Currently there are almost 800,000 Aboriginal or Torres Strait Islander people (see Box ATSI1) living in Australia, accounting for 2.8% of the Australian population [1]. 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 [2]. 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 [3]. Tobacco, alcohol, and other drugs are key risk factors contributing to the health gap between Indigenous and non-Indigenous Australians [2].

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, the Indigenous Australian survey data showed that 55% of Indigenous Australians aged 18 and over were smokers; 20 years later, in 2014–15, this had declined to 45% (Table S3.4).
• Over a similar 20-year period, the National Health Survey (NHS) the proportion of non-Indigenous smokers aged 18 and over declined, from 24% in 1995 to 16% in 2014–15 (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 2014–15. Even though the Indigenous Australian smoking rates are declining, the non-Indigenous rate is declining at a similar rate, therefore the gap remained constant [6] (Figure ATSI1).

Most of the decline in smoking occurred in non-remote areas. Over the 20-year period, the proportion of Indigenous Australians aged 18 and over in non-remote areas who were smokers declined from 55% to 42%, while the proportion in remote areas remained relatively stable at between 54% and 56% (Table S3.4).

In 2014–15, Indigenous males were more likely than Indigenous females to be smokers (47% compared with 42%) [1].

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 [4] (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:

• Indigenous mothers accounted for 19% of mothers who smoked tobacco at any time during pregnancy in 2015, despite accounting for only around 4% of mothers.
• The age-standardised rate of Indigenous mothers smoking during pregnancy has decreased from 50% in 2009 to 45% in 2015.
• Almost 1 in 2 (45%) Indigenous mothers reported smoking during pregnancy—compared with 12% of non-Indigenous mothers (age-standardised).
• The age-standardised rate of Indigenous mothers quitting smoking during pregnancy (14%) is about half that of non-Indigenous mothers (25%) (based on mothers who reported smoking in the first 20 weeks of pregnancy and not smoking after 20 weeks of pregnancy) [10].

Alcohol consumption

Abstinence (non-drinkers)

• The 2016 NDSHS found that Indigenous Australians aged 14 and over were more likely to abstain from drinking alcohol than non-Indigenous Australians (31% compared with 23%, respectively) and abstinence among Indigenous Australians has been increasing since 2010 when it was 25% [7] (Table S3.1).
• This pattern is consistent with data from the 2012–13 AATSIHS, where 28% of Indigenous Australians reported abstaining from drinking compared with 18% of non-Indigenous Australians [5].

Lifetime risk

• The 2014–15 NATSISS 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) decreased between 2008 and 2014–15 (19% compared with 15%; non age-standardised proportions). The overall change is largely due to a decline in non-remote areas (19% in 2008 to 14% in 2014–15) [4] (Table S3.6).
• Comparisons between Indigenous and non-Indigenous Australians are only available using age-standardised data from the 2012–13 AATSIHS and is not comparable to the 2014–15 NATSISS. The findings showed that lifetime risky drinking of Indigenous Australians aged 15 and over was similar to that of non-Indigenous Australians (9.8% compared with 9.7%; age-standardised) [5] (Table S3.7).

Single occasion risk

• According to the 2014–15 NATSISS, 30% of Indigenous Australians aged 15 and over exceeded the single occasion risk guidelines for alcohol consumption (non age-standardised proportions), which is a decline since 2002 (35%).
• Comparisons between Indigenous and non-Indigenous Australians are only available using age-standardised data from the 2012–13 AATSIHS and is not comparable to the 2014–15 NATSISS. The 2012–13 AATSIHS reported that 1 in 2 (50%) Indigenous Australians exceed the single occasion risky drinking guidelines (more than 4 standard drinks on a single occasion in past year). This was 1.1 times the rate that non-Indigenous Australians (44%) that exceeded these guidelines [5] (Table S3.7).

Risky alcohol consumption

• According to the 2016 NDSHS, almost 1 in 5 Indigenous Australians (18.8%) consumed 11 or more standard drinks at least once a month. This was 2.8 times the rate that non-Indigenous Australians (6.8%) consumed this amount of alcohol [7] (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 ATSI2). 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 [4] (Table S3.8).

Indigenous Australians residing in Western Australia (16%), New South Wales (16%) and Queensland (15%) surpassed the national average for exceeding lifetime risk guidelines [4] (Table S3.9).

