Drug and Alcohol Dependence 233 (2022) 109350

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Drug and Alcohol Dependence

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Trajectories of NEET (Not in Education, Employment, and Training) in

emerging adulthood, and later drug use disorder - a national cohort study.
Hélio Manhica a, *, Diego Yacamán-Méndez a, b, Hugo Sjöqvist a, Andreas Lundin a, b,
Emilie Agardh a, Anna-Karin Danielsson a
a
Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
b
Centre for Epidemiology and Community Medicine, Stockholm, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Being not in education, employment, or training (NEET) has been associated with poor health
Emerging adulthood outcomes. This study aimed to investigate the association between NEET during emerging adulthood and later
Not in Education drug use disorder (DUD) among males and females.
Employment
Method: A national cohort comprising 383,116 Swedish males and 362,002 females born between 1984 and
Or Training (NEET)
1990. NEET exposure was assessed annually between the ages 17 and 24 years, and follow-up for DUD between
DUD
Sibling-comparisons ages 25–33. Trajectories of NEET were estimated using group-based trajectory analysis. Cox regression analysis
And Trajectories was used to estimate hazard ratios (HR) of DUD. Sibling-comparison model was performed to account for po­
tential shared genetic and environmental factors.
Results: Four trajectories of NEET were identified: “constant low”, “transient peak”, “late increase”, and “constant
high”. Compared with the “constant low”, all other trajectories were associated with increased HRs of DUD. HR
was highest among males and females in the “late increase trajectory”; HR = 4.10 (3.79–4.44, 95% CI) and HR =
3.73 (3.29–4.24, 95% CI), after adjusting for domicile, origin, birth year, psychiatric diagnoses, and parental
psychiatric diagnoses. This association was reduced to about a twofold increased risk in the sibling comparison
analysis.
Conclusion: Being NEET during emerging adulthood was associated with later DUD for both males and females.
Neither origin, psychiatric diagnoses, parental psychiatric diagnoses, nor shared familial factors did fully explain
the association. Males and females belonging to the late increase NEET trajectory had about a twofold increased
risk of DUD.

1. Introduction
Emerging adulthood - covering the ages ~ 17 to ~ 25 (Arnett, 2000),
is a critical developmental period for life opportunities, such as educa­
tion and training for a long-term adult occupation, but it is also a period
where several health risk behaviours peak (Arnett, 2000; Hochberg and
Konner, 2020). Exclusion from the educational system or labour market
during this period might expose young people to a range of social and
environmental risk factors for drug use behaviours; through, for
instance, poor living conditions in deprived neighbourhoods, social
exclusion, limited life opportunities and psychological distress
(Boardman et al., 2001; Spooner and Hetherington, 2005; Henkel, 2011;
Karriker-Jaffe, 2011; Patrick et al., 2012).
The concept of NEET (Not in Education, Employment, or Training)
has been widely used as an indicator for capturing the extent of young
people’s multifaceted disadvantage in the labour market and educa­
tional system (Mascherini, 2019). NEET encompasses all young people
who are unemployed and inactive, not enrolled in any formal or
non-formal education, as well as those who suffer from long-term sick­
ness or are otherwise unable to work or not available for work
(Mascherini and Ledermaier, 2016). Across the OECD (Organisation for
Economic Co-operation and Development) countries, the NEET rate
fluctuates significantly between nations and age groups. For example, in
2019 the average proportion of NEET rates across the OECD countries
was 6.6% among the 15–19 age group, and 14.9% in the 20–24 age
group. In Sweden, the proportion of NEET was 3.3% and 9% respec­
tively. In Sweden, like in other OECD countries, NEET has been associ­
ated with low education, growing up in poor socioeconomic

* Correspondence to: Karolinska Institutet Department of Global Public Health (GPH), SE-171 77 Stockholm, Sweden.
E-mail address: helio.manhica@ki.se (H. Manhica).

