Alcohol, tobacco & other drugs in Australia

In 2016, there were almost 800,000 Aboriginal or Torres Strait Islander people (see Box INDIGENOUS1) living in Australia, 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.

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).

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 (Table S3.5) to 15.1% in 2018–19 (ABS 2019).
• 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).

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

Indigenous Australians are at an elevated risk of smoking during pregnancy compared with non-Indigenous Australians. The National Perinatal Data Collection showed that, in 2018, Indigenous mothers smoking at any time during pregnancy decreased from 52% in 2009 to 44% in 2018 (AIHW 2020c). After adjusting for differences in the age structure of the 2 populations, Indigenous mothers were almost 4 times as likely to smoke at some time during pregnancy, compared with non-Indigenous mothers (Table S2.59) (Figure INDIGENOUS2).

Of those Indigenous mothers who smoked, 10% quit during pregnancy (based on mothers who reported smoking in the first 20 weeks of pregnancy and not smoking after 20 weeks of pregnancy; non-age standardised) (AIHW 2020c).

Alcohol consumption

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 2020d) (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 2020d).

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 National Health and Medical Research Centre (NHMRC) 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 NHMRC 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 NHMRC 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 2020d) (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).

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).

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 2020d) (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 2020d).

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).

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).

Refer to Box IMPACT1 for different data sources on drug deaths.

Treatment

In 2018–19, the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS NMDS) showed that 16.5% of clients were Indigenous Australians aged 10 and over (AIHW 2020b). Indigenous Australians (3,580 per 100,000 population) were 7 times as likely to receive AOD treatment services than non-Indigenous Australians (515 per 100,000 population) (Table S3.13). Specifically, where the principal drug of concern was:

• amphetamines—1,014 per 100,000 population for Indigenous Australians compared with 141 per 100,000 population for non-Indigenous Australians.
• heroin—172 per 100,000 population for Indigenous Australians compared with 26 per 100,000 population for non-Indigenous Australians.
• cannabis—927 per 100,000 population for Indigenous Australians compared with 116 per 100,000 population for non-Indigenous Australians.
• alcohol—1,249 per 100,000 population for Indigenous Australians compared with 173 per 100,000 population for non-Indigenous Australians (AIHW 2020b) (Table S3.14).

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. For jurisdictions where data was provided, in 2019:

• Indigenous Australians were 3 times as likely (82 clients per 10,000 population) to receive pharmacotherapy treatment as non-Indigenous Australians (27 clients per 10,000 population) (AIHW 2020e) (Table S3.15).

Data from the 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 2017

The Aboriginal and Torres Strait Islander Health Performance Framework 2017 includes a suite of products that give the latest information on how Aboriginal and Torres Strait Islander people in Australia are faring according to a range of 68 performance measures across 3 tiers: Tier 1—health status and outcomes, Tier 2—determinants of health, and Tier 3—health system performance. The measures are based on the Aboriginal and Torres Strait Islander Health Performance Framework and cover data that has been collected on the entire health system, including Indigenous-specific services and programs, and mainstream services (DoH 2017a).

National Aboriginal 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 (AOD) on individuals, families and their communities (IGCD 2014).