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. Author manuscript; available in PMC: 2026 Jul 28.
Published in final edited form as: Int J Soc Psychiatry. 2024 Oct 22;71(1):168–178. doi: 10.1177/00207640241288211

Examining cultural background and the protective effect of marriage on alcohol use disorder in Sweden

Jessica E Salvatore 1, Sara Larsson Lönn 2, Karen G Chartier 3,4, Jan Sundquist 2, Kenneth S Kendler 4,5,6,*, Kristina Sundquist 2,*
PMCID: PMC13403085  NIHMSID: NIHMS2193908  PMID: 39435759

Abstract

Background

Little is known about whether the protective effect of marriage on alcohol use disorder (AUD) varies by cultural background.

Aims

Using Swedish national data, we examined whether marriage is associated with a stronger reduction in AUD risk among Swedes of a Swedish background (i.e. those with two Swedish-born parents) compared to Swedes with a foreign background (i.e. one or two foreign-born parents) and whether the protective effect of marriage depends on whether the spouse has a Swedish or foreign background.

Method

Among those born in Sweden 1960 to 1990 (3,093,439; 49% female), associations between cultural background and AUD registration during marriage were estimated with Cox models. Analyses of intra- and intermarriage on AUD registration were examined with Cox models and limited to groups of focal individuals for which there was sufficient statistical power, which included Swedes with two Swedish-born parents, two Finnish-born parents, or bicultural background (one Swedish and one foreign-born parent). Models were sex stratified.

Results

Marriage was associated with reductions in AUD risk among those with Swedish and with foreign backgrounds, though less protective for males of Finnish versus Swedish background as indicated by a significant interaction between marital status and parental region of birth, HR = 0.80, 95% CI [0.71, 0.90]. Marriage was also less protective for those with a bicultural versus Swedish background, HRmales = 0.87, 95% CI [0.81, 0.92] and HRfemales = 0.88, 95% CI [0.81, 0.97]. Among those of Swedish background, marriage to a spouse with a foreign versus Swedish background was associated with increased risk of AUD, HRmales = 1.26, 95% CI [1.19, 1.34] and HRfemales = 1.20, 95% CI [1.10, 1.31]. This risk was diminished when family-level confounders (genes, rearing environment) were controlled for.

Conclusions

The protective effect of marriage depends on cultural background, with some evidence that increased risks associated with a spouse’s foreign background are confounded by family-level factors.

Keywords: Marriage, alcohol use disorder, cultural background

Introduction

The likelihood of developing an alcohol use disorder (AUD) is multiply determined by individual characteristics and social and cultural factors and their interplay across the life course (Gordon et al., 2012; Sher et al., 2005). Marital status is one of the strongest sociodemographic correlates of alcohol use behaviors, such that married individuals compared to those never married or divorced/separated/widowed typically engage in lower alcohol consumption, problem drinking, and have a reduced risk for AUD (Grant et al., 2015; Kendler et al., 2016; Power et al., 1999). Yet, most of the evidence regarding the protective effect of marriage on AUD comes from general population samples in Western countries. For this reason, less is known about whether the protective effect of marriage may vary depending on one’s cultural background, and fewer yet have taken a dyadic perspective to examine how marriage to a partner with the same or different cultural background may be associated with the risk of developing AUD during marriage. These are important unanswered questions given the growth in the number of countries with sizeable foreign-born populations (>15%; OECD, 2023) and the corresponding increase in intermarriages between people of different ethnicities, racial groups, and religions (Behtoui, 2010; Cretser, 1999; Törngren et al., 2016).

Sweden is a unique context for examining the interplay between marriage, cultural background, and AUD risk. In recent years, immigration to Sweden has increased substantially, and so has the number of marital unions between those with two Swedish-born parents and those who have foreign backgrounds. For parsimony throughout the rest of this manuscript, we refer to unions between partners who have different cultural backgrounds as intermarriages, and unions between partners who share the same cultural background as intramarriages, but we recognize that these terms refer to a variety of concepts in prior research (Irastorza & Osanami Törngren, 2022). According to the most recent population data from 2023, 20.6% of the Swedish population is foreign born, and an additional 6.6% have two foreign-born parents, and 7.8% have one Swedish-born and one foreign-born parent (Statistics Sweden, 2024b). Foreign-born individuals come from a variety of drinking cultures as indicated by country-of-origin alcohol consumption data (World Health Organization, 2018). Finns are the largest foreign-born group (Statistics Sweden, 2024a), and Finland has a wet and permissive drinking culture (Makela et al., 2012). There is also a substantial minority of foreign born individuals from the Middle East and North Africa (MENA), which has a dry and restrictive drinking culture (Shield et al., 2013). Consistent with the idea that foreign-born individuals’ risk for AUD is influenced in part by their home country’s social and cultural norms for alcohol use and subsequently shaped by the norms in the host country (Cook et al., 2021), in an earlier report we found that Finnish immigrants’ risk of AUD decreased as acculturation (indexed by generational status and having a Swedish-born parent) increased (Chartier et al., 2023). In contrast, risk of AUD increased as acculturation increased among immigrants from MENA (Chartier et al., 2023). Such results underscore the heterogeneity in risk for AUD among foreign-born groups.

