Mixed messages? Exposure to reports about alcohol's suggested cardiovascular effects and hazardous alcohol use: a cross-sectional study of patients in cardiology care.

BACKGROUND: Hazardous alcohol use is a leading risk factor for disability and death, yet observational studies have also reported reduced cardiovascular disease mortality among regular, low-level drinkers. Such findings are refuted by more recent research, yet have received significant media coverage. We aimed to explore: (1) how patients with cardiovascular diseases access health information about moderate drinking and cardiovascular health; (2) the perceived messages these sources convey, and (3) associations with own level of alcohol use. METHODS: We conducted a cross-sectional survey of patients in cardiology services at three hospitals in Sweden. The study outcome was hazardous alcohol use, assessed using the AUDIT-C questionnaire and defined as ≥ 3 in women and ≥ 4 in men. The exposure was accessing information sources suggesting that moderate alcohol consumption can be good for the heart, as opposed to accessing information that alcohol is bad for the heart. Health information sources were described using descriptive statistics. Gender, age and education were adjusted for in multiple logistic regression analyses. RESULTS: A total of 330 (66.3%) of 498 patients (mean age 70.5 years, 65% males) who had heard that drinking moderately can affect the heart described being exposed to reports that moderate alcohol use can be good for the heart, and 108 (21.7%) met criteria for hazardous alcohol use. Health information sources included newspapers (32.9%), television (29.2%), healthcare staff (13.4%), friends/family (11.8%), social media (8.9%) and websites (3.7%). Participants indicated that most reports (77.9%) conveyed mixed messages about the cardiovascular effects of moderate drinking. Exposure to reports of healthy heart effects, or mixed messages about the cardiovascular effects of alcohol, was associated with increased odds of hazardous alcohol use (OR = 1.67, 95%CI = 1.02-2.74). CONCLUSIONS: This study suggests that many patients in cardiology care access health information about alcohol from media sources, which convey mixed messages about the cardiovascular effects of alcohol. Exposure to reports that moderate drinking has protective cardiovascular effects, or mixed messages about the cardiovascular effects of alcohol, was associated with increased odds of hazardous alcohol use. Findings highlight a need for clear and consistent messages about the health effects of alcohol.

Cannabis use disorder in relation to socioeconomic factors and psychiatric comorbidity: A cluster analysis of three million individuals born in 1970-2000.

BACKGROUND: Cannabis use disorder (CUD) is one of the main reasons for seeking substance use treatment. It is thus important to monitor and increase knowledge of individuals with CUD utilizing healthcare. We aimed to examine the number of CUD diagnoses over time, compare individuals with CUD with those without and identify subgroups based on CUD diagnosis, sex, birth year, socioeconomic factors and psychiatric comorbidity. METHODS: A Swedish, population-based study with 3,307,759 individuals, born in 1970-2000, with register data extending to 2016. K-mode cluster analysis was used to identify potential subgroups. RESULTS: The number of individuals with a CUD diagnosis was 14,046 (0.42%). CUD diagnoses increased over time (born 1990-1994: 61 per 100,000, born 1995-2000: 107 per 100,000, by 2016). A majority of those with a CUD had another psychiatric diagnosis (80%, compared with 19% for those without CUD). Four clusters were identified. Cluster 1 comprised mainly men with low income and substance use disorders, clusters 2, 3 and 4 comprised mainly women with higher proportions of mood-related, neurotic and stress-related and behavioural disorders. CONCLUSIONS: There was an increase in CUD diagnoses in Sweden over time, especially among younger birth cohorts. Individuals with CUD were more often male, from younger birth cohorts, with lower education and income than those without CUD. Men and women with CUD exhibited differences in education, income and psychiatric comorbidity. Our results demonstrate the importance of monitoring the impact of socioeconomic factors and psychiatric comorbidity in relation to CUD.

Early substance use disorders and subsequent NEET-not in education, employment or training-a national cohort study.

