13.5; females: 4.75%, 95% CI = 0.0, 6.6). The AUD-divorce genetic correlations were high (males: rA = +0.76, 95% CI = 0.53, 0.90; females +0.52, 95% CI = 0.24, 0.67). The non-shared environmental correlations were modest (males: rE = +0.32, 95% CI = 0.31, 0.40; females: +0.27, 95% CI = 0.27, 0.36).

CONCLUSIONS

Divorce and alcohol use disorder are correlated strongly in the Swedish population, and the heritability of divorce is consistent with previous studies. Covariation between AUD and divorce results from overlapping genetic and non-shared environmental factors. Latent genetic and non-shared environmental correlations for alcohol use disorder and divorce are high and moderate.

Regional differences in alcohol consumption, alcohol addiction and drug use among Swedish adults

Introduction: Alcohol consumption and drug use, as well as alcohol- and drug-related problems, vary considerably in different regions in Sweden, and between men and women of different ages. Aim: The aim of the present study was to examine the regional, gender and socioeconomic distribution of risk consumption of alcohol, alcohol dependency and drug use in a random sample in Sweden. Material and methods: In both May 2003 and 2004, 7200 gender-stratified adults (a total of 14,400), randomly selected from 12 regions in Sweden, were contacted by mail, and asked to fill out an enclosed questionnaire. The questionnaire concerned use of alcohol, alcohol-related problems, and use of illicit drugs. Results: Heavy alcohol consumption and cannabis use were more frequent in the south of Sweden than in the north, and the further north, the lower the frequency. Alcohol and drug use decreased with age, and was higher for men than for women. On average, 11.5% of all men and 5.0% of all women consumed alcohol intensively at least weekly, 8.6% of men and 4.5% of women had a generally high alcohol consumption, 4.1% of men and 2.5% of women were alcohol addicted, and 2.9% of men and 1.3% of women had used cannabis during the last 12 months. Conclusions: High alcohol consumption and use of illegal drugs seem to be more prevalent in those parts of Sweden that are closer to the European continent. In our opinion, this might be an effect of the closeness to other European countries with lower prices for alcohol, less strict alcohol control policies, and higher availability of drugs. Consideration of regional, gender and age differences in problems related to alcohol and drugs seem to be important in the planning and development of preventive activities.

Predictors of 16-Year Mortality Among Individuals Initiating Help-Seeking for an Alcoholic Use Disorder

BACKGROUND AND METHODS

We examined rates and predictors of mortality in individuals (47% women) who had just initiated help-seeking for their alcohol use disorders (AUDs) at the start of the study (n=628) and were followed for 16 years.

RESULTS

For both women and men, the observed-to-expected mortality ratio (1.4) was lower than rates found in samples of treated individuals with AUDs, suggesting that those initiating help-seeking careers have better chances of long-term survival. Of the individuals for whom cause of death was known, 68% died of alcohol-related causes. Men were more likely to die than were women. When gender was controlled, individuals who were older and unmarried and had more alcohol dependence symptoms at baseline were more likely to die over the 16-year period. When these baseline characteristics were controlled, better drinking outcomes at 1 year were associated with a lower likelihood of subsequent death. The combination of a shorter duration of inpatient/residential care and better drinking outcomes at 1 year was related to a lower probability of death, as was the combination of a longer duration of outpatient care or Alcoholics Anonymous attendance and better drinking outcomes at 1 year.

CONCLUSIONS

Efforts should be made to help providers identify individuals who are not responding positively to inpatient or residential treatment and intervene to motivate participation in continuing outpatient care and community 12-step self-help groups to reduce the likelihood of a chronic and fatal AUD course.

Changes in alcohol consumption: an analysis of self-reported use of alcohol in a Swedish national sample 1988-89 and 1996-97

AIM

To analyse factors associated with alcohol consumption, and how these changed over the period 1988-97, a period during which Sweden entered the European Union.

METHODS

Data were used from two waves (1988-89 and 1996-97) of the representative longitudinal micro-level ULF survey in Sweden to estimate a two-part model of consumption.

