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Tier 2 - Determinants of health

2.16 Risky alcohol consumption

Key facts

Why is it important?

Excessive consumption of alcohol is associated with health and social problems in all populations (NHMRC 2008). The 2009 Australian Guidelines to Reduce Health Risks from Drinking Alcohol provide the current advice from the National Health and Medical Research Council (NHMRC) around alcohol consumption (NHMRC 2009). These guidelines have informed the survey data compiled for this measure. Revisions to these guidelines are due to be finalised in 2020 and will inform future data collections.

Long-term excessive alcohol consumption is associated with a variety of adverse health and social consequences. It is a major risk factor for conditions, including liver disease, pancreatitis, heart disease, stroke, diabetes, obesity and some types of cancer. It is also linked to social and emotional wellbeing, mental health and other drug issues (NHMRC 2009). When mothers have consumed alcohol during pregnancy, babies may be born with Fetal Alcohol Spectrum Disorders (FASD) (Telethon Institute for Child Health Research 2009).

‘Binge drinking’ contributes to injuries and death due to suicide, transport accidents, violence, burns and falls. For the general population, one-third of suicides for men and women and one-third of motor vehicle deaths for men have been linked to alcohol consumption (NHMRC 2009).

Harmful alcohol consumption can also affect families and communities. It has the potential to lead to anti-social behaviour, violence, assault, imprisonment and family breakdown (NHMRC 2009).

Aboriginal and Torres Strait Islander people are more likely to abstain from alcohol than non-Indigenous Australians; however those who do drink are more likely to do so at dangerous levels.

Burden of disease

The 2011 Burden of Disease study estimated that alcohol use accounts for 8% of the total burden of disease and injury for Indigenous Australians. Among the risk factors considered, alcohol was the leading risk factor contributing to the burden of disease and injury for Indigenous males aged 15–44 years and for females aged 15–24 (AIHW 2016).

Findings

What does the data tell us?

The NHMRC states that ‘drinking no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease or injury’ and that ‘drinking no more than four standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion’ (NHMRC 2009).

Abstinence

The 2018–19 National Aboriginal and Torres Strait Islander Health Survey (Health Survey) included questions about alcohol consumption, including the amount consumed on single occasions and frequency of drinking. In 2018–19, 30% of Indigenous Australians aged 15 and over reported that they had abstained from alcohol in the previous 12 months or never consumed alcohol (Table D2.16.18). In 2012–13, the proportion was 26% (ABS 2013) (Figure 2.16.1).

Figure 2.16.1: Alcohol risk levels, Indigenous Australians aged 15 and over, 2012–13 and 2018–19

This bar chart shows that the proportion of Indigenous Australians aged 15 and over who abstained from alcohol in the previous 12 months was 30% in 2018–19, compared with 26% in 2012–13. The proportion of Indigenous Australians aged 15 and over who exceeded the single occasion risk guideline, that is, drank more than four standard drinks on a single occasion, at least once in the two weeks before the survey, was 50% in 2018–19 compared with 54% in 2012–13 and the proportion who exceeded the lifetime risk guideline, that is, drank more than two standard drinks per day on average, remained unchanged at 18% in 2012–13 and 2018–19.

Source: Table D2.16.21. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey, 2018–19; Australian Aboriginal and Torres Strait Islander Health Survey 2012–13 (ABS Table 14_3).

After adjusting for differences in the age structure between the two populations, Indigenous Australians aged 15 and over were 1.4 times as likely to have abstained from drinking alcohol in the previous 12 months as non-Indigenous Australians (30% and 22%, respectively) in 2018–19 (ABS 2019) (Figure 2.16.2).

Single occasion risky alcohol consumption

In 2018–19, 50% of Indigenous Australians aged 15 and over exceeded the single occasion risk guidelines (drank more than four standard drinks on a single occasion) at least once in the 2 weeks prior to the survey (Table D2.16.19). This was down from 54% in 2012–13 (ABS 2013) (Figure 2.16.1).

