Senso de coerência e uso de substâncias em adultos: revisão sistemática e metanálise

Danigno, Júlia Freire; Dias, Mariane da Silva; Horta, Bernardo Lessa

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REVIEW • Cad. Saúde Pública 40 (9) • 2024 • https://doi.org/10.1590/0102-311XEN141323 copiar

Senso de coerência e uso de substâncias em adultos: revisão sistemática e metanálise

Autoria SCIMAGO INSTITUTIONS RANKINGS

O objetivo deste estudo foi fazer uma revisão sistemática das evidências sobre a associação entre senso de coerência (SOC) e uso de substâncias na vida adulta. Dois pesquisadores buscaram, independentemente, as bases de dados PubMed, LILACS, PsycINFO e Web of Science. Foram incluídos artigos originais que avaliaram o SOC e o uso de substâncias em adultos (idade > 19 anos). Dois revisores avaliaram, independentemente, os estudos em duas fases - inicialmente com base no título/resumo e, em seguida, no texto completo. Discrepâncias foram resolvidas por um terceiro revisor. Modelos de efeitos aleatórios foram usados para agrupar as estimativas. Identificamos 21 estudos que investigaram a associação entre SOC e uso de substâncias em adultos. Entre os 11 estudos que avaliaram a associação com o tabagismo, a chance de fumar foi de 0,92 (IC95%: 0,82; 1,01, grau de confiança muito baixo) entre aqueles com alto SOC, e a associação não foi modificada pela idade. Indivíduos com forte SOC tiveram menores chances de usar álcool (efeito combinado: OR = 0,70, IC95%: 0,50; 0,90, grau de confiança muito baixo), e o ajuste para confusão diminuiu a magnitude da associação (OR combinado = 0,89, IC95%: 0.80; 0.98). Esta revisão sistemática e metanálise sugere que um forte SOC protege contra o uso de substâncias entre adultos, independentemente da idade, com implicações práticas para intervenções preventivas e estratégias personalizadas, especialmente para indivíduos de alto risco. Estudos longitudinais são necessários para entender o impacto do SOC no uso de substâncias. Examinar as interações com fatores socioeconômicos e incluir diversas populações aumentaria a generalização.

Palavras-chave:
Senso de Coerência; Uso de Substâncias; Fumar; Droga Ilícita; Consumo de Bebidas Alcoólicas

Study/Country (Year)	Study design	Sample/Follow-up rate (%)	Mean age (in years)	SOC	Categorization of SOC	Substance use	Scale of substance use	Categorization of substance use	Effect measures (95%CI) *	Control for confounding
Neuner et al. ¹⁶16. Neuner B, Miller P, Maulhardt A, Weiss-Gerlach E, Neumann T, Lau A, et al. Hazardous alohol consumption and sense of coherence in emergency department patients with minor trauma. Drug Alcohol Depend 2006; 82:143-50. Germany (2006)	Prospective	2,056 30.2%	34 ± 12	SOC-L9	Quartiles: strongest vs. weakest	Alcohol	AUDIT score	Hazardous alcohol consumption (yes/no). Yes, in men: AUDIT 8-40 points; in women: AUDIT 5-40 points)	OR = 0.51 (0.36; 0.72)	Age, gender, income, education, additional substance use
						Smoking	Structured self-designed questionnaire	Smokers (current)/ex and non-smokers	OR = 0.59 (0.45; 0.78)
						Drugs	Structured self-designed questionnaire	No/Yes. Yes: use of illicit drugs at least 1 to 3 times within the last 12 months	OR = 0.46 (0.33; 0.66)
