Unemployment and Early Cause-Specific Mortality: A Study Based on the Swedish Twin Registry

Margaretha Voss, PhD, MPH; Lotta Nylén, MPH; Birgitta Floderus, PhD; Finn Diderichsen, MD, PhD; Paul D. Terry, PhD

Am J Public Health. 2004;94(12)

Conclusions

Unemployment is associated with an increased risk of early death, especially from suicide and external undetermined cause. Our results suggest that characteristics of the individual prior to unemployment cannot explain this increased risk. They further indicate that the association between unemployment and mortality may be strengthened by social factors, personality characteristics, and health-related factors. An increased risk of early mortality related to unemployment should be recognized.

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Acknowledgments

M. Voss and L. Nylén contributed substantially in the conceptualization and design of the study and had main responsibility for the analyses and the reporting. B. Floderus initiated the study and supervised all aspects of its implementation. F. Diderichsen contributed to conceptualization of ideas. P.D. Terry assisted with the analyses. All authors helped to interpret the findings and reviewed drafts of the article.

Funding information

Support for this study was provided by the Karolinska Institutet and the National Institute for Working Life, Stockholm, Sweden.

Reprint Address

Margaretha Voss, PhD, MPH, Department of Clinical Neuroscience, Section of Personal Injury Prevention, Karolinska Institutet, Box 12718, SE-112 94 Stockholm, Sweden. E-mail: margaretha.voss@cns.ki.se.

Cite this: Unemployment and Early Cause-Specific Mortality: A Study Based on the Swedish Twin Registry - Medscape - Dec 01, 2004.

Table 1. Prevalence (%) of Social, Behavioral, Health, and Personality Characteristics Among Women and Men, by Unemployment History: Sweden, 1973
Characteristic	Women					Men
	History of Unemployment			Age-Adjusted Difference^a (95% CI)		History of Unemployment			Age-Adjusted Difference^a (95% CI)
	Never	Short-Term^b	Long-Term^c	Short-Term	Long-Term	Never	Short-Term^b	Long-Term^c	Short-Term	Long-Term
Marital status
Unmarried	27	41	38	-4 (-10, 1)	5 (-0.6, 10)	32	67	53	14 (6, 22)	15 (10, 21)
Divorced	5	6	10	--^d	7 (3, 11)	3	3	6	--^d	5 (1, 8)
Widow/widower	1	1	0	--	--	0	0	0	--	--
No children	38	56	40	-1 (-10, 8)	-6 (-11, 1)	41	71	62	11 (2, 19)	15 (10, 21)
Education: elementary school	41	35	54	-0.6 (-11, 9)	16 (9, 22)	45	41	41	2 (-7, 10)	-2 (0, -4)
Smoking status
Current smoker	40	61	63	21 (11, 31)	22 (16, 29)	52	61	66	8 (-0.7, 17)	12 (6, 18)
Former smoker	13	14	12	-2 (-7, 3)	-0.4 (-5, 4)	14	10	13	0.1 (-7, 7)	-0.2 (-4, 4)
Alcohol consumption
None	43	43	46	4 (-6, 13)	4 (-3, 12)	22	25	26	5 (-5, 14)	4 (-2, 10)
>250 g/mo	15	28	18	10 (0.5, 18)	2 (-4, 7)	46	52	50	4 (-7, 15)	4 (-3, 11)
Use of sedatives
Sleeping pills occasionally/regularly	6	9	14	6 (-1, 14)	9 (4, 14)	3	6	10	5 (-1, 10)	9 (4, 13)
Sleeping pills regularly	1	3	7	2 (-2, 6)	6 (3, 10)	1	3	4	--	4 (1, 7)
Tranquilizers occasionally/regularly	14	16	27	7 (-2, 16)	17 (11, 23)	7	13	16	9 (2, 16)	11 (7, 16)
Tranquilizers regularly	4	8	10	7 (-0.3, 14)	8 (4, 13)	2	7	6	5 (1, 10)	6 (3, 10)
Stressful life situation	15	13	18	-1 (-8, 6)	5 (-0.2, 10)	19	17	20	3 (-5, 10)	2 (-3, 6)
Shift work	11	20	25	9 (0.4, 17)	14 (9, 20)	23	27	29	4 (-3, 11)	7 (1, 12)
Personality
Extrovert	51	57	47	13 (5, 21)	-4 (-10, 3)	62	55	58	-16 (-24, -8)	-5 (-11, 1)
Unstable	26	47	48	19 (9, 29)	24 (17, 30)	15	30	28	14 (7, 22)	14 (9, 19)
Long-lasting/serious illness	15	19	19	12 (3, 21)	8 (2, 13)	15	22	20	11 (3, 19)	7 (2, 12)
Low socioeconomic status	77	87	90	9 (2, 16)	14 (10, 18)	70	85	82	11 (3, 18)	11 (7, 16)

