Aims: This study aimed to examine age, cohort and period trends in alcohol abstinence.

Design: Two surveys, the Level of Living Survey collected in 1968, 1974, 1981, 1990 and 2000, and the Swedish Panel Study of the Oldest Old (SWEOLD) collected in 1992 and 2002, were studied with graphical depictions of cross-sectional and longitudinal data presented over time and over age. Cross-sectional 10-year age group differences, time-lag differences between waves and within-cohort differences between waves for 10-year birth cohorts were examined. Logistic regression models were applied to confirm the observed patterns.

Setting: The samples were representative of the Swedish population.

Participants: Participants ranged in age from 18 to 75 (n = 5000 per wave), and 77+ at later waves (n = 500).

Measurements: Alcohol abstinence was determined by asking 'Do you ever drink wine, beer, or spirits?', where a 'no' response indicated abstinence.

Findings: Decreases in abstinence rates were observed from 1968 to 2000/02. While cross-sectional analysis indicated increased abstinence with advancing age, the longitudinal analysis suggested otherwise. Inspection of cohort differences revealed little change within cohorts and large differences between cohorts; abstinence rates declined in later-born cohorts up to the 1940s birth cohorts; stability was observed in cohorts born since the 1940s. Logistic regression models indicated that neither age nor period were significant (P > 0.05) predictors of abstinence when cohort (P < 0.001) was included.

Conclusion: Decreasing proportions of total alcohol abstainers in Sweden from 1968 to 2000 appear to be attributable primarily to decreases in successive cohorts rather than drinkers becoming abstainers.

Aims  This study aimed to examine age, cohort and period trends in alcohol abstinence.

Design  Two surveys, the Level of Living Survey collected in 1968, 1974, 1981, 1990 and 2000, and the Swedish Panel Study of the Oldest Old (SWEOLD) collected in 1992 and 2002, were studied with graphical depictions of cross-sectional and longitudinal data presented over time and over age. Cross-sectional 10-year age group differences, time-lag differences between waves and within-cohort differences between waves for 10-year birth cohorts were examined. Logistic regression models were applied to confirm the observed patterns.

Setting  The samples were representative of the Swedish population.

Participants  Participants ranged in age from 18 to 75 (n = 5000 per wave), and 77+ at later waves (n = 500).

Measurements  Alcohol abstinence was determined by asking ‘Do you ever drink wine, beer, or spirits?’, where a ‘no’ response indicated abstinence.

Findings  Decreases in abstinence rates were observed from 1968 to 2000/02. While cross-sectional analysis indicated increased abstinence with advancing age, the longitudinal analysis suggested otherwise. Inspection of cohort differences revealed little change within cohorts and large differences between cohorts; abstinence rates declined in later-born cohorts up to the 1940s birth cohorts; stability was observed in cohorts born since the 1940s. Logistic regression models indicated that neither age nor period were significant (P > 0.05) predictors of abstinence when cohort (P < 0.001) was included.

Conclusion  Decreasing proportions of total alcohol abstainers in Sweden from 1968 to 2000 appear to be attributable primarily to decreases in successive cohorts rather than drinkers becoming abstainers.

Aims: Peer status reflects the extent to which an individual is accepted by the group. Some studies have reported that low peer status in adolescence is associated with a higher risk of smoking, while others found the reverse. No studies have investigated peer status influences on adult smoking. The aim of the study was therefore to examine the relationship between adolescents' peer status and the intensity of smoking in adulthood.

Design: Prospective cohort study.

Setting: Stockholm, Sweden.

Participants: A subsample (n = 2329) of the cohort with information about adult smoking.

Measurements: Peer status was assessed sociometrically at age 13 and information on smoking was gathered through a questionnaire at age 32. Relative risks (RR) for self-reported level of smoking were calculated using multinomial logistic regression. Several family-related and individual variables were included as control variables.

Findings: Lower peer status in adolescence was associated with smoking of any intensity in adulthood. For example, the risk of heavy smoking was more than threefold (RR = 3.67) among individuals in the lowest status positions. The association with occasional smoking was abolished by controlling for factors related to adolescents' attitude to school and cognitive ability. For regular and heavy smoking the relationship was attenuated by controlling for these factors.

Conclusions: Low peer status in adolescence appears to be a risk factor for smoking in adulthood. Part of this association may be explained by adolescents' feelings towards school and cognitive ability. However, being unpopular in adolescence remains a strong risk factor for regular and heavy smoking in adulthood.

AimTo test if training and support, financial reimbursement and option of referring screen-positive patients to an internet-based method of giving advice (eBI) can increase primary health-care providers delivery of Alcohol Use Disorders Identification Test (AUDIT)-C-based screening and advice to heavy drinkers. DesignCluster randomized factorial trial with 12-week implementation and measurement period. SettingPrimary health-care units (PHCU) in different locations throughout Catalonia, England, the Netherlands, Poland and Sweden. ParticipantsA total of 120 PHCU, 24 in each of Catalonia, England, the Netherlands, Poland and Sweden. InterventionsPHCUs were randomized to one of eight groups: care as usual, training and support (TS), financial reimbursement (FR) and eBI; paired combinations of TS, FR and eBI, and all of FR, TS and eBI. MeasurementsThe primary outcome measure was the proportion of eligible adult (age 18+ years) patients screened during a 12-week implementation period. Secondary outcome measures were proportion of screen-positive patients advised; and proportion of consulting adult patients given an intervention (screening and advice to screen-positives) during the same 12-week implementation period. FindingsDuring a 4-week baseline measurement period, the proportion of consulting adult patients who were screened for their alcohol consumption was 0.059 per PHCU (95% CI 0.034 to 0.084). Based on the factorial design, the ratio of the logged proportion screened during the 12-week implementation period was 1.48 (95% CI=1.13-1.95) in PHCU that received TS versus PHCU that did not receive TS; for FR, the ratio was 2.00 (95% CI=1.56-2.56). The option of referral to eBI did not lead to a higher proportion of patients screened. The ratio for TS plus FR was 2.34 (95% CI=1.77-3.10), and the ratio for TS plus FR plus eBI was1.68 (95% CI=1.11-2.53). ConclusionsProviding primary health-care units with training, support and financial reimbursement for delivering Alcohol Use Disorders Identification Test-C-based screening and advice to heavy drinkers increases screening for alcohol consumption. Providing primary health-care units with the option of referring screen-positive patients to an internet-based method of giving advice does not appear to increase screening for alcohol consumption.

Background and Aims: The prevalence of cannabis use based on self-reports is likely to be underestimated in population surveys, especially in contexts where its use is a criminal offence. Indirect survey methods ask sensitive questions ensuring that answers cannot be identified with an individual respondent, therefore potentially resulting in more reliable estimates. We aimed to measure whether the indirect survey method ‘randomized response technique’ (RRT) increased response rate and/or increased disclosure of cannabis use among young adults compared with a traditional survey.

Design: We conducted two parallel nation-wide surveys during the spring and the summer of 2021. The first survey was a traditional questionnaire-based one (focusing on substance use and gambling). The second survey applied an indirect survey method known as ‘the cross-wise model’ to questions related to cannabis use. The two surveys employed identical procedures (e.g. invitations, reminders and wording of the questions)

Setting and Participants: The participants were young adults (aged 18–29 years) living in Sweden. The traditional survey had 1200 respondents (56.9% women) and the indirect survey had 2951 respondents (53.6% women).

