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Journal of Public Health

Illicit drug abuse in second-generation immigrants: a register study in a national cohort of Swedish
residents
Anders Hjern
Scand J Public Health 2004 32: 40
DOI: 10.1080/14034940310001677
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ORIGINAL ARTICLE

Illicit drug abuse in second-generation immigrants:

a register study in a national cohort of Swedish
residents
Anders Hjern
Centre for Epidemiology, National Board of Health and Welfare, Stockholm, Sweden, and Department of Children and Womens
Health, Uppsala University, Sweden

Scand J Public Health 2004; 32: 4046

Aims: This study investigates ethnic and socioeconomic risk factors for hospital admissions related to illicit drug abuse in
second-generation immigrants in Sweden. Method: Cox analyses of proportional hazards were used to estimate the relative
risk of sociodemographic covariates in analyses of register data on hospital admissions because of illicit drug abuse during
1990 99. The study population was a national cohort of 1.25 million residents (aged 10 30 years). Results: Secondgeneration immigrants had two- to three fold higher age and sex-adjusted relative risks (RRs) for hospital admissions
because of illicit drug use compared with the Swedish majority population with a limited variation between different ethnic
groups. The RRs decreased greatly after the model was adjusted for socioeconomic indicators of the childhood household.
Intercountry adoptees had the highest risk for hospital admission related to illicit drug abuse of all study groups after
adjustment for sociodemographic variables (RR 2.8). Conclusions: Second-generation immigrants are at particular risk for
illicit drug abuse in Sweden. Adverse socioeconomic living conditions are very important in explaining this high risk.
Key words: addiction, adoption, drug abuse, ethnicity, immigrants, inequity, migration, socioeconomic, substance abuse,
youth.
Anders Hjern, Centre for Epidemiology, Swedish National Board of Health and Welfare, SE-106 30 Stockholm, Sweden. Fax:
46-8-55 55 33 27, e-mail: anders.hjern@sos.se

INTRODUCTION
The last four decades have seen the development of
illicit drug use as an important public health concern
in Sweden. In response Sweden has implemented a
restrictive policy against illicit drugs with widespread
support of the general Swedish population. Young and
adult users of all illicit drugs, including cannabis, are
penalized and can be taken into coercive care if certain
legal requirements are met (1). Over the same time period
Sweden has developed into a multicultural society with
the settlement of migrant workers and refugees from
many parts of the world, with the result that approximately 15% of the children in Sweden were raised by
one or two foreign-born parents during the 1990s (2).
Since the mid-1960s the adoption of foreign-born
children by Swedish-born couples has been another
addition to Swedish society, accounting for approximately 1.5% of the cohorts born since 1970 (3).
The European School Survey on Alcohol and other
Drugs (ESPAD) of 15- to 16-year-old students in
Scand J Public Health 32

different countries in Europe in 1999 demonstrated

comparatively low rates in lifetime experience of use
of illicit drugs and cannabis in Sweden (4). Concerns
have been raised that immigration may cause increased
use of illicit drugs in Swedish society with the settlement of ethnic groups with a more liberal use of and a
more permissive attitude towards illicit drugs. From
another perspective, illicit drug abuse in immigrants
has been discussed in the context of the adverse living
conditions and high unemployment rates in this population in Sweden during the 1990s (2). In this study
we used the unique possibilities of Swedish national
health databases to investigate these hypotheses by
comparing rates of hospital admissions because of
illicit drug use in second-generation immigrants with
the majority population. Are second-generation immigrants and intercountry adoptees more often admitted
to hospitals because of illicit drug use? If so, to what
extent is this explained by adverse living conditions?
Do admission rates vary between different ethnic
minorities?
# Taylor & Francis 2004. ISSN 1403-4948
DOI: 10.1080/14034940310001677

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Illicit drug abuse in second-generation immigrants