BACKGROUND: Substance use problems have been associated with poor labour market outcomes. This study investigated whether substance use disorders (SUD) in emerging adulthood increase the likelihood of later being not in employment, education or training (NEET). METHODS: A national cohort study of 23 5295 males and 227 792 females born between 1981 and 1987. SUD was assessed between ages 17 and 24 years. Logistic regression models were used to estimate the odds ratios (ORs) of NEET, between ages 25-34. Sibling-comparison analysis was performed to account for potential shared genetic and environmental factors. RESULTS: Having been diagnosed with a SUD was associated with the likelihood of being NEET among males [OR = 1.37, 95% confidence interval (CI), 1.25-1.49] and females (1.19, 1.13-1.27) after adjusting for domicile, origin, psychiatric diagnosis and parental psychiatric diagnosis. Early SUD was also associated with a gradual increase in the ORs of accumulation of years being NEET. This was more evident among females. In the sibling-comparison analysis, we found a higher OR of NEET among same-sex sibling males 1.39 (1.06-1.82) and females 1.28 (0.99-1.66) with SUD. These risks were fully attenuated when another psychiatric diagnosis was adjusted for. CONCLUSION: Early SUD was associated with an increased likelihood of being NEET in both males and females. Neither origin, domicile, psychiatric diagnoses nor parental psychiatric diagnoses did fully explain the association. The combination of unmeasured familial factors and having other psychiatric disorders largely explained these associations.

Alcohol and type 2 diabetes: The role of socioeconomic, lifestyle and psychosocial factors.

AIMS: We investigate (a) alcohol consumption in association with type 2 diabetes, taking heavy episodic drinking (HED), socioeconomic, health and lifestyle, and psychosocial factors into account, and (b) whether a seemingly protective effect of moderate alcohol consumption on type 2 diabetes persists when stratified by occupational position. METHODS: This population-based longitudinal cohort study comprises 16,223 Swedes aged 18-84 years who answered questionnaires about lifestyle, including alcohol consumption in 2002, and who were followed-up for self-reported or register-based diabetes in 2003-2011. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated in a multivariable-adjusted logistic regression model for all participants and stratified by high and low occupational position. We adjusted for HED, socioeconomic (occupational position, cohabiting status and unemployment), health and lifestyle (body mass index (BMI), blood pressure, smoking, physical inactivity, poor general health, anxiety/depression and psychosocial (low job control and poor social support) characteristics one by one, and the sets of these factors. RESULTS: Moderate consumption was inversely associated with type 2 diabetes after controlling for health and lifestyle (OR=0.47; 95% CI: 0.29-0.79) and psychosocial factors (OR=0.40; 95% CI: 0.22-0.79) when compared to non-drinkers. When adjusting for socioeconomic factors, there was still an inverse but non-significant association (OR=0.59; 95% CI: 0.35-1.00). In those with high occupational position, there was no significant association between moderate consumption and type 2 diabetes after adjusting for socioeconomic (OR=0.67; 95% CI: 0.3-1.52), health and lifestyle (OR=0.70; 95% CI: 0.32-1.5), and psychosocial factors (OR=0.75; 95% CI: 0.23-2.46). On the contrary, in those with low occupational position, ORs decreased from 0.55 (95% CI: 0.28-1.1) to 0.35 (95% CI: 0.15-0.82) when adjusting for psychosocial factors, a decrease that was solely due to low job control. HED did not influence any of these associations. CONCLUSIONS: Moderate alcohol consumption is associated with a lower risk of type 2 diabetes, after adjusting for HED, health and lifestyle, and psychosocial characteristics. The association was inverse but non-significant after adjusting for socioeconomic factors. When stratified by occupational position, there was an inverse association only in those with low occupational position and after adjusting for low job control.

Fathers' Alcohol Consumption and Long-Term Risk for Mortality in Offspring.