Measurements: In both surveys, cannabis use was assessed according to three time-frames: life-time use; use during the past year; and use during the past 30 days.

Findings: The estimated prevalence of cannabis use was two- to threefold higher on all measures when estimated using the indirect survey method compared with the traditional survey: use during life-time (43.2 versus 27.3%); during the past year (19.2 versus 10.4%); and during the past 30 days (13.2 versus 3.7%). The discrepancy was larger among males and individuals with an education shorter than 10 years, who were unemployed, and who were born in non-European countries.

Conclusions: Indirect survey methods may provide more accurate estimates than traditional surveys on prevalence of self-reported cannabis use.

No abstract is available for this article.

This article summarizes the contents of Alcohol: No Ordinary Commodity (2nd edn). The first part of the book describes why alcohol is not an ordinary commodity, and reviews epidemiological data that establish alcohol as a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. This section also documents how international beer and spirits production has been consolidated recently by a small number of global corporations that are expanding their operations in Eastern Europe, Asia, Africa and Latin America. In the second part of the book, the scientific evidence for strategies and interventions that can prevent or minimize alcohol-related harm is reviewed critically in seven key areas: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drink-driving countermeasures, restrictions on marketing, education and persuasion strategies, and treatment and early intervention services. Finally, the book addresses the policy-making process at the local, national and international levels and provides ratings of the effectiveness of strategies and interventions from a public health perspective. Overall, the strongest, most cost-effective strategies include taxation that increases prices, restrictions on the physical availability of alcohol, drink-driving countermeasures, brief interventions with at risk drinkers and treatment of drinkers with alcohol dependence.

Background and Aims: This article summarizes the findings and conclusions of the third edition of Alcohol: No Ordinary Commodity. The latest revision of this book is part of a series of monographs designed to provide a critical review of the scientific evidence related to alcohol control policy from a public health perspective.

Design: A narrative summary of the contents of the book according to five major issues.

Findings: An extensive amount of epidemiological evidence shows that alcohol is a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. Trends in alcohol products and marketing are described, indicating that a large part of the global industry has been consolidated into a small number of transnational corporations that are expanding their operations in Asia, Africa and Latin America. The main part of the book is devoted to a review of strategies and interventions designed to prevent or minimize alcohol-related harm. Overall, the most effective strategies to protect public health are taxation that decreases affordability and restrictions on the physical availability of alcohol. A total ban on alcohol marketing is also an effective strategy to reduce consumption. In addition, drink-driving counter-measures, brief interventions with at-risk drinkers and treatment of drinkers with alcohol dependence are effective in preventing harm in high-risk contexts and groups of hazardous drinkers.

Conclusion: Alcohol policy is often the product of competing interests, values and ideologies, with the evidence suggesting that the conflicting interests between profit and health mean that working in partnership with the alcohol industry is likely to lead to ineffective policy. Opportunities for implementation of evidence-based alcohol policies that better serve the public good are clearer than ever before as a result of accumulating knowledge on which strategies work best.

The second edition of Drug Policy and the Public Good presents up-to-date evidence relating to the development of drug policy at local, national and international levels. The book explores both illicit drug use and non-medical use of prescription medications from a public health perspective. The core of the book is a critical review of the scientific evidence in five areas of drug policy: (1) primary prevention programs in schools and other settings; (2) treatment interventions and harm reduction approaches; (3) attempts to control the supply of illicit drugs, including drug interdiction and law enforcement; (4) penal approaches, decriminalization and other alternatives; and (5) control of the legal market through prescription drug regimens. It also discusses the trend towards legalization of some psychoactive substances in some countries and the need for a new approach to drug policy that is evidence-based, realistic and coordinated. The accumulated evidence provides important information about effective and ineffective policies. Shifting the emphasis towards a public health approach should reduce the extent of illicit drug use, prevent the escalation of new epidemics and avoid the unintended consequences arising from the marginalization of drug users through severe criminal penalties.

Drug Policy and the Public Good was written by an international group of scientists from the fields of addiction, public health, criminology and policy studies to improve the linkages between drug research and drug policy. The book provides a conceptual basis for evidence-informed drug policy and describes epidemiological data on the global dimensions of drug misuse. The core of the book is a critical review of the cumulative scientific evidence in five general areas of drug policy: primary prevention programmes in schools and other settings; health and social services for drug users; attempts to control the supply of drugs, including the international treaty system; law enforcement and ventures into decriminalization; and control of the psychotropic substance market through prescription drug regimes. The final chapters discuss the current state of drug policies in different parts of the world and describe the need for future approaches to drug policy that are coordinated and informed by evidence.

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Background and Aims The global growth of mobile phone use has led to new opportunities for health interventions, including through text messaging. We aimed to estimate the effects of text messaging interventions on alcohol consumption among risky drinkers. Methods Systematic review and meta-analysis of reports on randomized controlled trials (RCTs) published in English. Searches were conducted on 23 May 2019 in PubMed; PubMed Central; CENTRAL; CDSR; DARE; NHS-EED; Scopus; PsycINFO; PsycARTICLES; CINAHL; and Web of Science. Measurements included number of episodes of heavy drinking (HED) per month and weekly alcohol consumption (WAC) in grams. Trials among risky drinkers who were not receiving co-interventions were included in the review (n = 3481, mean age 29 years, 41% female). Data were extracted from reports and authors were contacted for additional data. Results Ten trials were included and all analyses were based on random-effects models. Primary analyses, including seven trials (n = 2528) for HED and five trials (n = 2236) for WAC, found that the interventions may reduce self-reported HED [-0.33 episodes per month; 95% confidence interval (CI) = -0.79, 0.12] and WAC (-18.62 g per week; 95% CI = -39.61, 2.38), although both estimates included the null. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) quality of evidence was judged to be low for both HED and WAC, primarily due to risk of attrition and performance bias, heterogeneity and influence of pilot trials on estimates. Conclusions Text messaging alcohol interventions may reduce alcohol consumption compared with no or basic health information; however, there are doubts about the overall quality of the evidence.

To study the links between parental alcohol-related disorders and offspring school performance and, specifically, whether associations vary by gender of parent or child and whether associations are mediated by other adverse psychosocial circumstances commonly appearing together with parental alcohol problems, such as parental mental health problems or criminal behaviour.

Register study in a national cohort.

Setting

Sweden.

740 618 individuals born in Sweden in 1990-1996.

Parental hospital admissions for alcohol-related disorders and school performance in their offspring, in the final year of compulsory school at age 15-16, was analysed in relation to sociodemographic confounders and psychosocial covariates, using linear and logistic regressions.

