Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697634037471.pdf (Australia)
G Model DRUPOL-1179; No.

of Pages 4 ARTICLE IN PRESS International Journal of Drug Policy xxx (2013) xxx– xxx Contents lists available at SciVerse ScienceDirect International Journal of Drug Policy j o u r n a l h o m e p a g e : w w w .

e l s e v i e r .
c o m / l o c a t e / d r u g p o Patterns of alcohol, tobacco and cannabis use and related harm in city, regional and remote areas of Australia Amanda Roxburgh a,∗, Peter Miller b, Matthew Dunn a,c a National Drug and Alcohol Research Centre, University of New South Wales, Australia b School of Psychology, Deakin University, Australia c School of Health and Social Development, Deakin University, Australia a r t i c l e i n f o a b s t r a c t Article history: Received 9 August 2012 Received in revised form 24 January 2013 Accepted 7 February 2013 Keywords: Alcohol Cannabis Epidemiology Australia Rural Background: Prevalence of substance use and related harms differs across geographic locations, with prevalence increasing with remoteness.
This paper builds on previous research, investigating patterns of problematic use by remoteness.

Methods: Analysis of the National Drug Strategy Household Survey (NDSHS) data from 2007 by geographic location (in accordance with the Australian Standard Geographical Classiﬁcation (ASGC) remoteness index).

Results: Problematic cannabis use was predicted by demographics; older males with less education were more likely to report problematic cannabis use regardless of location.
Younger, less educated males in inner regional and remote areas were more likely to report risky alcohol consumption for short term harms, while older, less educated males in outer regional and remote areas were more likely to report daily drinking.

People from remote areas were signiﬁcantly more likely to report driving under the inﬂuence of alcohol.

Conclusions: It is clear that men with lower levels of education were signiﬁcantly more likely to report problematic alcohol and cannabis use patterns.
An additional level of risk is associated with living in inner regional and remote areas, particularly in relation to risky drinking.

Findings suggest a complex relationship between remoteness and substance use which requires further investigation.

© 2013 Elsevier B.V. All rights reserved.


Introduction The United Nations Ofﬁce on Drugs and Crime (UNODC) esti- mates 3.3–6.1% of the global population aged 15–64 years has used an illicit drug in the past year (United Nations Ofﬁce on Drugs & Crime, 2011); the World Health Organization (WHO) esti- mates that, in 2005, 6.13 litres of pure alcohol was consumed by every person aged 15 years or older (World Health Organization, 2011).
Both reports indicate there is variation in consumption between countries; higher levels of alcohol consumption are seen in countries such as Argentina, Australia and New Zealand (World Health Organization, 2011).

Research also shows within-country variance.

Studies in the United States have shown that adolescents living in rural communi- ties report higher levels of alcohol and tobacco use than adolescents in urban communities (Hanson et al., 2009).
Although there is some indication this difference may extend to illicit substance use (Lambert, Gale, & Hartley, 2008), other studies have shown higher ∗ Corresponding author.

Tel.

: +61 02 9385 0333; fax: +61 02 9385 0222.

E-mail address: a.roxburgh@unsw.edu.au (A. Roxburgh).

0955-3959/$ – see front matter © http://dx.doi.org/10.1016/j.drugpo.2013.02.001 2013 Elsevier B.V. All rights reserved.

rates among urban adolescents (Hanson et al., 2009).
Research from Victoria, Australia has found adolescents in regional and rural areas report high-risk alcohol consumption compared to those in urban areas (Livingston, Laslett, & Dietze, 2008).

Geographical differences cease to exist for tobacco consumption among adolescents and those in urban areas report higher levels of illicit substance use, with the exception of cannabis (Australian Institute of Health & Welfare, 2008).

Rural communities also show greater harm from substance use.
A research review in Australia has shown that rural communi- ties show substantially greater harm from alcohol consumption than urban populations (Miller, Coomber, Staiger, Zinkiewicz, & Toumbourou, 2010).

