EXPERT REACTION: Aussie smoking rate falls, alcohol consumption stable, but use of some illicit drugs is up

The National Household Survey is an invaluable tool for legislators and policy makers to gauge the 'temperature' of the Australian public on attitudes to drugs & alcohol, and inform future policy that reflects those attitudinal shifts. And there are shifts worth noting.

For the first time, more people said they supported the legalisation of cannabis (41%) than opposed it (37%). Interestingly, and also for the first time, more Australians support cannabis being used regularly by adults (19.6%) than those that support regular tobacco smoking (15.4%). Perhaps the least surprising finding but politically controversial finding is that between a half and 2/3 of Australians (57%) support 'pill testing' or potential drug users being able to test their pills or other drugs at designated sites.

There is a growing realisation that education, rather than law enforcement, should be the preferred strategy to reduce the use of illicit drugs. For the first time, respondents were more inclined to allocate more of their taxpayers dollars to education, rather than to law enforcement.

Of more concern to those working in acute medical environments, there has also been a decline in support for policies aimed at reducing the problems associated with alcohol related harm. Support for reducing trading hours for pubs and clubs declined from 39% in 2016 to 31% in 2019.

These findings represent a mixed bag for legislators and our elected representatives. It is clear that attitudes in Australia regarding drugs and alcohol are changing. There is almost always a lag between such changes and the introduction of policy that reflects these changes. Whether our policy makers have the gumption to reform legislation in a manner that reflects the evidence, and increasingly the attitudes of the public, remains to be seen. Failure to do so will, for those in a profession so dependent on public approval for employment, runs the risk of being replaced by those that will.

One of the more significant things from the report is not about trends but about attitudes. For the first time ever, more people support legalisation of cannabis for personal use than oppose it. Before this there was overwhelming community support for removing the criminal penalties (or decriminalisation) but not for legalisation. Many countries around the world have moved to legalise cannabis. Our neighbours in New Zealand are about to have a referendum on it. A number of government inquiries in Australia have recommended legalisation of cannabis, including most recently the Qld Productivity Commission. One of the biggest harms with using cannabis is the risk of contact with the criminal justice system. It’s the illicit drug most used by Australians by far, so many people are at risk. When the laws are creating more harms than the drug itself, it’s time to review the laws.
 
The number of people who use methamphetamine is stable at 1.3% after 20 years of decline. The recent community concern about methamphetamine has been driven not by increasing numbers but by increasing harms. Around 2013 we saw a switch in preference from the powdered form (speed) to the more pure crystal form (ice), which is more harmful, even though numbers of people using had declined.

The proportion of people using other stimulants has increased, including MDMA and particularly cocaine. We don’t know why these increases have occurred but the rise in MDMA is possibly related to the rise in music festivals over the last few years. It really reinforces why we need to introduce harm reduction measures like drug checking at festivals. There has never been such a thing as a drug free society. We need to face the fact that drugs are not going away and work out how to make them safer.

Should we be worried about the increase in cocaine use? Most use is occasional. Purity is still low. Both cocaine and MDMA are associated with high social advantage. But frequency of use has increased - more people are using monthly - as have presentations to treatment services. It’s probably one to watch, but unless we start to see crack cocaine in Australia, harms are likely to remain relatively low.

The National Drug Strategy Household Survey (NDSHS) is an important report as it collects information from almost 23,000 Australians on alcohol and tobacco consumption, and illicit drug use among the general population in Australia.

It is encouraging to see declines in alcohol consumption, tobacco use, non-medical pharmaceutical use, and substance use in younger generations. This has been consistent with other major research and is attributed to the hard work of community groups, certain policy decisions, and to the attitudes of Australians in wanting to live a healthier lifestyle.

The areas of increase that are of concern are with increased use of cocaine and ecstasy, particularly those aged in their 20s and 30s. Also of concern is the continued use of the crystal form of methamphetamine.

Support for the legalisation of cannabis continued to grow in 2019 (41%; up from 35% in 2016), reaching almost double the level of support in 2007 (21%) (Table 9.23). For the first time, more people supported the legalisation of cannabis than opposed it (41% compared with 37%). This indicates a significant decrease in opposition, which was 59% in 2007. Fewer people thought that possession of cannabis should be a criminal offence (down from 26% in 2016 to 22% in 2019).There was also an increase in the recent use of cannabis from 10.4% in 2016 to 11.6% 2019, although over the past two decades the trend has been steadily downward since the highest reported levels of 17.9% in 1998.