AIM: This study examined associations between fathers' alcohol consumption and risk for total and cause-specific mortality in offspring. SHORT SUMMARY: We examined the associations between fathers' alcohol consumption and total and cause-specific mortality in adult offspring. Fathers' alcohol consumption was associated with increased risk of alcohol-related mortality in offspring. The association appeared to be weaker for causes of death in which alcohol plays a smaller, or less direct, role. METHODS: Data on fathers' alcohol consumption, and offspring's risky use of alcohol, smoking, mental health and contact with police/childcare authorities were collected among 46,284 men (sons) aged 18-20 years, during conscription for compulsory military training in 1969/70. Data on offspring mortality were obtained from the National Cause of Death register, 1971-2008. The mortality outcomes included total mortality, alcohol-related causes of death and violent causes of death (categorized into suicides vs violent/external causes excluding suicides). RESULTS: Compared to sons whose fathers never used alcohol, the risk for total and alcohol-related mortality among sons increased with the father's consumption level. The risk of violent death was significantly elevated among sons whose fathers drank alcohol occasionally or often, but the risk of suicide increased in the highest consumption category only. After adjustment for covariates, the results remained for alcohol-related mortality whereas they were significantly attenuated, or disappeared, for total mortality, violent death and suicide. CONCLUSIONS: Fathers' alcohol consumption is associated with increased risk of alcohol-related mortality in the offspring. Alcohol use among fathers also increases the offspring's risk of later total mortality, suicide and violent death, but these associations appear to be mediated or confounded by factors related to parental drinking and/or adverse childhood psychosocial circumstances.

Cannabis, Tobacco, Alcohol Use, and the Risk of Early Stroke: A Population-Based Cohort Study of 45 000 Swedish Men.

BACKGROUND AND PURPOSE: Current knowledge on cannabis use in relation to stroke is based almost exclusively on clinical reports. By using a population-based cohort, we aimed to find out whether there was an association between cannabis use and early-onset stroke, when accounting for the use of tobacco and alcohol. METHODS: The cohort comprises 49 321 Swedish men, born between 1949 and 1951, who were conscripted into compulsory military service between the ages of 18 and 20. All men answered 2 detailed questionnaires at conscription and were subject to examinations of physical aptitude, psychological functioning, and medical status. Information on stroke events up to ≈60 years of age was obtained from national databases; this includes strokes experienced before 45 years of age. RESULTS: No associations between cannabis use in young adulthood and strokes experienced ≤45 years of age or beyond were found in multivariable models: cannabis use >50 times, hazard ratios=0.93 (95% confidence interval [CI], 0.34-2.57) and 0.95 (95% CI, 0.59-1.53). Although an almost doubled risk of ischemic stroke was observed in those with cannabis use >50 times, this risk was attenuated when adjusted for tobacco usage: hazards ratio=1.47 (95% CI, 0.83-2.56). Smoking ≥20 cigarettes per day was clearly associated both with strokes before 45 years of age, hazards ratio=5.04 (95% CI, 2.80-9.06), and with strokes throughout the follow-up, hazards ratio=2.15 (95% CI, 1.61-2.88). CONCLUSIONS: We found no evident association between cannabis use in young adulthood and stroke, including strokes before 45 years of age. Tobacco smoking, however, showed a clear, dose-response shaped association with stroke.

Disease burden attributed to alcohol: How methodological advances in the Global Burden of Disease 2013 study have changed the estimates in Sweden.

AIM: The Global Burden of Disease (GBD) study continuously refines its estimates as new data and methods become available. In the latest iteration of the study, GBD 2013, changes were made related to the disease burden attributed to alcohol. The aim of this study was to briefly present these changes and to compare the disease burden attributed to alcohol in Swedish men and women in 2010 using previous and updated methods. METHODS: In the GBD study, the contribution of alcohol to the burden of disease is estimated by theoretically assessing how much of the disease burden can be avoided by reducing the consumption of alcohol to zero. The updated methods mainly consider improved measurements of alcohol consumption, including less severe alcohol dependence, assigning the most severe injuries and removing the protective effect of drinking on cardiovascular diseases if combined with binge drinking. RESULTS: The overall disease burden attributed to alcohol in 2010 increased by 14% when using the updated methods. Women accounted for this overall increase, mainly because the updated methods led to an overall higher alcohol consumption in women. By contrast, the overall burden decreased in men, one reason being the lower overall alcohol consumption with the new methods. In men, the inclusion of less severe alcohol dependence resulted in a large decrease in the alcohol attributed disease burden. This was, however, evened out to a great extent by the increase in cardiovascular disease and injuries. CONCLUSIONS WHEN USING THE UPDATED GBD METHODS, THE OVERALL DISEASE BURDEN ATTRIBUTED TO ALCOHOL INCREASED IN WOMEN, BUT NOT IN MEN.