The incidence of exceeding the single occasion risk guidelines was higher for Indigenous males (61%) than Indigenous females (40%) and was similar between Non-remote (50%) and Remote areas (49%) (Table D2.16.19).

Of Indigenous Australians aged 15 and over who exceeded the single occasion risk guidelines, 18% drank at least once a week and 32% drank less than once a week (Table D2.16.9).

After adjusting for differences in the age structure between the two populations, Indigenous Australians aged 15 and over exceeded the single occasion alcohol risk guidelines at 1.2 times the rate of non-Indigenous Australians (49% and 42%, respectively) (ABS 2019) (Figure 2.16.2).

Figure 2.16.2: Age-standardised alcohol risk levels for persons aged 15 and over, by Indigenous status, 2018–19

This bar chart shows that in 2018–19, after adjusting for differences in the age-structure between the two populations, 30% of Indigenous Australians aged 15 and over abstained from alcohol compared with 22% of non-Indigenous Australians. 49% of Indigenous Australians aged 15 and over exceeded the single occasion risk guideline, that is, drank more than four standard drinks on a single occasion, at least once in the two weeks before the survey, compared with 42% of non-Indigenous Australians aged 15 and over. 19% of Indigenous Australians aged 15 and over exceeded the lifetime risk guideline, that is, drank more than two standard drinks per day on average, compared with 15% of non-Indigenous Australians aged 15 and over.

Source: AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19 (ABS Table 13.3).

In 2018–19, Indigenous Australians aged 18–24 were most likely to exceed the single occasion alcohol risk guidelines (65%) and those aged 15–17 had the lowest rate (18%) (Table D2.16.19).

Lifetime risk

In 2018–19, 18% of Indigenous Australians aged 15 and over drank at levels that exceeded the NHMRC lifetime risk guidelines (no more than two standard drinks per day on average) (Table D2.16.20). This was the same in 2012–13 (ABS 2013) (Figure 2.16.1).

The rate of exceeding the lifetime alcohol risk guidelines was higher for Indigenous males than Indigenous females (28% and 10%) and higher in Non-remote areas than Remote areas (19% and 16%) (Table D2.16.20, Figure 2.16.3).

After adjusting for differences in the age structure between the two populations, Indigenous Australians aged 15 and over exceeded the lifetime alcohol risk guidelines at 1.2 times the rate of non-Indigenous Australians (19% and 15%, respectively) (ABS 2019) (Figure 2.16.2).

Of Indigenous Australians who exceeded the lifetime risk guidelines in 2018–19, 37% consumed two to three standard drinks daily, 15% consumed three to four standard drinks, and 48% consumed more than four standard drinks. For non-Indigenous Australians who exceeded the lifetime risk guidelines, 39% consumed two to three standard drinks, 23% consumed three to four and 38% consumed more than four standard drinks (ABS 2019).

Figure 2.16.3: Indigenous Australians aged 15 and over who exceeded the lifetime alcohol risk guidelines, by remoteness and sex, 2018–19

This bar chart shows that in 2018–19, the proportion of Indigenous Australians aged 15 and over who exceeded the lifetime alcohol risk guideline, that is, drank two or more standard drinks a day on average, was 19% in non-remote areas compared with 16% in remote areas. 28% of Indigenous males aged 15 and over exceeded the lifetime alcohol risk guideline compared with 10% of Indigenous females.  Nationally, 18% of Indigenous Australians aged 15 and over exceeded the lifetime alcohol risk guideline in 2018–19.

Source: Table D2.16.20. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19.

Limitations of survey data

The survey data indicate the prevalence of alcohol consumption but underestimate actual consumption. Further, it cannot be assumed that patterns of consumption are uniform across geographic regions (Stockwell et al. 2004). After considering a range of evidence, a review by Wilson and others estimated the prevalence of harmful alcohol use in the Indigenous population at twice that of the non-Indigenous population (Wilson et al. 2010). 