With examples of cannabis legalisation in the Americas, the expansion of medical cannabis in Australia, and increasing rates of recent non-medical use, it is not surprising that support for cannabis legalisation among the Australian public continues to grow.

However, cannabis legalisation is not an all-or-nothing issue, and debate now needs to shift to what sort of legal model might be best for cannabis in this country. The profit driven, commercial cannabis markets that have emerged in the US and Canada seem to be replicating many of the problems we have seen with commercial alcohol and tobacco markets. A number of non-commercial, ‘middle ground’ legalised cannabis regulation options also exist, that put health before profit, and these need more discussion in Australia.

It’s great news that teenagers are continuing the trend towards delaying alcohol use. It’s also very encouraging that we’re seeing a substantial increase in the proportion of women choosing not to drink while pregnant or breastfeeding. These are crucial steps towards improving Australia’s future relationship with alcohol.

Less encouraging are current levels of single occasion risky drinking among young Australians of legal purchase age, which remain substantial. At least once a month, well over a third of 18-29 year olds drink at levels that put them at risk of short-term harm during a single drinking occasion.

Other research tells us that young people dominate attendances at emergency departments for injuries arising from alcohol intoxication. They present in large numbers for alcohol poisoning and unconsciousness; falls and fractures; broken hands and faces sustained through violence; fractured skulls and soft tissue injury from glassings; mental health episodes and self-harm; and road trauma. The toll on young people, their families and friends from drinking to intoxication is long overdue urgent attention by policy makers. Change is needed to address alcohol affordability, availability and enforcement of regulation concerning service to intoxication. 

Professor Steve Allsop, National Drug Research Institute, Curtin University, noted that the latest report draws attention to the importance of addressing drug use among older Australians.

"We have seen consistent evidence that legal and illegal drug related problems don’t just occur among young people. While many people change their drug use as they get older, we are seeing increasing numbers of people in their 40s and beyond using a range of substances and experiencing adverse outcomes. Some of us appear to be taking at least a little of our drug using behaviour from our youth into our later years."

Cancer Council has welcomed this new data showing smoking rates in Australia have fallen to a historic low of 11 per cent. The figures on the number of young people who smoke are particularly encouraging and we are now seeing the percentage of younger Australians who have never smoked reach an all-time high. This augurs well for the nation’s future health and reflects the benefits of de-normalising smoking over the past two decades. 63 per cent of Australians now report they have never smoked with that figure increasing to almost 97 per cent among those under the age of 18.

The declines in older age groups have been slower, highlighting the need for more of what works to bring smoking rates down further among all populations.

To reduce smoking rates in older Australians we need to see a revival of hard-hitting anti-smoking campaigns, which research shows are effective in older smokers – particularly those with families and those who have smoked for some time and may be increasingly susceptible to hard-hitting messages about the health harms.

Despite long-standing abstinence recommendations, one third of women in Australia continue to drink some alcohol when pregnant, the national household drug survey shows.

Findings from the National Household Drug Survey 2019 released today show that the proportion of women who drink alcohol when pregnant has steadily declined from 60% in 2007 to 35% in 2019. Most women who did drink would typically have no more than one or two standard drinks. This amounts to one typical home-poured glass of wine for example.

The results from the survey also show that the proportion of women continuing to drink declined to 14.5% as soon as they found out that they were pregnant. These downwards trends are important and encouraging. But the information also tells us that we have more work to do in educating women of childbearing age and their partners about the potential harms from any level of alcohol use.

Alcohol changes the normal development of a baby, including the brain at any stage during pregnancy. This can result in later difficulties with physical activities, language, memory, learning and behaviour. While the risk is highest when drinking heavily, there is no safe amount of alcohol that pregnant women can drink.

It is important that health professionals pass on the message that ‘No alcohol when planning a pregnancy and while pregnant and breastfeeding is the safest option’ and the community understands the risks of drinking alcohol during pregnancy and the effects it can have on the developing baby.

This is excellent news with smoking prevalence heading downwards again. As in previous years, declining uptake of smoking is the main driver. How to increase quitting among older established smokers remains a challenge.

The annual tobacco tax increases appear to be having an impact. They have likely reduced smoking uptake. Smokers are also changing their behaviour to reduce the cost of smoking, such as switching to roll-your-own tobacco and reducing how much they smoke. Hence, additional polices are needed to help these smokers to quit.

Vaping has increased among all age groups, but prevalence remains very low compared to smoking, with only 2.5% of people, mostly smokers, having used e-cigarettes recently. Interestingly, the increase in vaping has been greatest among the age groups with the largest drop in smoking, namely adults aged 18 to 29. 

