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Intergenerational transmission of alcohol misuse: mediation and interaction by school performance in a Swedish birth cohort
  1. Ylva B Almquist,
  2. Lauren Bishop,
  3. Nina-Katri Gustafsson,
  4. Lisa Berg
  1. Department of Public Health Sciences, Stockholm University, Faculty of Social Sciences, Stockholm, Sweden
  1. Correspondence to Ylva B Almquist, Department of Public Health Sciences, Stockholm University, Faculty of Social Sciences, Stockholm, SE-106 91, Sweden; ylva.almquist{at}


Background Children whose parents misuse alcohol have increased risks of own alcohol misuse in adulthood. Though most attain lower school marks, some still perform well in school, which could be an indicator of resilience with protective potential against negative health outcomes. Accordingly, the aim of this study was to examine the processes of mediation and interaction by school performance regarding the intergenerational transmission of alcohol misuse.

Methods Data were drawn from a prospective Swedish cohort study of children born in 1953 (n=14 608). Associations between parental alcohol misuse (ages 0–19) and participants’ own alcohol misuse in adulthood (ages 20–63) were examined by means of Cox regression analysis. Four-way decomposition was used to explore mediation and interaction by school performance in grade 6 (age 13), grade 9 (age 16) and grade 12 (age 19).

Results Mediation and/or interaction by school performance accounted for a substantial proportion of the association between parental alcohol misuse and own alcohol misuse in adulthood (58% for performance in grade 6, 27% for grade 9 and 30% for grade 12). Moreover, interaction effects appeared to be more important for the outcome than mediation.

Conclusion Above-average school performance among children whose parents misused alcohol seems to reflect processes of resilience with the potential to break the intergenerational transmission of alcohol misuse. Four-way decomposition offers a viable approach to disentangle processes of interaction from mediation, representing a promising avenue for future longitudinal research.

  • Alcohol misuse
  • Intergenerational
  • School performance
  • Mediation
  • Interaction
  • Sweden

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors YBA designed the study, drafted the manuscript and conducted the analysis. LB contributed to the study design and revised the manuscript. NKG and LB participated in the interpretation of the results and revised the manuscript for important intellectual content. All authors approved the final version of the manuscript.

  • Funding This study was financially supported by the Swedish Research Council for Health, Working Life and Welfare (Grant No. 2016-07148 and Grant No. 2019-00058), and Systembolaget’s Alcohol Research Council (Grant No. FO 2019-0011).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical permission for the current study was obtained from the Swedish Ethical Review Authority (no. 2019-04376).

  • Data availability statement Owing to ethical regulations regarding the Stockholm Birth Cohort Multigenerational Study (SBC Multigen), access to the data is restricted. If there is interest in the unpublished data from this research article, a request can be made to the main author, who will forward it to the steering committee of the SBC Multigen.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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