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Good health is not shared equally among people in Australia. There are substantial differences in the health of different groups, including differences in rates of death and disease, life expectancy, self-perceived health, health behaviours, health risk factors and health service utilisation. These 'health inequities' are associated with a range of factors including differences in education, occupation, income, employment status, rural location, ethnicity, Aboriginality and gender (Draper et al. 2004).
Certain groups within the population are at greater risk of developing harmful drug use behaviours or undergoing drug-related harm. These groups may require particular targeting in terms of education, treatment and prevention programs (AIHW 2007).
Social and economic factors shape risk behaviour and the health of drug users. They affect health indirectly by shaping individual drug-use behaviour, and directly by affecting the availability of resources, access to social welfare systems, marginalisation and compliance with medication. Minority groups experience a disproportionately high level of the social issues that adversely affect health, factors that contribute to disparities in health among drug users (Galea & Vlahov 2002).
There is a complex relationship between these broad social determinants and individual risk and protective factors, which means that some individuals do better than others on all health measures, including drug misuse, despite their material deprivation. Furthermore, these relationships are more pronounced for some drug types where they have more adverse outcomes than others (Loxley et al. 2004).
Social determinants are the 'environmental' or 'societal' factors that influence health outcomes of populations. These include the economic environment, the physical environment and sociocultural environment (Spooner & Hetherington 2005).
The health of individuals and populations is largely determined by social and economic factors, which can both protect against or increase the risk of ill health or harmful alcohol and other use. A review of the evidence, conducted for the World Health Organization, found a clear link between socioeconomic deprivation and risk of dependence on alcohol, nicotine and other drugs (Wilkinson & Marmot 2003).
There is scope to highlight many population groups in Australia but this chapter focuses on 6 groups—socioeconomically disadvantaged people, those living in rural and remote areas, Indigenous Australians, pregnant women, the unemployed, people who identify as being homosexual or bisexual and people with mental illnesses and high levels of psychological distress as for these groups we observe some of the largest disparities in tobacco, alcohol and other drug use.
All data presented in this chapter are available through the online specific population group tables.
This section of the report focuses on 3 key social determinants of health—remoteness, SES and employment. Refer to online tables for results by marital status, household composition, education, and culturally and linguistically diverse populations.
The ABS 2011 Australian Statistical Geography Standard was used to allocate remoteness categories to areas across Australia.
Overall, people living in rural and remote areas have a poorer SES than those in major cities, and they are often disadvantaged in relation to access to primary health-care services, educational and employment opportunities and income. They generally have poorer health than their major city counterparts, reﬂected in their higher levels of mortality, disease and health risk factors. Further, they are more likely to have higher rates of risky health behaviours, such as smoking and heavy alcohol use (AIHW 2012). Rural residents also face difficulties in accessing drug treatment services.
A substantially higher proportion of people in Remote and very remote areas smoke tobacco daily (Figure 8.1) and they were twice as likely to smoke as those in Major cities (22% compared with 11.0%). Tobacco smoking is the major cause of lung cancer and people in remotes areas had 1.3 times the rate of lung cancer (between 2004 and 2008) than those living in Major cities (AIHW & AACR 2012). As smoking remains higher in these areas, the difference in lung cancer rates between people in Major cities and remote areas is likely to continue.
While smoking rates in Major cities declined between 2010 and 2013 (from 13.7% to 11.0%), there was no significant reduction in the proportion of people who smoked daily for people in Inner regional, Outer regional and Remote and very remote areas. The proportion of people smoking daily rose with increasing remoteness. 2013 survey results showed 11.0%, 15.4%, 19.4% and 22% of people smoked daily in, respectively, Major cities, Inner regional, Outer regional and Remote and very remote areas. The average number of cigarettes smoked per week declined in all remoteness areas except for those living in Remote and very remote areas.
Figure 8.1: Proportion of daily smokers, people aged 14 or older, by remoteness area, 2010 and 2013 (per cent)
Source: Online Table 8.1.
Not only were people in Remote and very remote areas more likely to smoke, they were also more likely to drink alcohol in quantities that place them at risk of harm from an alcohol-related disease or injury over a lifetime or at risk of alcohol-related injury arising from a single drinking occasion (Figure 8.2).
Alcohol consumption was consistently higher in Remote and very remote areas and the proportion of those drinking at risky levels increased with increasing remoteness. Results showed 16.7%, 19.1%, 23% and 35% of people consumed alcohol at risky levels for lifetime risk, and 25%, 27%, 32% and 42% at risky levels for single occasion risk in, respectively, Major cities, Inner regional, Outer regional and Remote and very remote areas.
There was also no significant change in the proportion of people in Outer regional and Remote and very remote areas drinking at risky levels for both lifetime and single occasion harm, despite significant declines for people in Major cities and Inner regional areas.
