Alcohol, tobacco & other drugs in Australia

The health burden of alcohol and other drug use is considerable and includes hospitalisation from injury and other disease, mental illness, pregnancy complications, injection-related harms, overdose and mortality.

Drug-induced deaths

Drug-induced deaths are defined as those that can be directly attributable to drug use, as determined by toxicology and pathology reports (ABS 2017). Multiple drug types may have been reported on a single death record. As a result, the sum of each drug type may be more than the total number of deaths.

AIHW analysis of the AIHW National Mortality Database (Figure IMPACT1; Table S1.1) showed:

• In 2018, there were 1,740 drug-induced deaths (a rate of 7.0 per 100,000 population). Although the number of drug-induced deaths in 2018 was the same as the number recorded in 1999, the rate of drug-induced deaths in 2018 (7.0 deaths per 100,000 population) was 23% lower than in 1999 (9.1 deaths per 100,000 population).
• Opioids were the most common drug class identified in drug-induced deaths over the past 2 decades. Opioids include the use of a number of drug types, including heroin, opiate based analgesics (such as codeine and oxycodone) and synthetic opioid prescriptions (such as tramadol and fentanyl).
• In 2018, opioids were present in nearly two-thirds of drug-induced deaths (64.5% or 1,123 deaths) — a rate of 4.6 per 100,000 population. Analysis by the ABS found that in almost two-thirds (63.1% or 708 deaths) of opioid-induced deaths, benzodiazepines were also present (ABS 2019). The majority of opioid-induced deaths were accidental (80%). The rate of opioid-induced deaths involving synthetic opioids has increased over the past decade (ABS 2019).
• By single drug type, the most common substance present in drug-induced deaths in 2018 were benzodiazepines, identified in 883 deaths (51%). It is important to note that benzodiazepines may not have been recorded as the underlying cause of death (see also Non-medical use of pharmaceutical drugs: Harms: Deaths).
• Over the past decade, drug-induced deaths were more likely to be due to prescription drugs than illegal drugs, and there has been a substantial rise in the number of deaths with a prescription drug present. However, since 2014, there has been an increase in the proportion of deaths attributed to illegal drugs (from 17% in 2014 to 30% in 2018) and a decrease in the proportion attributed to prescription drugs only (from 75% in 2014 to 60% in 2018) (Man et al. 2019).
• The rate of drug-induced deaths in 2018 was higher in Regional and remote areas (7.2 per 100,000 population) compared with Major cities (6.8 per 100,000 population) (Table S2.71).
• The rate of drug-induced deaths has fluctuated over the past decade (2009–2018) in both Major cities and Regional and remote areas. However, when comparing the rates for 2009 and 2018, in Regional and remote areas the rate increased by 20% while the rate in Major cities in 2018 was equal to that in 2009 (Table S2.71).

Deaths due to harmful alcohol consumption

The harmful consumption of alcohol can contribute to mortality in a number of different ways, and deaths can be directly attributable or partially attributable to harmful alcohol consumption. In Australia, deaths that are certified as being directly attributable to alcohol are coded as the underlying cause of death (the condition which initiated the train of morbid events). Alcohol-induced deaths are defined as those that can be directly attributable to alcohol use, as determined by toxicology and pathology reports (ABS 2018).

Alcohol may also play a substantial role in a person’s death, yet not be recognised as the underlying cause of death. In such cases, the alcohol use would be referred to as an associated cause of death. Alcohol-related deaths are defined as deaths directly attributable to alcohol and together with deaths where alcohol was listed as an associated cause of death (ABS 2018).

Data from the ABS showed:

• There were 1,366 registered alcohol-induced deaths in 2017; the highest in 2 decades (1,156 deaths in 1997).
• In 2017, the alcohol-induced death rate was 5.1 per 100,000 population; this has remained stable since a low of 4.5 deaths per 100,000 in 2012.
• The rate of alcohol-induced deaths for males has been on average 3.5 times higher than that of females over the past 2 decades.
• There were an additional 2,820 deaths where alcohol was mentioned as a contributory cause of death in 2017. This highlights that people were twice as likely to have alcohol certified at death as a contributory factor than to have died from an alcohol-induced death (ABS 2018).