The take home message is that combustible cigarettes remain the main nicotine product used in Australia and the greatest avoidable risk factor for early death. Current policies are deterring uptake among young people, but more needs to be done to help established smokers quit. As daily smoking prevalence is getting close to 10%, it is time to start serious planning for how we can phase out cigarettes and become a smokefree country.

It is very encouraging that there has been a further decrease in smoking. We have seen a remarkable decline in smoking in Australia from 24% in 1991 to 11% in 2019. That means literally tens of thousands of deaths prevented. It is also good news that we have seen such a marked decline in younger people taking up smoking. So the trends are very much heading in the right direction. 

There is further good news, in that the decline could be significantly accelerated if the federal government were to re-start the National Tobacco Campaign. We have not seen a major national TV campaign on tobacco since 2013. We know that hard-hitting television advertisements that graphically portray the health consequences of smoking encourage smokers to make quit attempts, and over time this drives down rates of smoking across the community. A commitment of $40 million a year for the campaign would only be 0.24% of estimated revenue from tobacco tax in the last financial year.

The time is right for a concerted effort combining public education, further regulation and further cessation support for smokers who want to quit. This can maintain Australia’s position as a world leader in reducing smoking.

The recent NDSHS figures indicating increased e-cigarette use among Australians are very concerning. Although marketed as a healthier alternative to traditional cigarettes, e-cigarettes are not harmless and there are significant health risks associated with their use. Short-term consequences of use have been known for quite some time and data on the long-term health consequences of e-cigarette use are beginning to emerge, with studies linking vaping with cell death and increased risk of cardiovascular disease and cancer.

The increasing use of e-cigarettes among young adult non-smokers is especially worrying. Figures released today indicate that use among non-smokers aged 18 to 24 years has quadrupled in just 6 years: from 5% in 2013 to 20% in 2019. Furthermore, 65% of adolescents and 39% of young adults who report using e-cigarettes for the first time have never previously smoked*.  These concerning proportions are likely being driven by the vaping industry’s narrative that e-cigarettes are ‘harmless’. Increasing use among non-smoking youth also speaks to the vaping industry’s continued targeting of this population via youth-oriented marketing and the development of new youth-oriented e-juice flavours, such as bubblegum and Red Bull. These are the same techniques used by the tobacco industry in the 1960’s – and history has shown us how that turned out. The vaping and tobacco industries need a new population of individuals to become addicted to nicotine to drive their profits. The NDSHS figures suggest the strategies they are using to entice youth and non-smokers are working.

Increased efforts are needed to turn the tide. E-cigarette policy in Australia is comprehensive but effective control of importation at the border is crucial to minimising uptake and use of e-cigarettes. The NDSHS figures indicate the Australian Government’s proposed crackdown on the illegal importation of liquid nicotine is urgently needed. It is disappointing this effort to protect the health of Australians has been delayed as result of heavy industry lobbying.

The statistically significant fall in daily smoking from 12.2 to 11% (nearly a 10% fall in proportional rates) takes Australia to the front row of low national smoking prevalence anywhere in the world.  Only 0.7% of 14-17 years old girls are smoking daily, and 3.1% of boys. These are the lowest rates ever recorded in Australia.

The biggest contribution to falling smoking prevalence has been the continuing rise in the number of people who have never taken it up, particularly younger people. The proportion of young adults aged 18–24 never smoking more than 100 cigarettes in their life has increased from 58% to 80% between 2001 and 2019. This wonderful trend reflects the impact of continuing “slow burn” policies like tax rises, total advertising bans, plain packaging, graphic health warnings and the thorough denormalization of smoking in public indoor settings.

There is considerable international evidence that vaping  holds far more smokers in smoking than it helps tip out of it. The rise of vaping in Australia (9.7% of smokers are also vaping) may be an important reason why cessation rates are not falling as much as they should.

We have not had a major national quit smoking campaign in Australia since 2013. The slight falling off in concerns about smoking is likely to reflect that.

The National Drug Strategy Household Survey provides important insights for tackling the harms of alcohol and other drugs in Australia. Survey findings reveal that risky drinking among adolescents and Indigenous Australians has continued to decline since 2001. The survey also shows that more women are increasingly abstaining from alcohol during pregnancy. This is great news and demonstrates that alcohol harm minimisation strategies in Australia are having positive impacts on populations where the harms of alcohol are felt disproportionately. However, it is important not to be complacent. Continued investment in evidence-based health promotion and prevention efforts, alongside strong alcohol legislation measures, are critical for addressing the social and economic harms of alcohol in Australia in a sustained way.