https://doi.org/10.1016/j.drugalcdep.2022.109350
Received 16 November 2021; Received in revised form 27 January 2022; Accepted 7 February 2022
Available online 11 February 2022
0376-8716/© 2022 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
H. Manhica et al.
environments (OECD, 2016), having a migrant background, (Manhica
et al., 2019) experiencing mental health problems (Baggio et al., 2015;
Rodwell et al., 2018; Plenty et al., 2021; Ringbom et al., 2021), or
having parents with substance use disorder (Pitkänen et al., 2021;
Welford et al., 2022), With regards to sex differences, findings are
mixed; some studies have shown that youth males in Sweden are more
likely to be NEET than females (Forslund and Liljeberg, 2021), others
have shown the opposite (OECD, 2016).
Previous studies have reported associations between NEET and
negative social and health outcomes, including anxiety/depression
symptoms, smoking (Basta et al., 2019), increased risk of social exclu­
sion (OECD, 2021), suicidal behaviour (Benjet et al., 2012), and crime or
violence (Henderson et al., 2017). However, most of the prior research
relies on cross-sectional data (O’Dea et al., 2014; Stewart et al., 2017;
OECD, 2021). This limits the understanding of the associations between
NEET and health outcomes. In addition, although shared familial genetic
and environmental factors have been associated with drug use or dis­
orders in both males and females (Kendler et al., 2003), there is, to our
knowledge, no study that has accounted for familial genetic and envi­
ronmental factors shared among siblings that might account for the
associations between NEET and drug use disorders. Also, previous
studies of NEET have measured NEET as a fixed moment in youth´s life
(Mascherini, 2019), although in reality this situation may be continu­
ously changing. For some, being NEET might be temporary, while for
others it may be persistent; young people are moving in and out of being
NEET.
Even if the prevalence of drug use disorders in males and women is
narrowing worldwide (McHugh et al., 2018), males account for
approximately 75% of all drug-related deaths in Sweden (Leifman,
2016). Therefore, studying drug use disorders separately in males and
females is important for developing effective policy responses. Also,
drug use problems might vary across ages. For example, while the DUD
peaks in early adulthood, it decreases thereafter (Vasilenko et al., 2017).
The influence of migrant background on patterns of illicit drug use and
their response to drug problems might be particularly important, for
example through the effect of acculturation in shaping migrants’
healthcare-seeking behaviours to become similar to the native popula­
tion (Berry, 2001). Acculturation might also be stressful and cause
psychological distress due to culture clashes and hostile socioeconomic
environments (Revollo et al., 2011). These stressors might encourage
illicit drug use as a coping strategy (Fosados et al., 2007). Moreover,
illicit drug use has been linked to urban environments (Galea et al.,
2005), particularly those characterized by socio-economic deprivation
(Pear et al., 2019).
In this study, we aimed to explore NEET longitudinally and examine
the associations between trajectories of NEET during emerging adult­
hood and the risk of later drug use disorder (DUD) among males and
females.
Specifically, we wanted to answer the following questions:
1. To what extent are different trajectories of NEET during emerging
adulthood associated with later risk of DUD?
2. Are potential associations explained by origin, domicile, other psy­
chiatric disorders, and/or parental psychiatric disorders?
3. To what extent are potential associations explained by shared fa­
milial factors among siblings?
2. Material and methods
2.1. Study population
The study population comprised all individuals born between 1984
and 1990, who were alive and registered in Sweden on their 17th
birthday between January 2001 and December 2007, according to the
Register of the Swedish Total Population. These individuals were
followed-up annually for NEET between 2001 and 2014, when they
2
Drug and Alcohol Dependence 233 (2022) 109350
were aged 17–24 years, using data from Statistics Sweden’s Longitudinal
Integration Database for Health Insurance and Labor Market Studies -
LISA (SCB, 2017), and for DUD diagnoses between January 2008 and
December 2016, when they were between 25 and 33 years of age, from
the Swedish National in- and out-patient register. Individuals who died,
and those with a diagnosis of DUD before their 25th birthday (n = 9171)
were excluded from the analyses. The final study population consisted of
745,118 individuals (383,116 males and 362,002 females). See sup­
plements: timeline (efigure 1). This study adhered to the Reporting of
Observational Studies in Epidemiology (STROBE) Statement. See sup­
plements (eTable 1). This research was done without patient or public
involvement. Neither were involved in the study design or invited to
comment on the study design and main results.
2.2. NEET
NEET was based on a model created by the European Statistical
Office (Eurostat) for estimating the prevalence of labour market
vulnerability facing youths. The definition of NEET proposed by Euro­
stat was built using data from the EU Labour Force Survey. The indicator
comprises the proportion of the population aged 15–29 who have
remained outside education, employment or training for 6 months or
more during the preceding 12 months (Mascherini and Ledermaier,