MATERIALS AND METHODS
Study population
This study was based on data from the national
registers held by the Swedish National Board of Health
and Welfare and Statistics Sweden linked through
each individuals unique personal identification number.
The study population consisted of the 1.25 million children born 1968 79 who were recorded as living in family
households in the 1985 census. The study period started
in November 1990, in conjunction with the 1990 census,
and lasted until December 1999. Residents in the 1985
census who were no longer recorded to be Swedish
residents in 1990 were excluded from the study population. The study population thus consisted of residents who had lived in Sweden for at least five years.
Categories of study subjects
Information on the country of birth of the study
population and the adults who lived in their households in 1985 was obtained from the Swedish Population and Housing Census of 1985. This information
was used for categorization of the study group:
. Swedish majority population: Child, as well as all
adults in the household, was born in Sweden.
. Intercountry adoptees: Children who were born
outside Europe, had no record of biological parents
in the Swedish Parent Register and lived in a household where all adults were Swedish-born. The continents of birth of the intercountry adoptees were in
73.0% Asia (mainly south Korea, India, and Sri
Lanka), in 22.7% Latin America (most commonly
Colombia and Chile) and in 4% Africa.
. Second-generation immigrants. Children in households where at least one adult in the household was
foreign-born. This category was further classified
into six geographically defined groups according to
the country of birth of the adults in the household
in the census of 1985 (Table I) as a proxy for
ethnicity. When the adults in the household had
diverse ethnicity the child was classified according
to the oldest female, and if there were no female
adults in the household, the oldest male in the
household. If at least one, but not all, adults in the
households were born in Sweden, the youth was
classified in an intermediate, mixed, group.
Sociodemographic variables
Sociodemographic variables were created by linkage
to the following registers:
. Swedish Population and Housing Census 1985: year
of birth, sex, socioeconomic status (SES) of the
household, and housing situation. SES was defined

41

Table I. Country of birth of the adults in the households

of the study population, 1985 census
n

Country of birth
Sweden

Sweden
Sweden: parents of
intercountry adoptees

Finland

Finland

Western

Norway
Denmark
Iceland
Germany
Great Britain
USA and Canada
Other Western

7,103
8,330
524
8,466
1,973
1,379
3,678

Eastern Europe

Poland
Hungary
Other Eastern Europe

6,464
3,367
5,441

Southern Europe

Yugoslavia
Greece
Italy
Other Southern Europe

Middle East

Turkey
Iran
Iraq
Other Middle East

5,229
934
537
2,293

Non-European

Far East
South Asia
Chile
Other Latin America
Africa

2,772
1,176
3,186
2,417
2,259

All

1313,925
14,480
56,076

12,895
3,831
1,560
2,040

1,472,335

according to a classification used by Statistics Sweden,

which is based on occupation but also takes educational level of occupation, type of production, and
position at work of the head of the household into
account (5).
. Swedish Population and Housing Census 1990:
geographic location of the home (residency).
. Total Enumeration Income Survey for 1990: Social
welfare benefits received in 1990 by the head of the
household in the census of 1985.
The non-European immigrant (Middle East and
other non-European) households had the least satisfactory socioeconomic situation, with the lowest SES,
the highest proportion of social welfare recipients
and the least satisfactory housing situation (Table II).
The Finnish and other European households had
a socioeconomic situation that was better than the
non-Europeans, but less satisfactory than the Swedish
majority population. The intercountry adoptees stand
out with a female preponderance of 62% among the
adoptees themselves and the most privileged socioeconomic situation of all households. Living in one-adult
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42
A Hjern

Scand J Public Health 32

Table II.

Percentage of sociodemographic indicators by ethnicity

Sweden
n~1,056,156

Intercountry
adoptees
n~11,856

Finland
n~35,534

Western
n~9,562

Eastern
Europe
n~8,258

Southern
Europe
n~14,448

Middle
East
n~10,160

Other
non-European
n~9986

Mixed
n~97491

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Sex

Male
Female

47.0
53.0

37.6
62.4

49.4
50.6

49.5
50.5

50.8
49.2

51.2
48.8

51.5
48.6

50.9
49.1

52.3
47.7

SES:

Unclassified
Manual labour
Skilled labour
White collar I
White collar II
White collar III