Both mothers’ and fathers’ alcohol-related hospital admissions were associated with lower z-scores of grades and national mathematic tests scores. After adjustment for parental education and sociodemographic confounders, beta-coefficients of z-scores of grades were -0.42 (95% CI -0.45, -0.39) and -0.42 (95 % CI -0.43,-0.40), and beta-coefficients of mathematic tests scores were -0.36 (95% CI -0.39, -0.33) and -0.31 (95% CI -0.33, -0.29), for mothers’ and fathers’ alcohol-related disorders, respectively. Adjusted ORs for not being eligible for secondary school were 1.99 (95% CI 1.84-2.15) and 2.04 (95% CI 1.95-2.15) for mothers’ and fathers’ alcohol-related disorders, respectively. Adjusting the analyses for psychosocial factors in the family almost eradicated the statistical effects of parental alcohol-related disorders on offspring school performance to beta-coefficients of 0.03 to -0.10 and ORs of 0.89 to 1.15. The effect of a mother's alcohol-related hospital admission on school performance was stronger in girls than in boys, whereas no gender differences were seen for a father's alcohol-related hospital admission.

Conclusions

In Sweden, alcohol-related disorders in both mothers and fathers are associated with lower school performance in their children at age 15-16, with most of the statistical effects being attributed to psychosocial circumstances of the family, such as parental psychiatric disorders, drug use, and criminality and receipt of social or child welfare interventions.

Background and aims Although an individual's childhood adversity is predictive of later substance misuse, the effect of adversity within an individual's friendship network has not been established. The current study aims to estimate the strength of the association between exposure to childhood adversity among individuals' friends at the onset of adolescence, relative to individuals' own exposure to childhood adversity, and hospitalization for substance misuse between young adulthood and retirement. Design Prospective cohort study. Setting Stockholm, Sweden. Participants Individuals born in 1953, living in Stockholm in 1963, and who nominated three best friends in the 6th grade school class (n = 7180; females = 3709, males = 3471), followed to 2016. Measurements The outcome was hospitalization with a main or secondary diagnosis attributed to substance misuse, reflected in Swedish inpatient records (ages 19-63 years). Five indicators of childhood adversity (ages 0-12 years) were operationalized into composite measures for individuals and their friends, respectively. Friendships were identified using sociometric data collected in the school class setting (age 13 years). Findings Individuals' own childhood adversity does not predict childhood adversity among friends (P > 0.05). Childhood adversity among friends is independently associated with an increased risk of an individual's later substance misuse [hazard ratio (HR) = 1.17, 95% confidence interval (CI) = 1.09-1.24], independently of an individual's own childhood adversity (HR = 1.47, 95% CI = 1.34-1.61). However, childhood adversity among friends does not moderate the association between individuals' own childhood adversity and later substance misuse. Conclusions Within a birth cohort of individuals born in 1950s Stockholm, Sweden, childhood adversity among an individual's friends appears to predict the individual's substance misuse in later life independently of an individual's own exposure to childhood adversity.

Aims: To compare the costs of hospital care and sick leave/disability pensions between two groups of driving while impaired (DWI) offenders: participants in an alcohol ignition interlock programme (AIIP) and controls with revoked licences, but with no comparable opportunity to participate in an AIIP. Setting: As an alternative to licence revocation DWI offenders can participate in a voluntary 2-year AIIP permitting the offender to drive under strict regulations entailing regular medical check-ups. The participants are forced to alter their alcohol habits and those who cannot demonstrate sobriety are dismissed from the programme. Participants: are liable for all costs themselves. Design: Quasi-experimental, with a non-equivalent control group used for comparison; intent-to-treat design. Based on the number of occasions/days in hospital and on sick leave/disability pension, the health-care costs for public insurance have been calculated. Finding: Average total health-care costs were 25% lower among AIIP participants (1156 individuals) than among controls (815 individuals) during the 2-year treatment period. This corresponds to over €1000 (SEK9610) less annual costs per average participant. For those who complete the 2-year programme the cost reduction was more pronounced; 37% during the treatment and 20% during the post-treatment period. Conclusions: The positive health-care effects were due apparently to reduced alcohol consumption. The social benefit of being allowed to drive while in the AIIP may also have contributed. The reduction in health-care costs was significant only during the 2-year treatment period, but among those who completed the entire AIIP sustained effects were also observed in the post-treatment period. The effects were comparable to those of regular alcoholism treatment programmes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)(journal abstract)

Aims: To compare the costs of hospital care and sick leave/disability pensions between two groups of driving while impaired (DWI) offenders: participants in an alcohol ignition interlock programme (AIIP) and controls with revoked licences, but with no comparable opportunity to participate in an AIIP. Setting: As an alternative to licence revocation DWI offenders can participate in a voluntary 2-year AIIP permitting the offender to drive under strict regulations entailing regular medical check-ups. The participants are forced to alter their alcohol habits and those who cannot demonstrate sobriety are dismissed from the programme. Participants: are liable for all costs themselves. Design: Quasi-experimental, with a non-equivalent control group used for comparison; intent-to-treat design. Based on the number of occasions/days in hospital and on sick leave/disability pension, the health-care costs for public insurance have been calculated. Finding: Average total health-care costs were 25% lower among AIIP participants (1156 individuals) than among controls (815 individuals) during the 2-year treatment period. This corresponds to over €1000 (SEK9610) less annual costs per average participant. For those who complete the 2-year programme the cost reduction was more pronounced; 37% during the treatment and 20% during the post-treatment period. Conclusions: The positive health-care effects were due apparently to reduced alcohol consumption. The social benefit of being allowed to drive while in the AIIP may also have contributed. The reduction in health-care costs was significant only during the 2-year treatment period, but among those who completed the entire AIIP sustained effects were also observed in the post-treatment period. The effects were comparable to those of regular alcoholism treatment programmes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)(journal abstract)

Aim  To identify the most important reasons for selecting a particular route of heroin administration and for subsequent transitions during a period of epidemic HIV transmission. To study temporal trends in these reasons.

Design  Cross-sectional survey.

Participants  Nine hundred heroin users in three Spanish cities: 305 in Seville, 297 in Madrid and 298 in Barcelona.

Measurements  A separate analysis was made of the reasons for five types of behaviour: (a) selecting injection as the initial usual route of heroin administration (URHA); (b) changing the URHA to injection; (c) never having injected drugs; (d) selecting the smoked or sniffed route as the initial URHA; and (e) changing the URHA to a non-injected route. Subjects were invited to evaluate the importance of each reason included in a closed list. Spontaneously self-perceived reasons were also explored in an open-ended question for each of the five types of behaviour studied.

Findings  The primary reason selected for each type of behaviour was: (a) pressure of the social environment; (b) belief that injection is a more efficient route than smoking or sniffing heroin; (c) concern about health consequences (especially fears of HIV and overdose), and fear of blood or of sticking a needle into one's veins; (d), pressure of the social environment and (e) concern about health consequences and vein problems. For women, having a sexual partner who injected heroin played a decisive role in initiating or changing to injection. Few people spontaneously mentioned market conditions for purchasing heroin as an important reason for any behaviour, nor did many mention risk of overdose as reasons for (c) or (d).

Conclusions  These findings should be considered when designing interventions aimed at preventing initiation of injecting or facilitating the transition to non-injected routes.

Background and aims: Treatment-resistant depression (TRD), defined as inadequate treatment response after at least two adequate treatment trials, is common among patients initiating antidepressant treatment. Current or previous substance use disorders (SUD) are common among patients with depression and often lead to worse treatment outcomes. However, in clinical studies, SUD have not been found to increase the risk for TRD. The aim of this study was to investigate the association between SUD and TRD.