Hospitalisation rates are generally higher; up to 24.7% of men living in rural or remote areas experience hospi- talisations due to alcohol-related disease (such as cirrhosis of the liver) and alcohol-related injury (such as road injuries) as com- pared to 17.6% of men living in metropolitan areas.
The trend is the same for women (Hanlan, Jonas, Laslett, Dietze, & Rumbold, 2000).

Exploring differences in patterns of substance use and related harm between urban, regional and rural locations is not new.

However, these differences are often discerned using prevalence measures, which include those who may have only used a substance Please cite this article in press as: Roxburgh, A., et al.

Patterns of alcohol, tobacco and cannabis use and related harm in city, regional and remote areas of Australia.
International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.02.001 Need for a nationally-consistent approach to alcohol-fuelled violenceSubmission 47 - Attachment 31 G Model DRUPOL-1179; No.

of Pages 4 2 ARTICLE IN PRESS A. Roxburgh et al.

/ International Journal of Drug Policy xxx (2013) xxx– xxx once over a period of time.

It is important to explore patterns of problematic substance use, which are more likely to confer harm.
Using data collected from a nationally-representative pop- ulation survey, the current paper seeks to identify differences between urban, regional and rural populations regarding problem- atic substance use, and harm and highlight areas requiring further investigation.

Method Survey Data from the 2007 National Drug Strategy Household Sur- vey (NDSHS) were analysed.

Approximately 24,000 respondents participated.


The multistage stratiﬁed sampling methodology (in which the sample is stratiﬁed by geographic region) is designed to provide a close-to-random sample to obtain data on drug and alco- hol use in the Australian population over 14 years of age.

Selection of respondents is designed to be unbiased.
However, the result- ing samples required weighting to correct for imbalances arising in the design and execution of the sampling, and differential response rates across geographic location.

Detailed descriptions of samp- ling methodology are available elsewhere (Australian Institute of Health & Welfare, 2009).

The overall response rate for the survey was 49.3%.
Measures Geographic location was coded in accordance with the Aus- tralian Bureau of Statistics (ABS) Australian Standard Geographical Classiﬁcation (ASGC) remoteness index.

There are four levels of the classiﬁcation used in this paper; (1) major cities (2) inner regional (3) outer regional (4) remote.

There is an additional sub- classiﬁcation of very remote; however, this was combined with remote by the AIHW for conﬁdentiality purposes.
Level of disad- vantage was measured using the Socio-Economic Indexes for Areas (SEIFA) quintile measure calculated by the AIHW.

Demographic measures included: gender, age, marital status, secondary and tertiary education, country of birth, employment, level of relative advantage/disadvantage.

Past year (‘recent’) use of tobacco, alcohol, cannabis, and any illicit drug were analysed by geographic location.

Patterns of alco- hol and cannabis use were analysed further.
Proportions reporting: (1) weekly or more frequent cannabis use; (2) weekly or more fre- quent risky drinking for short term harm (deﬁned as 7 or more standard drinks for men per occasion and 5 or more standard drinks for women per occasion in accordance with the 2001 drinking guidelines that were in place when the 2007 NDSHS was con- ducted) (National Health & Medical Research Council, 2001); and (3) daily drinking are presented.

These were selected as repre- senting harmful patterns of use.
Harms were measured by past year prevalence of having been verbally or physically assaulted by a person under the inﬂuence of alcohol or illicit drugs and hav- ing driven a motor vehicle under the inﬂuence of alcohol or illicit drugs.

Ethical considerations The dataset was provided to National Drug and Alcohol Research Centre researchers as a de-identiﬁed unit record ﬁle following approval from the AIHW Ethics Committee.
Results Recent substance use Recent substance use was signiﬁcantly more prevalent among respondents from remote areas (alcohol 87.6%, cannabis 14.4%) compared to those from City areas (82.7%, 9%).

Post hoc analy- ses on recent tobacco use (based on ﬁndings from multivariate analyses) revealed younger males without secondary education qualiﬁcations were more likely to report recent tobacco use.
Risky patterns of substance use Respondents in the inner regional areas (41%, OR 1.5, 95% CI 1.07–1.99) were more likely to report weekly or more frequent cannabis use than respondents in City areas (32.2%).