Effect on communities

Excess alcohol consumption affects communities. In 2014–15, 19% of Indigenous Australians aged 15 years and over reported experiencing a family stressor related to alcohol problems. The rate was higher in Remote areas (23%) than Non-remote areas (18%). 

One study in New South Wales found that, after controlling for social and demographic variables, the rate of offensive behaviour and property damage tended to be higher in areas with higher levels of alcohol sales (Stevenson et al. 1999). There is also a clear link between alcohol and violence and imprisonment (see measure 2.11 Contact with the criminal justice system). 

Hospitalisation

Over the period July 2015 to June 2017, there were 11,254 hospitalisations of Indigenous Australians with a principal diagnosis related to alcohol use, which represented 2% of all hospitalisations of Indigenous Australians (excluding dialysis) (Table D2.16.11, Table 1.02.1).

After adjusting for difference in the age structure between the two populations, Indigenous Australians were hospitalised with alcohol-related diagnoses at 3.9 times the rate of non-Indigenous Australians (9.1 and 2.4 per 1,000).

Indigenous males were hospitalised with a principal diagnosis related to alcohol use at 1.4 times the rate of Indigenous females (11 per 1,000 compared with 7.6 per 100,000).

Hospitalisations related to alcohol use for Indigenous Australians were highest in Remote areas (16 per 1,000) and lowest in Inner regional areas (4.5 per 1,000) (Table D2.16.12). By jurisdiction, hospitalisations related to alcohol use for Indigenous Australians were highest in the Northern Territory (19 per 1,000) and lowest in Victoria and Tasmania (both 4.5 per 1,000) (Table D2.16.15, Figure 2.16.4).

Figure 2.16.4: Age-standardised rate of hospitalisations with a principal diagnosis related to alcohol use, by Indigenous status and jurisdiction, July 2015 to June 2017

This bar chart shows that in July 2015 to June 2017, the age-standardised rate of hospitalisations with a principal diagnosis related to alcohol use for Indigenous Australians ranged from 5 per 1,000 hospitalisations in Victoria and Tasmania (the lowest rates) to 19 per 1,000 in the Northern Territory (the highest rate). In comparison, the age-standardised hospitalisation rate with a principal diagnosis related to alcohol use for non-Indigenous Australians was between 2 to 3% for all jurisdictions. Nationally, the age-standardised rate of hospitalisations related to alcohol use was 9% for Indigenous Australians and 2% for non-Indigenous Australians.

Source: Table D2.16.15. AIHW analysis of National Hospital Morbidity Database.

Acute intoxication was the most common reason Indigenous Australians were hospitalised for alcohol use (62%), followed by dependence syndrome (13%), alcoholic liver disease (9%) and withdrawal (9%). For non-Indigenous Australians, the most common reasons were dependence syndrome (50%), acute intoxication (21%), alcoholic liver disease (9%) and withdrawal (9%).

Over the period July 2015 to June 2017, Indigenous Australians were hospitalised for acute intoxication at 11 times the rate of non-Indigenous Australians, 4.6 times the rate for alcoholic liver disease, 3.8 times for withdrawal and the same proportion for dependence syndrome (Table D2.16.11).

Between 2004–05 and 2016–17, hospitalisations for a principal diagnosis related to alcohol use increased for Indigenous females (from 4.4 to 8.1 per 1,000) and Indigenous males (from 9.1 to 10.8 per 1,000) (Table D2.16.13).

Mortality

In the period 2014–2018, Indigenous males died from alcohol-related causes at 4.3 times the rate of non-Indigenous males (31 and 7.2 per 100,000), and Indigenous females at 4.7 times the rate of non-Indigenous females (11 and 2.3 per 100,000). This was for the five jurisdictions with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory combined).