Design: Nested case-control study.

Setting: Nation-wide governmental health-care registers in Sweden.

Cases and controls: Data on prescribed drugs and diagnoses from specialized health care were used to establish a prospectively followed cohort of antidepressant initiators with depression (n = 121 669) from 2006 to 2014. Of these, 15 631 patients (13%) were defined as TRD cases, with at least three treatment trials within a single depressive episode. Each case with TRD was matched on socio-demographic data with five controls with depression.

Measurements: Crude and adjusted odds ratios (aOR) with 95% confidence intervals (CI) estimated the association between TRD and SUD diagnosis and/or treatment in five different time intervals until the time for fulfillment of TRD definition for the case. The analysis was adjusted for clinical and socio-demographic covariates.

Findings: Having any SUD during, or <= 180 days before start of, antidepressant treatment was associated with almost double the risk for TRD [<= 180 days before: adjusted OR (aOR) = 1.86, CI = 1.70-2.05]. Increased risks for TRD were found <= 180 days before treatment start for the subcategories of sedative use (aOR = 2.37; 1.88-2.99), opioids (aOR = 2.02; 1.48-2.75), alcohol (aOR = 1.77; CI = 1.59-1.98) and combined substance use (aOR = 2.31; 1.87-2.99).

Conclusions: Recent or current substance use disorders is positively associated with treatment resistance among patients initiating treatment for depression.

Background and aims Treatment-resistant depression (TRD) is common among patients with major depressive disorder (MDD). MDD may increase the risk for developing substance use disorders (SUD). The aim of this study was to investigate the risk for developing SUD among patients with TRD compared with other depressed patients.

Design Observational cohort study.

Setting Nation-wide governmental health registers in Sweden.

Participants All patients aged 18-69 years with an MDD diagnosis in specialized health care who had received at least one antidepressant prescription during 2006-14 were identified. Patients with at least three treatment trials within a single depressive episode were classified with TRD.

Measurements Patients with TRD were compared with the whole MDD cohort regarding risk for obtaining a SUD diagnosis or medication using survival analyses adjusted for socio-demographics and comorbidities.

Findings Of 121 669 MDD patients, 13% were classified with TRD. Among the patients without any history of SUD, patients with TRD had a risk increase for any SUD both ≤ 1 and > 1 year after antidepressant initiation [> 1 year hazard ratio (HR) = 1.4; 95% confidence interval (CI) = 1.3-1.5]. Risks were elevated for the subcategories of opioid (HR = 1.9, 95% CI = 1.4-2.5) and sedative SUD (HR = 2.7, 95% CI = 2.2-3.2). Patients with a history of SUD had a risk increase for any SUD ≤ 1 year after start of treatment (HR = 1.2, 95% CI = 1.1-1.4), and both ≤ 1 year and > 1 year for sedative (> 1 year HR = 2.0, 95% CI = 1.3-3.0) and multiple substance SUD (HR = 1.9, 95% CI = 1.4-2.5).

Conclusions Patients with treatment-resistant depression may be at greater risk for substance use disorders compared with other patients with major depressive disorder. Patterns may differ for patients with and without a history of substance use disorders, and for different categories of substance use disorder.

Background and aims: Survey questions on usual quantity and frequency of alcohol consumption are regularly used in screening tools to identify drinkers requiring intervention. The aim of this study was to measure age-based differences in quantity and frequency of alcohol consumption on the Alcohol Use Disorders Identification Test (AUDIT) and how this relates to the prediction of harmful or dependent drinking.

Design: Cross-sectional survey.

Setting: Australia.

Participants: Data were taken from 17 399 respondents who reported any alcohol consumption in the last year and were aged 18 and over from the 2016 National Drug Strategy Household Survey, a broadly representative cross-sectional survey on substance use.

Measurement: Respondents were asked about their frequency of consumption, usual quantity per occasion and the other items of the AUDIT.

Findings: In older drinkers, quantity per occasion [β = 0.53, 95% confidence interval (CI) = 0.43, 0.64 in 43–47-year-olds as an example] was a stronger predictor of dependence than frequency per occasion (β = 0.24, 95% CI = 0.17, 0.31). In younger drinkers the reverse was true, with frequency a stronger predictor (β = 0.54, 95% CI = 0.39, 0.69 in 23–27-year-olds) than quantity (β = 0.26, 95% CI = 0.18, 0.34 in 23–27-year-olds). Frequency of consumption was not a significant predictor of dependence in respondents aged 73 years and over (β = −0.03, 95% CI = −0.08, 0.02). Similar patterns were found when predicting harmful drinking. Despite this, as frequency of consumption increased steadily with age, the question on frequency was responsible for at least 65% of AUDIT scores in drinkers aged 53 years and over.

Conclusions: In younger drinkers, frequent drinking is more strongly linked to dependence and harmful drinking subscale scores on the Alcohol Use Disorders Identification Test (AUDIT) than quantity per occasion, yet quantity per occasion has a stronger influence on the overall AUDIT score in this group. In older drinkers, frequency of consumption is not always a significant predictor of the AUDIT dependence subscale and is a weak predictor of the harmful drinking subscale.

Aim While drinking in the event is an important factor in injury occurrence, the pattern of usual drinking may also be important in risk of injury. Explored here is the relationship of an alcohol-related injury with an individual usual drinking pattern. Design Alcohol-related injury is examined using hierarchical linear models, taking into account individual usual volume of consumption over the past 12 months, as well as aggregate-level detrimental drinking pattern (DDP) and alcohol policy measures. Setting Data analyzed are from emergency departments (EDs) in 19 countries, comprising three collaborative studies on alcohol and injury, all of which used a similar methodology. Participants The sample comprised 14 132 injured drinkers across 46 emergency room (ER) studies. Measurements Alcohol-related injury was measured, separately, by any self-reported drinking prior to injury, a blood alcohol concentration (BAC) = 0.08 and self-reported causal attribution of injury to drinking. Findings While individual usual volume strongly predicted an alcohol-related injury for all three measures, usual drinking pattern also predicted an alcohol-related injury (controlling for volume), with episodic heavy and frequent heavy drinking both more predictive of alcohol-related injury than other drinking patterns. When individual usual volume and drinking pattern were controlled, DDP was no longer a significant predictor of alcohol-related injury. Alcohol policy measures were predictive of both BAC and causal attribution (the stronger the policy the lower the rates of alcohol-related injury). Conclusions Volume of alcohol typically consumed and occurrence of heavy drinking episodes are associated independently with incidence of alcohol-related injury. The stronger the anti-alcohol policies in a country, the lower the rates of alcohol-related injury.

