Anna-Karin Danielsson

Alcohol use, heavy episodic drinking and subsequent problems among adolescents in 23 European countries: does the prevention paradox apply?

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.

Heavy Episodic Drinking in Early Adolescence: Gender-Specific Risk and Protective Factors

This longitudinal study examined possible gender differences regarding risk and protective factors for heavy episodic drinking among 1,222 seventh-grade students (aged 13) in the City of Stockholm, Sweden, with follow-up 2 years later. Logistic regression analyses showed that several factors predicted heavy episodic drinking. The strongest predictors for boys’ heavy episodic drinking in the ninth grade were heavy episodic drinking (odds ratio [OR] = 5.30) and smoking in the seventh grade (OR = 5.80). Drinking peers (OR = 2.47) and smoking (OR = 2.44) in the seventh grade showed the strongest association for girls. Furthermore, high parental monitoring and having a secure attachment to parents may have a protective effect when risk factors are present. Our results lend support to prevention initiatives to strengthen the parent–child relation and focus on adolescents’ ability to resist peer pressure and of limiting parental provision of alcohol. The studys limitations are noted.

Severity of alcohol dependence in the Swedish adult population: Association with consumption and social factors

The severity of alcohol dependence can be estimated by the number of DSM-IV criteria that are fulfilled for this disorder. This paper describes the proportions in a general population sample that meet different numbers of diagnostic criteria for alcohol dependence and their association with drinking and social background factors. Data came from a random, cross-sectional, self-report survey of adults from 12 Swedish communities. 28,800 persons, age 19-70, were surveyed through postal questionnaires. 14,706 questionnaires (51%) could be used for analysis. Alcohol dependence was assessed by questions relating to the seven DSM-IV criteria for alcohol dependence. Alcohol consumption and social background factors were examined in relation to alcohol dependence. A total of 73.8% of the general population fulfilled no criteria for alcohol dependence; 4.0% reported 3 or more criteria and qualified for the diagnosis of alcohol dependence. There were trends toward an increasing number of dependence criteria with increasing consumption levels and negative social background factors. The majority of people with alcohol dependence however did not drink at the highest consumption levels, did not live alone, and were not unemployed. Given the current definition of alcohol dependence the majority of people have few criteria fulfilled (3 or 4) and few social problems. This has important implications for treatment as dependence with low severity may require less treatment and less specialist involvement.

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.

Technology-based support via telephone or web: A systematic review of the effects on smoking, alcohol use and gambling

A systematic review of the literature on telephone or internet-based support for smoking, alcohol use or gambling was performed. Studies were included if they met the following criteria: The design being a randomized control trail (RCT), focused on effects of telephone or web based interventions, focused on pure telephone or internet-based self-help, provided information on alcohol or tobacco consumption, or gambling behavior, as an outcome, had a follow-up period of at least 3months, and included adults. Seventy-four relevant studies were found; 36 addressed the effect of internet interventions on alcohol consumption, 21 on smoking and 1 on gambling, 12 the effect of helplines on smoking, 2 on alcohol consumption, and 2 on gambling. Telephone helplines can have an effect on tobacco smoking, but there is no evidence of the effects for alcohol use or gambling. There are some positive findings regarding internet-based support for heavy alcohol use among U.S. college students. However, evidence on the effects of internet-based support for smoking, alcohol use or gambling are to a large extent inconsistent.

Cannabis use, depression and anxiety: A 3-year prospective population-based study.

BACKGROUND Whether or not cannabis use may increase the risk for depression and/or anxiety is not clear. For one thing, it has not been possible to draw a definitive conclusion regarding the direction of causality, i.e. whether cannabis use increases the risk for depression/anxiety or vice versa. This study aimed at examining possible associations between cannabis use, depression and anxiety, using all three measures as both exposure and outcome. METHODS Data were obtained from a longitudinal cohort study comprising 8598 Swedish men and women, aged 20-64, with a three-year-follow-up. RESULTS Adjusted for sex and age, cannabis use at baseline was associated with an increased relative risk (RR) for depression and anxiety at follow-up, with RR=1.22 [1.06-1.42 Cl 95%] for depression and RR=1.38 [1.26-1.50 Cl 95%] for anxiety. Adjusted for all confounders (alcohol and illicit drug use, education, family tension, place of upbringing), the associations were no longer statistically significant; RR=0.99 [0.82-1.17 Cl 95%] for depression and RR=1.09 [0.98-1.20 Cl 95%] for anxiety. Age-adjusted, reporting depression or anxiety at baseline increased the risk of cannabis onset at follow-up three years later; RR=1.62 [1.28-2.03 CI 95%] and RR=1.63 [1.28-2.08 CI 95%] respectively. However, adjusted for other illicit drug use the associations were no longer statistically significant. LIMITATIONS Lack of information on frequency of cannabis use and of age of initiation of use. CONCLUSIONS We found no longitudinal associations between cannabis use and incidence of depression/anxiety, or between depression/anxiety and later cannabis use onset.

Cannabis use among Swedish men in adolescence and the risk of adverse life course outcomes: results from a 20 year-follow-up study.