The majority of Indigenous deaths related to alcohol use (298 out of 467) were due to alcoholic liver disease. Indigenous females were 4.7 times as likely as non-Indigenous females to die from alcoholic liver disease (7.7 compared with 1.7 per 100,000) Indigenous males died from alcoholic liver disease at 3.8 times the rate of non-Indigenous males (18 compared with 4.7 per 100,000) (Table D2.16.10, Figure 2.16.5).

Figure 2.16.5: Age-standardised rate of deaths related to alcohol use, NSW, Qld, WA, SA and the NT, 2014–2018

This bar chart shows that for the period 2014 to 2018, based on data from New South Wales, Queensland, Western Australia, South Australia and the Northern Territory, the rate of deaths related to alcohol use was 20.2 per 100,000 population for Indigenous Australians, compared with 4.7 per 100,000 for non-Indigenous Australians. The rate of deaths for alcoholic liver disease was 12.5 per 100,000 for Indigenous Australians, compared with 3.1 per 100,000 for non-Indigenous Australians. The rate of deaths from mental/behavioural disorders due to alcohol use was 4.1 per 100,000 for Indigenous Australians, compared with 0.9 per 100,000 for non-Indigenous Australians. The rate of deaths from alcohol poisoning was 1.5 per 100,000 for Indigenous Australians, compared with 0.3 per 100,000 for non-Indigenous Australians and the rate of deaths due to other alcohol-related causes was 2.1% for Indigenous Australians compared with 0.3% for non-Indigenous Australians.

Source: Table D2.16.10. AIHW and ABS analysis of the ABS Causes of Death Collection.

After adjusting for differences in the age structure between the two populations, the rate for alcohol-related deaths among Indigenous Australians declined by 40%, from 31 deaths per 100,000 in 1998 to 18 deaths per 100,000 in 2018. For non-Indigenous Australians, death related to alcohol use also declined (by 15%) from 5.4 per 100,000 in 1998 to 4.5 per 100,000 in 2018. From 2006 to 2018, the rate of death caused by alcohol use for Indigenous Australians declined by 11%, but this was not a statistically significant decrease. For non-Indigenous Australians, there was no change over this period (Table D2.16.22, Figure 2.16.6).

Figure 2.16.6: Age-standardised rate of deaths related to alcohol use, by Indigenous status, NSW, Qld, WA, SA and NT, 1998–2018

This line chart shows that after adjusting for differences in the age structure between the two populations, the rate of alcohol-related deaths among Indigenous Australians declined by 40%, from 31 deaths per 100,000 population in 1998 to 18 deaths per 100,000 in 2018. For non-Indigenous Australians, death related to alcohol use also declined (by 17%) from 5.4 per 100,000 population in 1998 to 4.5 per 100,000 in 2018.

Source: Table D2.16.22. AIHW and ABS analysis of the ABS Causes of Death Collection.

What do research and evaluations tell us?

Important differences exist between Indigenous and non-Indigenous Australians in relation to patterns and levels of consumption of alcohol, and patterns and levels of harm it can cause. Indigenous Australians are more likely to abstain from drinking alcohol than non-Indigenous Australians (30% compared with 22%). This includes lifetime abstainers and also those who used to drink but no longer do, often as a result of the harmful effects of alcohol consumption (Wilson et al. 2010). However, of the Indigenous Australians who do consume alcohol, a greater proportion does so at levels that pose both short-term and long-term risks to their health and the health of others (Chikritzhs et al. 2004; Gray et al. 2018).

There is evidence to show that a range of factors contributes to the higher levels of alcohol consumption by Indigenous Australians. The social determinants contributing to the health status of Indigenous Australians include current and past inequalities, racism and higher levels of emotional and social distress (Gray et al. 2018).

There is a link between social and emotional wellbeing and risky alcohol consumption. Findings from the 2016 National Drug Strategy Household Survey show that people who exceeded the single occasion risk guidelines at least weekly were more likely to have high or very high levels of psychological distress (16%) than those drinking at low levels for a single occasion (9.3%). Further, the diagnosis or treatment for a mental health condition was 1.2–1.3 times higher among those drinking at risky levels than those drinking at low-risk levels or abstaining from alcohol (AIHW 2017).