AimsTo examine associations between cannabis use in adolescence (at age 18) and unemployment and social welfare assistance in adulthood (at age 40) among Swedish men. DesignLongitudinal cohort study. Setting and ParticipantsA total of 49321 Swedish men born in 1949-51, who were conscripted to compulsory military service at 18-20 years of age. MeasurementsAll men answered two detailed questionnaires at conscription and were subject to examinations of physical aptitude psychological functioning and medical status. By follow-up in national databases, information on unemployment and social welfare assistance was obtained. FindingsIndividuals who used cannabis at high levels in adolescence had increased risk of future unemployment and of receiving social welfare assistance. Adjusted for all confounders (social background, psychological functioning, health behaviours, educational level, psychiatric diagnoses), an increased relative risk (RR) of unemployment remained in the group reporting cannabis use >50 times [RR=1.26, 95% confidence interval (CI)=1.04-1.53] only. For social welfare assistance, RR in the group reporting cannabis use 1-10 times was 1.15 (95% CI=1.06-1.26), RR for 11-50 times was 1.21 (95% CI=1.04-1.42) and RR for >50 times was 1.38 (95% CI=1.19-1.62). ConclusionsHeavy cannabis use among Swedish men in late adolescence appears to be associated with unemployment and being in need of social welfare assistance in adulthood. These associations are not explained fully by other health-related, social or behavioural problems.

Aims  According to the prevention paradox, a majority of alcohol-related problems in a population can be attributed to low to moderate drinkers simply because they are more numerous than heavy drinkers, who have a higher individual risk of adverse outcomes. We examined the prevention paradox in annual alcohol consumption, heavy episodic drinking (HED) and alcohol-related problems among adolescents in 23 European countries.

Design and setting  Survey data from the 2007 European School Survey Project on Alcohol and Drugs (ESPAD) among 16-year-old students were analysed.

Participants  A total of 38 370 alcohol-consuming adolescents (19 936 boys and 18 434 girls) from 23 European countries were included.

Measurements  The upper 10% and the bottom 90% of drinkers by annual alcohol intake, with or without HED, and frequency of HED, were compared for the distribution of 10 different alcohol-related problems.

Findings  Although the mean levels of consumption and alcohol-related problems varied largely between genders and countries, in almost all countries the heavy episodic drinkers in the bottom 90% of consumers by volume accounted for most alcohol-related problems, irrespective of severity of problem. However, adolescents with three or more occasions of HED a month accounted for a majority of problems.

Conclusions  The prevention paradox, based on measures of annual consumption and heavy episodic drinking, seems valid for adolescent European boys and girls. However, a minority with frequent heavy episodic drinking accounted for a large proportion of all problems, illustrating limitations of the concept. As heavy episodic drinking is common among adolescents, our results support general prevention initiatives combined with targeted interventions.

The Kettil Bruun Society for Social and Epidemiological Research on Alcohol (KBS) was established in 1987 and is an independent organization open to all scientists working on problems related to social and epidemiological research on alcohol. The aim of the Society is to promote social and epidemiological research which fosters a comparative understanding of the social aspects of alcohol use and alcohol problems. In line with this the Society also aims at promoting a spirit of international collaboration. The Kettil Bruun Society is based on individual membership and, by 2003, has 197 fully paid-up members, representing 34 different countries over five continents. The main activities include an annual meeting as well as thematic meetings. In these meetings, discussions are emphasized by having precirculated papers and assigned discussants. The KBS also serves as a basis for organizing international collaborative projects. Project meetings or work-shops are often organized around the annual meetings, and the projects tend to run over several years. The Society's primary influence is through the mutual influence of its members on each others' thinking, the work of the projects that KBS sponsors and the influence its members have collectively on the development of the field.

Aim: To test the association of alcohol consumption with total and cause-specific mortality risk. Design: Prospective observational multi-centre population-based study.

Setting: Sixteen cohorts (15 from Europe) in the MOnica Risk, Genetics, Archiving and Monograph (MORGAM) Project.

Participants: A total of 142 960 individuals (mean age 50 ± 13 years, 53.9% men).

Measurements: Average alcohol intake by food frequency questionnaire, total and cause-specific mortality.

Findings: In comparison with life-time abstainers, consumption of alcohol less than 10 g/day was associated with an average 11% [95% confidence interval (CI) = 7–14%] reduction in the risk of total mortality, while intake > 20 g/day was associated with a 13% (95% CI = 7–20%) increase in the risk of total mortality. Comparable findings were observed for cardiovascular (CV) deaths. With regard to cancer, drinking up to 10 g/day was not associated with either mortality risk reduction or increase, while alcohol intake > 20 g/day was associated with a 22% (95% CI = 10–35%) increased risk of mortality. The association of alcohol with fatal outcomes was similar in men and women, differed somewhat between countries and was more apparent in individuals preferring wine, suggesting that benefits may not be due to ethanol but other ingredients. Mediation analysis showed that high-density lipoprotein cholesterol explained 2.9 and 18.7% of the association between low alcohol intake and total as well as CV mortality, respectively.

Conclusions: In comparison with life-time abstainers, consuming less than one drink per day (nadir at 5 g/day) was associated with a reduced risk of total, cardiovascular and other causes mortality, except cancer. Intake of more than two drinks per day was associated with an increased risk of total, cardiovascular and especially cancer mortality.

Aims Risky single-occasion drinking (RSOD) by young people is a serious public health issue, yet little is known about the specific circumstances of risky drinking occasions. This study examined the independent effects of event- and individual-specific variables on RSOD. Design Longitudinal cohort study measuring self-reported RSOD and event- and individual-specific variables across two drinking occasions approximately 1 year apart. Setting Metropolitan Melbourne, Australia. Participants A sample of 710 young risky drinkers aged between 18 and 25years and defined as engaging in risky drinking practices (males: consumed alcohol in excess of 10 Australian Standard Drinks (ASD: 10g ethanol) in a single occasion in the previous year; females: consumed alcohol in excess of seven ASD for females in a single occasion in the previous year). Measurements Random digit-dial telephone landline survey of the most recent heavy drinking occasion and socio-demographic variables. The primary outcome was the log of the total drinks consumed in the most recent heavy drinking occasion. Event-specific (e.g. number of drinking locations) and time-varying (e.g. weekly income) and time-invariant (e.g. sex) individual-specific variables were examined as correlates of total drinks consumed. Findings Changes in event-specific characteristics including the length of the drinking occasion (Likelihood Ratio (2)(2)=24.4, P<0.001), the number of drinking locations (Wald (2)((1))=7.6, P=0.006) and the number of different drink types (Wald (2)((1))=13.6, P<0.001) were associated with increases in total drinks consumed, after adjustment for time-invariant and time-variant individual-specific variables such as gender, income level and weekly consumption. Few other effects were noted. Conclusions Event-specific characteristics are important predictors of the number of drinks consumed during risky single occasion drinking (RSOD) and illustrate the importance of event contexts when considering interventions targeting RSOD. The total number of drinks consumed in a RSOD session appears to rise independently with the duration of the drinking event, the number of drinking locations and the number of different types of beverage consumed.

Aims We aimed to map the context of the large increase in vodka consumption in Sweden during the transition from early modern to modern times (c. 17751855). What were the attitudes to alcohol among the groups that dominated society, and how did these attitudes relate to contemporary legislation and socio-economic change? Methods Qualitative analysis of diaries and memoirs. Information was also collected from legislation, writings of the temperance movement and previous research. Findings During the period studied, attitudes to alcohol among the socio-economic elite were positive if the drinker was a person of standing, whereas drinking among the working population was scorned and, from the 1830s onwards, a cause for concern. Legislation was characterized by frequent and radical changes. Consumption levels are difficult to estimate: in the 1820s, agricultural overproduction, liberal legislation and improved distilling methods probably resulted in a major consumption increase. In 184653, permissive licensing laws and the industrialization of distilling similarly led to very high consumption levels. Conclusions In Sweden in the late 18th and early 19th centuries the social elite appears to have used alcohol as a tool in their negotiations with the working population but later, as the spread of wage labour and cheap vodka coincided with Sweden's largest ever population growth, the view that popular drinking must be checked gained support in leading circles.