Pharmacotherapy for alcohol use disorder among adults with medical disorders in Sweden.

BACKGROUND: Alcohol-attributable medical disorders are prevalent among individuals with alcohol use disorder (AUD). However, there is a lack of research on prescriptions of pharmacological treatment for AUD in those with comorbid conditions. This study aims to investigate the utilization of pharmacological treatment (acamprosate, disulfiram and naltrexone) in specialist care among patients with AUD and comorbid medical diagnoses. METHODS: This was a descriptive register-based Swedish national cohort study including 132,728 adults diagnosed with AUD (N = 270,933) between 2007 and 2015. The exposure was alcohol-attributable categories of comorbid medical diagnoses. Odds ratios (OR) were calculated using mixed-effect logistic regression analyses for any filled prescription of acamprosate, disulfiram or oral naltrexone within 12 months post AUD diagnosis. RESULTS: Individuals with comorbid alcohol-attributable medical diagnoses had lower odds of filling prescriptions for any type of AUD pharmacotherapy compared to those without such comorbidities. Cardiovascular (OR = 0.41 [95% CI: 0.39-0.43]), neurological (OR = 0.52 [95% CI: 0.48-0.56]) and gastrointestinal (OR = 0.57 [95% CI: 0.54-0.60]) diseases were associated with the lowest rates of prescription receipt. The presence of diagnoses which are contraindications to AUD pharmacotherapy did not fully explain the low prescription rate. CONCLUSION: There is a substantial underutilization of AUD pharmacotherapy in patients with AUD and comorbid medical disorders in specialist care. Increasing the provision of pharmacotherapy to this group of patients is essential and may prevent morbidity and mortality. There is a need to further understand barriers to medical treatment both from the patient and prescriber perspective.

Feasibility of alcohol interventions in cardiology: A qualitative study of clinician perspectives in Sweden.

AIM: To identify barriers and facilitators to implementing alcohol screening and brief interventions (SBI) in cardiology services. METHODS AND RESULTS: Qualitative study. Individual, semi-structured interviews were conducted with 24 clinical cardiology staff (doctors, nurses, assistant nurses) of varying experience levels, and from various clinical settings (high dependency unit, ward, outpatient clinic), in three regions of Sweden. Reflexive thematic analysis was used, with deductive coding applying the Capability, Opportunity, Motivation (COM-B) theoretical framework. A total of 41 barriers and facilitators were identified, including twelve related to capability, nine to opportunity, and 20 to motivation. Four themes were developed: 1. Uncharted territory, where clinicians expressed a need to address alcohol use but lacked knowledge and a roadmap for implementing SBI; 2. Cardiology as a cardiovascular specialty, where tasks were prioritized according to established roles; 3. Alcohol stigma, where alcohol was reported to be a sensitive topic that staff avoid discussing with patients; 4. Window of opportunity, where staff expressed potential for implementing SBI in routine cardiology care. CONCLUSION: Findings suggest that opportunities exist for early identification and follow-up of hazardous alcohol use within routine cardiology care. Several barriers, including low knowledge, stigma, a lack of ownership, and a greater focus on other risk factors must be addressed prior to the implementation of SBI in cardiology. To meet current clinical guidelines, there is a need to increase awareness and to improve pathways to addiction care. In addition, there may be a need for clinicians dedicated to alcohol interventions within cardiology services. REGISTRATION: OSF (osf.io/hx3ts).

Preferences regarding treatment for alcohol problems.

AIMS: The aim of the study was to investigate preferences in the general population regarding type of treatment for alcohol problems and the preferred setting for delivery of treatment and reasons for not seeking treatment for alcohol problems. METHOD: Data were from a random, cross-sectional, interview survey of 9005 of the Swedish general population. Proportions of respondents preferring a certain treatment and source of treatment, and reasons suggested for why people do not seek treatment, were analysed in relation to number of standard drinks, employment status, education and income. RESULTS: Most frequently endorsed forms of treatment were alcoholics anonymous or similar support groups and psychotherapy. More than 50% preferred psychiatric or addiction specialist treatment. Around 10% preferred primary health care and around 20% the occupational health services. About 5% preferred the social services. Respondents rated 'feeling ashamed' as the most important reason why people would not seek help for alcohol problems. CONCLUSION: Large majorities of the respondents preferred treatment in the health care services and few in the social services. Internet-based treatment and pharmacological treatment attracted few respondents, the majority preferring more traditional forms of treatment. Alcohol treatment remains a stigmatized field, evidenced by shame being the most commonly reported reason for not seeking treatment.