Multiple processes contribute to the salutary health benefits typically associated with marriage (Kiecolt-Glaser & Newton, 2001), including the reduction in risk for AUD (Leonard & Rothbard, 1999). Yet, how these processes unfold in the context of intermarriage has received only limited attention to date (Honkaniemi et al., 2022; Oksuzyan et al., 2023; Östergren et al., 2023). According to social role theory (Yamaguchi & Kandel, 1985), individuals reduce their alcohol use in anticipation of and following the transition to marriage (Bachman et al., 1984; Salvatore et al., 2020) in order to minimize interference with meeting their spousal obligations. Given that marriage is considered one of the most significant life events across cultures (Thornton, 2009), we would accordingly expect some degree of protection against AUD associated with marriage regardless of cultural background. Yet, intermarried couples also face a unique and additional set of stressors beyond those faced by intramarried couples, including social disapproval, and intermarried couples are more likely to experience divorce than intramarried couples (Irastorza, 2016; Su, 2023; Törngren et al., 2016). In view of evidence that marital dissatisfaction is prospectively associated with AUD diagnoses (Whisman et al., 2006), we speculate that intermarriage may be less protective against AUD than intramarriage.

We used national registry data to examine the following research questions on cultural background, marriage, and AUD risk:

  1. Is marriage associated with a stronger reduction in AUD risk among Swedes of Swedish background (i.e. those with two Swedish-born parents) compared to Swedes of foreign backgrounds (i.e. those with one or two parents from other regions of birth)?

  2. Does the protective effect of marriage depend on whether spouses have the same or different cultural backgrounds (intramarried couples vs. intermarried couples)?

This study is unique in examining these questions with highly complete population level data. Our scientific rationale for focusing on marriages involving Swedish-born individuals of foreign-born parents (i.e. second generation immigrants) rather than foreign-born individuals (i.e. first generation immigrants) is to reduce bias attributable to age at immigration and lack of information regarding pre-immigration AUD status.

Methods

Sample

We linked nationwide Swedish registers via the unique 10-digit identification number assigned at birth or immigration to all Swedish residents. The identification number was replaced by a serial number to ensure people’s integrity. Data came from a series of population registries, including the: Total Population Register, containing information about year and country of birth, sex, family id, and marital status; Multi-Generation Register, linking individuals born after 1932 to their parents; Hospital Discharge Register, containing hospitalizations for Swedish inhabitants from 1964 to 2018; Prescribed Drug Register, containing all prescriptions in Sweden picked up by patients from July 2005 to 2018; Outpatient Care Register, containing information from all outpatient clinics from 2001 to 2018; Crime Register that included national complete data on all convictions in lower court from 1973 to 2018; Swedish Suspicion Register that included national data on individuals strongly suspected of crime from 1998 to 2018; and the Mortality Register with dates and causes of death from 1952 until 2018. Approval for this study was received from the Regional Ethical Review Board in Lund (No. 2008/409 and later amendments), and consent was waived.

Measures

AUD was defined from Swedish medical registries by the following ICD codes: ICD8: 571.0, 291, 303, 980; ICD9: V79B, 305A, 357F, 571A, 571B, 571C, 571D, 425F, 535D, 291, 303, 980; and ICD 10: E244, G312, G621, G721, I426, K292, K700, K701, K702, K703, K704, K709, K852, K860, O354, T510, T512, T511, T513, T518, T519, F101, F102, F103, F104, F105, F106, F107, F108, F109; and from the Prescribed Drug Register if retrieved disulfiram (Anatomical Therapeutic Chemical (ATC) Classification System N07BB01), acamprosate (N07BB03), or naltrexone (N07BB04). In addition, we identified as AUD cases those convicted for or suspected of at least two alcohol-related crimes according to law 1951:649, paragraph 4 and 4A and law 1994:1009, Chapter 20, paragraph 4 and 5 from the Swedish Crime Register, and code 3005 and 3201 in the Suspicion register.