2016; Mascherini, 2019). For this study, we defined emerging adulthood
as the period between 17 and 24 years of age, and NEET as individuals
who were living and registered in Sweden for an entire calendar year
with an annual income below the price-based amount (PBA) (a national
statistic calculated annually from the consumer-price index), not
receiving study loans or grants and not registered for education for more
than 60 h (MUCF, 2020). The exposure variable was coded as being
NEET (= 1) or not (= 0), each year from the age of 17 years to age 24.
This indicator of NEET was based on information on income sources
according to the LISA-database and was defined according to the
Swedish Agency for Youth and Civil Society (MUCF).
2.3. Drug Use Disorders
The outcome refers to the first visit to inpatient or outpatient care
from the age of 25 years and onwards, with a diagnosis of a drug use
disorder, following the definitions in the tenth edition of the World
Health Organization International Classification of Disorders, ICD-10.
This was defined as follows: mental and behavioural disorders due to
use of opioids (F11), cannabinoids (F12), sedatives or hypnotics (F13),
cocaine (F14), other stimulant related disorders (F15), hallucinogens
(F16), volatile solvents (F18), and other psychoactive substance-related
disorders and unspecified psychoactive substance-induced disorders
(F19).
2.4. Covariates
The following covariates were assessed at baseline (year they turned
24), as possible confounders of the association between NEET and drug
use disorders. Origin was based on the Multi-Generation Register and
categorized as: (i) Native Swedish, comprising all youths born in Sweden
with both parents born in Sweden; (ii) Offspring of migrants, encom­
passing Swedish-borns with at least one parent born abroad; and (iii)
Youth migrants, classified as individuals born outside Sweden with both
parents also born abroad. Domicile was categorized into three cate­
gories, in concordance with the Swedish Association of Local Authorities
and Regions: Big city referred to Sweden’s three largest cities: Stock­
holm, Gothenburg, and Malmö. Medium-sized town covered other pre­
dominately urban municipalities, and rural area the remainder (S.K.L,
2019). Sex was coded into female or male sex. Birth year varies between
1984 and 1990. Psychiatric diagnosis was captured from birth until the
age of 24 years. This referred to the history of any psychiatric diagnosis
other than drug use disorders (F01–F10, F17 and F20–F99), according to
H. Manhica et al.
the Swedish national inpatient and outpatient registers. Parental psy­
chiatric diagnosis was based on parental history of at least one episode
of hospital care with any psychiatric diagnosis, including substance use
disorders from the child’s birth up to 24 years of age.
2.5. Statistical analyses
First, we estimated the longitudinal developmental trajectories of
NEET at ages 17–24 years, using Group-Based Trajectory Modelling
(GBTM), a semi-parametric implementation of finite mixture models
that aims to estimate underlying trajectories within a population (Nagin,
2014). Participants with information on being NEET during at least
two-time points were included in the analysis. Model selection was done
stepwise, based on a comparison of the Bayes information criterion (BIC)
and Akaike information criterion (AIC) between different models as
measurements of the goodness of fit. Comparison of the models’ entropy
and a minimum posterior probability of group membership greater than
75% in each trajectory group was used as a criterion to assess group
discrimination, and a minimum predicted proportion of individuals
greater than 1% in each trajectory group was used as criteria to ensure
an adequate sample size in each trajectory group (van de Schoot et al.,
2017; Lennon et al., 2018).
We began with determining the number of underlying trajectories by
comparing models with 2–7 trajectories (k). This was followed by a
selection of the polynomial structure of the model by comparing com­
binations of linear, quadratic, cubic and quartic polynomial terms.
Additional information regarding model selection is available in Sup­
plementary material (eTable 2– 4). After model selection, individuals
were assigned to the trajectory group that they had the highest posterior
probability of belonging to. Missing data were imputed using full in­
formation maximum likelihood (FIML) estimation under the assumption
of missing at random (MAR).
Second, we estimated the proportions of DUD by covariates in males
and females, and the socio-demographic characteristics of trajectory
membership. We used Cox proportional hazards regression (the general
model) analyses to measure time-to-event, using age as the underlying
time scale (Hosmer Jr et al., 2008). Follow-up started from the age of 25
years and participants were censored at the first recorded hospital
admission due to drug use disorder, emigration, death, or the end of the
follow-up period on 31 December 2016.
Results were presented in 4 different models, as Hazard Ratios (HRs)
with 95% Confidence Intervals (CI). In all models, the “Constant low
trajectory of NEET” was chosen as the reference category. Model 1 was
adjusted for the calendar year and domicile; Model 2 added origin;
Model 3 adjusted for all aforementioned variables and psychiatric
diagnosis, while Model 4 added parental psychiatric diagnosis.
Third, we estimated Cox regression analyses using within-model
stratification (the sibling model). We allowed the model’s baseline
