Aboriginal and Torres Strait Islander people

In 2016, there were almost 800,000 Aboriginal or Torres Strait Islander people living in Australia (see Box INDIGENOUS1), accounting for 2.8% of the Australian population (ABS 2017b). There are substantial differences in measures of health and welfare between Aboriginal or Torres Strait Islander people and non-Indigenous Australians.

Key findings

The prevalence of smoking for Indigenous people declined from 55% in 1994 to 43% in 2018–19

Tobacco smoking

While the proportion of Indigenous Australians who consume alcohol at levels that exceed lifetime risk guidelines has decreased overall since 2008, this proportion increased from 14.7% in 2014 to 18.4% in 2018–19

Lifetime alcohol risk

In 2019, 23% of Indigenous Australians had used an illicit drug in the last 12 months. This was 1.4 times higher than for non-Indigenous Australians (16.6%)

Illicit drugs

In 2019, 15.5% of Indigenous Australians reported recent use of cannabis and 7.7% reported recent use of pharmaceuticals for non-medical purposes

Illicit drugs

In 2011, tobacco use accounted for 12% of the burden of disease for Indigenous Australians. This accounts for 23.3% of the health gap between Indigenous and non-Indigenous Australians

Health and harms

In 2019–20, 17% of clients seeking alcohol and other drug treatment services aged 10 and over were Indigenous Australians

Treatment

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Box INDIGENOUS1: Aboriginal and Torres Strait Islander people

The term ‘Aboriginal and Torres Strait Islander people’ is preferred in Australian Institute of Health and Welfare (AIHW) publications when referring to the separate Indigenous peoples of Australia. However, the term ‘Indigenous’ Australians is used interchangeably with ‘Aboriginal and Torres Strait Islander’ in order to assist readability.

The Australian Burden of Disease Study identified that Aboriginal or Torres Strait Islander people experience a burden of disease that is 2.3 times the rate of non-Indigenous Australians (AIHW 2016a). The gap in the disease burden is due to a range of factors including disconnection to culture, traditions and country, social exclusion, discrimination and isolation, trauma, poverty, and lack of adequate access to services (DoH 2017b). Tobacco, alcohol, and other drugs are key risk factors contributing to the health gap between Indigenous and non-Indigenous Australians (AIHW 2016a).The Australian Burden of Disease Study identified that Aboriginal or Torres Strait Islander people experience a burden of disease that is 2.3 times the rate of non-Indigenous Australians (AIHW 2016a). The gap in the disease burden is due to a range of factors including disconnection to culture, traditions and country, social exclusion, discrimination and isolation, trauma, poverty, and lack of adequate access to services (DoH 2017b). Tobacco, alcohol, and other drugs are key risk factors contributing to the health gap between Indigenous and non-Indigenous Australians (AIHW 2016a).

Box INDIGENOUS2: Data sources examining tobacco, alcohol and other drug use by Aboriginal and Torres Strait Islander people

A number of data sources provide information about tobacco, alcohol and other drug use by Aboriginal and Torres Strait Islander people.

The National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) (ABS 2019), National Aboriginal and Torres Strait Islander Social Survey (NATSISS) (ABS 2016) and the Australian Aboriginal and Torres Strait Islander Health Survey (AATSIHS) (ABS 2013) collected by the ABS are designed to obtain a representative sample of Indigenous Australians. In relation specifically to tobacco smoking, the ABS has consolidated data from 6 large, national, multistage random household surveys to identify trends between 1994 and 2014–15 (ABS 2017a).

The AIHW’s National Drug Strategy Household Survey (NDSHS) captures information about drug and alcohol use among the general Australian population; however it is not specifically designed to obtain reliable national estimates for Indigenous people. In 2019, 2.4% of the NDSHS (unweighted) sample aged 14 and over (or 533 respondents) identified as being of Aboriginal or Torres Strait Islander origin. The estimates produced by the NDSHS should be interpreted with caution due to the low sample size (AIHW 2020b). Differences between the results of the NATSIHS and the NDSHS may be due to the limited data collected from remote Indigenous communities in the NDSHS (which in the NATSIHS are deliberately oversampled) and the use of different weighting approaches (AIHW 2020b).