Drinking alcohol while pregnant may result in miscarriage, stillbirth, low birth weight, intrauterine growth restriction, preterm birth and a range of potentially lifelong physical, mental, behavioural and learning issues, collectively referred to as FASD (France et al. 2010; Mutch et al. 2015; Srikartika & O'Leary 2015). FASD are neurodevelopmental disorders caused when an unborn child is exposed to alcohol in the womb. While existing research has limitations, risks of harm are said to increase with the amount and frequency of alcohol consumed (see measure 2.21 Health behaviours during pregnancy) (O'Leary et al. 2010).

Nationally, the true prevalence of FASD for Indigenous Australians is not known; estimates vary from 2.7 to 4.7 per 1,000 births (HRSCSPLA 2012). A recent study in the Fitzroy Valley in Western Australia found the rate to be 120 per 1,000 children (Fitzpatrick et al. 2015). A community-led project to lower the risk of FASD in the Fitzroy Valley has achieved outstanding results. The project was guided by Elders and the evidence-based Marulu Strategy. It was developed in consultation with research partners the Telethon Kids Institute, the University of Sydney and the George Institute for Global Health. Intervention to lower the risk of FASD focused on prevention, diagnosis and providing therapy support to affected individuals and families coping with lifelong physical and mental health problems. A team of 20 local Aboriginal community researchers were trained and enlisted to run the program (Fitzpatrick et al. 2017; Telethon Kids Institute 2016). Midwife-collected data revealed a dramatic fall in drinking during pregnancy in the Fitzroy Valley in response to the program to below the rate of the general community in Australia. Previously, 65% of pregnant mothers drank, and this has now dropped to 18%. The project highlighted practical strategies (for example, educating the community on the harms of consumption during pregnancy) to reduce and eliminate FASD. These provide lessons for approaches in other Indigenous and non-Indigenous communities.

Research shows a link between incarceration and FASD. A study in Western Australia—the Banksia Hill Project—was conducted in a Western Australian youth correctional facility and found that neurodevelopmental impairments due to FASD can predispose young people to engagement with the law (Bower et al. 2018). It is the first study in Australia to assess and diagnose young people in a youth custodial facility. Ninety-nine young people completed a full assessment, 93% were male and 74% were Aboriginal. Thirty-six people were diagnosed with FASD, a prevalence of 36%, the majority of which had not previously been diagnosed.

The Northern Territory Government has introduced a suite of alcohol-related harm minimisation measures including the rewrite of the Northern Territory Liquor Act 1978, the introduction of the minimum floor price on alcohol, and the roll-out of Police Auxiliary Liquor Inspectors. Statistics released by the Northern Territory Government in September 2019 show that there has been a 22% reduction in alcohol-related assaults across the Northern Territory, including 40% in Alice Springs and 15.5% in Darwin, and a drop of 24.5% in alcohol-related emergency department presentations in Northern Territory hospitals (Northern Territory Government Newsroom 2019).

A recent study examined the effects of the introduction of the alcohol floor price on critical care admissions in Central Australia. While more time is required to evaluate the full effect of the floor price in the context of other supply reduction measures, the study found that hospitalisations for acute alcohol misuse dropped by 54% in the first six months after the introduction of an increase in the minimum floor price to $1.30 per standard drink (Secombe et al. 2020).

Alcohol was a major contributor to emergency department attendances for injuries and interpersonal violence (Gale et al. 2015; Hides et al. 2015; Miller et al. 2012; Poynton et al. 2005). Economic literature shows that restricting access to alcohol reduces alcohol-related harm such as mortality, crime, and injuries (Brand et al. 2007; Carpenter & Dobkin 2009; Wagenaar et al. 2010). Evaluations of alcohol restriction interventions in the Kimberley Health Region of Western Australia provided evidence that the restriction of selling high strength alcohol has contributed to a significant reduction in alcohol-related hospitalisations and emergency department attendances (Sun et al. 2019). Reducing the number of alcohol sales outlets may also be effective; the phased closure of the Aurukun tavern was most likely the cause of the 50% reduction in the number of assaults in Aurukun (DSS 2012).