hazard to vary for each family (strata) and thus account for the un­
measured familial confounding factors. Cox regression models were also
used to estimate the HRs of DUD in families of same-sex siblings with at
least one DUD diagnosis. The siblings were required to have the same
biological mother and father. Results were presented as HRs with 95%
CIs. Model 1 was adjusted for birth year and Model 2 added psychiatric
diagnosis. Because the analyses were stratified by sex, the sibling anal­
ysis focused on same-sex siblings for a more homogenous comparison.
In sensitivity analyses, we tested whether the fitted HRs of DUD by
trajectories of NEET varied during our study period and measured the
HRs in males and females within-time stratified ages: 25–28 and 29–33
years of age. This was done because age ranges may represent different
life events among young adults that might protect them against certain
health risk behaviours, leading to non-proportional hazards as age in­
creases. Furthermore, we tested whether the effect of NEET on the later
risk of DUD differ between those in short- and long-term NEET. We
assessed an alternative exposure (accumulation of years in NEET) and
compared the risks of DUD among youths who accumulated one or
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Drug and Alcohol Dependence 233 (2022) 109350
multiple episodes of NEET to those who did not experience NEET, after
adjusting for confounders. We also conducted additional Cox regression
analyses on siblings (i.e., without the strata command) to assess for
possible potential selection bias in the sibling sample, after adjusting for
birth year, origin, psychiatric diagnosis, and parental psychiatric
diagnosis.
We examined the proportional hazard assumption by using
Schoenfeld residuals (Beyersmann, 2009). Results suggested that there
is no evidence that the proportional-hazards assumption has been
violated. Statistical analyses were done using Stata 15 and GBTM was
implemented using the Traj_program (Jones and Nagin, 2012).
3. Results
We identified four distinctive trajectories of NEET in emerging
adulthood (Fig. 1). Trajectories of NEET were descriptively named: 1)
Constant low trajectory (71.9% of males and 88.9% of females), char­
acterized by a close to zero estimated probability of being NEET during
emerging adulthood; 2) Transient peak trajectory (12.5% of males and
6.7% of females), with an initial close to zero estimated probability of
being NEET, but a steep increase from the ages 19–21, followed by a
decrease almost to zero by the end of emerging adulthood; 3) Late in­
crease trajectory (12.8% of males and 8.6% of females), characterized
by a constant increase in probability of being NEET from age 19 until the
age of 22 for males and 23 for females; and 4) Constant high trajectory
(2.9% of males and 2.0% of females), characterized by individuals with
a high probability of being NEET during the whole study period.
Most of the study population were native Swedes and lived in
medium-sized towns. About 4.5% of females and 3.4% of males had a
psychiatric diagnosis. Nearly 11% of males and females had at least one
parent with a history of psychiatric diagnosis. About 30% of males and
females had siblings of the same sex. Also, 72% of males and 89% of
females had a constant low probability of being NEET (Table 1).
While the majority of the study population were in the constant low
trajectory; the proportion of individuals in the late increase trajectory
was about 20% and 17% in male migrants and offspring of migrants,
compared to 11% among native Swedes. The distribution of NEET tra­
jectories by socio-demographic characteristics are available in Supple­
mentary material (eTable 5).
When compared with those in the constant low trajectory group
(Table 2), the Hazard Ratios (HRs) of drug use disorders were highest
among males in the late increase trajectory (HR = 4.94 (4.57–5.33, 95%
CI)), and the constant high trajectory (HR = 4.54 (3.96–5.21, 95% CI))
after adjustments for birth year and domicile. These associations
decreased to HR = 4.10 (3.79–4.44, 95% CI) and HR = 3.03 (2.63–3.50,
95% CI), respectively, after adjusting for origin, other psychiatric di­
agnoses, and parental psychiatric diagnoses. Among females, the risks
were also highest in the late increase trajectory (HR = 5.17 (4.85–5.84,
95% CI)) and the constant high trajectory (HR = 4.65 (3.70–5.85, 95%
CI)), after adjustments for birth year and domicile. The estimates were
further attenuated in the fully adjusted model HR = 3.73 (3.29–4.24,
95% CI) and HR = 2.67 (2.11–3.38, 95% CI).
When comparing the risks of DUD between male siblings (Table 3),
we found an elevated risk of DUD in the late increase trajectory (HR=
2.44 (1.82–3.28, 95% CI)). No significant associations were found for
the other trajectories. The results for the female siblings also indicated
an approximate two-fold increased risk of DUD in the late increase
trajectory (HR = 2.21 (1.33–3.67, 95% CI)) when compared with the
constant low trajectory.
Our sensitivity analyses suggested that the associations between
NEET trajectories and DUD were consistent across the stratified age
groups (25–28 and 29–33 years). See supplements (eTable 6 and 7).
Second, additional analyses on the duration of NEET and later risk of
DUD suggested that more years being NEET was associated with
increased risks of DUD in both males and females, after adjusting for
birth years origin, other psychiatric diagnoses, and parental psychiatric
H. Manhica et al. Drug and Alcohol Dependence 233 (2022) 109350