24.4
28.3
6.7
18.0
16.4
6.1

18.2
13.7
4.8
21.2
27.1
15.0

25.8
45.9
10.5
8.7
7.1
1.9

36.4
31.2
6.9
10.2
10.6
4.7

38.4
22.4
6.3
12.8
11.2
8.8

34.6
48.4
8.4
3.9
3.9
0.8

69.9
20.2
4.8
1.2
2.7
1.2

49.7
29.6
7.2
4.4
7.1
2.0

27.4
28.6
6.9
15.6
14.8
6.7

Received social welfare 1990

Yes

4.8

2.0

12.0

12.3

12.5

7.1

35.1

27.6

6.4

Housing

Unclassified
Rents Apartment
Owns apartment
Own house

0.1
17.0
5.9
72.7

0.0
8.5
5.4
86.1

0.1
46.3
12.8
40.7

0.2
41.5
9.6
48.8

0.2
46.4
12.8
40.7

0.1
67.9
8.6
23.4

0.1
89.9
5.1
4.8

0.2
80.0
8.7
11.

0.1
25.1
8.9
66.0

Single adult household in 1985

Yes

9.3

5.9

18.0

25.4

24.4

10.6

5.6

20.2

2.1

Residency

Metropolitan area
Smaller city
Rural

25.9
52.4
21.6

30.0
53.6
16.4

38.2
49.1
12.7

38.8
44.6
17.3

61.1
34.3
4.5

55.7
40.2
4.1

54.4
44.0
1.6

64.8
32.2
3.1

37.0
46.7
16.3

Illicit drug abuse in second-generation immigrants

households was most common among immigrant households from Eastern and Western Europe (24 25%)
and least common in immigrant households from the
Middle East (6%).
Statistical methods
The outcome variable of hospital admission related
to illicit drug abuse was obtained through individual
record linkage to the Swedish Hospital Discharge
Register from November 1990 to December 1999. Illicit
drug abuse was defined as a main or contributory
diagnosis of 292, 304, 965.0, 968.5, 969.6 RR 969.7
(ICD-9) in 1990 96 and F11, F12, F14, F16 or F19
(ICD-10) in 1997 99. Data from 1997 99, with the
more elaborate classification of ICD-10, was used in
an analysis of ethnic patterns of abuse of specific
drugs.
Multivariate analyses were conducted by Cox regressions of proportional hazards of time to event with
illicit drug abuse (as defined above) as the outcome
variable (at least one hospital discharge/none). Time
in the study was calculated with date of hospital
admission, date of death from the National Cause
of Death Register and date of emigration. A method
developed by Ringback et al. (6) to minimize bias in
population records of unrecorded migration in foreignborn residents was used so that a year without any
household income from labour, benefits, or pension
was considered an indicator of emigration. Birth year
was entered as a continuous variable in the regression
models since the outcome variable was found to
decrease in a linear fashion with year of birth. Other
sociodemographic variables were entered as category
variables (using dummy variables) into the models.
The SPSS software package, version 10.0, was used in
all statistical analyses.

RESULTS
The cumulated incidence of hospital admissions related
to illicit drug abuse use was 0.55% for men and 0.32%
for women (Table III). African men had the highest
cumulated incidence (2.94%) and Middle Eastern women
the lowest (0.10%).
Main diagnosis of illicit drug abuse at the last hospital discharge during 1997 99 was analysed in relation
to ethnicity. A mixed diagnosis (ICD-10: F19) was
most common in the Swedish majority population, the
intercountry adoptees, the Western Europeans and the
mixed group (45 63%), while abuse of opiates was
the most common diagnosis in the second immigrant
study groups with heritage from Finland, Eastern and
Southern Europe, the Middle East, and other nonEuropean countries (39 60%). Cannabis abuse was