Cultural background was defined by parents’ country of birth (separately for the focal individual’s parents and their spouse’s parents) and categorized into Sweden and seven foreign regions of origin based on definitions from Chartier et al. (2023): Finland, Western Countries, Eastern Europe, Latin America and the Caribbean, Middle East and Northern Africa, Africa (excluding Northern Africa), and Asia (excluding Middle East) and Oceania. Both parents were used for the classification, and if they originated from different foreign regions it was categorized as Different regions for the analysis. Finland was examined separately because they represent one of the largest immigrant groups in Sweden and because they have higher AUD rates when compared to many other countries.

Yearly information of marital status and household (from the years 1960, 1965, 1970, 1975, 1980, and 1985) or family id (from 1990 and onwards) was obtained from the Total Population Register. Husbands and wives were identified as opposite-sex pairs, married, and with the same family identification number. Analyses were limited to opposite sex couples to reduce potential cohort effects given that registration of same-sex partnerships and marriages began in 1995 and 2009, respectively.

In sensitivity analyses, we examined deviant behavior prior to marriage, AUD predispositions, and socioeconomic status. Deviant behavior before marriage was assessed as drug use disorder (DUD) or criminal behavior, defined as conviction in lower court of violent crime, white collar crime or property crime (see Kendler et al., 2014; Salvatore et al., 2023, for more detailed definitions). To assess AUD predispositions, we assessed lifetime AUD in biological parents. Socioeconomic status was assessed by the highest parental education attained and categorized into low (compulsory school only), mid (upper secondary school), and high (university level).

Statistical methods

We utilized Cox proportional hazard models to investigate how marriage is associated with future risk of AUD depending on individuals’ Swedish or foreign background. Subjects were followed from age 18 years, and marital status was included as time-varying covariate, censoring at death, emigration, or end of follow-up, December 31, 2018. During the married phase we also censored at the time of divorce or widowhood. In a first set of analyses the association with marriage was allowed to depend on cultural background by including interactions between marital status and parents’ region of birth. We started with a crude model, including only the main effects of marital status and cultural background and the interaction between them. Next, we adjusted for birth year, deviant behavior prior to marriage, parental AUD, and parental education.

The second set of analyses were constrained to a subset of the population with sufficient power to investigate the influence of intramarriage and intermarriage on later AUD registration. The following three groups were included: individuals with two Swedish-born parents, with two Finnish-born parents, or with a bicultural background (one Swedish-born and one foreign-born parent). If we were not able to identify the spouse nor the spouse’s parents, the follow-up of the focal individual was censored at the time of marriage. The association with intramarriage or intermarriage was allowed to depend on the spouse’s cultural background by including interactions between marital status and spousal parental origin. Finally, to account for unmeasured familial confounding, we utilized same-sex full sibling pairs marrying spouses with different cultural backgrounds. By treating each pair as a stratum in the Cox regression analysis, the estimated association between spouse’s cultural background and AUD is adjusted for all environmental and genetic factors shared within a pair.

In view of prior evidence that marriage might have a different impact on the health behavior of males and females (Umberson, 1992), all analysis were stratified by sex.

Results

Descriptive statistics

In total, 3,093,439 individuals (1,505,929 or 48.68% female) met inclusion criteria for the present study. Descriptive statistics for the study cohort stratified by sex, marital status, and cultural background can be found in Table 1. Additional information regarding the AUD incidence rate per 10,000 person-years stratified by these factors can be found in Supplemental Table S1. Among both males and females, rates of AUD were higher among those who were unmarried compared to those who were married, corresponding to AUD incidence rates of 28.53 versus 11.50 in males and 11.68 versus 4.68 in females per 10,000 person-years. Rates of parental AUD were highest among those with a Finnish background, and lowest among those with origins from the Middle East/North Africa.

Table 1.

Descriptive statistics for parents’ region of birth, parental AUD, deviant behavior before age 18 years, and alcohol use disorder registration among unmarried and married males and females born 1960–1990.