Antonovsky et al. ¹⁷17. Antonovsky H, Hankin Y, Stone D. Patterns of drinking in a small development town in Israel. Br J Addict 1987; 82:293-303. Israel (1987)	Cross-sectional	120 (male) 83.64%	41.1	SOC-7	Dichotomous: strong vs. weak	Alcohol	Structured self-designed questionnaire	Drinkers/Non-drinkers. Drinkers: drink once to several times per day	OR = 0.46 (0.18; 1.18)	No
Tobamidanik & Zabkiewicz ¹⁸18. Tobamidanik L, Zabkiewicz D. Indicators of sense of coherence and alcohol consumption-related problems: the 2000 U.S. National Alcohol Survey. Subst Use Misuse 2009; 44:357-73. United States (2009)	Cross-sectional	4,630	62.4 ± 19	SOC-3	Terciles: strongest vs. weakest	Alcohol	Alcohol dependence - DSM-IV	Drinkers/Non-drinkers. Drinkers: 5 or more drinks consumed at least once per week	OR = 0.30 (0.24; 0.37)	Age, gender, income, education, additional substance use
Wainwright et al. ¹⁹19. Wainwright NW, Surtees PG, Welch AA, Luben RN, Khaw KT, Bingham SA. Healthy lifestyle choices: could sense of coherence aid health promotion? J Epidemiol Community Health 2007; 61:871-6. United Kingdom (2007)	Cross-sectional	18,287 87.40%	41.0-80.0	SOC-3	Dichotomous: strong vs. weak	Smoking	Structured self-designed questionnaire	Smokers (current)/ex and non-smokers	OR = 0.74 (0.63; 0.86)	Age, gender, income, education
Morita et al. ⁵5. Morita Y, Ohta M, Inoue T, Honda T, Konno Y, Eguchi Y, et al. Sense of coherence is significantly associated with both metabolic syndrome and lifestyle in Japanese computer software office workers. Int J Occup Med Environ Health 2014; 27:967-79. Japan (2014)	Cross-sectional	167 90%	41.9 ± 9.8	SOC-29	Terciles: strongest vs. weakest	Smoking Alcohol	Lifestyle-related questionnaire	Smokers (current)/ex and non-smokers	OR = 1.19 (0.43; 3.34)	Age, gender, income, social support
	Cross-sectional	167 90%	41.9 ± 9.8	SOC-29	Terciles: strongest vs. weakest	Smoking Alcohol	Lifestyle-related questionnaire	Drinkers/Non-drinkers. Drinkers: drinking more than 1 gou ** per day	OR = 0.78 (0.33; 1.85)
Savolainen et al. ²⁰20. Savolainen J , Suominen-Taipale A, Uutela A, Aromaa A, Härkänen T, Knuuttila M. Sense of coherence associates with oral and general health behaviours. Community Dent Health 2009; 26:197-203. Finland (2009)	Cross-sectional	8,028 88%	41.8 ± 10.6	SOC-12	Quintiles: strongest vs. weakest	Smoking	Structured self-designed questionnaire	Smokers (current)/ex and non-smokers. Smokers: regular or occasional smokers	OR = 0.75 (0.61; 0.91)	Age, gender, education
Silarova et al. ⁴4. Silarova B, Nagyova I, Rosenberger J, Studencan M, Ondusova D, Reijneveld SA, et al. Sense of coherence as a predictor of health-related behaviours among patients with coronary heart disease. Eur J Cardiovasc Nurs 2014; 13:345-56. Slovakia (2014)	Cross-sectional	179 60.1%	58.32 ± 6.54	SOC-13	Dichotomous: strong vs. weak	Alcohol	European Health and Behaviour Survey	Drinkers/Non-drinkers. Drinkers: occasional and regular	OR = 1.01 (0.97; 1.05)	Age, gender, income
	Cross-sectional	179 60.1%	58.32 ± 6.54	SOC-13	Dichotomous: strong vs. weak	Smoking	European Health and Behaviour Survey		OR = 1.06 (1.00; 1.13)