Implications

The health effects of excess alcohol consumption are evident in both mortality and morbidity statistics. Alcohol is a serious public health issue facing many Indigenous Australian communities (Calabria et al. 2010). Reducing alcohol and other substance misuse can significantly reduce levels of assaults and homicides and disability while improving the overall health and wellbeing of the population (SCRGSP 2009). A reduction in alcohol and other substance misuse might also increase educational attainment, household and individual income levels and reduce crime and imprisonment rates (SCRGSP 2005). Among urban Indigenous Australians, 65% regard either alcohol abuse or alcohol-related violence as the most serious issue facing Indigenous communities (DHSH 1995).

A number of local, regional and national strategies, including the National Alcohol Strategy
2019–28, have been implemented with the aim of reducing risky and high-risk alcohol consumption, including some that restrict supply. Some of these are whole-of-community strategies, while others are targeted solely at Indigenous Australians. Many have had substantial success, others less so (d'Abbs & Togni 2000). At present, most legal provisions governing the supply of liquor are the responsibility of the states and territories, limiting the role the Commonwealth can directly play. In many discrete Indigenous communities in remote areas of Northern and Central Australia, alcohol is totally or partly banned. Further research and evaluations to assess the effectiveness of these strategies need to be undertaken.

The overarching principle of Australia’s National Drug Strategy is that of harm minimisation, which comprises three pillars: demand reduction, supply reduction and harm reduction. Strategies should align with the three pillars and also address underlying social determinants, aim to prevent the uptake of harmful use, provide treatment for those who are dependent and support those whose lives are affected by others’ harmful alcohol and other drug use (Gray et al. 2018).

For those Indigenous Australians that access alcohol treatment, key themes identified for effective alcohol treatment include individual engagement, flexibility, assessment of suitability, Indigenous Australian staff, community engagement, practical support, counselling, coping with relapse and contingency planning (Brett et al. 2014) (see measure 3.11 Access to alcohol and drug services).

Further research is warranted into what policy settings are needed to encourage interventions that will reduce the prevalence of risky and high-risk alcohol consumption and the consequent harm to health among Indigenous Australians.

This measure uses different datasets to explore patterns of alcohol use and related health effects and harm. A potential inconsistency that needs further investigation is the survey data that may underestimate alcohol consumption. This may be particularly relevant for services in Remote areas where the survey data show a lower proportion of Indigenous Australians exceeding lifetime risk guidelines compared with Non-remote areas, while hospitalisation rates of alcohol-related conditions in Remote areas and the Northern Territory are much higher than other areas. This could point to issues around the availability of services in remote areas and also potentially higher quantities of alcohol consumed beyond the four-drink data category captured in the 2018–19 health survey data. To illustrate, the 2012–13 health survey captured 24-hour recall of amounts of alcoholic beverages consumed by Indigenous adults. This found that the median amount of alcoholic beverages consumed by Indigenous adults was higher in Remote areas (1,717 grams) than Non-remote areas (1,007 grams).

Aboriginal Community Controlled Health Services (ACCHSs) have made important contributions to improving the health of Indigenous Australians through the provision of culturally appropriate health care. ACCHSs vary in size, and the services they reflect the unique health needs of an individual community. Advocacy efforts of ACCHSs have been shown to improve alcohol-related policies that are associated with a reduction in alcohol-related assaults and alcohol-related presentations to health services (Campbell et al. 2018). ACCHSs can play a pivotal role in providing specific and culturally relevant alcohol services and should be considered in the development of alcohol harm prevention or reduction strategies.

The policy context is at Policies and strategies.

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