Once other demographic variables were entered into a multivariate model, geographic location was no longer signiﬁcant.

Those reporting weekly or more frequent cannabis use were signiﬁcantly more likely to be older males, without secondary education qualiﬁcations (Table 1).
Respondents in the inner regional (10.8%, OR 1.3, 95% CI; 1.1–1.5) and remote areas (13.6%, OR 1.6, 95% CI; 1.3–2.1) were signiﬁcantly more likely to report risky patterns of alcohol con- sumption for short term harm at least weekly than those in city areas (8.7%).
Controlling for demographic measures, risky patterns of alcohol consumption for short term harms were sig- niﬁcantly more likely to occur among younger males born in Australia, without secondary education qualiﬁcations living in inner regional areas, with ﬁndings from remote areas nearing sig- niﬁcance (Table 1).

Finally, respondents from outer regional areas (12.2%, OR 1.4, 95% CI 1.2–1.6) were more likely to report daily alcohol consumption than respondents in City areas (9.2%).
When demo- graphic measures were included in the model, geographic location remained signiﬁcant.

Findings from remote areas neared signiﬁ- cance.

Older males without secondary education who lived in outer regional and remote areas were signiﬁcantly more likely to report daily alcohol consumption (Table 1).
Harmful behaviours Respondents from inner regional areas (12%, OR 0.8, 95% CI 0.7–0.9) were signiﬁcantly less likely to have driven under the inﬂu- ence of alcohol in the past 12 months than respondents in City areas (13.9%), while those in remote areas (22.6%, OR 1.8 95% CI 1.5–2.3) were signiﬁcantly more likely to have driven under the inﬂuence of alcohol compared to their city counterparts.
Respondents living in remote areas (26.9%, OR 1.6 95% CI 1.2–2) were also signiﬁcantly more likely than those in city areas (20.3%) to report being verbally abused by someone under the inﬂuence of alcohol in the past 12 months.

Data analysis Data analysis was conducted in SAS for Windows release 9.2.

All analysis used weighting, strata and cluster variables as provided by the AIHW, to account for the complex sampling methodology.

Anal- ysis was conducted using logistic regression.
City was the referent group for all analysis.

Substantial differences existed between urban, regional and remote communities in problematic substance use and harms experienced.

However, different trends were apparent with dif- ferent levels of remoteness.

Recent alcohol and cannabis use Discussion Please cite this article in press as: Roxburgh, A., et al.

Patterns of alcohol, tobacco and cannabis use and related harm in city, regional and remote areas of Australia.
International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.02.001 Need for a nationally-consistent approach to alcohol-fuelled violenceSubmission 47 - Attachment 31 G Model DRUPOL-1179; No.

of Pages 4 ARTICLE IN PRESS A. Roxburgh et al.
/ International Journal of Drug Policy xxx (2013) xxx– xxx 3 Table 1 Multivariate analyses of problematic substance use patternsb Variable Unadjusted odds ratio Adjusted odds ratio Wald statistic P value 95% CI Weekly or more cannabis use Inner regional Outer regional Remote Sex Age No HSCa Risky patterns of alcohol use Inner regional Outer regional Remote Sex Age No HSCa Australian born Daily alcohol use Inner regional Outer regional Remote Sex Age No HSCa 1.5 1.4 .91 .67 1.02 2.1 1.27 1.13 1.6 .69 .97 1.09 1.72 1.13 1.37 1.25 .52 1.05 1.65 1.3 1.1 .86 .72 1.02 1.95 1.22 1.01 1.3 .65 .97 1.23 1.42 1.06 1.34 1.50 .50 1.05 1.15 2.44 .57 .26 7.2 12.2 28.0 5.45 .82 3.5 41.7 241.36 8.9 14.55 .56 10.86 3.91 131.04 716.80 5.09 0.11 .44 .61 <.01 <.01 <.0001 <.05 .91 .06 <.0001 <.0001 <.01 <.01 .45 <.01 .05 <.0001 <.0001 .03 .93–1.8 .81–1.60 .49–1.5 .57–.92 1.01–1.02 1.5–2.5 1.04–1.44 .82–1.25 .98–1.7 .568–.739 .967–.974 1.07–1.41 1.2–1.7 .912–1.23 1.13–1.60 1.01–2.25 .44–.56 1.04–1.05 1.02–1.31 a Higher school certiﬁcate.
b Level of disadvantage had no impact on these models, and was therefore left out.