Parents’ region of birth In total (col %) Parental AUD
(row %)		 Deviant behavior
before age 18 years
(row %)		 AUD (row %) In total (col %) Parental
AUD (row %)		 Deviant behavior
before age 18 years
(row %)		 AUD (row %)
Unmarried males Married males
Africa (excluding North Africa) 910 (0.06%) 75 (8.24%) 180 (19.78%) 36 (3.96%) 125 (0.02%) 9 (7.2%) 41 (32.8%) 0 (0%)
Asia (excluding Middle East) and Oceania 7,370 (0.46%) 514 (6.97%) 1,128 (15.31%) 242 (3.28%) 3,547 (0.48%) 195 (5.5%) 814 (22.95%) 36 (1.01%)
Eastern Europe 13,152 (0.83%) 1,630 (12.39%) 2,061 (15.67%) 666 (5.06%) 5,852 (0.79%) 587 (10.03%) 1,332 (22.76%) 93 (1.59%)
Finland 25,682 (1.62%) 6,625 (25.8%) 4,198 (16.35%) 2,972 (11.57%) 10,486 (1.41%) 2,315 (22.08%) 2,392 (22.81%) 309 (2.95%)
Latin America and the Caribbean 2,151 (0.14%) 218 (10.13%) 419 (19.48%) 94 (4.37%) 473 (0.06%) 36 (7.61%) 138 (29.18%) 1 (0.21%)
Middle East/North Africa 5,045 (0.32%) 271 (5.37%) 970 (19.23%) 197 (3.9%) 1,666 (0.22%) 81 (4.86%) 520 (31.21%) 14 (0.84%)
Sweden 136,6870 (86.1%) 186,259 (13.63%) 115,374 (8.44%) 64,441 (4.71%) 647,184 (87.26%) 78,886 (12.19%) 88,409 (13.66%) 9,861 (1.52%)
Western countries 8,652 (0.55%) 757 (8.75%) 1,096 (12.67%) 462 (5.34%) 4,418 (0.6%) 355 (8.04%) 888 (20.1%) 77 (1.74%)
Different regions 9,453 (0.6%) 1,376 (14.56%) 1,546 (16.35%) 644 (6.81%) 3,662 (0.49%) 488 (13.33%) 837 (22.86%) 73 (1.99%)
One Swedish, one foreign-born parent 148,225 (9.34%) 25,214 (17.01%) 18,292 (12.34%) 9,303 (6.28%) 64,261 (8.66%) 9,610 (14.95%) 12,042 (18.74%) 1,114 (1.73%)
Unmarried females Married females
Africa (excluding North Africa) 908 (0.06%) 73 (8.04%) 60 (6.61%) 12 (1.32%) 259 (0.03%) 25 (9.65%) 39 (15.06%) 1 (0.39%)
Asia (excluding Middle East) and Oceania 6,848 (0.45%) 464 (6.78%) 305 (4.45%) 24 (0.35%) 4,250 (0.51%) 284 (6.68%) 276 (6.49%) 9 (0.21%)
Eastern Europe 12,308 (0.82%) 1,591 (12.93%) 713 (5.79%) 147 (1.19%) 6,777 (0.82%) 809 (11.94%) 602 (8.88%) 34 (0.5%)
Finland 24,466 (1.62%) 6,450 (26.36%) 1,335 (5.46%) 990 (4.05%) 13,399 (1.62%) 3,293 (24.58%) 1,088 (8.12%) 192 (1.43%)
Latin America and the Caribbean 2,055 (0.14%) 195 (9.49%) 174 (8.47%) 43 (2.09%) 677 (0.08%) 55 (8.12%) 97 (14.33%) 1 (0.15%)
Middle East/North Africa 4,945 (0.33%) 245 (4.95%) 328 (6.63%) 40 (0.81%) 2,534 (0.31%) 133 (5.25%) 258 (10.18%) 6 (0.24%)
Sweden 1,296,128 (86.07%) 178,531 (13.77%) 41,530 (3.2%) 22,811 (1.76%) 717,763 (86.65%) 94,111 (13.11%) 34,373 (4.79%) 4,924 (0.69%)
Western countries 8,192 (0.54%) 783 (9.56%) 282 (3.44%) 87 (1.06%) 4,628 (0.56%) 445 (9.62%) 281 (6.07%) 29 (0.63%)
Different regions 8,897 (0.59%) 1,341 (15.07%) 574 (6.45%) 214 (2.41%) 4,419 (0.53%) 599 (13.56%) 415 (9.39%) 45 (1.02%)
One Swedish, one foreign-born parent 141,182 (9.38%) 24,343 (17.24%) 6,819 (4.83%) 3,497 (2.48%) 73,615 (8.89%) 12,024 (16.33%) 5,152 (7%) 613 (0.83%)
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Marriage, cultural background, and AUD registration