Fig. 1. Trajectories of NEET.

that there is no bias in the siblings sample (eTable 11).

Table 1
Socio-demographic characteristics and rates of drug use disorders by covariates
4. Discussion
among males and females, 2008–2016.
Covariates Drug Use disorders
We identified four NEET trajectories during emerging adulthood in
Male (N = 383 116) Females (N = 362 002) males and females: the “constant low", ”transient peak”, “late increase”,
Trajectory of NEET % DUD % DUD and “constant high” trajectories. When compared with the “constant
Constant low 72.0 1 399 83.0 783 low”, we found that all trajectories were associated with an excessive
Transient peak 12.5 312 6.7 195 risk of later drug use disorders, including after adjustment for birth year,
Late increase 12.6 1 162 8.4 396
domicile, origin, psychiatric diagnosis, and parental psychiatric diag­
Constant high 2.9 239 1.9 81
Origin nosis. Males and females from the “late increase” trajectory had the
Native Swedish 78.7 2 056 78.8 1 051 highest risks. When accounting for shared familial factors in the males
Youth migrant 6.1 302 5.8 80 and females’ sibling-comparison models, the “late increase” trajectory
Offspring of migrants 12.2 754 15.4 324 showed a two-fold risk of later drug use disorder. However, no signifi­
Calendar year
1984 12.6 607 12.5 245
cant risk was found for the other trajectories.
1985 13.2 516 13.2 255 To our knowledge, this is the first study investigating the associations
1986 13.6 523 13.6 277 between trajectories of NEET during emerging adulthood and the risk of
1987 13.8 501 14.0 221 later drug use disorder among males and females, respectively. Our re­
1988 15.0 414 14.9 181
sults suggest that the cumulative effect of NEET (eTable 8) as well as the
1989 15.4 347 15.4 179
1990 16.4 204 16.4 97 critical period, i.e., exposure to NEET at the end of emerging adulthood,
Domicile seems to have a stronger association with later drug use disorders.
Large city 33.2 1 251 36.2 627 Furthermore, it is also possible that persistence and recurrence of NEET
Medium-sized town 49.4 1 418 47.9 615 status through young adulthood might further obstruct future labour
Rural area 17.4 433 15.9 213
market participation and increase vulnerability to DUD. Findings that
Psychiatric diagnosis
No 96.6 2 689 95.5 1 076 NEET is a dynamic phenomenon in emerging adulthood corroborate
Yes 3.4 423 4.5 379 previous research that has examined NEET longitudinally (Baggio et al.,
Psychiatric diagnosis 2015; Contini et al., 2019), providing insights into sensitive periods for
No 89.4 2 377 89.3 1 082
targeted policy interventions to meet the needs of youth subgroups. Like
Yes 10.6 735 10.7 373
Siblings with the same sex several cross-sectional studies on associations between NEET and poor
No 70.5 2 310 72.1 1 103 health outcomes (Benjet et al., 2012; O’Dea et al., 2014; Henderson
Yes 29.5 802 27.9 352 et al., 2017; Stewart et al., 2017; Stea et al., 2019). Our findings showed
that being NEET during emerging adulthood was associated with an
increased risk of later DUD. These findings suggest that the exclusion
diagnosis (eTable 8 and 9). When we also tested this association in the
from the educational system or the labour market during emerging
sibling analyses using within-model stratification; the risks were atten­
adulthood might lead to psychological distress (Gariépy and Iyer, 2019),
uated considerably, and there were no statistical differences between the
which in turn, may result in excessive drug use, as a coping strategy to
length of NEET and DUD. Results are available in Supplementary ma­
deal with feelings of distress (Weiss et al., 1992; Khantzian, 1997). In
terial (eTable 10). When we tested the HRs of the general models for
addition, it is possible individuals whose parents’ misused drugs are
DUD among the siblings (without the strata command), associations
prone to develop later drug use problems themselves (Knight et al.,
were approximately equal to those of the general models, suggesting