There are also other data sources that provide information relevant to Aboriginal and Torres Strait Islander people.

  • Australia’s Burden of Disease study analyses the impact of nearly 200 diseases and injuries in terms of living with illness (non-fatal burden) and premature death (fatal burden). In 2015, a report was released that provides estimates of burden of disease for Indigenous and non-Indigenous Australians (AIHW 2016b).
  • The Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS NMDS) contains information on treatment provided to clients by publicly funded alcohol and other drug services including Indigenous clients (AIHW 2021a).
  • The Online Services Report (OSR) contains information on the majority of Australian Government-funded Aboriginal and Torres Strait Islander substance use services (AIHW 2019a).
  • The National Perinatal Data Collection covers each birth in Australia and includes information on Indigenous mothers and their babies (AIHW 2021b).

Tobacco smoking

While tobacco smoking is declining in Australia, it remains disproportionately high among Indigenous Australians. Data from the Australian Bureau of Statistics (ABS) has shown: 

  • In 1994, 54.5% of Indigenous Australians aged 18 and over were current smokers (Table S3.4); in 2018–19, this had declined to 43.4% (ABS 2019).
  • Over a similar period, the proportion of non-Indigenous smokers aged 18 and over declined, from 23.5% in 1995 to 15.1% in 2017–18 (Table S3.5).
  • There appears to have been no change to the gap in smoking prevalence between the Indigenous Australian adult population and the non-Indigenous Australian adult population from 1994 to 2018–19. Even though the Indigenous Australian smoking rates are declining, the non-Indigenous rate declined at a similar rate, therefore the gap remained constant (ABS 2017a; tables S3.4 and S3.5; Figure INDIGENOUS1).

Most of the decline in smoking between 1994 and 2018–19 occurred in Non-remote areas. The proportion of Indigenous Australians aged 18 and over in Non-remote areas who were smokers declined from 54.5% in 1994 to 39.6% in 2018–19, while the proportion in Remote areas rose slightly from 54.3% to 59.3% (Table S3.4).

In 2018–19, Indigenous males aged 18 and over were more likely than Indigenous females to be current smokers (45.6% compared with 41.2%) (ABS 2019) (Table S3.4).

The figure shows that the proportion of Indigenous Australian people aged 18 and over who smoke has steadily declined, from 54.5% in 1994 to 43.4% in 2018–19. Similarly, the proportion of non-Indigenous Australian people who smoke declined from 24% in 2002 to 15.1% in 2017–18.

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Geographic trends

The 2014–15 NATSISS provides estimates of tobacco smoking for Indigenous Australians by jurisdiction. According to the 2014–15 NATSISS, 39% of Indigenous Australians aged 15 and over smoked daily. Those from the Northern Territory (45%) and Western Australia (42%) surpassed this national average, while Indigenous Australians from South Australia (35%) were the least likely to be a current daily smoker (ABS 2016) (Table S3.3).

Tobacco smoking in pregnancy

Smoking rates for Indigenous mothers have decreased since 2009, however, Indigenous Australians remain at an elevated risk of smoking during pregnancy compared to non-Indigenous Australians (AIHW 2021b). After adjusting for differences in population age structures, the National Perinatal Data Collection showed that:

  • The proportion of Indigenous mothers who smoked at any time during pregnancy decreased from 50% in 2009 to 44% in 2019.
  • In 2019, Indigenous mothers (44%) were more than 3 and a half times as likely as non-Indigenous mothers (12.1%) to smoke at any time during pregnancy.
  • In 2019, 43% of Indigenous mothers reported smoking in the first 20 weeks of pregnancy and 39% reported smoking after 20 weeks (Table S2.59; Figure INDIGENOUS2) (AIHW 2021b).