Aims We aimed to map the context of the large increase in vodka consumption in Sweden during the transition from early modern to modern times (c. 17751855). What were the attitudes to alcohol among the groups that dominated society, and how did these attitudes relate to contemporary legislation and socio-economic change? Methods Qualitative analysis of diaries and memoirs. Information was also collected from legislation, writings of the temperance movement and previous research. Findings During the period studied, attitudes to alcohol among the socio-economic elite were positive if the drinker was a person of standing, whereas drinking among the working population was scorned and, from the 1830s onwards, a cause for concern. Legislation was characterized by frequent and radical changes. Consumption levels are difficult to estimate: in the 1820s, agricultural overproduction, liberal legislation and improved distilling methods probably resulted in a major consumption increase. In 184653, permissive licensing laws and the industrialization of distilling similarly led to very high consumption levels. Conclusions In Sweden in the late 18th and early 19th centuries the social elite appears to have used alcohol as a tool in their negotiations with the working population but later, as the spread of wage labour and cheap vodka coincided with Sweden's largest ever population growth, the view that popular drinking must be checked gained support in leading circles.

Aims: We aimed to map the context of the large increase in vodka consumption in Sweden during the transition from early modern to modern times (ca 1775-1855). What were the attitudes to alcohol among the groups that dominated society, and how did these attitudes relate to contemporary legislation and socio-economic change?

Methods: Qualitative analysis of diaries and memoirs. Information was also collected from legislation, writings of the temperance movement, and previous research.

Findings: During the period studied, attitudes to alcohol among the socio-economic elite were positive if the drinker was a person of standing, wereas drinking among the working population was scorned and, from the 1830s on, a cause for concern. Legislation was characterized by frequent and radical changes. Consumption levels are difficult to estimate: in the 1820s, agricultural overproduction, liberal legislation and improved distilling methods probably resulted in a major consumption increase. In 1846-53, permissive licensing laws and the industrialization of distilling similarly led to very high consumption levels.

Conclusions: In Sweden in the late 18th and early 19th centuries the social elite appears to have used alcohol as a tool in their negotiations with the working population; but later, as the spread of wage labour and cheap vodka coincided with Sweden's largest ever population growth, the view that popular drinking must be checked gained support in leading circles.

Aims To estimate differences in the strength and shape of associations between alcohol use and diagnosis-specific sickness absence. Design A multi-cohort study. Participants (n = 47 520) responded to a survey on alcohol use at two time-points, and were linked to records of sickness absence. Diagnosis-specific sickness absence was followed for 4-7 years from the latter survey. Setting and participants From Finland, we had population cohort survey data from 1998 and 2003 and employee cohort survey data from 2000-02 and 2004. From France and the United Kingdom, we had employee cohort survey data from 1993 and 1997, and 1985-88 and 1991-94, respectively. Measurements We used standard questionnaires to assess alcohol intake categorized into 0, 1-11 and > 11 units per week in women and 0, 1-34 and > 34 units per week in men. We identified groups with stable and changing alcohol use over time. We linked participants to records from sickness absence registers. Diagnoses of sickness absence were coded according to the International Classification of Diseases. Estimates were adjusted for sex, age, socio-economic status, smoking and body mass index. Findings Women who reported drinking 1-11 units and men who reported drinking 1-34 units of alcohol per week in both surveys were the reference group. Compared with them, women and men who reported no alcohol use in either survey had a higher risk of sickness absence due to mental disorders [rate ratio = 1.51, 95% confidence interval (CI) = 1.22-1.88], musculoskeletal disorders (1.22, 95% CI = 1.06-1.41), diseases of the digestive system (1.35, 95% CI = 1.02-1.77) and diseases of the respiratory system (1.49, 95% CI = 1.29-1.72). Women who reported alcohol consumption of > 11 weekly units and men who reported alcohol consumption of > 34 units per week in both surveys were at increased risk of absence due to injury or poisoning (1.44, 95% CI = 1.13-1.83). Conclusions In Finland, France and the United Kingdom, people who report not drinking any alcohol on two occasions several years apart appear to have a higher prevalence of sickness absence from work with chronic somatic and mental illness diagnoses than those drinking below a risk threshold of 11 units per week for women and 34 units per week for men. Persistent at-risk drinking in Finland, France and the United Kingdom appears to be related to increased absence due to injury or poisoning.

Aims To estimate differences in the strength and shape of associations between alcohol use and diagnosis-specific sickness absence. Design A multi-cohort study. Participants (n = 47 520) responded to a survey on alcohol use at two time-points, and were linked to records of sickness absence. Diagnosis-specific sickness absence was followed for 4-7 years from the latter survey. Setting and participants From Finland, we had population cohort survey data from 1998 and 2003 and employee cohort survey data from 2000-02 and 2004. From France and the United Kingdom, we had employee cohort survey data from 1993 and 1997, and 1985-88 and 1991-94, respectively. Measurements We used standard questionnaires to assess alcohol intake categorized into 0, 1-11 and > 11 units per week in women and 0, 1-34 and > 34 units per week in men. We identified groups with stable and changing alcohol use over time. We linked participants to records from sickness absence registers. Diagnoses of sickness absence were coded according to the International Classification of Diseases. Estimates were adjusted for sex, age, socio-economic status, smoking and body mass index. Findings Women who reported drinking 1-11 units and men who reported drinking 1-34 units of alcohol per week in both surveys were the reference group. Compared with them, women and men who reported no alcohol use in either survey had a higher risk of sickness absence due to mental disorders [rate ratio = 1.51, 95% confidence interval (CI) = 1.22-1.88], musculoskeletal disorders (1.22, 95% CI = 1.06-1.41), diseases of the digestive system (1.35, 95% CI = 1.02-1.77) and diseases of the respiratory system (1.49, 95% CI = 1.29-1.72). Women who reported alcohol consumption of > 11 weekly units and men who reported alcohol consumption of > 34 units per week in both surveys were at increased risk of absence due to injury or poisoning (1.44, 95% CI = 1.13-1.83). Conclusions In Finland, France and the United Kingdom, people who report not drinking any alcohol on two occasions several years apart appear to have a higher prevalence of sickness absence from work with chronic somatic and mental illness diagnoses than those drinking below a risk threshold of 11 units per week for women and 34 units per week for men. Persistent at-risk drinking in Finland, France and the United Kingdom appears to be related to increased absence due to injury or poisoning.

AIMS: Hypothalamic-pituitary-adrenal (HPA) axis activity may prove a viable biomarker for identifying those susceptible to alcohol use disorders. The purpose of this study was to examine the relation of the age at which adolescents begin drinking with diurnal and stress cortisol.

DESIGN: Adolescents' diurnal cortisol levels on a normal day and cortisol levels during a stress procedure were examined in relation to the age of onset of alcohol use.