4
H. Manhica et al. Drug and Alcohol Dependence 233 (2022) 109350

Table 2
Cox regression models for drug use disorders by trajectories of NEET in males and females 2008–2016.
Trajectory of NEET during emerging adulthood N DUD HR 95% CI HR 95% CI HR 95% CI HR 95% CI

Males Model 1 Model 2 Model 3 Model 4

Constant low 300, 012 1 399 ref ref ref ref

Transient peak 24, 306 312 1.28 (1.30–1.44) 1.26 (1.12–1.43) 1.25 (1.11–1.42) 1.24 (1.10–1.41)
Late increase 30, 594 1 162 4.94 (4.57–5.33) 4.69 (4.34–5.08) 4.31 (3.98–4.67) 4.10 (3.79–4.44)
Constant high 7, 090 239 4.54 (3.96–5.21) 4.26 (3.70–4.88) 3.22 (2.80–3.71) 3.03 (2.63–3.50)
Females
Constant low 275, 309 783 ref ref ref ref
Transient peak 47, 750 195 3.19 (2.72–3.73) 3.16 (2.70–3.70) 2.73 (2.33–3.20) 2.57 (2.20–3.02)
Late increase 48, 989 396 5.17 (4.85–5.84) 5.13 (4.54–5.80) 3.94 (3.48–4.48) 3.73 (3.29–4.24)
Constant high 11, 068 81 4.65 (3.70–5.85) 4.62 (3.64–5.82) 2.84 (2.25–3.60) 2.67 (2.11–3.38)