van Loon et al. ²¹21. van Loon AJM, Tijhuis M, Surtees PG , Ormel J. Personality and coping: their relationship with lifestyle risk factors for cancer. Pers Individ Dif 2001; 31:541-53. The Netherlands (2001)	Longitudinal	1,431 women 54%	42.6 ± 10.9	SOC-3	Dichotomous: strong vs. weak	Smoking	The Health and Life Experiences Questionary	Smokers (current) and ex/never	OR = 1.16 (0.98; 1.36)	Age
	Longitudinal	1,083 men	42.6 ± 10.9	SOC-3	Dichotomous: strong vs. weak	Smoking	The Health and Life Experiences Questionary	Smokers (current) and ex/never	OR = 1.05 (0.88; 1.25)	Age
Saade & Marchand ²²22. Saade SL, Marchand A. Work organisation conditions, alcohol misuse: the moderating role of personality traits. Work 2013; 44:191-200. Canada (2013)	Longitudinal	7,338 81%	43.82 ± 10.16	SOC-13	Numerical	Alcohol	Canadian norms	Alcohol misuse. Yes: man drinks more than 14 drinks per week or when a woman drinks more than 9 drinks per week	OR = 0.99 (0.98; 1.00)	Age, gender, income, education, marital status, social support
Von Ah et al. ²³23. Von Ah D, Ebert S, Ngamvitroj A, Park N, Kang DH. Factors related to cigarette smoking initiation and use among college students. Tob Induc Dis 2005; 3:27-40. United States (2005)	Cross-sectional	161 40%	19.6 ± 4.09	SOC-29	Numerical	Smoking	4-item tobacco self-efficacy questionnaire	Smokers (current)/ex and non-smokers. Current smoker: an individual who smoked a whole cigarette within the last 30 days	OR = 1.01 (0.97; 1.04)	No
Ristkari et al. ⁶6. Ristkari T, Sourander A, Helenius H, Nikolakaros G, Salanterä S, Multimäki P, et al. Sense of coherence among Finnish young men - a cross-sectional study at military call-up. Nord J Psychiatry 2005; 59:473-80. Finland (2005)	Longitudinal	2,314 78.7%	67 ± 11	SOC-13	Quartiles: strongest vs. weakest	Smoking	Structured self-designed questionnaire	Smokers (current) and ex/never. Smokers: smoked during the last 6 months	OR = 0.99 (0.78; 1.26)	No
						Alcohol	Structured self-designed questionnaire	Drinker/Non-drinkers. Drunkers: drunk during the last 6 months	OR = 0.69 (0.49-0.87)
						Drugs	Structured self-designed questionnaire	Yes/No. Yes: drugs during the last 6 months	OR = 0.18 (0.10; 0.33)
Larm et al. ²⁴24. Larm P, Åslund C, Starrin B, Nilsson KW. How are social capital and sense of coherence associated with hazardous alcohol use? Findings from a large population-based Swedish sample of adults. Scand J Public Health 2016; 44:525-33. Sweden (2016)	Cross-sectional	40,674 59.2%	53.8 ± 17.9	SOC-13	Terciles: strongest vs. weakest	Alcohol	AUDIT-C	Hazardous alcohol consumption. Yes, in men: AUDIT 8-40 points; in women: AUDIT 6-40 points)	OR = 0.48 (0.36; 0.64)	Yes
Thomas et al. ²⁵25. Thomas K, Nilsson E, Festin K, Henriksson P, Lowén M, Löf M, et al. Associations of psychosocial factors with multiple health behaviors: a population-based study of middle-aged men and women. Int J Environ Res Public Health 2020; 17:1239. Sweden (2020)	Cross-sectional	1,007 62.5%	57 ± 7.2	SOC-29	Numerical	Alcohol	Structured self-designed questionnaire	Hazardous alcohol consumption. Drinking more than 9 standard glasses per week for women and more than 14 glasses per week for men, and/or reporting drinking 4 or more standard glasses for women and 5 or more glasses for men on a typical day when drinking	OR = 0.79 (0.64; 0.96)	Age, sex, education, income
