Level of education, labor-market marginalization, and alcohol-related mortality: a cohort study of Swedish men

Social inequalities in alcohol-related morbidity and mortality are well-established, but the reasons are not fully understood. One possible reason is labor market difficulties stemming from lower educational qualifications, leading to alcohol-related harm. The present study aims to investigate the extent to which differences in labour market marginalization (LMM) (including differences in timing and type of LMM) explain educational differences in alcohol-related mortality, and whether this is independent of pre-labor market selection factors. A register-based cohort study included all men born between 1949 and 1951 who underwent Swedish military conscription in 1969/70 and were alive at age 55 (n = 45 168). Nationwide registers provided data on education level and alcohol-related mortality. LMM was measured by unemployment, sickness absence, and disability pension. Pre-labor market factors included health behaviors, cognitive ability, and health from conscription exams. Cox regression analyses were used to obtain hazard ratios (HR) with 95% confidence intervals (CI). The explanatory role of LMM was assessed by percentage attenuation of HR. Men with primary and secondary education had higher risks of alcohol-related mortality (HR: 4.23, HR: 2.92) compared to those with university education. LMM explained a substantial part of these differences (42% and 37%). However, LMM's effect was smaller (18% and 7%) when pre-labor market factors were considered. Men with lower education levels in Sweden are more likely to die from alcohol-related causes compared to higher educated men. While differences in LMM contribute to these disparities, its explanatory power diminishes when considering pre-labor market factors, suggesting potential selection effects.