CI: Confidence interval; HR: Hazard ratio; Ref: reference category. N: population in the trajectories
Model 1 adjusted for birth year and domicile, Model 2 additionally adjusted for country of origin, Model 3 additionally adjusted for psychiatric diagnosis. Model 4
additionally adjusted for parental psychiatric diagnosis *DUD = hospital admission due to any drug use disorder.

the late increase group, the elevated risks for DUD even in the sibling
Table 3
analysis indicate that familial factors do not entirely account for the
Sibling comparison Cox regression models for drug use disorders by trajectories
association. This suggests that interventions aimed at reducing the risks
of NEET in males and females with at least one brother or sister alive during
2008–2016. of being long-term NEET, particularly in late-emerging adulthood,
might help to reduce risks of later drug use disorders.
The trajectory of NEET during N DUD HR 95% CI HR 95% CI
emerging adulthood

Males Model 1 Model 2 4.1. Strengths and Limitations

Constant low 83, 377 ref ref
680 A major strength of this study was that it was based on data from a
Transient peak 14, 75 1.13 1.09 combination of national registers covering the entire population living
667 (0.75–1.72) (0.71–1.66) in Sweden. To our knowledge, this is the first longitudinal study inves­
Late increase 14, 291 2.44 2.33 tigating the association between trajectories of NEET and later DUD. We
547 (1.82–3.28) (1.73–3.16)
Constant high 3, 59 1.66 1.60
analyzed females and males separately and adjusted for important
342 (0.99–2.79) (0.94–2.72) confounding variables. In addition, we conducted sibling analyses to
Females account for potential unmeasured familial confounding factors.
Constant low 86, 196 ref ref Some limitations with our study should be noted. First, NEET and
469
drug use disorders might share many additional overlapping risk factors
Transient peak 6, 41 0.91 0.93
898 (0.47–1.76) (0.48–1.85) (e.g., family situation, health status, neighbourhood), on which we had
Late increase 8, 98 2.21 1.89 no information (albeit the sibling analyses might attenuate some of
795 (1.33–3.67) (1.12–3.19) those issues). Second, our registers only capture DUD in those who have
Constant high 1, 17 1.27 1.01 been in contact with specialized health care and received a diagnosis. As
981 (0.50–3.28) (0.36–2.77)
this is an indicator of care-seeking behaviours, individuals who face
CI: Confidence interval; HR: Hazard ratio. Ref: reference category. N = Sibling barriers to seeking care for drug use problems are not captured in the
pairs registers. As a result, the true proportion of individuals suffering from
Model 1 adjusted for birth year; Model 2 adjusted for birth year and drug use disorders is likely to be higher than those reported in our study.
DUD = hospital admission due to any drug use disorder.
Third, even if we excluded individuals diagnosed with DUD before their
25th birthday, it is still possible that NEET instead is a result of drug use
2014; Bears Augustyn et al., 2019, Rothenberg et al., 2020). problems not captured in our registers. Thus, the results should be
In contrast to our findings, where NEET and DUD were accessed interpreted with caution.
longitudinally through national registers, findings from Switzerland did Fourth, the concept of NEET has been criticized by different scholars
not suggest negative effects of NEET on mental health and substance use due to the heterogeneity of the population groups it captures
behaviors in males (Baggio et al., 2015). These investigations assessed (Mascherini, 2019). For one thing, youth who are NEET are by definition
NEET and substance use through self-reported data, which might be a group with very different experiences, characteristics, and needs,
prone to response bias (Rosenman et al., 2011). Furthermore, the au­ encompassing both vulnerable and non-vulnerable individuals (O’Reilly
thors considered NEET as an uncommon and transient phenomenon et al., 2018). Furthermore, the definition of NEET used in this study was
among young men in Switzerland. derived from data on income sources and education. This means that
Our findings also suggest that potential confounders available in the individuals with unknown activity or undeclared income and those who
register data (e.g. domicile, origin, other psychiatric disorders, and were travelling or working abroad (but were still registered in Sweden)
parental psychiatric diagnosis) explained part of the association be­ may have been defined as being NEET. Which if they had a lower risk of
tween trajectories of NEET and later drug use disorders. In sibling an­ DUD would lead to deflated risk estimates.
alyses, we intended to account for possible unreported familial social Fifth, although Group-Based Trajectory Modelling and other finite
environmental factors shared among siblings that might account for mixture models are useful tools to summarize complex patterns of data,
DUD. Although the number of outcomes in some trajectory groups was there are methodological limitations related to their use (Herle et al.,
limited, our results suggest that the underlying structure of the social- 2020). The basic assumption of GBTM is that the observed data consists
environmental risk factors for NEET and DUD is quite similar for of several unobserved, underlying subpopulations with similar devel­
males and females. Additionally, our findings that males and females opmental trajectories. Every individual data point is assigned to the
from the “late increase” trajectory were at particular risk for DUD sug­ sub-population it was most likely generated from. In theory, this might
gested that the association are not explained fully by familial social introduce bias due to misclassification of the exposure (Nagin, 2009).
environmental factors shared among the same-sex siblings. That is for However, the uncertainty of assigning an observation to a certain