Figure 8.2: Risk of alcohol-related harm over a lifetime or from a single drinking occasion (at least monthly), people aged 14 or older, by remoteness area, 2010 and 2013 (per cent)
There are multiple and interrelated causes of illicit drug use in rural and regional Australia. Studies in rural Victoria and rural South Australia have identified distance and isolation, lack of public transport, lack of employment opportunities, uncertainty about the future and lack of leisure activities as contributing to illicit drug use in rural communities (NRHA 2012).
People in Remote and very remote areas were more likely to have used an illicit drug in the last 12 months than people in Major cities and Inner regional areas, but the type of drug used varied by remoteness area (Figure 8.3). For example:
There were no significant changes in illicit use of drugs for non-remote areas, however there was a rise in the misuse of pharmaceuticals among people living in Major cities (from 4.1% to 4.7%; Online Table 8.1).
Figure 8.3: Recent(a) use of selected illicit drugs, people aged 14 or older, by remoteness area, 2013 (per cent)
Although the overall level of health and wellbeing of the Australian population is high when compared with the populations of many overseas countries, there are substantial differences in the health of speciﬁc groups within the population. One of the most important contributors to these differences is SES. Socioeconomic characteristics are key determinants of health and wellbeing, and contribute to differences in health or 'health inequality' across the population (AIHW 2008).
It is well established that people with lower incomes and/or lower levels of completed education are more likely to smoke (AIHW 2011) and these are risk factors for a number of long-term health conditions such as respiratory diseases, lung cancer and cardiovascular diseases (AIHW 2012).
Tobacco smoking is strongly associated with low SES; people with the lowest SES were almost 3 times more likely to smoke daily than people with the highest SES (19.9% compared with 6.7%) but significant declines were seen in both these groups between 2010 and 2013 (Figure 8.4).
While people with the lowest SES were more likely to smoke, it was people with the highest SES who were more likely to drink at all and consume alcohol in quantities that placed them at risk of an alcohol-related disease, illness or injury. People with the lowest SES were twice as likely to abstain and a little less likely to drink alcohol in risky quantities compared with people in highest SES group (Figure 8.4).
There were fewer people in the lowest and highest socioeconomic areas drinking more than 2 standard drinks per day in 2013 (declining from 19.1% to 15.9% and from 21% to 18.4% respectively). People in the lowest SES group were also less likely to drink at risky levels at least once a month (from 27% in 2010 to 24% in 2013) but there was no change in drinking at these levels among people from the highest SES group.
Illicit drug use patterns vary by SES depending on the drug type of interest (Figure 8.4). People with the lowest SES were slightly more likely to use meth/amphetamines (2.2% compared with 1.8%), while people with the highest SES were almost twice as likely to use ecstasy (2.9% compared with 1.6%) and 3 times more likely to use cocaine (3.5% compared with 1.2%).
There were no significant changes in illicit use of drugs for people in the lowest SES group, however there was an increase in the misuse of pharmaceuticals among people with the highest SES, from 3.8% to 5.1% (Online Table 8.2).
Figure 8.4: Daily smoking, risky alcohol consumption and illicit drug use by people with lowest and highest socioeconomic status, people aged 14 or older, 2013 (per cent)
Source: Online Table 8.2.
Employment status, and unemployment in particular, is strongly related to health status. Unemployed people have higher mortality and more illness and disability than those who are employed (AIHW 2008). Unemployment is a major risk factor for substance use and the subsequent development of substance-use disorders (Henkel 2011).
Drug abuse can reduce a person's employment prospects, both by reducing productivity and by decreasing the chance of getting a job. Those who are unemployed or otherwise out of the labour force may also face financial hardship or simply have more unstructured time, either of which can result in a higher propensity to consume substances (Badel & Greaney 2013).
Figure 8.5 and Online Table 8.3 show that people who were unemployed were:
A similar pattern was also seen among people who were unable to work. They were: 2.4 times more likely to smoke daily, 1.4 times more likely to use cannabis, 1.7 times more likely to use meth/amphetamines and 1.8 times more likely to misuse pharmaceuticals. But they were less likely to use ecstasy or cocaine than employed people (Online Table 8.3). There were also no significant changes in the drug-taking behaviours of unemployed people and people who were unable to work between 2010 and 2013.
Compared to use in 2010, employed people were less likely to:
Figure 8.5: Drug use by employment status, people aged 14 or older, 2013 (per cent)
Source: Online Table 8.3.
In addition to the factors outlined above, there are other groups within the population who are at greater risk of misusing substances or who show higher than average drug use when compared to the general population. Drug use can have a major impact on disadvantaged groups and lead to intergenerational patterns of disadvantage. Under the National Drug Strategy 2010–2015, socially inclusive strategies and actions are needed that recognise the particular vulnerabilities and needs of these disadvantaged groups (MCDS 2011).