SETTING AND PARTICIPANTS: All adolescents (aged 14-20 years) were part of a general population study in the Netherlands (n = 2286).

MEASUREMENTS: Ten assessments of salivary cortisol taken on a normal day (diurnal cortisol), as well as during a social stress procedure (stress cortisol) were used as indicators of HPA axis activity.

FINDINGS: The age at which the first alcoholic drink was consumed varied as a function of cortisol levels at the onset of as well as during the stress procedure. Those who began drinking at an earlier age showed lower cortisol levels at the onset of the stressful tasks (r(2) = 0.14, P < 0.001) and during the stressful tasks (r(2) = 0.10, P < 0.05), although not after the tasks (cortisol recovery). Effects were strongest for anticipatory pre-task cortisol levels. Differences in diurnal cortisol levels did not explain variance in the age at which adolescents had begun drinking.

CONCLUSIONS: Lessened activity of the hypothalamic-pituitary-adrenal axis at the onset of and during a stress procedure is present in adolescents who begin drinking at an early age.

AIMS: To characterize changes in patterns of adolescent substance use in Sweden between 1988 and 2011, and to assess whether sex and psychosomatic problems were associated with substance use and whether these associations changed over time.

DESIGN: Secondary analysis of repeated cross-sectional survey data. Survey data were collected eight times and analyzed as four cohorts (1988-91, 1995-98, 2002-05 and 2008-11).

SETTING AND PARTICIPANTS: The sample included all 15-16-year-olds in Värmland County, Sweden (n = 20 057).

MEASUREMENTS: Binary-coded substance use measures included life-time use of alcohol and tobacco, getting drunk and past school year use of inhalants. An eight-item scale was used to assess psychosomatic problems.

FINDINGS: A three-class model fitted the data best (i.e. non/low use, mainly alcohol use and polysubstance use). The patterns of substance use were different among cohorts; most notably, adolescents in the last cohort had lower odds of being included in the alcohol and polysubstance use classes rather than the non/low use class than in the earlier cohorts (all Ps < 0.001). Males had higher odds than females of being in the polysubstance use class rather than the non/low use class among the first three cohorts (all Ps < 0.001) but not the last. Sex was not associated with inclusion in the alcohol use class rather than the non/low use class. Adolescents who reported more psychosomatic problems had higher odds of being included in the alcohol and polysubstance use classes rather than the non/low use class (all Ps < 0.001). The associations of sex and psychosomatic problems with class inclusion did not change during the study period.

CONCLUSIONS: Between 1988 and 2011, patterns of substance use among adolescents in Sweden shifted away from polysubstance use and alcohol use to non-use or low use. Associations between patterns of substance use and sex and psychosomatic problems remained largely consistent across the study period.

Aims To characterize changes in patterns of adolescent substance use in Sweden between 1988 and 2011, and to assess whether sex and psychosomatic problems were associated with substance use and whether these associations changed over time. Design Secondary analysis of repeated cross-sectional survey data. Survey data were collected eight times and analyzed as four cohorts (1988-91, 1995-98, 2002-05 and 2008-11). Setting and participants The sample included all 15-16-year-olds in Varmland County, Sweden (n = 20 057). Measurements Binary-coded substance use measures included life-time use of alcohol and tobacco, getting drunk and past school year use of inhalants. An eight-item scale was used to assess psychosomatic problems. Findings A three-class model fitted the data best (i.e. non/low use, mainly alcohol use and polysubstance use). The patterns of substance use were different among cohorts; most notably, adolescents in the last cohort had lower odds of being included in the alcohol and polysubstance use classes rather than the non/low use class than in the earlier cohorts (all Ps < 0.001). Males had higher odds than females of being in the polysubstance use class rather than the non/low use class among the first three cohorts (all Ps < 0.001) but not the last. Sex was not associated with inclusion in the alcohol use class rather than the non/low use class. Adolescents who reported more psychosomatic problems had higher odds of being included in the alcohol and polysubstance use classes rather than the non/low use class (all Ps < 0.001). The associations of sex and psychosomatic problems with class inclusion did not change during the study period. Conclusions Between 1988 and 2011, patterns of substance use among adolescents in Sweden shifted away from polysubstance use and alcohol use to non-use or low use. Associations between patterns of substance use and sex and psychosomatic problems remained largely consistent across the study period.

Aims: To detect risk factors for sudden death from heroin injection. Design: Evaluation of data from forensic investigations of all fatal cases of suspected heroin death in a metropolitan area. Only cases with detectable morphine and 6-monoacetylmorphine (6-MAM) in blood were included in order to select heroin intoxication cases. Setting: Stockholm, Sweden. Measurements: Autopsy investigation and toxicological analysis of blood and urine: and police reports. Findings: In two-thirds of the 192 cases, death occurred in public places, and mostly without any time delay. Blood concentrations of morphine ranged from 50 to 1200 ng/g, and of 6-MAM from 1 to 80 ng/g. Codeine was detected in 96% of the subjects. In the majority of cases the forensic investigation indicated polydrug use, the most common additional findings being alcohol and benzodiazepines. However, in one-quarter of the cases other drug combinations were found. Previous abstinence from heroin and use of alcohol were identified as risk factors. For 6-MAM there was also a correlation with the presence of THC and benzodiazepines. Despite a high frequency of heart abnormalities (e.g. myocarditis and focal myocardial fibrosis), these conditions did not correlate with morphine or 6-MAM blood concentrations. Conclusions: We confirm that alcohol intake and loss of tolerance are risk factors for death from heroin use, whereas no connection to heart pathology was observed. Further, prospective, studies should focus on other possible risk factors.

Aim: To determine the total mortality related to the Stockholm methadone programme during the period 1988-2000, both the mortality related to the treatment and fatal methadone intoxications in the Stockholm area during the same period. Methods: The study comprised all individuals (n = 848) who had been in contact with the methadone programme in Stockholm during the study period, including those patients who had been discharged from treatment and those opiate users who had applied for but not received methadone treatment. All deaths that had been the subject of medico-legal examination at the Department of Forensic Medicine in Stockholm where methadone was found in blood or urine were also analysed during the same period. Results: The mortality was lower among those opiate users who remained in maintenance treatment and 91% of the deceased individuals had died due to natural causes, in most cases related to HIV or hepatitis C, acquired before admission to the programme. Those who had been discharged from methadone treatment had a 20 times higher risk of dying from unnatural causes compared to the patients who remained in treatment. The majority died due to heroin injections ('overdoses'). Eighty-nine cases of fatal methadone intoxication were found, but in only two of these cases was there evidence of leakage from maintenance treatment. Conclusion: The 'high threshold programme' is safe as long as the patients remain in treatment and there are very few deaths due to leakage from the programme. However, there is a high mortality among those discharged from the programme and only a minority of the heroin users in Stockholm had applied for treatment.