The most common cause of alcohol-induced death was alcoholic liver disease; while mental and behavioural conditions due to alcohol use, including alcohol addiction, is the most common contributor to alcohol-related deaths. Mental and behavioural disorders due to alcohol abuse also made up about 20% of alcohol-induced deaths in 2017 (ABS 2018).

Burden of disease

Burden of disease analysis is used to compare the impact of different diseases, conditions or injuries on a population (AIHW 2019a). It combines the burden of living with ill health (non-fatal burden) with the burden of dying prematurely (fatal burden). This is measured through the calculation of disability-adjusted life years (DALY) – one DALY is one year of 'healthy life' lost due to illness and/or death.

Tobacco, alcohol and illicit drug use contribute to increased chronic disease, injury, poisoning and premature death and are among the leading risk factors contributing to disease burden in Australia (AIHW 2019a) (Figure IMPACT2). Analysis of data from the Australian Burden of Disease Study 2015 including revised analysis of estimates for tobacco, alcohol and illicit drug use based on the latest evidence of linked diseases indicated the following:

• Tobacco, alcohol and illicit drug use collectively accounted for 16.5% of the total burden of disease in Australia in 2015 (AIHW 2019b).
• Tobacco use contributed to 9.3% of the total burden of disease in Australia in 2015. It was responsible for 41% of the burden of respiratory diseases, 22% of cancers, 11.5% of cardiovascular diseases, and 6.8% of infections (AIHW 2019a).
• Alcohol use contributed to 4.5% of the total burden of disease in Australia in 2015 and was the leading risk factor for males aged 25–44 (11.9% compared to females 3.4%) (AIHW 2019a). Males experienced a greater proportion of disease burden attributable to alcohol use than females. Alcohol use was responsible for 100% of the burden due to alcohol use disorders, 40% of liver cancer burden, 28% of chronic liver disease burden, 22% of road traffic injuries—motor vehicle occupant burden and 14% of suicide burden (Table S2.63) (AIHW 2019a).  
• Illicit drug use contributed to 2.7% of the total burden of disease in Australia in 2015, most of which was experienced by males and females aged 25–44 (AIHW 2019a). Males aged 25–44 experienced a greater proportion of total disease burden attributable to illicit drug use than females (10% compared to 4.4%) (AIHW 2019a). Illicit drug use was responsible for 100% of the burden of drug use disorders (excluding alcohol) and 27% of the poisoning burden. It was also responsible for 75% of the acute Hepatitis C burden, 37% of the acute Hepatitis B burden, and 7.9% of the HIV/AIDS burden (AIHW 2019a).
• Opioid use accounted for the largest proportion (37%) of the illicit drug use burden, followed by amphetamine use (21%), cocaine (11.4%) and cannabis (8.3%). In addition, 18.2% of the burden was from diseases contracted through unsafe injecting practices (Table S2.69) (AIHW 2019a).

Injury and hospitalisation

Recent consumers of alcohol (past 12 months)

• According to the 2019 National Drug Strategy Household Survey (NDSHS):
  •  1.2% of consumers aged 14 years or older had been injured while under the influence of alcohol and required medical attention and 0.4% required admission to hospital for their injuries. 
  • less than 1% of consumers aged 14 years or older required medical attention (0.3%) or hospitalisation (0.2%) because they were so intoxicated (Table S1.4).
• People who consumed alcohol in risky quantities (lifetime or single occasion risk) were far more likely to require medical attention or admission to hospital due to injuries sustained while drinking or due to intoxication. This was even higher among people aged 14 years or older who consumed 11 or more standard drinks at least monthly with 4.9% requiring medical attention for their injuries (AIHW 2020c) (Table S1.5).
• According to information drawn from the National Hospital Morbidity Database on drug-related principal diagnosis, alcohol was the drug with the highest number of hospital separations across the 5-year period from 2014–15 to 2018–19, accounting for about half of those separations (54%).

People who have recently used illicit drugs (past 12 months):

2019 NDSHS data on injury and hospitalisation for people who have recently used illicit drugs have a high relative standard error and should be interpreted with caution (AIHW 2020b).