	Cross-sectional	1,007 62.5%	57 ± 7.2	SOC-29	Numerical	Smoking	Structured self-designed questionnaire	Smokers (current)/ex and non-smokers	OR = 0.84 (0.71; 1.00)
Poppius et al. ²⁶26. Poppius E, Tenkanen L, Kalimo R, Heinsalmi P. The sense of coherence, occupation and the risk of coronary heart disease in the Helsinki Heart Study. Soc Sci Med 1999; 49:109-20. Finland (1999)	Longitudinal	4,405 73%	40-55	SOC-29	Terciles: strongest vs. weakest	Smoking	Structured self-designed questionnaire	Smokers (current)/ex and non-smokers	OR = 0.96 (0.82; 1.12)	Age
Gajdosova et al. ²⁷27. Gajdosova B, Orosova O, Geckova AM, Tavel P, van Dijk JP. Personality dimensions, sense of coherence and self-esteem as risk/protective factors for smoking among university students. Stud Psychol (Bratisl) 2009; 51:183-92. Slovakia (2009)	Cross-sectional	830 94.1%	20.5 ± 1.4	SOC-13	Numerical	Smoking	Structured self-designed questionnaire	Smokers (current)/ex and non-smokers	β: -0.61 (-2.06; 0.84)	No
Ahlstrand et al. ²⁸28. Ahlstrand I, Larsson I, Larsson M, Ekman A, Hedén L, Laakso K, et al. Health-promoting factors among students in higher education within health care and social work: a cross-sectional analysis of baseline data in a multicentre longitudinal study. BMC Public Health 2022; 22:1314. Sweden (2022)	Cross-sectional	851 37.3%	28	SOC-13	Numerical	Smoking	Structured self-designed questionnaire	Smokers (current)/ex and non-smokers. No: no or rarely	β: -3.33 (-5.63; -1.03)	Gender, additional substance use
	Cross-sectional	851 37.3%	28	SOC-13	Numerical	Alcohol	Structured self-designed questionnaire	Smokers (current)/ex and non-smokers. Current: > once per month	β -1.76 (-3.37-0.15)
Luszczynska ²⁹29. Luszczynska A. Sense of coherence and smoking in a sample of abused women. Psychol Rep 2002; 90(3 Pt 2):1123-8. Poland (2002)	Cross-sectional	83 women 100%	35.6 ± 9.0	SOC-29	Terciles: strongest vs. weakest	Smoking	Structured self-designed questionnaire	Cigarettes daily	β: -4.50 (-10.87; 1.86)	No
Vilela & Alisson ³⁰30. Vilela LD, Allison PJ. An investigation of the correlates of sense of coherence in a sample of Brazilians with head and neck cancer. Oral Oncol 2010; 46:360-5. Canada (2010)	Cross-sectional	162	25-88	SOC-13	Numerical	Smoking	Structured self-designed questionnaire	Smokers (current) and ex/non-Smokers	β: -4.40 (-13.73; 4.91)	Age, education, marital status
	Cross-sectional	162	25-88	SOC-13	Numerical	Alcohol	Structured self-designed questionnaire	Smokers (current) and ex/non-smokers	β: 2.30 (-10.47; 15.06)
Igna et al. ³¹31. Igna CV, Julkunen J, Ahlström R. Sense of coherence relates with smoking. J Health Psychol 2008; 13:996-1001. Sweden (2008)	Cross-sectional	841	59.4 ± 8.1	SOC-13	Numerical	Smoking	Structured self-designed questionnaire	Smokers (current) and ex/non-smokers	β: -3.20 (-4.79; -1.61)