Table 1. Prevalence (%) of Social, Behavioral, Health, and Personality Characteristics Among Women and Men, by Unemployment History: Sweden, 1973
Characteristic	Women					Men
	History of Unemployment			Age-Adjusted Difference^a (95% CI)		History of Unemployment			Age-Adjusted Difference^a (95% CI)
	Never	Short-Term^b	Long-Term^c	Short-Term	Long-Term	Never	Short-Term^b	Long-Term^c	Short-Term	Long-Term
Marital status
Unmarried	27	41	38	-4 (-10, 1)	5 (-0.6, 10)	32	67	53	14 (6, 22)	15 (10, 21)
Divorced	5	6	10	--^d	7 (3, 11)	3	3	6	--^d	5 (1, 8)
Widow/widower	1	1	0	--	--	0	0	0	--	--
No children	38	56	40	-1 (-10, 8)	-6 (-11, 1)	41	71	62	11 (2, 19)	15 (10, 21)
Education: elementary school	41	35	54	-0.6 (-11, 9)	16 (9, 22)	45	41	41	2 (-7, 10)	-2 (0, -4)
Smoking status
Current smoker	40	61	63	21 (11, 31)	22 (16, 29)	52	61	66	8 (-0.7, 17)	12 (6, 18)
Former smoker	13	14	12	-2 (-7, 3)	-0.4 (-5, 4)	14	10	13	0.1 (-7, 7)	-0.2 (-4, 4)
Alcohol consumption
None	43	43	46	4 (-6, 13)	4 (-3, 12)	22	25	26	5 (-5, 14)	4 (-2, 10)
>250 g/mo	15	28	18	10 (0.5, 18)	2 (-4, 7)	46	52	50	4 (-7, 15)	4 (-3, 11)
Use of sedatives
Sleeping pills occasionally/regularly	6	9	14	6 (-1, 14)	9 (4, 14)	3	6	10	5 (-1, 10)	9 (4, 13)
Sleeping pills regularly	1	3	7	2 (-2, 6)	6 (3, 10)	1	3	4	--	4 (1, 7)
Tranquilizers occasionally/regularly	14	16	27	7 (-2, 16)	17 (11, 23)	7	13	16	9 (2, 16)	11 (7, 16)
Tranquilizers regularly	4	8	10	7 (-0.3, 14)	8 (4, 13)	2	7	6	5 (1, 10)	6 (3, 10)
Stressful life situation	15	13	18	-1 (-8, 6)	5 (-0.2, 10)	19	17	20	3 (-5, 10)	2 (-3, 6)
Shift work	11	20	25	9 (0.4, 17)	14 (9, 20)	23	27	29	4 (-3, 11)	7 (1, 12)
Personality
Extrovert	51	57	47	13 (5, 21)	-4 (-10, 3)	62	55	58	-16 (-24, -8)	-5 (-11, 1)
Unstable	26	47	48	19 (9, 29)	24 (17, 30)	15	30	28	14 (7, 22)	14 (9, 19)
Long-lasting/serious illness	15	19	19	12 (3, 21)	8 (2, 13)	15	22	20	11 (3, 19)	7 (2, 12)
Low socioeconomic status	77	87	90	9 (2, 16)	14 (10, 18)	70	85	82	11 (3, 18)	11 (7, 16)