Figure INDIGENOUS2: Tobacco smoking at any time during pregnancy, by Indigenous status and smoking status, 2009 to 2019 (age-standardised per cent)

This figure shows that, after adjusting for differences in age structure, 43.9% of Indigenous mothers smoked at any time during pregnancy in 2019. This has declined from 49.9% in 2009. Around 12.1% of non-Indigenous mothers smoked during pregnancy, down from 16.3% in 2009. 

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Alcohol consumption

New Australian guidelines to reduce health risks from drinking alcohol were released in December 2020. Data for alcohol risk in this report are measured against the 2009 guidelines (see Box ALCOHOL1). National Drug Strategy Household Survey data relating to the updated guidelines are available in the Measuring risky drinking according to the Australian alcohol guidelines report.

Abstinence (non-drinkers)

Data from multiple sources indicate that Indigenous Australians are more likely to abstain from drinking alcohol than non-Indigenous Australians.  

The 2019 NDSHS found that:

  • Abstinence among Indigenous Australians has increased from 25% in 2010 to 29% in 2019 (AIHW 2020b) (Table S3.1).
  • After adjusting for differences in age, Indigenous Australians aged 14 and over were more likely to abstain from drinking alcohol than non-Indigenous Australians (AIHW 2020b).

This pattern is consistent with data from the 2018–19 NATSIHS, where 15.4% of Indigenous Australians reported they did not consume alcohol in the last 12 months compared with 7.9% of non-Indigenous Australians (ABS 2019).

Lifetime risk

The proportion of Indigenous Australians exceeding lifetime risk guidelines for drinking fluctuated between 2002 and 2018–19, with no clear trend evident. The proportion of Indigenous Australians exceeding these guidelines is slightly higher than that of non-Indigenous Australians.

  • The 2018–19 NATSIHS found that the proportion of Indigenous Australians aged 15 years and over who exceeded the lifetime risk guidelines for alcohol consumption (consuming more than 2 standard drinks per day on average) increased between 2014–15 and 2018–19 (14.7% compared with 18.4%; non age-standardised proportions) (ABS 2016; ABS 2019) (Table S3.6).
  • The 10 year comparison between 2008 and 2018–19 showed a decrease from 19.2% to 18.4% (non-age standardised proportions) (Table 3.6).

  • Comparisons between Indigenous and non-Indigenous Australians using age-standardised data are available from the 2018–19 NATSIHS. The findings showed that lifetime risky drinking of Indigenous Australians aged 15 and over was slightly higher than that of non-Indigenous Australians (18.7% compared with 15.2%; age-standardised) (ABS 2016; ABS 2019) (Table S3.7). 

Single occasion risk

There has been an increase in the proportion of Indigenous Australians who exceeded single occasion risk guidelines for drinking.

  • According to the 2018–19 NATSIHS, 50% of Indigenous Australians aged 15 and over exceeded the single occasion risk guidelines for alcohol consumption (non age-standardised proportions), which is an increase since 2002 (35%) (Table S3.6).
  • Comparisons between Indigenous and non-Indigenous Australians using age-standardised data are available from the 2018–19 NATSIHS. The findings showed that almost 1 in 2 (48.5%) Indigenous Australians exceeded the single occasion risky drinking guidelines (more than 4 standard drinks on a single occasion in past year). This was higher than the proportion for non-Indigenous Australians (41.6%) exceeding these guidelines (ABS 2019) (Table S3.7).

Risky alcohol consumption

According to the 2019 NDSHS, the proportion of Indigenous Australians who consumed 11 or more drinks at least once a month declined from 18.8% in 2016 to 10.6% in 2019. For non-Indigenous Australians, this figure remained stable (6.8% and 6.4%) (AIHW 2020b) (Table S3.1).

Geographic trends

Between 2002 and 2014–15 there was a decline in the proportion of Indigenous Australians that resided in New South Wales, Victoria, Queensland, South Australia, Western Australia and the Australian Capital Territory that exceeded the lifetime and single occasion risk guidelines (Figure INDIGENOUS3). Indigenous Australians residing in Tasmania (36%), the Australian Capital Territory (ACT) (35%), Queensland (33%) and Western Australia (33%) had higher rates of exceeding the single occasion drinking guidelines than the national average (ABS 2016) (Table S3.8).