Verešová & Gatial ³²32. Verešová M, Gatial V. Sense of coherence and proactive coping of university students: relations with alcohol and tobacco use frequency. Psychol Health 2010; 25:360. Romania (2010)	Cross-sectional	158	19-25	SOC-29	Numerical	Alcohol	No information	Smokers (current)/ex and non-smokers	β: -38.0 (-47.8; -28.8)	No
Kouvonen et al. ³³33. Kouvonen AM, Väänänen A, Woods SA, Heponiemi T, Koskinen A, Toppinen-Tanner S. Sense of coherence and diabetes: a prospective occupational cohort study. BMC Public Health 2008; 8:46. Finland (2008)	Longitudinal	313 5.7%	36-82	SOC-13	Terciles: strongest vs. weakest	Alcohol	Structured self-designed questionnaire	Hazardous alcohol consumption. Excessive drinking leading intoxication twice or more per month vs. less than twice per month	β: -4.24 (-4.27; -4.21)	Age, education, marital status, additional substance use

STUDY	BIAS DUE TO CONFOUNDING	BIAS IN SELECTION OF PARTICIPANTS INTO THE STUDY	BIAS IN CLASSIFICATION OF INTERVENTIONS	BIAS DUE TO DEVIATIONS FROM INTENDED INTERVENTIONS	BIAS DUE TO MISSING DATA	BIAS IN MEASUREMENT OF OUTCOMES	BIAS IN SELECTION OF THE REPORTED RESULT	OVERALL BIAS
Antonovsky et al. ¹⁷17. Antonovsky H, Hankin Y, Stone D. Patterns of drinking in a small development town in Israel. Br J Addict 1987; 82:293-303.	Serious	Serious	Low	Moderate	Moderate	Moderate	Low	Serious
Ahlstrand et al. ²⁸28. Ahlstrand I, Larsson I, Larsson M, Ekman A, Hedén L, Laakso K, et al. Health-promoting factors among students in higher education within health care and social work: a cross-sectional analysis of baseline data in a multicentre longitudinal study. BMC Public Health 2022; 22:1314.	Moderate	Low	Low	Low	Moderate	Low	Low	Moderate
Gajdosova et al. ²⁷27. Gajdosova B, Orosova O, Geckova AM, Tavel P, van Dijk JP. Personality dimensions, sense of coherence and self-esteem as risk/protective factors for smoking among university students. Stud Psychol (Bratisl) 2009; 51:183-92.	Serious	Serious	Low	Low	Low	Low	Low	Serious
Igna et al. ³¹31. Igna CV, Julkunen J, Ahlström R. Sense of coherence relates with smoking. J Health Psychol 2008; 13:996-1001.	Serious	Low	Low	Low	NI	Low	Low	Serious
Kouvonen et al. ³³33. Kouvonen AM, Väänänen A, Woods SA, Heponiemi T, Koskinen A, Toppinen-Tanner S. Sense of coherence and diabetes: a prospective occupational cohort study. BMC Public Health 2008; 8:46.	Low	Low	Low	Low	Moderate	Low	Low	Moderate
Larm et al. ²⁴24. Larm P, Åslund C, Starrin B, Nilsson KW. How are social capital and sense of coherence associated with hazardous alcohol use? Findings from a large population-based Swedish sample of adults. Scand J Public Health 2016; 44:525-33.	Low	Low	Low	Low	Low	Low	Low	Low
Luszczynska ²⁹29. Luszczynska A. Sense of coherence and smoking in a sample of abused women. Psychol Rep 2002; 90(3 Pt 2):1123-8.	Serious	Serious	Low	Low	Low	Low	Moderate	Serious
Tobamidanik & Zabkiewicz ¹⁸18. Tobamidanik L, Zabkiewicz D. Indicators of sense of coherence and alcohol consumption-related problems: the 2000 U.S. National Alcohol Survey. Subst Use Misuse 2009; 44:357-73.	Low	Low	Low	Low	NI	Low	Low	Low
Morita et al. ⁵5. Morita Y, Ohta M, Inoue T, Honda T, Konno Y, Eguchi Y, et al. Sense of coherence is significantly associated with both metabolic syndrome and lifestyle in Japanese computer software office workers. Int J Occup Med Environ Health 2014; 27:967-79.	Low	Moderate	Low	Low	Low	Low	Low	Moderate