The results from Cox proportional hazard models of cultural background, marital status, and the interaction between cultural background (based on parents’ region of birth) and marital status as predictors of AUD registration are summarized in Table 2. There was a main effect of cultural background. Compared to those with a Swedish background, those with a bicultural background (one foreign-born parent and one Swedish-born parent) or parental origins from Eastern Europe (males only), Finland, Latin America and the Caribbean, MENA (males only), Western countries (males only), or two different regions had a higher likelihood of AUD registration during the unmarried phase. There was also a main effect of marriage, such that marriage was associated with a reduced likelihood of AUD registration. A global test of whether the associations between marriage and AUD registration differed by cultural background was statistically significant (p < .001). A formal test of whether the effect of marriage differed by background, which was tested with interactions between marital status and parents’ regional origins, revealed two statistically significant differences. Marriage was less protective against AUD among males with a Finnish background compared to males with a Swedish background, HRinteraction = .80 (0.71, 0.90). Likewise, marriage was less protective against AUD among males and females with a bicultural background compared to those with a monocultural Swedish background, HRmales/interaction = 0.87, 95% CI [0.81, 0.92] and HRfemales/interaction = 0.88, 95% CI [0.81, 0.97]. The same pattern of interaction effects, whereby marriage was less protective for some individuals of foreign background compared to those of Swedish background, held in an adjusted model that included birth year, deviant behavior, parental AUD, and parental education (Supplemental Table S2). Descriptive information about parental region of origin for those with a bicultural background are provided in Supplemental Table S3. Most foreign-born parents came from Western countries (29.29% of mothers and 25.33% of fathers), Finland (22.81% of mothers and 13.56% of fathers), and Eastern Europe (5.33% of mothers and 7.69% of fathers).

Table 2.

Cox regressions models of parents’ region of birth, marital status, and their interaction predicting AUD during marriage in males and females.

Parents’ region of birth Males
 Females
Main effect parents’
region of birth HR
[95% CI]		 Main effect of
marriage HR
[95% CI]		 Interaction HR
[95% CI]		 Main effect parents’
region of birth HR
[95% CI]		 Main effect of
marriage HR
[95% CI]		 Interaction HR
[95% CI]
Africa (excluding North Africa) 1.34 [0.96, 1.85] — — 1.27 [0.72, 2.24] 0.53 [0.07, 4.10] 1.66 [0.22, 12.79]
Asia (excluding Middle East) and Oceania 1.12 [0.99, 1.27] 0.39 [0.27, 0.55] 1.13 [0.79, 1.6] 0.36 [0.24, 0.54] 0.55 [0.26, 1.19] 1.73 [0.80, 3.72]
Eastern Europe 1.22 [1.13, 1.32] 0.35 [0.29, 0.44] 1.03 [0.83, 1.28] 0.82 [0.69, 0.96] 0.35 [0.24, 0.51] 1.09 [0.75, 1.58]
Finland 2.42 [2.34, 2.51] 0.27 [0.24, 0.31] 0.80 [0.71, 0.90] 2.28 [2.14, 2.43] 0.29 [0.25, 0.34] 0.92 [0.78, 1.08]
Latin America and the Caribbean 1.34 [1.09, 1.64] 0.10 [0.01, 0.70] 0.28 [0.04, 2.03] 1.77 [1.31, 2.38] 0.12 [0.02, 0.84] 0.36 [0.05, 2.63]
Middle East/North Africa 1.36 [1.18, 1.56] 0.38 [0.22, 0.64] 1.09 [0.63, 1.87] 0.85 [0.62, 1.16] 0.36 [0.15, 0.84] 1.11 [0.47, 2.63]
Sweden Ref 0.34 [0.34, 0.35] Ref Ref 0.32 [0.31, 0.33] Ref
Western countries 1.14 [1.04, 1.25] 0.31 [0.25, 0.4] 0.91 [0.71, 1.16] 0.63 [0.51, 0.78] 0.42 [0.27, 0.64] 1.3 [0.86, 1.99]
Different regions 1.59 [1.47, 1.72] 0.33 [0.26, 0.42] 0.96 [0.75, 1.23] 1.53 [1.34, 1.76] 0.38 [0.27, 0.52] 1.18 [0.85, 1.63]
One Swedish, one foreign-born parent 1.36 [1.33, 1.39] 0.3 [0.28, 0.32] 0.87 [0.81, 0.92] 1.44 [1.39, 1.49] 0.28 [0.26, 0.31] 0.88 [0.81, 0.97]
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Intramarriage, intermarriage, and AUD registration

Descriptive information about spousal cultural background is shown in Table 3. Among focal individuals of Swedish background (with two Swedish-born parents), the majority married spouses of Swedish background (males: 87.15%, females: 87.57%). Among focal individuals of Finnish background, the majority married a spouse of Swedish background (males: 74.78%, females: 76.54%), with a substantial minority marrying spouses of Finnish background (males: 10.47%, females: 10.00%). Among focal individuals of a bicultural background, the majority married spouses with a Swedish background (males: 82.95%, females 83.19%), with a substantial minority marrying spouses that also had a bicultural background (males: 10.21%, females: 10.00%). Detailed information regarding spousal cultural background when the spouse’s parents came from a different region from the focal individual are provided in Table S4. Marriage to a spouse with one Swedish- and one foreign-born parent was most frequently observed.