Indigenous Australians residing in Western Australia (17%), New South Wales (16%) and Queensland (15%) surpassed the national average for exceeding lifetime risk guidelines (ABS 2016) (Table S3.9).

Figure INDIGENOUS3: Alcohol consumption, by lifetime or single occasion risk of harm and state/territory of usual residence, Aboriginal and Torres Strait Islander persons aged 15 and over—2002, 2008 and 2014–15 (per cent)

This figure shows that, nationally, the proportion of Indigenous Australian people at lifetime risk of alcohol-related harm decreased from 35.0% in 2002 to 30.1% in 2014–15. This pattern was similar in all states except Tasmania, where there was a steady increase from 32.7% to 36.0%. In 2014–15, the proportion of Indigenous Australian people at risk of lifetime harm was lowest in South Australia (24.5%) and highest in Tasmania (36.0%).

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Illicit drugs

In the 2018–19 NATSIHS, Aboriginal and Torres Strait Islander people aged 15 and over were asked whether they had used illicit substances in the last 12 months, and the types of illicit substances they had used during that period (ABS 2019). The data showed that:

  • Over one quarter (28.3%) of Indigenous Australians aged 15 and over had used illicit substances in the last 12 months.
  • Males were substantially more likely than females to have used illicit substances (36.7% compared with 21.1%).
  • Those aged 45 years and over were less likely to report that they had used substances in the last 12 months (21.2% compared with 32.9% for those aged 15–29 years and 31% for those aged 30–44 years).
  • Marijuana, hashish or cannabis resin was the most commonly reported illicit drug used by Aboriginal and Torres Strait Islander people in the last 12 months at 24% (31.4% of males compared with 17.7% of females).
  • Lower proportions of use were reported for: other drugs (including heroin and cocaine) (5.9%); the non-medical use of analgesics and sedatives (such as painkillers, sleeping pills and tranquilisers) (3.8%); amphetamines, ice or speed (3.3%); and ecstasy or designer drugs (3.3%) (ABS 2019) (Figure INDIGENOUS4).

The overall findings are consistent with the 2014–15 NATSISS, which also showed that there was an increase between 2014–15 (30%) and 2008 (22%) in the proportion of Indigenous Australians aged 15 and over who reported using illicit substances in the last 12 months (ABS 2016).

Figure INDIGENOUS4: Substances used by Aboriginal and Torres Strait Islander people, by sex, 2018–19 (per cent)

Figure INDIGENOUS4: Substances used by Aboriginal and Torres Strait Islander people, by sex, 2018–19 (per cent)

The figure shows that in 2018–19, marijuana (including hashish and cannabis resin) was the most common substance used by Indigenous Australian people (24.0%), followed by other (5.9%), analgesics and sedatives for non-medical use (3.8%), and amphetamines or speed (3.3%). Drug use was more common for males than females across all drug types.

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The 2019 NDSHS data showed that (other than ecstasy, cocaine and hallucinogens), a higher proportion of Indigenous Australians aged 14 and over had recently used illicit drugs, compared with non-Indigenous Australians (Figure INDIGENOUS5, Table S3.2). In 2019, after adjusting for age:

  • just under one-quarter (23%) of Indigenous Australians had used any illicit drug in the last 12 months—almost 1.4 times higher than non-Indigenous Australians (16.6%)  
  • 15.5% had used cannabis in the last 12 months—almost 1.3 times higher than non-Indigenous Australians (12.0%)
  • 7.7% had used a pharmaceutical for non-medical use—almost 1.9 times higher than non-Indigenous Australians (4.1%)
  • 3.1% had used meth/amphetamine in the last 12 months—almost 2.4 times higher than non-Indigenous Australians (1.3%). The estimate for Indigenous Australians has a relative standard error of 25% to 50% and should be interpreted with caution (AIHW 2020b) (Table S3.2).