Neuner et al. ¹⁶16. Neuner B, Miller P, Maulhardt A, Weiss-Gerlach E, Neumann T, Lau A, et al. Hazardous alohol consumption and sense of coherence in emergency department patients with minor trauma. Drug Alcohol Depend 2006; 82:143-50.	Low	Moderate	Low	Low	Moderate	Low	Low	Moderate
Poppius et al. ²⁶26. Poppius E, Tenkanen L, Kalimo R, Heinsalmi P. The sense of coherence, occupation and the risk of coronary heart disease in the Helsinki Heart Study. Soc Sci Med 1999; 49:109-20.	Moderate	Low	Low	Low	Low	Low	Low	Moderate
Ristkari et al. ⁶6. Ristkari T, Sourander A, Helenius H, Nikolakaros G, Salanterä S, Multimäki P, et al. Sense of coherence among Finnish young men - a cross-sectional study at military call-up. Nord J Psychiatry 2005; 59:473-80.	Serious	Low	Low	Low	Moderate	Low	Low	Serious
Saade & Marchand ²²22. Saade SL, Marchand A. Work organisation conditions, alcohol misuse: the moderating role of personality traits. Work 2013; 44:191-200.	Low	Low	Low	Low	Low	Low	Low	Low
Savolainen et al. ²⁰20. Savolainen J , Suominen-Taipale A, Uutela A, Aromaa A, Härkänen T, Knuuttila M. Sense of coherence associates with oral and general health behaviours. Community Dent Health 2009; 26:197-203.	Moderate	Low	Low	Low	Low	Low	Low	Low
Silarova et al. ⁴4. Silarova B, Nagyova I, Rosenberger J, Studencan M, Ondusova D, Reijneveld SA, et al. Sense of coherence as a predictor of health-related behaviours among patients with coronary heart disease. Eur J Cardiovasc Nurs 2014; 13:345-56.	Moderate	Moderate	Low	Low	Moderate	Low	Low	Moderate
Thomas et al. ²⁵25. Thomas K, Nilsson E, Festin K, Henriksson P, Lowén M, Löf M, et al. Associations of psychosocial factors with multiple health behaviors: a population-based study of middle-aged men and women. Int J Environ Res Public Health 2020; 17:1239.	Low	Low	Low	Low	Moderate	Low	Low	Moderate
Verešová & Gatial ³²32. Verešová M, Gatial V. Sense of coherence and proactive coping of university students: relations with alcohol and tobacco use frequency. Psychol Health 2010; 25:360.	Serious	Serious	NI	Moderate	NI	Moderate	Moderate	Serious
Vilela & Alisson ³⁰30. Vilela LD, Allison PJ. An investigation of the correlates of sense of coherence in a sample of Brazilians with head and neck cancer. Oral Oncol 2010; 46:360-5.	Low	Moderate	Low	Low	NI	Low	Low	Moderate
Von Ah et al. ²³23. Von Ah D, Ebert S, Ngamvitroj A, Park N, Kang DH. Factors related to cigarette smoking initiation and use among college students. Tob Induc Dis 2005; 3:27-40.	Serious	Moderate	Low	Moderate	Serious	Low	Low	Serious
van Loon et al. ²¹21. van Loon AJM, Tijhuis M, Surtees PG , Ormel J. Personality and coping: their relationship with lifestyle risk factors for cancer. Pers Individ Dif 2001; 31:541-53.	Moderate	Low	Low	Low	Moderate	Low	Low	Moderate
Wainwright et al. ¹⁹19. Wainwright NW, Surtees PG, Welch AA, Luben RN, Khaw KT, Bingham SA. Healthy lifestyle choices: could sense of coherence aid health promotion? J Epidemiol Community Health 2007; 61:871-6.	Low	Low	Low	Low	Low	Low	Low	Low