Table 2. Relative Risks for Specific Causes of Death and Total Mortality Among Women and Men, by Exposure to Unemployment: Sweden, 1973
Cause of Death (ICD-8 Codes)	RR (95% CI) at 24-y Follow-Up				RR (95% CI) at 10-y Follow-Up
Cause of Death (ICD-8 Codes)	Total No. of Deaths	No. of Deaths Among Those Exposed to Unemployment	Age-Adjusted	Full Model^a	Total No. of Deaths	No. of Deaths Among Those Exposed to Unemployment	Age-Adjusted	Full Model^a
Women
Total mortality	399	42	1.7 (1.2, 2.4)	1.4 (1.0, 1.9)	73	8	1.7 (0.8, 3.7)	1.4 (0.7, 3.0)
Malignant neoplasms (140-209)	208	16	1.3 (0.8, 2.1)	1.1 (0.7, 1.9)	37	1	0.4 (0.1, 3.2)	0.4 (0.1, 2.8)
Malignant neoplasm of trachea, bronchus, or lung (162)	22	1	0.9 (0.1, 6.8)	0.6 (0.1, 4.2)	2	0	--	--
Diseases of the circulatory system (390-458)	68	6	1.6 (0.7, 3.7)	1.3 (0.5, 3.0)	11	0	--	--
Ischemic heart diseases (410-414)	31	3	1.8 (0.5, 5.9)	1.3 (0.4, 4.5)	3	3	--	--
Injuries, poisoning, other external causes (E800-E999)	50	11	2.8 (1.4, 5.7)	2.0 (1.0, 4.1)	18	6	6.2 (2.2, 17.5)	4.2 (1.5, 12.3)
Suicide (E950-E959)	30	8	4.1 (1.7, 9.5)	2.7 (1.2, 6.5)	13	4	5.3 (1.6, 18.0)	3.7 (1.0, 13.0)
External undetermined cause (E980-E989)^b	4	2	15.8 (1.3, 196.4)	10.7 (0.9, 133.0)	2	1	--	--
Other diagnoses	73	9	2.0 (1.0, 4.0)	1.3 (0.6, 2.7)	7	1	1.8 (0.2, 16.1)	1.6 (0.2, 13.8)
Alcoholism, cirrhosis of liver, pancreatitis (303, 571, 577)	10	1	1.3 (0.2, 11.0)	1.0 (0.1, 8.1)	2	1	14.7 (0.9, 252.9)	10.4 (0.6, 185.2)
Men
Total mortality	792	97	1.6 (1.3, 1.9)	1.3 (1.0, 1.6)	208	32	1.9 (1.3, 2.8)	1.5 (1.0, 2.2)
Malignant neoplasms (140-209)	224	26	1.6 (1.0, 2.4)	1.4 (0.9, 2.1)	47	8	2.5 (1.1, 5.3)	2.1 (0.9, 4.6)
Malignant neoplasm of trachea, bronchus, or lung (162)	38	5	1.7 (0.7, 4.5)	1.5 (0.6, 4.1)	5	1	3.1 (0.3, 29.0)	2.9 (0.3, 28.0)
Diseases of the circulatory system (390-458)	237	23	1.4 (0.9, 2.2)	1.2 (0.8, 1.8)	40	5	1.9 (0.7, 5.0)	1.4 (0.5, 3.8)
Ischemic heart diseases (410-414)	161	15	1.4 (0.8, 2.4)	1.2 (0.7, 2.1)	27	2	1.1 (0.3, 4.7)	0.8 (0.2, 3.6)
Injuries, poisoning, other external causes (E800-E999)	200	35	1.8 (1.2, 2.6)	1.5 (1.0, 2.2)	91	16	1.8 (1.0, 3.1)	1.5 (0.8, 2.6)
Suicide (E950-E959)	91	12	1.3 (0.7, 2.4)	1.0 (0.6, 2.0)	38	4	1.1 (0.4, 3.2)	0.9 (0.3, 2.6)
Undetermined cause of death (E980-E989)^b	23	10	7.7 (3.3, 17.9)	5.8 (2.4, 14.0)	8	4	8.6 (2.1, 36.2)	5.8 (1.3, 25.4)
Other diagnoses	131	13	1.2 (0.7, 2.2)	0.9 (0.5, 1.5)	30	3	1.4 (0.4, 4.7)	0.9 (0.3, 3.2)
Alcoholism, cirrhosis of liver, pancreatitis (303, 571, 577)	40	6	2.0 (0.8, 4.8)	1.3 (0.5, 3.3)	14	2	2.2 (0.5, 10.2)	1.6 (0.3, 7.5)