increased with remoteness, while demographic differences were important mediators of the relationship between geographic location and recent tobacco use.

Post hoc analyses revealed that male gender, younger age, and no secondary education qualiﬁcations, were all signiﬁcant predictors of recent tobacco use.

A complex relationship was found between risky patterns of substance use and geographic location.
Problematic cannabis use did not increase in a linear manner with remoteness.

Once other factors were controlled for, geographic location was no longer signiﬁcant.

Older males, without secondary education qualiﬁca- tions, were signiﬁcantly more likely to report problematic cannabis use.

Geographic location (inner and outer regional, and remote) remained an important predictor for problematic alcohol use.
Males with lower levels of education were more likely to report these patterns; younger males reported risky alcohol consump- tion for short term harms and older males reported daily alcohol consumption.

In relation to harms, respondents in remote communities were more likely to drive under the inﬂuence of alcohol and to have experienced abuse from someone under the inﬂuence of alcohol compared to those in urban areas.
These ﬁndings accord with pre- vious research (Toumbourou, Miller, Staiger, Hemphill, & Catalano, 2011).

These ﬁndings have important public health implications.

Over- all, prevalence of smoking in remote areas has not changed; in 1995 32% of people in these areas reported smoking (Australian Institute of Health & Welfare, 2009) in comparison to 31.6% in 2007.
This shows a worrying resistance to improvement in com- parison to urban trends which have steadily reduced over the same period, and in contrast to overall national rates of 16.6% of people being daily smokers.

The resistance to public health cam- paigns may reﬂect closer cultures that hold stronger mythologies about health behaviours (Lawlor, Frankel, Shaw, Ebrahim, & Smith, 2003), or indicate that health messages are not reaching people in remote settings.
Delivery of credible harm reduction messages to remote communities about tobacco consumption remains an important public health imperative, particularly given the rela- tively high level of burden tobacco-related disease places on health services in Australia (Australian Institute of Health & Welfare, 2012).
Problematic substance use patterns occurred largely among men with levels of education, suggesting that service delivery, and messages about reducing use, needs to target this demographic across all geographic locations.

lower Findings around alcohol-related harm highlight the need for targeted drink-driving programs in remote communities, where there is a culture of tolerance of drink-driving.
Previous research in rural Victoria found drink driving behaviours were particularly resilient among high risk drinkers, despite enforcement measures such as breathalyser stations being in place (Harrison & Fitzharris, 1999).

Reaching those most at risk (i.e.

high risk drinkers–young men with low levels of education) is an important challenge.
Previous research in Australia, investigating attitudes to target- ing substance use and harms in non-urban settings, suggests that including local stakeholders in the development of interven- tions to reduce use and harms is the preferred option (rather than increased law enforcement, and development of education campaigns without consultation) among remote community mem- bers and health professionals (Shakeshaft, Petrie, Doran, Breen, & Sanson-Fisher, 2012).
Enhancement of service provision and deliv- ery in remote areas also remains a key priority, particularly given that service needs in these areas often go unmet (Peterson et al., 2007).

The complexity of the relationship between remoteness and substance use is an interesting ﬁnding.

Tobacco use rates have con- sistently been found to be higher in more deprived populations, and, these groups are the least likely to successfully quit (Duncan, Jones, & Moon, 1999).
Similarly, males are more likely to report substance use across almost every substance type and geographi- cal location (Australian Institute of Health & Welfare, 2009).