Aims To identify methadone-related deaths and determine the prevalence among youth and young adults in Sweden 2006-15. Design, Setting and Participants National retrospective registry study comparing data from all forensic autopsy examinations and toxicology cases involving methadone during 2006-15 in individuals aged 15-29 years with police records, previous pharmaceutical prescriptions and health-care episodes. Measurements Multinomial logistic regression. To assess the factors contributing to the deaths, we compared individuals with and without previous substance use treatment and opioid use-related diagnoses with regard to previous opioid agonist treatment (OAT), psychiatric care and previous pain medication. To assess the circumstances of deaths, we analyzed the presence of other drugs and other factors at time of death. Findings We identified 269 methadone-related deaths, and the rate increased during the study period. Seventy-two (27%) cases had not previously received substance use treatment, 112 (42%) had received treatment but had no opioid use-related diagnosis and 85 (32%) had received treatment and had an opioid use-related diagnosis. In total, only 10 individuals had been prescribed methadone during the year before death. Prescriptions of benzodiazepines (60%), antidepressants (62%) and opioids for pain (22%) the year before death were common. Most deaths occurred during sleep with a time lag from ingestion of methadone. Conclusion Prescription opioid- and methadone-related deaths increased in the group aged 15-29 years in Sweden between 2006 and 2015. Exposure to non-prescribed methadone and prescribed benzodiazepines, antidepressants and opioids for pain appears to be common in drug-related deaths in youth and young adults in Sweden.

Aim To investigate whether socio-economic status (SES) in childhood and school failure at 15 years of age predict illicit drug abuse in youth and young adulthood. Design setting and participantsRegister study in a Swedish national cohort born 1973-88 (n=1405763), followed from age 16 to 20-35 years. Cox regression analyses were used to calculate hazard ratios (HR) for any indication of drug abuse. Measurements Our outcomes were hospital admissions, death and criminality associated with illicit drug abuse. Data on socio-demographics, school grades and parental psychosocial problems were collected from censuses (1985 and 1990) and national registers. School failure was defined as having mean school grades from the final year in primary school lower than -1standard deviation and/or no grades in core subjects. Findings School failure was a strong predictor of illicit drug abuse with an HR of 5.87 (95% CI: 5.76-5.99) after adjustment for age and sex. Childhood SES was associated with illicit drug abuse later in life in a stepwise manner. The lowest stratum had a HR of 2.28 (95% CI: 2.20-2.37) compared with the highest stratum as the reference, when adjusted for other socio-demographic variables. In the fully adjusted model, the effect of SES was greatly attenuated to an HR of 1.23 (95% CI: 1.19-1.28) in the lowest SES category, while the effect of school failure remained high with an HR of 4.22 (95% CI: 4.13-4.31). Conclusions School failure and childhood socio-economic status predict illicit drug abuse independently in youth and young adults in Sweden.

Aim To investigate whether socio-economic status (SES) in childhood and school failure at 15 years of age predict illicit drug abuse in youth and young adulthood. Design setting and participantsRegister study in a Swedish national cohort born 1973-88 (n=1405763), followed from age 16 to 20-35 years. Cox regression analyses were used to calculate hazard ratios (HR) for any indication of drug abuse. Measurements Our outcomes were hospital admissions, death and criminality associated with illicit drug abuse. Data on socio-demographics, school grades and parental psychosocial problems were collected from censuses (1985 and 1990) and national registers. School failure was defined as having mean school grades from the final year in primary school lower than -1standard deviation and/or no grades in core subjects. Findings School failure was a strong predictor of illicit drug abuse with an HR of 5.87 (95% CI: 5.76-5.99) after adjustment for age and sex. Childhood SES was associated with illicit drug abuse later in life in a stepwise manner. The lowest stratum had a HR of 2.28 (95% CI: 2.20-2.37) compared with the highest stratum as the reference, when adjusted for other socio-demographic variables. In the fully adjusted model, the effect of SES was greatly attenuated to an HR of 1.23 (95% CI: 1.19-1.28) in the lowest SES category, while the effect of school failure remained high with an HR of 4.22 (95% CI: 4.13-4.31). Conclusions School failure and childhood socio-economic status predict illicit drug abuse independently in youth and young adults in Sweden.

AIMS:

To investigate the triggering effects of alcohol, illegal substances and major classes of prescribed psychotropic drugs on criminal violence.

DESIGN:

A case-crossover design, using each subject as its own control.

SETTING AND PARTICIPANTS:

A consecutive sample of 133 violent offenders was recruited from a forensic psychiatric evaluation unit and a national prison evaluation unit in Sweden during 2002-03.

MEASUREMENTS:

Offenders were assessed with structured interviews. Risk estimates were based on hazard periods of 24 hours. We used standard Mantel-Haenszel methods for statistical analyses.

FINDINGS:

A 13.2-fold increase of risk of violence [95% confidence interval (CI): 8.2-21.2] was found within 24 hours of alcohol consumption. This increase in violence risk was similar among individuals combining alcohol with benzodiazepines [Relative risk (RR) = 13.2, 95% CI: 4.9-35.3]. Use of benzodiazepines alone in regular doses (RR = 0.4, 95% CI: 0.2-0.5) or antidepressants [selective serotonin reuptake inhibitors (SSRIs) or tricyclics] (RR = 0.4, 95% CI: 0.3-0.8) was associated with a lowered risk for violence.

CONCLUSIONS:

This study confirmed that alcohol is a strong trigger of criminal violence. Benzodiazepines in combination with alcohol caused no further increase of violence risk. Benzodiazepines in regular doses and antidepressants may inhibit violence, but further studies are needed to verify causality. The case-crossover method can contribute to research on the proximal causes of criminal violence.

Background and Aims: Fathers' parental leave has been associated with decreased risks of alcohol-related hospitalizations and mortality. Whether this is attributable to the health protections of parental leave itself (through stress reduction or behavioral changes) or to selection into leave uptake remains unclear, given that fathers are more likely to use leave if they are in better health. Using the quasi-experimental variation of a reform incentivizing fathers' leave uptake (the 1995 Father's quota reform), this study aimed to assess whether fathers' parental leave influences alcohol-related morbidity and mortality.

Design: Quasi-experimental interrupted time series and instrumental variable analyses.

Setting: Sweden.

Participants: Fathers of singleton children born from January 1992 to December 1997 (n = 220 412).

Measurements: Exposure was indicated by the child's birthdate before or after the reform and used to instrument fathers' 2- and 8-year parental leave uptake. Outcomes included fathers' hospitalization rates for acute alcohol-related (intoxication; mental and behavioral disorders) and chronic alcohol-related diagnoses (cardiovascular, stomach and other diseases; liver diseases), as well as alcohol-related mortality, up to 2, 8 and 18 years after the first child's birthdate.

Findings: In interrupted time series analyses, fathers of children born after the reform exhibited immediate decreases in alcohol-related hospitalization rates up to 2 (incidence rate ratio [IRR] = 0.66, 95% confidence interval [CI] = 0.51–0.87), 8 (IRR = 0.74, 95% CI = 0.57–0.96) and 18 years after birth (IRR = 0.72, 95% CI = 0.54–0.96), particularly in acute alcohol-related hospitalization rates, compared with those with children born before. No changes were found for alcohol-related mortality. Instrumental variable results suggest that alcohol-related hospitalization decreases were driven by fathers' parental leave uptake (e.g. 2-year hospitalizations: IRR = 0.16, 95% CI = 0.03–0.84).

Conclusions: In Sweden, a father's parental leave eligibility and uptake may protect against alcohol-related morbidity.