Table 2. Relative Risks for Specific Causes of Death and Total Mortality Among Women and Men, by Exposure to Unemployment: Sweden, 1973
Cause of Death (ICD-8 Codes)	RR (95% CI) at 24-y Follow-Up				RR (95% CI) at 10-y Follow-Up
Cause of Death (ICD-8 Codes)	Total No. of Deaths	No. of Deaths Among Those Exposed to Unemployment	Age-Adjusted	Full Model^a	Total No. of Deaths	No. of Deaths Among Those Exposed to Unemployment	Age-Adjusted	Full Model^a
Women
Total mortality	399	42	1.7 (1.2, 2.4)	1.4 (1.0, 1.9)	73	8	1.7 (0.8, 3.7)	1.4 (0.7, 3.0)
Malignant neoplasms (140-209)	208	16	1.3 (0.8, 2.1)	1.1 (0.7, 1.9)	37	1	0.4 (0.1, 3.2)	0.4 (0.1, 2.8)
Malignant neoplasm of trachea, bronchus, or lung (162)	22	1	0.9 (0.1, 6.8)	0.6 (0.1, 4.2)	2	0	--	--
Diseases of the circulatory system (390-458)	68	6	1.6 (0.7, 3.7)	1.3 (0.5, 3.0)	11	0	--	--
Ischemic heart diseases (410-414)	31	3	1.8 (0.5, 5.9)	1.3 (0.4, 4.5)	3	3	--	--
Injuries, poisoning, other external causes (E800-E999)	50	11	2.8 (1.4, 5.7)	2.0 (1.0, 4.1)	18	6	6.2 (2.2, 17.5)	4.2 (1.5, 12.3)
Suicide (E950-E959)	30	8	4.1 (1.7, 9.5)	2.7 (1.2, 6.5)	13	4	5.3 (1.6, 18.0)	3.7 (1.0, 13.0)
External undetermined cause (E980-E989)^b	4	2	15.8 (1.3, 196.4)	10.7 (0.9, 133.0)	2	1	--	--
Other diagnoses	73	9	2.0 (1.0, 4.0)	1.3 (0.6, 2.7)	7	1	1.8 (0.2, 16.1)	1.6 (0.2, 13.8)
Alcoholism, cirrhosis of liver, pancreatitis (303, 571, 577)	10	1	1.3 (0.2, 11.0)	1.0 (0.1, 8.1)	2	1	14.7 (0.9, 252.9)	10.4 (0.6, 185.2)
Men
Total mortality	792	97	1.6 (1.3, 1.9)	1.3 (1.0, 1.6)	208	32	1.9 (1.3, 2.8)	1.5 (1.0, 2.2)
Malignant neoplasms (140-209)	224	26	1.6 (1.0, 2.4)	1.4 (0.9, 2.1)	47	8	2.5 (1.1, 5.3)	2.1 (0.9, 4.6)
Malignant neoplasm of trachea, bronchus, or lung (162)	38	5	1.7 (0.7, 4.5)	1.5 (0.6, 4.1)	5	1	3.1 (0.3, 29.0)	2.9 (0.3, 28.0)
Diseases of the circulatory system (390-458)	237	23	1.4 (0.9, 2.2)	1.2 (0.8, 1.8)	40	5	1.9 (0.7, 5.0)	1.4 (0.5, 3.8)
Ischemic heart diseases (410-414)	161	15	1.4 (0.8, 2.4)	1.2 (0.7, 2.1)	27	2	1.1 (0.3, 4.7)	0.8 (0.2, 3.6)
Injuries, poisoning, other external causes (E800-E999)	200	35	1.8 (1.2, 2.6)	1.5 (1.0, 2.2)	91	16	1.8 (1.0, 3.1)	1.5 (0.8, 2.6)
Suicide (E950-E959)	91	12	1.3 (0.7, 2.4)	1.0 (0.6, 2.0)	38	4	1.1 (0.4, 3.2)	0.9 (0.3, 2.6)
Undetermined cause of death (E980-E989)^b	23	10	7.7 (3.3, 17.9)	5.8 (2.4, 14.0)	8	4	8.6 (2.1, 36.2)	5.8 (1.3, 25.4)
Other diagnoses	131	13	1.2 (0.7, 2.2)	0.9 (0.5, 1.5)	30	3	1.4 (0.4, 4.7)	0.9 (0.3, 3.2)
Alcoholism, cirrhosis of liver, pancreatitis (303, 571, 577)	40	6	2.0 (0.8, 4.8)	1.3 (0.5, 3.3)	14	2	2.2 (0.5, 10.2)	1.6 (0.3, 7.5)