43

Table III. Rates of hospital admission related to illicit

drug abuse by ethnicity
Parental country
of birth

Cases Men % Women %

Sweden
1056225 3906
Intercountry adoptees
11787
80
Mixed
97491 611
Second-generation
immigrants
Finland
35534 376
Eastern Europe
8258 109
Western Europe
9562
81
Southern Europe
14488 134
Middle East
10160
85
Latin American
5559
67
African
1464
25
Asian
2963
7
All
1253491 5481

0.46
0.79
0.78

0.28
0.61
0.46

1.44
1.93
1.01
1.40
1.53
1.75
2.94
0.26
0.55

0.68
0.69
0.68
0.42
0.10
0.65
0.42
0.21
0.32

most frequently reported from second-generation immigrants from Finland, Western Europe, and non-European
countries outside the Middle East (20 28%), while
diagnoses of cocaine and hallucinogens were more
uncommon in all ethnic groups (1 7%).
A multivariate model of proportional hazard
(Table IV; Model 2) demonstrated that the risk of
hospital admissions related to illicit drug abuse was
higher in metropolitan areas compared with rural areas
and smaller cities. It was also associated with low SES
(RRs 1.4 and 1.6 respectively in manual and skilled
workers, RR 1.3 in white collar I compared with white
collar III), having received social welfare during 1990
(RR 3.4), single adult households in 1985 (RR 1.5),
and living in an apartment (rented apartment RR 2.2
compared with living in a house).
A higher age- and sex-adjusted risk for hospital
admissions related to illicit drug use was demonstrated
in all second-generation immigrants compared with
the Swedish majority population, with RRs of 2.0 3.6
(Table V; Model 1), while youth in households with
one Swedish-born and one foreign-born parent had an
RR of 1.7. When the multivariate analysis was adjusted
to socioeconomic variables (Table V; Model 2) the
difference between the second-generation immigrants
and the Swedish majority population disappeared in
the Middle East and the non-European study group
and decreased greatly in the European study groups
(RRs 1.4 1.7) , while the risk of youth in households
with one Swedish-born and one foreign-born parent
changed little (RR 1.5).
Second-generation immigrants who settled in Sweden
during adolescence (13 17 years of age) had a lower
risk (RR 0.6 95% C.I. 0.4 0.9) for illicit drug abuse
than second-generation immigrants born in Sweden
in a multivariate analysis in the second-generation
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44

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Table IV. Cox regression models of sociodemographic determinants with hospital admission because of illicit drug abuse
as the outcome variable
Model 1 RR (95%C.I.)

Model 2 RR (95%C.I.)

Sex
Male
Female

1.8 (1.7 1.9)

1

1.8 (1.7 1.9)

1

SES of the household

Unclassified
Manual workers
Skilled workers
White collar I
White collar II
White collar III

2.2
1.7
1.9
1.4
1.0
1

1.5
1.4
1.6
1.3
1.0
1

Received social welfare 1990

Yes
No

5.9 (5.5 6.3)

1

3.4 (3.2 3.7)

1

Housing
Unclassified
Rents apartment
Owns apartment
Own house

4.0 (2.3 7.0)

4.1 (3.9 4.3)
2.5 (2.3 2.7)
1

2.2 (1.2 3.9)

2.4 (2.2 2.5)
1.8 (1.7 2.0)
1

Single adult households

Yes
No

3.1 (2.9 3.3)

1

1.5 (1.4 1.6)

1

Residency
Stockholm, Malmo, Gothenburg
Other city
Rural

1
0.6 (0.6 0.6)
0.4 (0.4 0.4)

1
0.7 (0.6 0.7)
0.5 (0.4 0.5)

(1.9 2.5)
(1.5 2.0)
(1.7 2.3)
(1.2 1.6)
(0.8 1.1)

(1.3 1.7)
(1.2 1.6)
(1.3 1.9)
(1.1 1.5)
(0.8 1.2)

Notes: Model 1 presents estimates for each variable after adjustment to year of birth only; Model 2 is a multivariate model
that includes all variables in the table as well as year of birth.
Table V. Cox regression models of ethnicity with hospital
admission because of illicit drug abuse as the outcome
variable