Risk of readmission among individuals with cannabis use disorder during a 15-year cohort study: the impact of socio-economic factors and psychiatric comorbidity.

BACKGROUND AND AIM: Cannabis use disorder (CUD) is one of the main reasons for seeking substance treatment in the Nordic countries, but there are few studies on readmission to care. We aimed to characterize CUD readmission and estimate the magnitude of how socio-economic factors and psychiatric comorbidity influence the risk of CUD readmission. DESIGN, SETTING AND PARTICIPANTS: This was a nation-wide cohort study carried out between 2001 and 2016 in Sweden. The participants were individuals with CUD, aged 17 years and above (n = 12 143). MEASUREMENTS: Information on predictors was obtained from registers and included education, income and psychiatric comorbidity assessed by six disease groups. The outcome measure was readmission, defined as a CUD visit to health-care at least 6 months after initial CUD diagnosis. Hazard ratios (HR) were estimated using Cox survival analyses and flexible parametric survival analyses to assess risk of readmission and how the risk varied with age. FINDINGS: The vast majority of CUD visits took place in outpatient care (~80%). Approximately 23% of the included individuals were readmitted to care during follow-up. The fully adjusted model showed an increased risk of readmission among those with schizophrenia and other psychotic disorders [HR = 1.54, 95% confidence interval (CI) = 1.29-1.84], low education (HR = 1.40, 95% CI = 1.24-1.57), personality disorders (HR = 1.27, 95% CI = 1.05-1.54) or mood disorders (HR = 1.27, 95% CI = 1.12-1.45). Flexible parametric modeling revealed increased risk of readmission mainly in individuals aged 18-35 years. CONCLUSIONS: The risk of readmission was highest among those with low education, schizophrenia and other psychotic disorders, mood-related disorders or personality disorders. Individuals aged 18-35 years showed the highest risk of readmission. Our findings highlight individuals with complex health-care needs.

Indications of alcohol or drug use disorders in five different national registers in Sweden: a cross-sectional population-based study.

OBJECTIVE: The purpose of this study is to examine the prevalence of indications of alcohol or drug use disorders in five different national Swedish registers and to investigate the correlation between these registers. Furthermore, the intent is to investigate whether combining data from different registers increases the prevalence of these indications in the population due to the identification of different demographic groups in different registers. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Individuals living in Sweden aged 20-64 years in 2006, n=5 453 616. PRIMARY OUTCOME: National registers included the Registers of Inpatient Care, Outpatient Care, Medications, Social Insurance and Convictions. Demographic variables were sex, age, migrant status, education and civil status. Indications of alcohol or drug use disorders were presented as prevalence in percentage (%), correlation was examined using phi correlation coefficients and differences across demographic factors were studied using logistic regression. RESULTS: The prevalence of an indication of alcohol or drug use disorder varied between registers, meaning that prevalence increased when all registers were considered together. The prevalence of alcohol use disorder increased by 60% and 66% among men and women, respectively, while the prevalence of drug use disorder increased by 45% and 80% among men and women, respectively, when all registers were combined, compared with only using the register with the highest prevalence. Registers contributed different indications of drug and alcohol use disorders. CONCLUSIONS: Accurate estimates of alcohol or drug use disorders are critical for healthcare and rehabilitation. This study shows that using a single register alone underestimates the burden of disease unevenly, while combining a range of registers can provide a more accurate picture.

Educational level and the risk of mental disorders, substance use disorders and self-harm in different age-groups: A cohort study covering 1,6 million subjects in the Stockholm region.