Table 3. Interactions Between Unemployment and Risk Indicators of Mortality for Women and Men: Sweden, 1973
Risk Indicator	n^a	Ever Unemployed, Without Risk Indicator,^b OR (95% CI)	Never Unemployed, With Risk Indicator,^b OR (95% CI)	Ever Unemployed, With Risk Indicator,^b (95% CI)	Synergy Index^c OR (95% CI)
Women
Unmarried, divorced, widow	477	1.6 (1.0, 2.5)	1.4 (1.1, 1.7)	2.5 (1.6, 3.9)	1.5 (0.5, 4.4)
No children	526	2.1 (1.4, 3.1)	1.2 (0.9, 1.5)	1.6 (0.9, 2.7)	0.5 (0.1, 2.3)
Elementary school	381	1.9 (1.2, 3.0)	1.1 (0.9, 1.4)	1.8 (1.1, 2.9)	0.8 (0.2, 2.7)
Smoker	492	1.6 (0.9, 2.7)	1.7 (1.4, 2.1)	2.9 (1.9, 4.3)	1.5 (0.6, 3.7)
Alcohol consumption >250 g	123	2.0 (1.4, 2.8)	1.4 (1.1, 1.9)	1.2 (0.4, 3.4)	0.2 (0.0, 40.1)
Use of sleeping pills	70	1.4 (1.0, 2.1)	1.4 (1.0, 2.0)	6.6 (1.1, 12.5)	7.0 (2.2, 22.5)
Use of tranquilizers	175	1.4 (0.9, 2.1)	1.5 (1.2, 2.0)	3.5 (2.1, 5.7)	2.7 (1.0, 7.6)
Shift work	176	1.9 (1.3, 2.7)	1.3 (0.9, 1.7)	1.5 (0.7, 3.2)	0.4 (0.0, 4.8)
Extravert personality	445	1.2 (0.7, 2.1)	1.3 (1.0, 1.5)	2.8 (1.8, 4.1)	3.9 (0.7, 22.7)
Unstable personality	405	1.1 (0.7, 2.0)	1.4 (1.1, 1.7)	3.0 (2.0, 4.5)	3.8 (0.9, 15.6)
Long-lasting or serious illness	154	1.6 (1.1, 2.4)	1.8 (1.5, 2.4)	3.4 (2.0, 5.9)	1.6 (0.7, 4.0)
Blue-collar worker or lower white-collar worker	779	1.5 (0.5, 4.3)	1.1 (0.9, 1.5)	2.0 (1.4, 3.0)	1.5 (0.1, 16.5)
Men
Unmarried, divorced, widower	704	1.8 (1.3, 2.4)	1.9 (1.6, 2.3)	2.1 (1.5, 2.9)	0.6 (0.3, 1.3)
No children	788	1.9 (1.4, 2.6)	1.5 (1.2, 1.7)	1.6 (1.1, 2.3)	0.4 (0.2, 1.1)
Elementary school	543	1.1 (0.8, 1.6)	1.2 (1.0, 1.4)	2.3 (1.8, 3.1)	4.1 (1.0, 16.7)
Smoker	800	1.5 (1.0, 2.3)	1.9 (1.6, 2.2)	2.7 (2.0, 3.6)	1.2 (0.7, 2.2)
Alcohol consumption >250g	530	1.4 (1.0, 1.9)	1.3 (1.2, 1.6)	2.3 (1.7, 3.1)	1.7 (0.8, 3.9)
Use of sleeping pills	60	1.5 (1.1, 1.8)	1.8 (1.2, 2.5)	3.5 (1.9, 6.8)	2.1 (0.7, 6.1)
Use of tranquilizers	130	1.5 (1.1, 1.9)	1.5 (1.1, 1.9)	2.6 (1.6, 4.2)	1.7 (0.6, 4.5)
Shift work	395	1.5 (1.1, 1.9)	1.1 (0.9, 1.3)	1.8 (1.3, 2.6)	1.4 (0.5, 4.1)
Extravert personality	783	1.8 (1.3, 2.5)	1.1 (0.9, 1.3)	1.5 (1.1, 2.0)	0.5 (0.2, 1.6)
Unstable personality	350	1.3 (1.0, 1.8)	1.5 (1.3, 1.9)	2.6 (1.8, 3.6)	1.8 (0.8, 3.8)
Long-lasting or serious illness	233	1.4 (1.0, 1.8)	1.4 (1.2, 1.7)	2.7 (1.9, 4.0)	2.2 (1.0, 5.0)
Blue-collar worker or lower white-collar worker	1085	1.8 (1.1, 3.0)	1.3 (1.1, 1.5)	1.8 (1.4, 2.3)	0.7 (0.3, 1.9)