• Data from the 2019 NDSHS shows that 1.2% of people aged 14 and over who have recently used illicit drugs reported that they had injured themselves while under the influence of illicit drugs and required medical attention and 0.5% said their injury was serious enough to require hospitalisation (Table S1.6).
• Less than 1% of people who have recently used illicit drugs reported that they had overdosed and required medical attention (0.9%) or hospitalisation (0.4%) (Table S1.6). This was higher among people who had used meth/amphetamines in the previous 12 months (2.0% had overdosed and required medical attention and 0.8% required hospitalisation) (AIHW 2020c) (Table S1.7).

Information on drug-related hospitalisations is drawn from the National Hospital Morbidity Database.

• In 2018–19, there were 11.5 million separations in Australia’s public and private hospitals (AIHW 2020a), and drug-related principal diagnoses (considered to be responsible for an episode of admitted patient care to hospital) accounted for 140,578 (1.2%) of these separations (Table S1.8a).
• The total number of drug-related hospital separations increased from 124,956 in 2014–15 to 140,578 in 2018–19. At the same time, total hospital separations have increased, with drug-related hospital separations consistently making up about 1% of all hospital separations across this 5-year period (Table S1.8b).
• Sedatives and hypnotics continued to account for the highest proportion of hospital separations with a drug-related principal diagnosis (61% of all such separations), with alcohol making up 89% of separations for sedatives and hypnotics (Figure IMPACT3).
• Stimulants and hallucinogens, which includes cannabis, cocaine and methamphetamines, accounted for 17% of all separations where the principal diagnosis was drug-related (Table S1.8a).
• Overnight separations continued to be more common for drug-related treatment than same-day separations, accounting for 59% of all drug-related separations (Table S1.8a).
• There was a notable increase in methamphetamine drug-related principal diagnoses, rising from 4.5% of all drug-related principal diagnoses in 2014–15 to 8.6% of all drug-related principal diagnoses in 2018–19 (Table S1.8b).

The most recent analysis of the National Hospital Morbidity Database by the National Drug and Alcohol Research Centre (NDARC) identified a lower number of drug-related hospital separations in 2017–18 (60,627) (Chrzanowska et al. 2019) than the AIHW analysis for that period (136,156; tables S1.8a-c). This is primarily due to the exclusion of alcohol-related hospital separations from the NDARC analysis (see Box IMPACT2).

According to the NDARC analysis:

• the 5 drugs responsible for the highest proportion of drug-related hospital separations in 2017–18 were: amphetamines and other stimulants (23%); antiepileptic, sedative-hypnotic and antiparkinsonism drugs (16%); opioids (14%); non-opioid analgesics (13%); and cannabinoids (10%). The AIHW analysis, excluding alcohol, provides similar findings.
• the age-standardised rate of drug-related hospital separations in 2017–18 (250 per 100,000 population) was lower than that for 2015–16 and 2016–17 (both 272 per 100,000 population). However, the rate remains higher than rates reported for previous years (Chrzanowska et al. 2019).

Overdose and misuse

Overdose and misuse of alcohol and other drugs are public health concerns that affect the community on many levels. Surveillance and monitoring of AOD overdose and misuse can help to form an evidence base in relation to trends and emerging patterns of harms (Moayeri et al. 2020).

Data from the 2020 Illicit Drug Reporting System (IDRS) and 2020 Ecstasy and Related Drugs Reporting System (EDRS) shows rates of self-reported overdose.

• Of participants of the 2020 IDRS who regularly inject drugs, 13% reported a non-fatal heroin overdose in the past 12 months (Peacock et al. 2020b).
• Of participants in the 2020 EDRS who regularly  use ecstasy and other stimulants, 18% reported experiencing a non-fatal stimulant overdose in the past 12 months (Peacock et al. 2020a).

Data on alcohol and other drug-related ambulance attendances, sourced from the National Surveillance System for Alcohol and Other Drug Misuse and Overdose report, are currently available for New South Wales, Victoria, Tasmania and the Australian Capital Territory. Data are reported for 4 snapshot months per year, specifically March, June, September and December. Please see the data quality statement for further information.