OBJECTIVE: To investigate the associations between low education and risk of mental disorders, substance use disorders and self-harm in different age-groups. METHODS: All subjects in Stockholm born between 1931 and 1990 were linked to their own or their parent's highest education in 2000 and followed-up for these disorders in health care registers 2001-2016. Subjects were stratified into four age-groups: 10-18, 19-27, 28-50, and 51-70 years. Hazard Ratios with 95% Confidence Intervals (CIs) were estimated with Cox proportional hazard models. RESULTS: Low education increased the risk of substance use disorders and self-harm in all age-groups. Males aged 10-18 with low education had increased risks of ADHD and conduct disorders, and females a decreased risk of anorexia, bulimia and autism. Those aged 19-27 years had increased risks of anxiety and depression, and those aged 28-50 had increased risks of all mental disorders except anorexia and bulimia in males with Hazard Ratios ranging from 1.2 (95% CIs 1.0-1.3) for bipolar disorder to 5.4 (95% CIs 5.1-5.7) for drug use disorder. Females aged 51-70 years had increased risks of schizophrenia and autism. CONCLUSION: Low education is associated with risk of most mental disorders, substance use disorders and self-harm in all age-groups, but especially among those aged 28-50 years.

Does the prevention paradox apply to various alcohol habits and problems among Swedish adolescents?

BACKGROUND: The prevention paradox states that a majority of alcohol-related problems in a population come from moderate drinkers because they are more numerous than heavy drinkers, although the latter have a higher individual risk of adverse outcomes. We examined the extent to which the prevention paradox applies to the relationship between alcohol consumption, heavy episodic drinking (HED) and alcohol-related problems in adolescents; an area in which studies are lacking. METHODS: A total of 7288 alcohol-consuming adolescents aged 13-17 years were examined. The proportions (%) of problems related to drinking measures [the upper 10% and bottom 90% of drinkers by annual alcohol intake, and those with frequent (monthly), less frequent, and no heavy drinking episodes] were calculated. RESULTS: The bottom 90% of consumers by annual intake accounted for a large majority of the alcohol-related problems among boys and girls at all ages. The share of problems accounted for by monthly HEDs increased with age, from ∼10% among those aged 13 years to >50% among those aged 17 years. Attributable proportions for the top 10% alcohol consumers ranged between 22% and 37%. CONCLUSIONS: Our analyses suggest that the prevention paradox is valid for adolescent boys and girls aged ≥15 years and applies to a large range of alcohol-related problems of varying severity. Our results imply that not only that prevention directed at all adolescents is essential, but also that HED should be particularly noticed.

Fathers' alcohol consumption and risk of substance-related disorders in offspring.

BACKGROUND: Few studies have assessed how children are affected by parental alcohol consumption without clinically diagnosed alcohol problems, especially in relation to more long-term and severe consequences. The aim is to investigate how fathers' alcohol use is related to the risk for substance-related disorders in offspring. METHOD: A prospective cohort study of 64 710 Swedish citizens whose fathers were conscripted for compulsory military training at ages 18-20 in 1969/70. Information on fathers' alcohol consumption, frequency of intoxication and apprehended for drunkenness, was collected during conscription. Offspring was followed for substance-related disorders from age 12 to end of follow up in 2009. RESULTS: All measures of fathers' alcohol use were significantly and positively associated with risk for substance-related disorders in offspring. The associations were to a large extent explained by other risk factors in childhood. In the fully adjusted model, those with fathers in the highest alcohol consumption quintile still had a 63% higher risk (HR=1.63 CI 1.26-2.12) of substance-related disorders compared to those whose fathers' reported abstinence. The highest risk was found among offspring to fathers with alcohol-related disorders or that had been apprehended for drunkenness, with a more than two-fold increased risk for substance-related disorders. CONCLUSIONS: Despite the lower risk found among offspring to fathers with sub-clinical drinking when compared to those with alcohol-related disorders, the former group accounts for a much larger proportion of all cases of substance-related disorders in the population, prompting universal prevention efforts targeting the level of total alcohol consumption in society.

Parental substance use disorder and offspring not in education, employment or training: a national cohort study of young adults in Sweden.