RESULTS

Experiencing financial stress, monthly salary, and not being married were all correlated with alcohol consumption, especially for males in 1988-89. In 1996-97 these correlations were much weaker, revealing a levelling-out trend towards conformity. The pattern was less clear for females. Further, the youngest age group (16-29 years) increased its consumption significantly more than the older age groups.

CONCLUSION

There were significant changes in alcohol behaviour, especially for males, coinciding with Sweden joining the EU and preceding the very substantial general increase in consumption levels since 1998. This underlying process should be kept in mind when analysing the more recent trends. The results support the contention that alcohol policy should be a combination of measures targeting the whole population (e.g. via public health campaigns) with specific measures directed towards more vulnerable groups (e.g. young people).

Mental symptoms, psychotropic drug use and alcohol consumption in immigrated middle-aged women. The Women's Health in Lund Area (WHILA) Study

This study aims to analyse mental symptoms, psychotropic drug use and alcohol consumption, in immigrant women born in Finland, the other Nordic countries, Eastern Europe, Western Europe and countries outside Europe, compared with Swedish-born women, and furthermore, to study if age at immigration may have an influence. All women (n=10,766) aged 50-59 years and living in the Lund area of southern Sweden received a postal invitation to a health survey named the Women's Health in Lund Area; 64.2% (n=6917) participated. The participants answered a questionnaire including prevalence of mental symptoms during the past 3 months, regular use of psychotropic drugs, alcohol consumption during an average week, country of birth and age at immigration. Severe mental symptoms were more common among most immigrant groups compared with native Swedes, but the association to country of birth was not significant after adjustment for possible confounders. Regular use of hypnotics was more common among Nordic immigrants only (odds ration, OR = 4.4). East European and non-European immigrants less often were alcohol consumers (OR = 1.6 and OR = 3.8). Heavy drinking was more common among non-Nordic immigrants who immigrated at a younger age than at an older age. Furthermore, it was found that although East European and non-European immigrants had a higher educational level, they were less often gainfully employed compared with native Swedes. In middle-aged women, country of birth as well as age at immigration are important factors to consider in relation to alcohol consumption, but these factors may be of less importance considering mental health.

Hospitalization due to alcohol and drug abuse in first- and second-generation immigrants: a follow-up study in Sweden

The detrimental effects of substance abuse on the individual and on society are well known. Health care resources must target where they are most needed. This study investigated (1) whether the increased risk of being hospitalized for alcohol abuse and drug abuse among certain immigrant groups is present in the next generation and (2) whether having one parent born in the host country (i.e., Sweden) has a protective effect on the risk of being hospitalized for alcohol abuse and drug abuse among second-generation immigrants. In total, 2,243,546 persons aged 20-39 years were followed from 1 January 1992 until 31 December 1999 for first hospital admission due to alcohol abuse or drug abuse. A Cox regression model was used to estimate hazard ratios for each diagnosis group. When the Swedish majority population was used as reference, the highest risks of alcohol abuse and drug abuse were found among first- and second-generation Finns, after adjustment for income. Among second-generation Finns with one parent born in Sweden, the increased risk of being hospitalized for alcohol abuse and drug abuse was lower than among second-generation Finns with both parents born in Finland. Health care resources need to target certain groups of first- and second-generation immigrants.

Self-help groups reduce mortality risk: a 5-year follow-up study of alcoholics in the Tokyo metropolitan area