Table 3.

Spouse’s parents’ region of birth and rates of AUD during marriage for probands (focal individuals) with two Swedish born parents, two Finnish born parents, and one Swedish and one foreign-born parent.

Spouse’s parents region
of birth		 Probands with two Swedish born parents
 Probands with two Finnish born parents
 Probands with one Swedish, one foreign-born parent
Number (col %) With AUD (row %) Number (col %) With AUD (row %) Number (col %) With AUD (row %)
Spouse’s parents Males
Two Swedish born 492,300 (87.15%) 7,213 (1.47%) 6,414 (74.78%) 179 (2.79%) 44,152 (82.95%) 782 (1.77%)
Same country — — 898 (10.47%) 37 (4.12%) 5,437 (10.21%) 89 (1.64%)
Different country 72,617 (12.85%) 1,319 (1.82%) 1,265 (14.75%) 35 (2.77%) 3,641 (6.84%) 61 (1.68%)
Females
Two Swedish born 541,452 (87.57%) 13,590 (0.66%) 8,217 (76.54%) 116 (1.41%) 49,340 (83.19%) 425 (0.86%)
Same country — — 1,074 (10.00%) 14 (1.30%) 59,230 (10.00%) 53 (0.89%)
Different country 76,888 (12.43%) 601 (0.78%) 1,445 (13.46%) 21 (1.44%) 4,042 (6.81%) 34 (0.84%)
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Note. As the information about probands with two Swedish born parents married to spouses with parents from the same country (Sweden) are already presented in the row above, these fields are left blank.

The results from Cox proportional hazard models of the spouse’s cultural background on focal individual AUD registration during marriage are summarized in Table 4. Among individuals of Swedish background, intramarriage (i.e. marriage to a spouse with a Swedish background) was associated with a reduced likelihood of AUD registration, HRmales = 0.32, 95% CI [0.31, 0.32], HRfemales = 0.30, 95% CI [0.29, 0.32]. Intermarriage (i.e. marriage to a spouse with a foreign background, as indexed by two foreign-born parents) was also associated with a reduced likelihood of AUD registration, HRmales = 0.40, 95% CI [0.38, 0.42], HRfemales = 0.37, 95% CI [0.34, 0.40]. Among those with a Swedish background, the reduction in risk associated with intermarriage was significantly less than the reduction in risk associated with intramarriage (p < .05). Intermarriage was associated with a higher likelihood of AUD registration compared intramarriage, HRmales = 1.26, 95% CI [1.19, 1.34] and HRfemales = 1.20, 95% CI [1.10, 1.31]. Among individuals with a Finnish background or a bicultural background, the reduction in AUD risk associated with marriage did not vary at a statistically significant level as a function of the spouse’s cultural background. This pattern of effects held in an adjusted model that included birth year, parental education, parental AUD, and deviant behavior (Supplemental Table S5).

Table 4.

Cox regression models of spouse’s parents’ region of birth predicting proband (focal individual) AUD during marriage for those with two Swedish born parents, two Finnish born parents, and one Swedish and one foreign-born parent.