This section explores drug use among: Aboriginal and Torres Strait Islander people (Indigenous Australians); people who identified as being homosexual or bisexual; pregnant women and the potential risk placed on their unborn child; and people with mental health problems and high levels of psychological distress.
Indigenous Australians experience signiﬁcantly more ill health than other Australians. The socioeconomic disadvantage experienced by Indigenous Australians compared with other Australians places them at greater risk of exposure and vulnerability to health risk factors such as smoking and alcohol misuse.
Indigenous Australians suffer a disproportionate amount of harms from alcohol, tobacco and other drug use. Drug-related problems play a major role in disparities in health and life expectancy between Indigenous and non-Indigenous Australians (MCDS 2011).
As Indigenous Australians constitute only 1.9 per cent of the sample, the results must be interpreted with caution, particularly those for illicit drug use.
Indigenous Australians are more likely to die of smoking-related illnesses, such as diseases of the respiratory system and cancers, than other Australians (AIHW 2008). In 2013, the smoking rate among Indigenous Australians was considerably higher than non-Indigenous people and they were 2.5 times more likely to smoke daily than non-Indigenous people (Figure 8.6). The Indigenous daily smoking rate declined from 35% in 2010 to 32% in 2013 but this was not statistically significant. The NDSHS was not designed to detect differences this small among the Indigenous population but the percentage point decline is similar to the results from the Australian Aboriginal and Torres Strait Islander Health Survey which was specifically designed to represent Indigenous Australians (see the data quality statement for further information).
There was a substantial drop in the average number of cigarettes smoked by current smokers, declining significantly from 154 in 2010 to 115 in 2013 (Online Table 8.4). After adjusting for differences in age structures, Indigenous people were 2.6 times as likely to smoke daily as non-Indigenous people (Online Table A8.4).
Overall, Indigenous Australians were more likely to abstain from drinking alcohol than non-Indigenous Australians (28% compared with 22% respectively). However, among those who did drink, a higher proportion of Indigenous Australians drank at risky levels (Figure 8.6).
Positively, there was a significant decline in the proportion of Indigenous people exceeding the NHMRC guidelines for lifetime risk of alcohol-related disease by consuming, on average, more than 2 standard drinks per day. There were fewer Indigenous Australians drinking alcohol at levels that put them at risk of harm from a single drinking occasion at least once a month in 2013 (from 45% to 38%), but this decrease was not significant.
Other than ecstasy and cocaine, Indigenous Australians use illicit drugs at a higher rate than the general population (Figure 8.6). In 2013, Indigenous Australians were: 1.6 times more likely to use any illicit drug in the last 12 months; 1.9 times more likely to use cannabis; 1.6 times more likely to use meth/amphetamines; and 1.5 times more likely to misuse pharmaceuticals than non-Indigenous people. These differences were still apparent even after adjusting for differences in age structure (Online Table A8.4). There were no significant changes in illicit use of drugs among Indigenous Australians between 2010 and 2013.
Figure 8.6: Drug use by Indigenous status, people aged 14 or older, 2010 and 2013 (per cent)
Note: Due to the small sample sizes of Aboriginal and/or Torres Strait Islander people, estimates should be interpreted with caution.
Source: Online Table 8.4.
There is a growing body of evidence to suggest that people who identify as gay, lesbian, bisexual, transgender and intersex (GLBTI) may be at a higher risk of developing mental health and substance use problems. Overall, there is a range of risk and protective factors related to drug use and mental health. Some of these factors are relevant for both GLBTI and non-GLBTI populations. However, many of these risk factors are experienced to a greater extent by GLBTI populations than other populations (Ritter et al. 2012). This section only presents findings on people who identified as gay, lesbian or bisexual as the survey does not capture information on people who were transgender or intersex.
Findings for people who identify as homosexual and bisexual were grouped together for data quality purposes but it's important to note that there are differences in substance use among these 2 groups, for example, 35% of bisexual people had used cannabis in the previous 12 months compared with 23% of homosexual people. Figure 8.7 shows that:
After adjusting for differences in age, people who were homosexual or bisexual were still far more likely than others to smoke daily, consume alcohol in risky quantities, use illicit drugs and misuse pharmaceuticals (Online Table A8.5).
The trends in drug use that were seen nationally were not seen among this group—there were no significant declines in daily smoking, risky alcohol consumption or ecstasy use, and no significant rise in the misuse of pharmaceuticals.
Figure 8.7: Drug use by sexual orientation, people aged 14 or older, 2010 and 2013 (per cent)
Source: Online Table 8.5.