AIMS: To test the hypothesis that exposure to parental substance use disorder is associated with an increased risk of being not in education, employment or training (NEET) in male and female offspring during young adulthood. DESIGN, SETTING AND PARTICIPANTS: A register-based, national cohort study of 797 376 individuals born between 1984 and 1990, residing in Sweden at age 17 years. Participants were followed from age 17 years to maximum age 32 years and assessed annually for being NEET. MEASUREMENTS: The exposure variable was binary, defined as any diagnosis of substance use disorder (alcohol and/or drug use disorder) in one or both parents, measured between offspring's birth and age 17 years. Cox regression analysis was used to obtain hazard ratios (HRs) for being NEET, assessed annually as a binary variable using income and employment data. FINDINGS: We found that 4.4% of individuals were exposed to parental substance use disorder. When adjusted for birth year, domicile, origin, psychiatric diagnosis, household income and parental psychiatric diagnosis, HRs for being NEET were HR = 1.13 (95% CI 1.09-1.16) for males, and HR = 1.15 (95% CI 1.12-1.19) for females. When stratified by age, adjusted HRs for experiencing the first episode of NEET peaked at age 17-19 years, HR = 1.37 (95% CI 1.25-1.50) for males, and HR = 1.31 (95% CI 1.18-1.44) for females. CONCLUSIONS: In Sweden, exposure to parental substance use disorder before age 17 years is associated with increased risk of being not in education, employment or training during early adulthood. The risks were highest at age 17-19 years for both males and females, decreasing with greater age.

Trajectories of NEET (Not in Education, Employment, and Training) in emerging adulthood, and later drug use disorder - a national cohort study.

BACKGROUND: Being not in education, employment, or training (NEET) has been associated with poor health outcomes. This study aimed to investigate the association between NEET during emerging adulthood and later drug use disorder (DUD) among males and females. METHOD: A national cohort comprising 383,116 Swedish males and 362,002 females born between 1984 and 1990. NEET exposure was assessed annually between the ages 17 and 24 years, and follow-up for DUD between ages 25-33. Trajectories of NEET were estimated using group-based trajectory analysis. Cox regression analysis was used to estimate hazard ratios (HR) of DUD. Sibling-comparison model was performed to account for potential shared genetic and environmental factors. RESULTS: Four trajectories of NEET were identified: "constant low", "transient peak", "late increase", and "constant high". Compared with the "constant low", all other trajectories were associated with increased HRs of DUD. HR was highest among males and females in the "late increase trajectory"; HR = 4.10 (3.79-4.44, 95% CI) and HR = 3.73 (3.29-4.24, 95% CI), after adjusting for domicile, origin, birth year, psychiatric diagnoses, and parental psychiatric diagnoses. This association was reduced to about a twofold increased risk in the sibling comparison analysis. CONCLUSION: Being NEET during emerging adulthood was associated with later DUD for both males and females. Neither origin, psychiatric diagnoses, parental psychiatric diagnoses, nor shared familial factors did fully explain the association. Males and females belonging to the late increase NEET trajectory had about a twofold increased risk of DUD.

Poverty in adolescence and later drug use disorders: understanding the mediation and interaction effects of other psychiatric disorders.

BACKGROUND: Poverty in adolescence is associated with later drug use. Few studies have evaluated the role of adolescent psychiatric disorders in this association. AIMS: This study aimed to investigate mediation and interaction simultaneously, enabling the disentanglement of the role of adolescent psychiatric disorders in the association between poverty in adolescent and later drug use disorders. METHOD: A national cohort study of 634 223 individuals born in 1985-1990, residing in Sweden between the ages of 13 and 18 years, was followed from age 19 years until the first in-patient or out-patient care visit with a diagnosis of drug use disorder. A four-way decomposition method was used to determine the total effect of the association with poverty and possible mediation by and/or interaction with diagnosis of adolescent psychiatric disorders. RESULTS: The hazard ratios for drug use disorders among those experiencing poverty compared with those 'never in poverty' were 1.40 (95% CI, 1.32-1.63) in females and 1.43 (95% CI, 1.37-1.49) in males, after adjusting for domicile, origin and parental psychiatric disorders. Twenty-four per cent of this association in females, and 13% in males, was explained by interaction with and/or mediation by adolescent psychiatric disorders. CONCLUSIONS: Part of the association between poverty in adolescence and later drug use disorders was due to mediation by and/or interaction with psychiatric disorders. Narrowing socioeconomic inequalities in adolescence might help to reduce the risks of later drug use disorders. Interventions aimed at adolescents with psychiatric disorders might be especially important.