Table 1. Prevalence (%) of Social, Behavioral, Health, and Personality Characteristics Among Women and Men, by Unemployment History: Sweden, 1973
Characteristic	Women					Men
	History of Unemployment			Age-Adjusted Difference^a (95% CI)		History of Unemployment			Age-Adjusted Difference^a (95% CI)
	Never	Short-Term^b	Long-Term^c	Short-Term	Long-Term	Never	Short-Term^b	Long-Term^c	Short-Term	Long-Term
Marital status
Unmarried	27	41	38	-4 (-10, 1)	5 (-0.6, 10)	32	67	53	14 (6, 22)	15 (10, 21)
Divorced	5	6	10	--^d	7 (3, 11)	3	3	6	--^d	5 (1, 8)
Widow/widower	1	1	0	--	--	0	0	0	--	--
No children	38	56	40	-1 (-10, 8)	-6 (-11, 1)	41	71	62	11 (2, 19)	15 (10, 21)
Education: elementary school	41	35	54	-0.6 (-11, 9)	16 (9, 22)	45	41	41	2 (-7, 10)	-2 (0, -4)
Smoking status
Current smoker	40	61	63	21 (11, 31)	22 (16, 29)	52	61	66	8 (-0.7, 17)	12 (6, 18)
Former smoker	13	14	12	-2 (-7, 3)	-0.4 (-5, 4)	14	10	13	0.1 (-7, 7)	-0.2 (-4, 4)
Alcohol consumption
None	43	43	46	4 (-6, 13)	4 (-3, 12)	22	25	26	5 (-5, 14)	4 (-2, 10)
>250 g/mo	15	28	18	10 (0.5, 18)	2 (-4, 7)	46	52	50	4 (-7, 15)	4 (-3, 11)
Use of sedatives
Sleeping pills occasionally/regularly	6	9	14	6 (-1, 14)	9 (4, 14)	3	6	10	5 (-1, 10)	9 (4, 13)
Sleeping pills regularly	1	3	7	2 (-2, 6)	6 (3, 10)	1	3	4	--	4 (1, 7)
Tranquilizers occasionally/regularly	14	16	27	7 (-2, 16)	17 (11, 23)	7	13	16	9 (2, 16)	11 (7, 16)
Tranquilizers regularly	4	8	10	7 (-0.3, 14)	8 (4, 13)	2	7	6	5 (1, 10)	6 (3, 10)
Stressful life situation	15	13	18	-1 (-8, 6)	5 (-0.2, 10)	19	17	20	3 (-5, 10)	2 (-3, 6)
Shift work	11	20	25	9 (0.4, 17)	14 (9, 20)	23	27	29	4 (-3, 11)	7 (1, 12)
Personality
Extrovert	51	57	47	13 (5, 21)	-4 (-10, 3)	62	55	58	-16 (-24, -8)	-5 (-11, 1)
Unstable	26	47	48	19 (9, 29)	24 (17, 30)	15	30	28	14 (7, 22)	14 (9, 19)
Long-lasting/serious illness	15	19	19	12 (3, 21)	8 (2, 13)	15	22	20	11 (3, 19)	7 (2, 12)
Low socioeconomic status	77	87	90	9 (2, 16)	14 (10, 18)	70	85	82	11 (3, 18)	11 (7, 16)

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Unemployment and Early Cause-Specific Mortality: A Study Based on the Swedish Twin Registry

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