However, this gap has been narrowing over time. From 2016 to 2019, there were no significant changes in illicit use of drugs among Indigenous Australians, while use significantly increased for non-Indigenous Australians for a range of drugs (including cannabis, ecstasy, and cocaine). Due to the small sample sizes for Indigenous Australians, the estimates of the NDSHS should be interpreted with caution (AIHW 2020b). 

Figure INDIGENOUS5: Recenta illicit drug use by Indigenous status, people aged 14 and over, 2019 (age-standardised per cent)

Figure INDIGENOUS5: Recent illicit drug use by Indigenous status, people aged 14 and over, 2019 (Age standardised per cent)

The figure shows that, after adjusting for differences in age structure, cannabis was the most common illicit drug used by Indigenous Australians (15.5%) and non-Indigenous Australians (12%). Pharmaceuticals was the next most common drug type, with 7.7% of Indigenous Australians and 4.1% of non-Indigenous Australians reporting recent use. For Indigenous Australians, the third most common drug used was painkillers/analgesics and opioids (5.9%), while for non-Indigenous Australians it was cocaine (4.4%).

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Geographic trends

Indigenous Australians aged 15 and over residing in the Northern Territory (22%) were the least likely to report substance use, while those from the Australian Capital Territory (41%) and Victoria (40%) were the most likely to report using substances.

Indigenous Australians from the Northern Territory (22%) and Queensland (29%) were the only jurisdictions below the national average (30%) (ABS 2016) (Table S3.3).

Health and harms

Exposure to second-hand smoke

The Aboriginal and Torres Strait Islander Health Performance Framework report 2020 found that in 2018–19:

  • 1 in 10 (10% or 83,900) Indigenous Australians lived in household with a daily smoker who smoked indoors
  • almost 1 in 7 (15% or 23,900) of Indigenous children aged 0–14 lived in a household with someone who smoked indoors (AIHW 2020a).

Smoking reduction or cessation

In 2018–19, over half of Indigenous Australian smokers aged 15 and over (52%) had tried to quit smoking in the previous 12 months. In 2014–15, 30% of Indigenous current smokers had  tried to quit smoking in the previous 12 months, 18% had tried to reduce their smoking and 21% had tried to do both (AIHW 2017; AIHW 2020a; DoH 2017a).

Indigenous Australians smoked a median of 10 cigarettes a day in 2018–19, a decrease from 12 cigarettes a day in 2008 (AIHW 2020a; DoH 2017a).

Almost 1 in 2 Indigenous Australians with a mental health condition were daily smokers (46%) and about 2 in 5 (39%) have used substances in the last 12 months. This was higher than for Indigenous Australians with other long-term health conditions (33% and 24%, respectively) or those with no long-term health condition (39% and 29%, respectively) (ABS 2016) (Table S3.11).

The Australian Burden of Disease Study provides an indication of the risk factors that contribute to the health gap between Indigenous and non-Indigenous Australians. In 2011, tobacco use accounted for 12% of the burden of disease for Indigenous Australians. This accounts for 23.3% of the health gap between Indigenous and non-Indigenous Australians. Alcohol and drug use contributed to 8.1% and 4.1% of the gap, respectively (AIHW 2016a; AIHW 2016b) (Table S3.12).

Alcohol-related deaths

Over the 2013 to 2017 period—on average the rate of alcohol-related deaths was 23.8 per 100,000 population compared with 4.7 per 100,000 population for non-Indigenous Australians (ABS 2018).

The Aboriginal and Torres Strait Islander Health Performance Framework (AIHW 2020a) reports that the rate of alcohol-related deaths among Indigenous Australians was 18 deaths per 100,000 population in 2018. This is a decrease of 40% from 2008 (31 deaths per 100,000).

Drug-related deaths

The Penington Institute’s annual overdose report highlights that in 2018 the rate per capita of unintentional drug-related deaths per 100,000 population was almost 3 times higher for Indigenous Australians than for non-Indigenous Australians (17.3 compared with 6.0). The rate of unintentional drug-induced deaths among Indigenous Australians has increased between 2001 and 2018 (from 9.5 to 17.3 deaths per 100,000). However, it should be noted that:

  • rate calculations can be volatile due to smaller numbers of Indigenous deaths.
  • these data are reported for New South Wales, Queensland, Western Australia, South Australia and the Northern Territory only, which are considered to have adequate levels of Indigenous identification in the mortality data (Penington Institute 2020). For more information, see Health impacts: Box IMPACT1.