Illicit drug use

In the 2014–15 NATSISS, 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 [4]. The data showed that:

• Almost one-third (30%) of Indigenous Australians aged 15 and over reported having used illicit substances in the last 12 months, up from 22% in 2008.
• Males were significantly more likely than females to have used illicit substances (34% compared with 27%), as were people in non-remote areas compared with those in remote areas (33% compared with 21%).
• Cannabis was the most commonly reported illicit drug used by Aboriginal and Torres Strait Islander people in the last 12 months at 19% (25% of males compared with 14% of females).
• The non-medical use of analgesics and sedatives (such as painkillers, sleeping pills and tranquilisers) was also relatively common (13%), with females (15%) being more likely than males (11%) to have used analgesics and sedatives.
• One in twenty (5%) Indigenous Australians aged 15 and over reported having used amphetamines or speed in the last 12 months (6% of males compared with 3% of females) [4] (Figure ATSI3).

The 2016 NDSHS data showed that (other than ecstasy and cocaine), Indigenous Australians aged 14 and over recent used of illicit drugs was at a higher rate than non-Indigenous Australians (Table S3.1). Rates of illicit drug use in 2016 for Indigenous Australians aged 14 and older were:

• Over one in four (27%) used any illicit drug in the last 12 months—1.8 times higher than non-Indigenous Australians (15.3%)
• One in five (19.4%) used cannabis in the last 12 months—1.9 times higher than non-Indigenous Australians (10.2%)
• Around one in 10 (10.6%) used a pharmaceutical for non-medical use—2.3 times higher than non-Indigenous Australians (4.6%) [7] (Table S3.1)
• 3.1% used meth/amphetamines in the last 12 months—2.2 times higher than non-Indigenous Australians (1.4%).

The differences between Indigenous and non-Indigenous Australians were still apparent even after adjusting for differences in age structure (Figure ATSI4). There were no significant changes in illicit use of drugs among Indigenous Australians between 2013 and 2016, however due to the small sample sizes for Indigenous Australians, the estimates of the NDSHS should be interpreted with caution.

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%) [4] (Table S3.3).

Health and harms

The health status of Aboriginal and Torres Strait Islander people are considerably lower than for non-Indigenous Australians. For instance:

• 35.1% of Aboriginal or Torres Strait Islander people compared with 58.3% of non-Indigenous Australia self-assessed their health as ‘excellent’ or ‘very good’ (age-standardised per cent).
• 32.5% of Indigenous Australians compared with 12.3% of non-Indigenous Australians reported high/very high psychological distress (age-standardised per cent).
• 71.0% of Aboriginal or Torres Strait Islander people reported having a long-term health condition compared with 55.3% of non-Indigenous Australians (age-standardised per cent) [4] (Table S3.6).

Almost 1 in 2 Indigenous Australians with a mental health condition were a daily smoker (46%) and about 2 in 5 (39%) to 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) [4] (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 23.3% of the gap, and alcohol and drug use contributed to 8.1% and 4.1% of the gap, respectively [8] (Table S3.12).

Treatment

Indigenous Australians are also overrepresented in drug and alcohol treatment services. In 2016–17, the Alcohol and Other Drug Treatment Services National Minimum Dataset (AODTS-NMDS) showed that 15% of clients were Indigenous Australians aged 10 and over (Table S3.13). Indigenous Australians (3,313 per 100,000 population) were 7 times more likely to receive AOD treatment services than non-Indigenous Australians (430 per 100,000 population) were. Specifically where:

• Amphetamines was the principal drug of concern, Indigenous Australians (1,204 per 100,000 population) were 8 times more likely than non-Indigenous Australians (155 per 100,000 population).
• Heroin was the principal drug of concern Indigenous Australians (911 per 100,000 population) were 7 times more likely than non-Indigenous Australians (123 per 100,000 population) were.
• Cannabis was the principal drug of concern Indigenous Australians (867 per 100,000 population) were 7 times more likely than non-Indigenous Australians (126 per 100,000 population) were.
• Alcohol was the principal drug of concern Indigenous Australians (136 per 100,000 population) were 7 times more likely than non-Indigenous Australians (26 per 100,000 population) [9] (Table S3.14).

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 2017:

• Around 1 in 10 clients (9%) were Indigenous, an overrepresentation relative to their population size.
• Indigenous Australians were almost 3 times as likely (70 clients per 10,000 population) to receive pharmacotherapy treatment as non-Indigenous Australians (26 clients per 10,000 population) [11] (Table S3.15).

Data from the OSR shows that 2015–16, there were 80 organisations around Australia that provided alcohol and other drug treatment services to around 32,700 Aboriginal and Torres Strait Islander clients [6]. The OSR data also shows that:

• All 80 organisations reported that alcohol was one of the top five common substance-use issue, followed by cannabis (94%) and amphetamines (70%)
• Treatment episodes were more likely to be to occur in non-residential settings (87%)
• One third of all treatment episodes were in Very remote areas (32%) and the highest proportion of clients were located in Major cities (35%).

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 [12].

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 [13].