There is a strong association between illicit drug use and mental health issues (Figure 8.8). However, it can be difficult to isolate to what degree drug use causes mental health problems, and to what degree mental health problems give rise to drug use, often in the context of self-medication (Loxley et al. 2004). It is therefore important to note that, by themselves, these findings do not establish a causal link between mental illness and drug use—the mental illness may have preceded the drug use or vice versa (AIHW 2010).
In addition to asking people if they have been diagnosed or treated for a mental illness in the previous 12 months, the survey also includes the Kessler 10 scale (K10), which was developed for screening populations for psychological distress. The scale consists of 10 questions on non-specific psychological distress and relates to the level of anxiety and depressive symptoms a person may have experienced in the preceding 4-week period. The psychological distress may have preceded the drug use for some and, for others, drug use may have preceded the psychological distress.
According to the 2013 NDSHS, 1 in 10 (10.1%) people aged 18 or older experienced high or very high levels of distress. A further 13.9% had been diagnosed or treated for a mental illness in the previous 12 months, increasing from 12.0% in 2010 (Online Table 8.6). However, when this group is split into those who had used and those who had not used selected drugs in the last month, there was about a twofold difference in that experience:
Again it is important to note that, by themselves, these findings do not establish a causal link between psychological distress and drug use—the drug use may have preceded the psychological distress, or vice versa.
Figure 8.8: Level of psychological distress(a), by illicit drug use status, people aged 18 or older, 2013 (per cent)
Source: Online Table 8.7.
Figure 8.9: People diagnosed or treated for mental illness(c), by illicit drug use status, people aged 18 or older, 2010 and 2013 (per cent)
Source: Online Table 8.8.
A similar pattern to illicit drug users also emerged for daily smokers:
The association between alcohol use and high or very high psychological distress and diagnosis or treatment of a mental health condition was less marked. The 2013 findings showed that:
Substance use among pregnant women is a particular concern as drugs can cross into the placenta and therefore leads to a range of health problems, including abnormal fetal growth and development (ACMD 2006).
Women who smoke while pregnant are at increased risk of a wide range of problems including ectopic pregnancy, miscarriage and premature labour (SGV 2014) and are twice as likely to give birth to a low birthweight baby compared to non-smokers (AIHW 2012).
Alcohol use during pregnancy can disturb the development of the fetus and lead to problems later in life. Fetal Alcohol Spectrum Disorder is a general term which describes the range of effects that can occur in a baby who has been exposed to alcohol in their mother's womb (NHMRC 2009). It is not yet known how much alcohol is safe to drink during pregnancy. However, it is known that the risk of damage to the baby increases the more women drink and that binge drinking is especially harmful. Therefore the NHMRC advises that the safest option for pregnant women is to abstain from drinking if they are pregnant, planning a pregnancy or breastfeeding.
The questions on drug use during pregnancy were updated in 2013 to provide a more accurate snapshot of drinking during pregnancy. Each question collects information about slightly different concepts which should be taken into consideration when interpreting these results.
More specifically, the 2013 survey asked women about their drinking before and after knowledge of pregnancy, as well as about whether they drank more, less or the same amount compared to when they were not pregnant. The way in which pregnant women answered these 2 questions is somewhat problematic as the proportions reporting that they did use alcohol during pregnancy were different (see Chapter 10 'Explanatory notes' for further information).
As women are more likely to answer a question honestly about what they did before knowledge of their pregnancy, Online Table 8.11 provides the most accurate estimate on the amount of alcohol consumed during pregnancy. However, Figure 8.10 is useful for monitoring trends over time as this question has remained consistent since 2004.
Since 2007, the proportion of women consuming alcohol during pregnancy has declined and the proportion abstaining has risen (Figure 8.10). Between 2010 and 2013 the proportion of pregnant women abstaining from alcohol slightly increased from 49% to 53% but this rise was not statistically significant.
Figure 8.10: Pregnant women who drank more, less or the same amount of alcohol compared with when they were not pregnant, pregnant women aged 14–49, 2007 to 2013 (per cent)
Note: Base is only pregnant women or women pregnant and breastfeeding.
Source: Online Table 8.10.
For the first time in 2013, the survey included questions specifically on the amount of alcohol consumed while pregnant. The majority of women did not drink alcohol during pregnancy, and of those who did, most drank infrequently (monthly or less) and consumed 1‒2 standard drinks (Online Table 8.11). More specifically:
Pregnant women were asked if there was any time during their pregnancy that they were not aware they were pregnant and what their drug-taking behaviours were during this time. Of pregnant women who were unaware of their pregnancy:
Regardless of whether women knew they were pregnant or not, the following proportion consumed drugs during pregnancy:
Figure 8.11: Drug-taking behaviours before and after knowledge of pregnancy, pregnant women aged 14–49, 2013 (per cent)
Source: Online Table 8.12.