Treatment

The Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS NMDS) provides information on treatment provided to clients by publicly funded AOD treatment services, including government and non-government organisations. 

Data from the AODTS NMDS showed that Indigenous Australians accounted for 17% of all clients of AOD treatment services in 2019–20 (3,606 clients per 100,000 population) (AIHW 2021a). The rate of Indigenous clients who received treatment for their own drug use where:

  • Alcohol was the principal drug of concern was 1,209 clients per 100,000 population.
  • Amphetamines was the principal drug of concern was 1,051 clients per 100,000.
  • Cannabis was the principal drug of concern was 893 clients per 100,000 population.
  • Heroin was the principal drug of concern was 190 per 100,000 (Table S3.14; AIHW 2021a).   

In 2016–17, Indigenous clients travelled 1 hour or longer to their treatment service in about 1 in 4 (26%) closed treatment episodes. About 1 in 8 (13%) closed treatment episodes for non-Indigenous clients had a travel time of 1 hour or longer (AIHW 2019b).

Indigenous clients who sought treatment in Regional and remote areas travelled 1 hour or longer to the treatment service in 37% of closed treatment episodes, compared with 13% of closed treatment episodes for Indigenous clients in Major cities (AIHW 2019b).

It should be noted that as remoteness areas increase (become more remote), the accuracy of time travel/distance estimates decrease, due to the larger size of Remote areas (AIHW 2019b).  

Dependence on opioid drugs (including codeine, heroin and oxycodone) can be treated with pharmacotherapy therapy using substitute drugs such as methadone or buprenorphine. The National Opioid Pharmacotherapy Statistics Annual Data collection (NOPSAD) provides information on clients receiving opioid pharmacotherapy treatment on a snapshot day each year. In June 2020:

  • 5,693 clients who received pharmacotherapy treatment identified as Indigenous Australians.
  • Indigenous Australians were 3.7 times more likely (66 clients per 10,000 population) to receive pharmacotherapy treatment than non-Indigenous Australians (18 clients per 10,000 population) (AIHW 2021c) (Table S3.15).

Data from the Online Services Report (OSR) show that in 2016–17, there were 80 organisations around Australia that provided alcohol and other drug treatment services to around 39,400 Aboriginal and Torres Strait Islander clients (AIHW 2018). The OSR data also shows that:

  • All 80 organisations reported that alcohol was one of the top 5 common substance-use issue, followed by cannabis (95%) and amphetamines (80%)
  • Treatment episodes were more likely to occur in non-residential settings (89%)
  • One quarter of all treatment episodes were in Very remote areas (24%) and the highest proportion of clients were located in Major cities (37%).

Policy context

The Aboriginal and Torres Strait Islander Health Performance Framework

The Aboriginal and Torres Strait Islander Health Performance Framework (HPF) monitors progress in Aboriginal and Torres Strait Islander health outcomes, health system performance and the broader determinants of health. The HPF consists of 68 performance measures across 3 tiers: Tier 1—health status and outcomes, Tier 2—determinants of health, and Tier 3—health system performance.  In December 2020, the HPF was released on a new website. The website brings together information from numerous sources to provide up-to-date determinants of health designed to inform policy planning, program development and research (AIHW & NIAA 2020).

National Aboriginal and Torres Strait Islander Peoples Drug Strategy 2014–2019

The National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy 2014–2019 was a sub-strategy of the National Drug Strategy 2010–2015 and remains a sub-strategy under the National Drug Strategy 2017–2025. The overarching goal of this sub-strategy is to improve the health and wellbeing of Aboriginal and Torres Strait Islander people by preventing and reducing the harmful effects of alcohol and other drugs on individuals, families and their communities (IGCD 2014).

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