Participants (studies)	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Overall certainty of evidence	Relative effect (95% CI)
Alcohol
53,855 (8 nonrandomized studies)	Serious	Serious *	Not serious	Not serious	None	⨁◯◯◯ Very low	OR = 0.7 (0.5; 0.9)
Smoking
44,494 (11 nonrandomized studies)	Serious	Serious *	Not serious	Not serious	None	⨁◯◯◯ Very low	OR = 0.92 (0.82; 1.01)
Illicit drugs
4,370 (2 nonrandomized studies)	Serious	Not serious	Not serious	Serious	Publication bias strongly suspected; strong association **	⨁◯◯◯ Very low	OR = 0.31 (0.04; 0.59)

Subgroup analysis	Smoking				Alcohol
Subgroup analysis	Number of estimates	Pooled OR (95%CI)	I-squared (%)	p-value *	Number of estimates	Pooled OR (95%CI)	I-squared (%)	p-value *
Follow-up rate (%)				0.125				0.190
< 50	2	0.81 (0.40; 1.22)	95.8		1	0.51 (0.33; 0.69)	0.0
50-70	4	1.02 (0.90; 1.14)	67.4		3	0.70 (0.17; 1.23)	99.4
> 70	6	0.84 (0.72; 0.96)	51.3		4	0.78 (0.52; 1.04)	78.8
Sample size				0.016				0.599
< 1,000	3	1.02 (0.99; 1.05)	0.0		3	0.82 (0.44; 1.19)	59.7
1,000-1,999	1	0.84 (0.70; 0.98)	0.0		1	0.79 (0.63; 0.95)	0.0
≥ 2,000	7	0.88 (0.74; 1.03)	81.7		4	0.62 (0.17; 1.07)	99.3
Participants age				0.605				0.259
Young	2	0.81 (0.40; 1.22)	95.8		1	0.51 (0.33; 0.69)	0.0
Adult	6	0.97 (0.83; 1.11)	76.9		6	0.74 (0.51; 0.97)	98.9
Older adult	1	0.99 (0.75; 1.23)	0.0		1	0.69 (0.50; 0.88)	0.0
Study design				0.660				0.736
Cross-sectional	6	0.90 (0.78; 1.01)	84.3		5	0.67 (0.24; 1.10)	98.8
Longitudinal	5	0.95 (0.75; 1.15)	83.3		3	0.74 (0.41; 1.01)	94.5
Adjustment for confounding				< 0.001				< 0.001
No	5	0.94 (0.82; 1.07)	79.9		3	0.48 (0.17; 0.79)	86.4
Age	3	0.91 (0.69; 1.13)	82.6		1	0.79 (0.63; 0.95)	0.0
Age + gender + 1 socioeconomic status variable	1	1.06 (1.00; 1.12)	84.3		1	1.01 (0.97; 1.05)	0.0
Age + gender + additional substance use	2	0.60 (0.43; 0.76)	0.0		3	0.76 (0.35; 1.17)	92.7
Continent				0.228				< 0.001
America	1	1.01 (0.98; 1.04)	0.0		5	0.66 (0.28; 1.04)	98.8
Europe	9	0.90 (0.78; 1.02)	85.9		1	0.99 (0.98; 1.00)	0.0
Asia	1	1.19 (0.26; 2.64)	0.0		2	0.56 (0.14; 0.97)	0.0
Categorization of sense of coherence				0.187				0.032
Numerical	2	0.94 (0.78; 1.10)			2	0.91 (0.71; 1.10)	83.3
Dichotomous	4	1.00 (0.81; 1.18)			2	0.79 (0.27; 1.32)	78.3
Terciles	2	0.96 (0.81; 1.11)			2	0.60 (0.42; 0.77)	34.3
Quartiles	2	0.78 (0.39; 1.17)			2	0.91 (0.71; 1.10)	45.0
Quintiles	1	0.75 (0.60; 0.90)
Categorization of smoking				0.012
Smokers (current)/ex and non-smokers	6	0.81 (0.62; 0.99)	89.7
Smokers (current) and ex/never	5	1.01 (0.98; 1.05)	0.0
Categorization of alcohol								0.002
Drinkers (current)/ex and non-drinker					4	0.79 (0.51; 1.06)	80.2
Hazardous alcohol consumption					3	0.53 (0.22; 0.84)	93.9
Alcohol misuse					1	0.99 (0.98; 1.00)	0.0
Total	11	0.92 (0.82; 1.01)			8	0.70 (0.50; 0.90)

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rua Leopoldo Bulhões, 1480 , 21041-210 Rio de Janeiro RJ Brazil, Tel.:+55 21 2598-2511, Fax: +55 21 2598-2737 / +55 21 2598-2514 - Rio de Janeiro - RJ - Brazil
E-mail: cadernos@ensp.fiocruz.br

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[1] Correspondence
J. F. Danigno Universidade Federal de Pelotas. Rua Marechal Deodoro 1160, Pelotas, RS 96020-220, Brasil. juliadanigno@yahoo.com.br