For the 4 jurisdictions that supplied data in 2019:

• the highest number (and rate) of ambulance attendances were alcohol intoxication-related (ranging from 142.2 per 100,000 population in New South Wales to 177.9 per 00,000 population in the Australian Capital Territory)
• ambulance attendance rates were considerably lower for all other drugs reported here, including meth/amphetamines (13.1 per 100,000 population in Tasmania to 25.8 per 100,000 population in Victoria)
• benzodiazepine-related ambulance attendances were predominantly for females, while attendances for alcohol and other drugs were predominantly for males
• around 90% of benzodiazepine-related ambulance attendances resulted in transfer to hospital, while heroin had the lowest rates of transfer to hospital, ranging from 38% to 66% of attendances
• the involvement of multiple drugs (excluding alcohol) was reported in over half of all opioid analgesic-related ambulance attendances, ranging from 51% of attendances in New South Wales to 67% in the Australian Capital Territory (Table S2.81) (Moayeri et al. 2020).

Data on alcohol and other drug-related ambulance attendances can be found in the specific drug types sections. See also: Harms in the Cannabis; Meth/amphetamine; Non-medical use of pharmaceuticals; and Illicit opioids, including heroin sections.

Mental health conditions

There is a strong association between illicit drug use and mental health issues. According to the 2019 NDSHS:

• between 2016 and 2019 there was an increase in the proportion of people who had recently used an illicit drug (in the past 12 months) experiencing high or very high levels of psychological distress (from 22% to 26%)
• the proportion of people who recently used drugs who had been diagnosed with or treated for a mental health condition in the previous 12 months remained stable at around 26% (Table S1.9). 

Over half of the participants of the 2020 Ecstasy and Related Drugs Reporting System (EDRS) reported mental health issues in the preceding 6 months. The primary issue of concern reported among this population of people who regularly use ecstasy and other stimulants was anxiety (69%) and depression (64%) (Peacock et al. 2020a) (refer to Box HARM1 for more information). It should be noted that this time period reflects behaviours both before and during the COVID-19 period. 

Pregnancy complications

Tobacco smoking in pregnancy is the most common preventable risk factor for pregnancy complications, and is associated with poorer perinatal outcomes, including low birthweight, being small for gestational age, pre-term birth and perinatal death.

Data from the National Perinatal Data Collection showed, in 2018, that babies of mothers who smoked during pregnancy were more likely than babies of mothers who did not smoke to be:

• low birthweight (12.7% compared with 6.0% of liveborn babies)
• small for gestational age (16.1% compared with 8.7% of liveborn singleton babies)
• born pre-term (14.0% compared with 8.1%) (AIHW 2020b).

Alcohol consumption during pregnancy is also associated with adverse impacts for development of the fetal brain. Fetal alcohol spectrum disorder (FASD) is the term used to describe the effects of prenatal alcohol exposure including fetal alcohol syndrome (FAS). There are currently no data available indicating the prevalence of FASD in Australia, however there have been some jurisdictional based studies which reported birth prevalence of FAS of between 0.01 and 0.68 per 1000 live births. Higher prevalence of FAS is commonly found among Indigenous communities, likely reflecting socioeconomic factors and patterns of alcohol use (Burns et al. 2013).

The 2009 Australian Guidelines to reduce Health risks from Drinking Alcohol from the National Health and Medical Research Council state, that for women who are pregnant or planning a pregnancy or breastfeeding, not drinking is the safest option (NHMRC 2009).

The 2019 NDSHS showed that 65% of pregnant women abstained from drinking alcohol during their pregnancy; this is an increase from 40% in 2007 and 56% in 2016. The remaining women reported that they reduced their drinking during pregnancy (35%) compared with when they were not pregnant, and less than 1% reported drinking the same (AIHW 2020c).

Injection-related harms

The 2019 NDSHS estimates that a very low proportion of the Australian general population aged 14 and over have injected drugs, either in their lifetime (1.5%) or in the past 12 months (0.3%) (AIHW 2020c) (tables S2.31 & S2.32).

See also: Illicit drugs in the People who inject drugs section.