The present study aimed to determine whether alcoholics who attend self-help groups experience fewer deaths than those who do not. Subjects were patients from the Alcoholism Treatment Program (ATP) of Matsuzawa hospital. A cohort of alcoholic patients recruited into a prospective study was followed from April 1994 to March 1999. A total of 469 alcoholic patients met the International Classification of Diseases (10th edition) criteria for alcohol dependency. Of these, 94 patients refused to participate in the study, leaving a total of 375 participants. After discharge from the ATP and a complete explanation of the present study, subjects decided whether to attend a self-help group (SHG) or not. The SHG comprised 208 subjects, and the non-self-help group (NSHG) comprised 167 subjects. Outcomes were evaluated with regard to death during follow-up for a mean of 2.4 years. Death was ascertained through the records of the Setagaya Department of Health and Welfare center, Matsuzawa hospital and other hospitals, and through personal contact with informants, relatives, and significant others of subjects. Deaths were confirmed for 47 NSHG subjects and only five SHG subjects. NSHG displayed a significantly decreased cumulative survival compared with SHG (P < 0.0001). Cox proportion hazard analysis was used to examine variables that may help to predict mortality among alcoholics. Alcoholics who attended self-help groups differed from those who did not, with regard to mortality experience. Attending a self-help group represented the most important predictor of prognosis for alcoholics.

Alcohol-related disorders in first- and second-generation immigrants in Sweden: a national cohort study

AIMS

The risk of alcohol-related disorders in first- and second-generation immigrants in Sweden were investigated and compared with the Swedish majority population to assess how alcohol habits are modified over generations in a new society.

DESIGN

Register study based on multivariate analyses of demographic data, including information on country of birth, from the Swedish Population and Housing Census of 1985 linked to data on hospital admissions for alcohol-related disorders during 1990-99 in the National Hospital Discharge Register.

PARTICIPANTS

The study population consisted of a national cohort of 1.25 million youth born 1968-79 and 1.47 million adults born 1929-65.

RESULTS

First- and second-generation immigrants from Finland had higher relative risks (RRs) for hospital admission because of an alcohol-related disorder compared to the Swedish majority population (socio-economic adjusted RRs 2.1 and 1.9, respectively), while first-generation immigrants born in southern Europe, the Middle East and other non-European countries had lower risks. Second-generation immigrants with heritage in southern Europe, the Middle East and other non-European countries had socio-economic adjusted RRs that were higher relative to the first generation immigrants but lower relative to the Swedish majority population. Intercountry adoptees had the highest adjusted RR (2.5).

CONCLUSIONS

Patterns of alcohol abuse in the country of origin are strong determinants of alcohol-related disorders in first-generation immigrants. The patterns in second-generation immigrants are influenced by parental countries of origin as well as patterns in the majority population. The Finnish minority and intercountry adoptees are of particular concern in prevention.

Finnish-born and Swedish-born patients in the Stockholm county health-based addiction treatment system

Even though the Finnish and Swedish alcohol cultures and societies are very similar, Finns have a reputation for drinking more heavily than Swedes. Earlier research in Sweden has shown that Finnish immigrants in Sweden experience more health problems and more alcohol related deaths than Swedes. Research results concerning their treatment consumption have been contradictory.

Based on interviews with 942 persons entering the health-based addiction treatment system in Stockholm county between November 2000 and November 2001, this article sets out to study to what extent the patients that were born in Finland (N = 82) differ from those born in Sweden (N = 771). It also examines to what extent the Finnish-born differ from Swedes if you control for work position as a sign of social status, and main drug use (alcohol or illegal drugs).

The data consists of structured interviews, conducted by trained interviewers in the research project. The results are presented as distributions and correlations tested with Pearson Chi2. In order to be able to say to what extent the problems of the Finnish born were related to their particular immigrant position compared to social status, a weighted sample of Swedes was constructed, using the variables “most common or last work position” and “main drug as reason for coming to treatment (alcohol or illicit drugs)”.

The results showed that the Finnish born patients were overrepresented in treatment. This could largely, but not fully, be explained by their social position and age structure.

The Finnish-born were a much more homogeneous group than the Swedes as they were mostly male and workers, and predominantly treated for their alcohol problems. They had a more problematic housing situation than comparable Swedes. Their alcohol consumption was somewhat higher than among comparable Swedish patients, and they had experienced some more symptoms of dependency and negative consequences of drinking, particularly those associated with health issues. They had more treatment experiences during the year before this treatment round, but not more days in treatment. Their attitudes to drinking and drug problems, and to treatment in general, as far as attitudes and expectations were concerned, seemed rather positive and very similar to the Swedish patients, however.

