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No effects of increased alcohol availability during adolescence on alcohol-related morbidity and mortality during four decades: a natural experiment
  1. Emelie Thern1,
  2. Ting Jia1,
  3. Mikaela Willmer1,2,
  4. Jeroen de Munter1,
  5. Thor Norström3,
  6. Mats Ramstedt4,
  7. George Davey Smith5,6,
  8. Per Tynelius1,7,
  9. Finn Rasmussen1,7
  1. 1Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
  2. 2Department of Health and Caring Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden
  3. 3Swedish Institute for Social Research, Stockholm University, Stockholm, Sweden
  4. 4The Swedish Council for Information on Alcohol and Other Drugs, Stockholm, Sweden
  5. 5MRC Integrative Epidemiology Unit (IEU), University of Bristol, Bristol, UK
  6. 6Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
  7. 7Centre for Epidemiology and Community Medicine, Stockholm County Council, Health Care Services, Stockholm, Sweden
  1. Correspondence to Emelie Thern, Department of Public Health Sciences, Karolinska Institutet, Stockholm 171 77, Sweden; emelie.thern{at}


Background A strict high legal age limit for alcohol purchases decreases adolescents’ access to alcohol, but little is known about long-term health effects. The aim was to estimate the effect of increased alcohol availability during adolescence on alcohol-related morbidity and mortality.

Methods A nationwide register-based study using data from a natural experiment setting. In two regions of Sweden, strong beer (4.5%–5.6% alcohol by volume) became temporarily available for purchase in grocery stores for individuals 16 years or older (instead of 21) in 1967/1968. The intervention group was defined as all individuals living in the intervention area when they were 14–20 years old (n=72 110). The remaining Swedish counties excluding bordering counties, without the policy change, were used as the control group (n=456 224). The outcomes of alcohol-related morbidity and mortality were collected from the Hospital Discharge Register and Cause of Death Register, in which average follow-up times were 38 years and 41 years, respectively. HRs with 95% CIs were obtained by Cox regression analysis.

Results In the fully adjusted model, no clear evidence of an association between increased alcohol availability during adolescence and alcohol-related morbidity (HR: 0.99, 95% CI 0.96 to 1.02) or mortality (HR: 1.02, 95% CI 0.95 to 1.10) was found.

Conclusion The initial elevated risk of alcohol-related morbidity and mortality later in life among adolescents exposed to increased access to strong beer in Sweden vanished when a regional measure population density of locality was included in the model, which is important to consider in future research.

  • natural experiment
  • alcohol policy
  • adolescents
  • alcohol-related morbidity
  • alcohol-related mortality
  • Sweden

Statistics from


  • Handling editor James Dunn.

  • Contributors FR conceived the study in collaboration with TN, MR and GDS. FR and JdM worked with the acquisition of the data. TJ performed the initial analyses in collaboration with FR, JdM and ET. MW drafted the initial version of the manuscript. PT and ET revised the initial analyses, and ET revised the manuscript critically for important intellectual content. All authors provided substantial editing to the final manuscript.

  • Funding This work was supported by grants to FR from the Swedish Research Council for Health, Working Life and Welfare (FORTE) number 2012-0989 and from Karolinska Institute’s funding for PhD students (KID) number 2012-126 (no 3-847/2013). GDS’s work was supported by the Medical Research Council Integrative Epidemiology Unit at the University of Bristol (MC_UU_12013/1, MC_UU_12013/9).

  • Competing interests None declared.

  • Ethics approval Stockholm Regional Ethical Review Board.

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

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