Sweden
Intercountry adoptees
Mixed
Second-generation
immigrants
Finland
Eastern Europe
Western Europe
Southern Europe
Middle East
Non-European

Model 1 RR

Model 2 RR

1
2.0 (1.6 2.5)
1.7 (1.5 1.8)

1
2.8 (2.2 3.4)
1.5 (1.4 1.6)

2.9
3.6
2.3
2.5
2.3
2.7

1.7
1.6
1.5
1.4
0.9
0.8

(2.6 3.2)
(3.0 4.4)
(1.8 2.9)
(2.1 3.0)
(1.9 2.8)
(2.2 3.3)

(1.5 1.9)
(1.4 2.0)
(1.1 1.8)
(1.2 1.7)
(0.7 1.1)
(0.6 1.1)

Notes: Model 1 is adjusted for year of birth and sex; Model

2 is adjusted for year of birth, sex, SES, single adult
household, housing, social welfare benefits and residency.

immigrants that included the sociodemographic confounders of Model 2 in Table V. Second-generation

immigrants who settled before adolescence (0 6
and 7 12 years) had a similar adjusted risk (RR 1.0
1.1) to that of second-generation immigrants born in
Sweden. Young men in the second-generation study

groups with heritage in the Middle East and other

non-European countries had a significantly higher risk
of illicit drug abuse than young women in these study
groups in comparison with the rest of the study
population (pv0.001). In an analysis of women only,
with the variables in Model 2 in Table V, the RR for
Middle Eastern women was 0.2 and for non-European
women 0.6 compared with the Swedish majority
population.
The intercountry adoptees had the highest risk
(RR 2.8) for hospital admission related to illicit
drug abuse of all study groups after adjustment for
socioeconomic and demographic variables (Table V:
Model 2).

DISCUSSION
This study demonstrates that illicit drug abuse is of
serious concern in second-generation immigrants in
Sweden with age- and sex-adjusted risk ratios ranging
from 2.0 to 3.6 in hospital admissions related to illicit
drug abuse in comparison with the majority population.
When the analysis is adjusted to socioeconomic indicators the risk ratios decrease greatly indicating that

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Illicit drug abuse in second-generation immigrants

adverse living conditions are very important in
explaining illicit drug abuse in second-generation
immigrants in Sweden. A similar high risk of illicit
drug abuse has been described in immigrants in The
Netherlands (7), in contrast with the comparatively
low risk for illicit drug abuse reported in Asian immigrants in Australia (8).
It should be remembered that the socioeconomic
indicators in this study are crude proxies that reflect
the situation of the childhood household in 1985
and 1990 rather than the socioeconomic situation of
the youth during the study period. Since the socioeconomic situation of immigrant populations in Sweden
worsened considerably during the 1990s, in connection
with rising unemployment rates among immigrants,
these proxies can be expected to have underestimated
the true effect of the socioeconomic context (2). One
should also bear in mind that the geographical and
housing indicators in this study are crude, and do not
adjust for the neighbourhood effects of segregated
housing within larger geographical areas. Recent reports
have demonstrated an increasing tendency for minority
population to cluster in low-status housing areas in
larger and medium-sized cities (2). Further research,
with a small-area approach, is needed to clarify the
role of neighbourhood effects for illicit drug abuse
in immigrant populations in Sweden. Associations of
socioeconomic variables with substance abuse always
have to be interpreted carefully. Poverty may increase
the risk for addiction but addiction also has very
significant socioeconomic effects on the household of
the addict. It seems reasonable, however, that the main
association between the socioeconomic conditions of
the childhood household and illicit drug abuse should
be interpreted as a causal one since the socioeconomic
indicators 1985 and 1990 could be expected to be quite
independent of illicit drug abuse after 1990 in this
young cohort.
There were no specific ethnic patterns of illicit drug
abuse in this study, but there was a tendency for opiate
abuse to be more common in all second-generation
immigrants with a non-Western European heritage,
and to a certain degree this was true also for cannabis
abuse. Since the categories of ethnicity and illicit drugs
were indeed crude and based on comparatively few
cases, no definite conclusions should be drawn from
this. One may, however, speculate that this pattern is
better explained by subcultures that include secondgeneration immigrants of diverse ethnicity than by
culture-specific habits (9, 10). The finding that secondgeneration immigrants who settle in Sweden as adolescents have a lower risk of illicit drug abuse is another
strong indication that illicit drug abuse in secondgeneration immigrants has more to do with the minority position in Sweden than with habits and attitudes