The fact that they received a lot of treatment but shorter treatment contacts than comparable Swedes might indicate that the Swedish system has not been able to meet their needs particularly well.

Migration and substance use: evidence from the U.S. National Health Interview Survey

Representative data from the U.S. National Health Interview Survey are used to investigate the substance use patterns of immigrants and compare them to those of the native born populations. The information examined is from the 1991 supplementary Drug and Alcohol Use Data File, which examined the self-reported substance use behaviors of approximately 21,000 adults aged 18-44. Findings indicate that immigrants to the U.S. in the late twentieth century are less likely to use alcohol and other drugs than are native born citizens. Additional findings suggest assimilation processes by which exposure to mainstream American society leads to patterns of alcohol and illicit drug use among long term immigrants that approximates that of the native born population. The patterns of substance use observed among immigrants, however, are not consistent with acculturative stress mechanisms. These findings provide an important and representative profile of the substance use patterns of one of the largest international migration streams of the past one hundred years.

Mortality risks in alcoholism and effects of abstinence and addiction treatment

The mortality rate from alcoholism and related comorbidities is high. Studies show multiple causes of premature death from alcoholism. Several studies showed that abstinence had a positive effective on the overall survival of alcoholics. Alcoholics who abstained from alcohol, particularly continuously, showed reduced mortality rates and increased years of longevity than alcoholics who relapsed to alcohol consumption. The sources of the findings tend to be derived from treatment populations, in which abstinence is expected to occur in higher rates than in the general population.

Comorbid cigarette and alcohol addiction: epidemiology and treatment

The close association of nicotine addiction and alcoholism is well established. As many as 80% of alcoholics smoke, and 30% of smokers are alcoholics. The mortality from cigarette smoking and alcoholism individually is very high, as an estimated 400,000 deaths from tobacco and 100,000 deaths from alcoholism are reported annually. Cigarettes and alcohol interact to cause certain cancers, e.g., head and neck. Only recently has attention been focused on the role of tobacco in abstinent alcoholics. An important study found high rates of mortality from tobacco in abstinent alcoholics in recovery. However, the mortality rates from alcoholism were high and predominant. Of great importance is that studies show that abstinence from alcohol essentially eliminates the premature deaths or increased mortality rates from active alcoholism. Similar studies showing a reduction in mortality from abstinence in nicotine addiction have not been forthcoming. The importance of treating nicotine addiction, however, is clear to reduce the high mortality rates from tobacco smoking in active or abstinent alcoholics.

Alcohol and drug use among displaced persons: an overview

This paper provides a brief introduction to current research concerned with alcohol and drug use, misuse, and treatment among displaced persons, including immigrants, refugees, and homeless individuals. Among the topics examined are theoretical issues related to our understanding of substance use processes among displaced populations, methodological considerations, and directions for future research. The review is followed by an annotated bibliography of recent work related to this topic.

Assessing gender interactions in the prediction of mortality in alcoholic men and women: a 20-year follow-up study

This study investigates the predictors of mortality in 259 male and female alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for > 20 years. The findings showed that, in addition to age, marital status, medical complications, and non-antisocial personality comorbidity were important independent predictors of time to death. Data pointed to gender interactions, in that marital disruption tended to be a stronger predictor of mortality in men, and delirium tremens tended to be a stronger predictor of mortality in women. Knowing and understanding that certain events and processes may differentially affect the survival of male and female alcoholics will allow for the development of more individualized and gender-specific therapeutic interventions.

Predictors of mortality in alcoholic men: a 20-year follow-up study

This study investigates the predictors of mortality in 156 male alcoholics who were psychiatrically hospitalized between 1967 and 1968 and followed for > 20 years. The findings showed that an older age, liver cirrhosis, and separation or divorce at intake were all associated with a shorter time to death. These results corroborate those of other follow-up studies that have identified age, health, and social support as independent correlates of mortality in alcoholics. From a therapeutic standpoint, the most alterable predictor is social support. Thus, the establishment of a salutary social network and social support system should be an integral part of the alcoholic's treatment plan.