Probands with two
Swedish Born Parents
HR [95% CI]		 Probands with two
Finnish born parents
HR [95% CI]		 Probands with one
Swedish, one foreign-
born parent HR [95% CI]
Model 1. Unmarried set as reference group
Males
Married, spouse two Swedish born parents 0.32 [0.31, 0.32] 0.28 [0.24, 0.33] 0.31 [0.28, 0.33]
Married, spouse parents’ same country as proband — 0.38 [0.28, 0.53] 0.30 [0.24, 0.37]
Married, spouse parents’ different country as proband 0.40 [0.38, 0.42] 0.30 [0.21, 0.42] 0.31 [0.24, 0.4]
Females
Married, spouse two Swedish born parents 0.30 [0.29, 0.32] 0.29 [0.24, 0.36] 0.29 [0.26, 0.33]
Married, spouse parents’ same country as proband — 0.27 [0.16, 0.45] 0.33 [0.25, 0.43]
Married, spouse parents’ different country as proband 0.37 [0.34, 0.4] 0.32 [0.2, 0.49] 0.32 [0.23, 0.45]
Model 2. Spouse with two Swedish born parents set as reference group.
Males
Married, spouse two Swedish born parents Ref Ref Ref
Married, spouse parents’ same country as proband — 1.36 [0.96, 1.94] 0.97 [0.78, 1.21]
Married, spouse parents’ different country as proband 1.26 [1.19, 1.34] 1.06 [0.74, 1.52] 1.01 [0.78, 1.31]
Females
Married, spouse two Swedish born parents Ref Ref Ref
Married, spouse parents’ same country as proband — 0.92 [0.53, 1.6] 1.10 [0.83, 1.47]
Married, spouse parents’ different country as proband 1.20 [1.1, 1.31] 1.09 [0.68, 1.73] 1.09 [0.77, 1.55]
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Note. As the information about probands with two Swedish born parents married to spouses with parents from the same country (Sweden) are already presented in the row above, these fields are left blank. Ref = reference group.

In view of evidence that factors that can differ between families are associated with rates of intermarriage (e.g. urban vs. rural residence, educational attainment; Choi & Tienda, 2017), we also examined the associations between the spouse’s cultural background on AUD registration within sibling pairs. The results of the co-sibling analyses are shown in Supplemental Table S6. The point estimates for the associations across the population-level and co-sibling results were generally in the same direction and of the same magnitude, though less precise in the co-sibling analyses as indicated by wider confidence intervals. There were two notable differences in the co-sibling analyses (which control for genetic and rearing environmental factors that siblings share) compared to the population-level analyses. Within families of Swedish background, there was no difference in AUD risk between siblings when one married a spouse with a foreign background compared to a sibling who married a spouse with a Swedish background, HRmen = 1.03, 95% CI [0.88, 1.20] and HRwomen = 1.02, 95% CI [0.81, 1.29]. Within families of Finnish background, males who married a spouse with foreign background had a higher likelihood of AUD registration compared to those who married a spouse with a Swedish background, HRmen 3.41 (1.27, 9.19).

Discussion

This study represents an initial effort to consider the role of cultural background when evaluating the impact of marriage on AUD risk, leveraging population information from Swedish national registries. As predicted by role incompatibility theory (Yamaguchi & Kandel, 1985), marriage was associated with reductions in AUD risk among all individuals, regardless of their background. There was also some heterogeneity in the protective effects of marriage. In partial support for our hypothesis, we found that the reduction in AUD risk associated with marriage among males of Finnish background and among males and females with a bicultural background (one Swedish-born parent and one foreign-born parent) was attenuated compared to individuals with two Swedish-born parents. Although both Finland and Sweden are highly socially progressive Nordic countries (The Social Progress Imperative, 2024), cross-national data indicate that Finns tend to engage in more frequent heavy episodic drinking than Swedes (Makela et al., 2006), and in a recent review Finnish drinking culture was described as increasingly wet and permissive (Makela et al., 2012). Most bicultural individuals’ foreign-born parent came from Finland or Western countries, the latter of which have some of the highest per capita alcohol consumption rates in the world (World Health Organization, 2018). We speculate that those with Finnish-born parents or a bicultural background may grow up with fewer restrictions around high-risk drinking and accordingly may not view high-risk drinking patterns as incompatible with marriage. It is notable that the protective effect of marriage for females with a Finnish background did not differ significantly from the effect among females with a Swedish background. These findings add to the broader literature documenting sex differences in the protective effect of marriage on a variety of health behaviors (Kiecolt-Glaser & Newton, 2001; Umberson, 1992) and further suggests that sex differences may be further modified by cultural background.

Also consistent with our hypothesis, we found that among males and females of Swedish background, intermarriage was less protective against AUD registration than intramarriage. One explanation for this pattern of effects is the unique stressors associated with intermarriage that can include social disapproval (Su, 2023), as well as different values and expectations that partners have for the marital partnership (Kalmijn, 1998) that may lead to conflict (Chartier & Caetano, 2012). Social stress is a known risk factor for AUD (Keyes et al., 2011; Pilowsky et al., 2013), and marital discord is prospectively associated with AUD onset (Whisman et al., 2006). For individuals with a Swedish background, these inter-cultural differences and discrepancies may be especially salient. In contrast, among males and females of Finnish background or a mixed cultural background, AUD risk did not statistically differ as a function of the spouse’s cultural background. It may be the case that individuals raised by parents also in a bicultural relationship have more exposure to and awareness of how cultural background may influence close relationship processes (e.g. communication) and social role expectations such as time spent together. This awareness may reduce perceptions of marital distress typically associated with intermarriage, and in turn the elevations in AUD risk associated with intermarriages among individuals with a monocultural Swedish background.