Abstract Aims To examine associations between cannabis use in adolescence (at age 18) and unemployment and social welfare assistance in adulthood (at age 40) among Swedish men. Design Longitudinal cohort study. Setting and Participants A total of 49 321 Swedish men born in 1949–51, who were conscripted to compulsory military service at 18–20 years of age. Measurements All 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. Findings Individuals 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). Conclusions Heavy 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.

Alcohol‐attributed disease burden in four Nordic countries: A comparison using the Global Burden of Disease, Injuries and Risk Factors 2013 study

Abstract Aims (1) To compare alcohol‐attributed disease burden in four Nordic countries 1990–2013, by overall disability‐adjusted life years (DALYs) and separated by premature mortality [years of life lost (YLL)] and health loss to non‐fatal conditions [years lived with disability (YLD)]; (2) to examine whether changes in alcohol consumption informs alcohol‐attributed disease burden; and (3) to compare the distribution of disease burden separated by causes. Design A comparative risk assessment approach. Setting Sweden, Norway, Denmark and Finland. Participants Male and female populations of each country. Measurements Age‐standardized DALYs, YLLs and YLDs per 100 000 with 95% uncertainty intervals (UIs). Findings In Finland, with the highest burden over the study period, overall alcohol‐attributed DALYs were 1616 per 100 000 in 2013, while in Norway, with the lowest burden, corresponding estimates were 634. DALYs in Denmark were 1246 and in Sweden 788. In Denmark and Finland, changes in consumption generally corresponded to changes in disease burden, but not to the same extent in Sweden and Norway. All countries had a similar disease pattern and the majority of DALYs were due to YLLs (62–76%), mainly from alcohol use disorder, cirrhosis, transport injuries, self‐harm and violence. YLDs from alcohol use disorder accounted for 41% and 49% of DALYs in Denmark and Finland compared to 63 and 64% in Norway and Sweden 2013, respectively. Conclusions Finland and Denmark has a higher alcohol‐attributed disease burden than Sweden and Norway in the period 1990–2013. Changes in consumption levels in general corresponded to changes in harm in Finland and Denmark, but not in Sweden and Norway for some years. All countries followed a similar pattern. The majority of disability‐adjusted life years were due to premature mortality. Alcohol use disorder by non‐fatal conditions accounted for a higher proportion of disability‐adjusted life years in Norway and Sweden, compared with Finland and Denmark.

Cannabis use and psychological distress: An 8-year prospective population-based study among Swedish men and women.

BACKGROUND Previous studies have reported positive associations between cannabis use and mental health problems. However, it has not been possible to draw a definitive conclusion regarding the causal direction between cannabis use and impaired mental health. This study aimed at examining possible associations between cannabis use and psychological distress (as measured by the General Health Questionnaire, GHQ-12) in men and women respectively, using both measures as both exposure and outcome. METHODS Data were obtained from a cohort study (the Stockholm Public Health Cohort) with an 8-year follow-up in the general population in Stockholm County, Sweden. The study sample comprised 19,327 men and women, aged 18-84years, who answered surveys in 2002 and 2010. RESULTS Cannabis use was associated with increased odds ratios (OR) for psychological distress in women at 8-year follow-up, with OR=1.37 [1.1-1.7, 95% CI], but not in men; OR=1.14 [0.9-1.5, 95% CI]. In women, this association remained when adjusted for potential confounders (tobacco smoking, alcohol consumption, socioeconomic position (SEP) and unemployment); OR=1.27 [1.0-1.6, 95% CI]. Moreover, women reporting psychological distress at baseline had an increased risk of cannabis use at follow-up; OR=1.40 [1.1-1.8 95% CI]. However, this association was no longer statistically significant when adjustments were made for baseline cannabis use, OR=1.10 [0.8-1.5, 95% CI]. CONCLUSIONS This study revealed that, in women, cannabis use was associated with an increased risk of psychological distress eight years later. Optimal interventions to identify these women seem warranted.

Alcohol–attributed disease burden and alcohol policies in the BRICS–countries during the years 1990–2013

Background We aimed to assess alcohol consumption and alcohol–attributed disease burden by DALYs (disability adjusted life years) in the BRICS countries (Brazil, Russia, India, China and South Africa) between 1990 and 2013, and explore to what extent these countries have implemented evidence–based alcohol policies during the same time period. Methods A comparative risk assessment approach and literature review, within a setting of the BRICS countries. Participants were the total populations (males and females combined) of each country. Levels of alcohol consumption, age–standardized alcohol–attributable DALYs per 100 000 and alcohol policy documents were measured. Results The alcohol–attributed disease burden mirrors level of consumption in Brazil, Russia and India, to some extent in China, but not in South Africa. Between the years 1990–2013 DALYs per 100 000 decreased in Brazil (from 2124 to 1902), China (from 1719 to 1250) and South Africa (from 2926 to 2662). An increase was observed in Russia (from 4015 to 4719) and India (from 1574 to 1722). Policies were implemented in all of the BRICS countries and the most common were tax increases, drink–driving measures and restrictions on advertisement. Conclusions There was an overall decrease in alcohol–related DALYs in Brazil, China and South Africa, while an overall increase was observed in Russia and India. Most notably is the change in DALYs in Russia, where a distinct increase from 1990–2005 was followed by a steady decrease from 2005–2013. Even if assessment of causality cannot be done, policy changes were generally followed by changes in alcohol–attributed disease burden. This highlights the importance of more detailed research on this topic.