5
H. Manhica et al.
sub-population is similar between all trajectory groups. This means that
misclassification would be non-differential, leading to a type 2 error. For
our findings, this means that significant associations between trajec­
tories of NEET and DUD are likely to be underestimated.
Additionally, model selection is based on measurements of the
goodness of fit and adequacy given the data from our study population
(Twisk and Hoekstra, 2012). Replication of the trajectory modelling
using external and independent data sets is needed to ensure external
validity.
Sibling analyses are used to account for shared familial confounding
– both environmental and genetic – but should be interpreted with
caution, due to their tendency to bias the risk towards the null (Frisell
et al., 2012). However, this supports the presence of a significantly
increased risk among those with a late increase NEET trajectory for
developing later DUD; this appears not to be fully explained by factors
other than those shared between same-sex siblings. Another limitation
of sibling analyses is a risk of selection bias, a result of restricting the
sample to families with same-sex siblings, wherein at least one has a
diagnosis of DUD.
5. Conclusions
Four trajectories of NEET in males and females were identified: the
“constant low”, “transient peak”, “late increase”, and “constant high”.
When compared to the constant low trajectory, all trajectories of NEET
were associated with an increased risk of later DUD, after adjusting for
domicile, origin, psychiatric diagnoses and parental psychiatric di­
agnoses. Sibling-comparison models supported the findings with regards
to the “late increase trajectory”, but not the other trajectories. Pre­
venting youths from being NEET in emerging adulthood might be
important in reducing their risks of later drug use disorders.
CRediT authorship contribution statement
Authors HM, DY-M, HS, AL, EA and AKD designed the study. Authors
HM and AKD conducted literature searches and author HM, DY-M, HS
did the statistical analyses. Author HM wrote the first draft of the
manuscript and all authors (HM, DY-M, HS, AL, EA and AKD) contrib­
uted to and have approved the final manuscript.
Author Disclosures
Statement 1: Role of Funding Source.
This study was supported by the Research Council for Health
Working Life and Welfare (Forte: 2016–07108). The funding source had
no role in designing and executing the study.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.drugalcdep.2022.109350.
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