The results of the co-sibling analyses add important nuance to our understanding of the mechanisms driving the associations between intermarriage and AUD risk. Among those with a Swedish background, intermarriage and intramarriage were similarly protective against AUD once between-family differences were accounted for. This suggests that some of the ‘risk’ associated with intermarriage may be cofounded by family-level factors that contribute to selection into intermarriage and risk for AUD, such as educational attainment and urban versus rural residency (Choi & Tienda, 2017). Interestingly, in the co-sib-ling analyses, for males with a Finnish background, marriage to a spouse whose parents originated from a different country/region was associated with increased risk of AUD compared to marriage to a spouse with a Swedish background. This provides additional support for the idea that intermarriage may be associated with stressors that in turn increase risk for AUD, even after controlling for background familial factors associated with intermarriage. The sex differences observed are also consistent with previous findings that wives’ drinking is a stronger predictor of husbands’ subsequent drinking behavior across years of marriage (Leonard & Mudar, 2004).

The results from this observational study have several potential implications for clinicians working with AUD-affected individuals and their families. Perhaps most critically, our findings bring awareness to how partners’ different cultural backgrounds impact risk for AUD. As noted by others, culture and ethnicity have historically not been considered as part of couple or family treatments for alcohol use disorder (McCrady & Flanagan, 2021). This underscores a need for greater attention to the generalizability of existing treatment paradigms to couples’ cultural backgrounds, as well as the inclusion of diverse couple types in future clinical trials. We recognize that these are not trivial barriers to overcome given that cultural factors also shape perceptions of alcohol problems and willingness to seek treatment (Vaeth et al., 2017). Our findings also give insight into mechanisms that could be used in a therapeutic context for intermarried couples with an AUD-affected partner, such as attention to how cultural background may influence relationship expectations regarding drinking behavior.

We also caution that the results should interpreted in the context of its limitations. First, given that AUD diagnoses came from national registries, they typically capture the more severely affected individuals. Individuals with mild-to-moderate AUD are likely under-diagnosed. Tempering concerns about under-diagnosis, we note that the rates of AUD observed here closely parallel the rates of alcohol dependence observed in an epidemiological study in nearby Norway (Kringlen et al., 2001). Second, our analyses were limited to legally married opposite-sex couples, and it is unknown whether the pattern of findings generalizes to non-marital cohabiting relationships, which are relatively common in Sweden (Organisation for Economic Co-operation and Development, 2016), or to same-sex couples. Understanding the associations between marriage and cultural background among sexual minority individuals represents an important future direction given the higher rates of AUD among sexual minority individuals compared to heterosexual individuals, and evidence that partner influences on alcohol use is not uniform across same- and opposite-sex couples (Pollitt et al., 2020). Third, follow-up was censored by divorce, which raises potential concerns about bias due to censoring given that intermarried couples are also at higher risk of experiencing divorce compared to intramarried couples (Kalmijn et al., 2005). We provide descriptive information regarding rates of divorce by cultural background in Supplemental Table S1, for which there is considerable variation ranging from 16.09% to 35.91%. Fourth, our analyses of intramarriage and intermarriage were necessarily limited to groups of focal individuals for which there was sufficient sample size, precluding a more fine-grained, country-level analysis.

In summary, the present study makes a novel contribution to the literature regarding the protective effect of marriage on AUD risk. We found that, in Sweden, the protective effect of marriage on AUD depends on one’s own and their spouse’s cultural background. Males with a Finnish background (which has a higher-risk drinking culture), and those from a bicultural background (with one Swedish born parent and one foreign-born parent) benefitted less from the protective effects of marriage compared to those with a Swedish background. And among those with two Swedish-born parents, marriage to a spouse with foreign-born parents was associated with increased risk of AUD compared to marriage to a spouse with two Swedish-born parents, although this effect was reduced when family-level factors were controlled for. Such results illustrate the complex interplay between culture, social roles, and their impact on AUD risk.

Supplementary Material

Online Supplement

Supplemental material for this article is available online.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by grants R01 DA030005 and R01 AA023534 from the National Institutes of Health, the Swedish Research Council (2020-01175) as well as ALF funding from Region Skåne.

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