45

from the parental country of origin. A similar low risk

of substance abuse has been reported among foreignborn compared with US-born Hispanic immigrants in
the USA (11), suggesting that migrants exposure to
illicit drugs may increase with integration into the
new society. The finding that young men with a nonEuropean heritage are more at risk than young women
in these minority groups should probably, however,
be explained in an ethnic context mediated by cultural
patterns guiding gender-specific behaviour during
adolescence (10).
The intercountry adoptees stand out as a high-risk
group for illicit drug abuse. Addiction is but one of a
range of problems related to social maladjustment and
psychiatric illness that are more common in intercountry adoptees (12). There are a number of different
factors that may be helpful in explaining this vulnerability. One may speculate that parental addiction may
be a reason for giving up a child for adoption, indicating that there may be a selection of genetically vulnerable individuals among the adoptees. Bohman found
such a mechanism to be important in understanding
the increased risk of alcoholism of adoptees born in
Sweden in the 1950s (13). Furthermore, the negative
long-term effects of malnutrition, deprivation, and
orphanage care have to be considered (14). The possibility that growing up with a physical appearance
that differs from the norm may increase the risk of
being attracted to destructive subcultures that include
illicit drug use and abuse also has to be accounted
for (15).
The size of the population of immigrants tends to
be overestimated in Swedish national statistics because
emigration from Sweden is less often reported to Swedish
authorities by foreign-born residents compared with
Swedish-born residents. This tendency is particularly
important for residents born in countries outside
north-eastern Europe (6). In this study we tried to
minimize the effect of this problem by using years of
individuals with no income in the household as an
indicator of emigration as suggested by Ringback et al.
(6). It is still possible, however, that a certain bias is
present, and that the true risk for these immigrants
is even higher.
Being admitted to a hospital is an indirect indicator
of illicit drug abuse. Many addicts of illicit drugs,
particularly cannabis, are probably never admitted to
hospital because of this habit. This makes our indicator very sensitive to patterns of access and use of
care. A recent study has demonstrated that immigrants in Sweden have access to care in a manner
similar to that of the majority population, but all the
same it is possible that certain minority groups tend to
refrain from seeking care for addictive problems thus
causing an underestimation of the magnitude of the
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46

A Hjern

risk (16). Another possible source of error is biased

use of a potentially stigmatizing diagnosis such as
illicit drug abuse by Swedish physicians. The fact that
most hospital discharges because of illicit drug abuse
in Sweden are made from special clinics devoted
entirely to treatment of drug addicts, however, makes
this a less likely source of error.
The finding that second-generation immigrants are
at particular risk for illicit drug abuse has important
implications for prevention and treatment of addiction. Immigrant parents and immigrant-dense neighbourhoods are important targets for prevention of
illicit drug abuse. Preventive strategies that include
collaboration with minority organizations and use of
minority health professionals should be given a high
priority. Information campaigns need to use channels
and languages that are effective in reaching minority
populations. There is also a need to develop treatment
strategies that are sensitive to a diverse cultural background to improve recruitment and efficacy in treatment of immigrant patients (17).

4.

5.
6.

7.

8.

9.
10.
11.

Conclusion
Second-generation immigrants and intercountry adoptees are at particular risk for illicit drug abuse in Sweden
and should be of particular concern for prevention
and development of treatment strategies. Adverse
socioeconomic living conditions are very important in
explaining this high risk in second-generation immigrants.

12.
13.
14.

ACKNOWLEDGEMENTS
The author would like to thank professor Bengt
Haglund for valuable advice on the presentation of
the statistical analysis.

15.

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16.

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