Lower educational levels, being male and coming from lower socioeco- nomic levels of advantage are all risk factors identiﬁed in previous research and explain some of the variance in the difference between rural and urban populations (Spoth, Goldberg, Neppl, Trudeau, & Ramisetty-Mikler, 2001).
The unique contribution of remote- ness remains somewhat unexplained, and the complex relationship between demography, remoteness and substance use requires fur- ther investigation.

Please cite this article in press as: Roxburgh, A., et al.

Patterns of alcohol, tobacco and cannabis use and related harm in city, regional and remote areas of Australia.
International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.02.001 Need for a nationally-consistent approach to alcohol-fuelled violenceSubmission 47 - Attachment 31 G Model DRUPOL-1179; No.

of Pages 4 4 Limitations ARTICLE IN PRESS A. Roxburgh et al.

/ International Journal of Drug Policy xxx (2013) xxx– xxx The response rate for the NDSHS is low, which limits the gener- alizability of the ﬁndings.
The NDSHS does not accurately capture substance use in non-urban areas, or among disadvantaged popu- lations.

Oversampling in rural areas goes some way to redress this issue.

Nevertheless, there is a need to accurately and comprehen- sively describe the substance use issues facing remote Australian communities, particularly to identify which sub-populations might be experiencing the greatest harm; ﬁndings presented here may assist in highlighting areas that warrant in-depth investigation.
Conclusions To the best of our knowledge, this paper is the ﬁrst to report on urban, regional and rural patterns of problematic substance use and substance-related harms in Australia using population-level data.

Findings related to tobacco and alcohol show sustained increases in use and associated harm with increasing remoteness.
As two of the most signiﬁcant contributors to global burden of disease (Rehm et al., 2010), there is a continued need for further research into why rural communities report disproportionate use of sub- stances.

Further, ﬁndings highlight that current efforts aimed at reducing drug-related harm in remote communities appear to have far less impact, suggesting the need for more targeted and inclusive interventions.
Acknowledgments The authors would like to acknowledge the Australian Institute of Health & Welfare (AIHW) for the provision of the National Drug Strategy Household Survey (NDSHS) data.

The authors would also like to acknowledge the Australian Social Science Data Archive for access to the NDSHS.

The National Drug and Alcohol Research Cen- tre (NDARC) is funded by the Australian Government Department of Health and Ageing.
Conﬂict of interest statement None of the authors have any conﬂicts of interest to declare in relation to this work.

References Australian Institute of Health and Welfare.

(2008).

Rural, regional and remote health: indicators of health status and determinants of health.

Canberra: Australian Insti- tute of Health and Welfare.

Australian Institute of Health and Welfare.

(2009).

2007 National Drug Strategy Household Survey: detailed ﬁndings.

Canberra: Australian Institute of Health and Welfare.


(2012).

Australia’s health 2012.

Australia’s health series no.

13.

Canberra: Australian Institute of Health and Welfare.

Duncan, C., Are 497–505.

(1999).

Smoking and deprivation: Science & Medicine, 48(4), Social Jones, K., & Moon, G. there neighbourhood effects?

Hanlan, K., Jonas, H., Laslett, A., Dietze, P., & Rumbold, G. (2000).

Patterns and trends in alcohol-related hospitalizations in Victoria, Australia, 1987/88–1995/96.
Drug and Alcohol Review, 19, 381–390.

Hanson, C., Novilla, M., Barnes, M., Eggett, D., McKell, C., Reichman, P., & Havens, P. (2009).

Using the rural–urban continuum to explore adolescent alcohol, tobacco, and other drug use in Montana.

Journal of Child and Adolescent Substance Abuse, 18, 93–105.

Harrison, W. A., & Fitzharris, M. (1999).

Drinking and Driving in Rural Victoria: A Survey of Hotel Patrons.

Monash University Accident Research Centre.

Lambert, D., Gale, J., & Hartley, D. (2008).


Substance abuse by rural youth and young adults in rural America.

American Journal of Rural Health, 24, 221–228.

Lawlor, D. A., Frankel, S., Shaw, M., Ebrahim, S., & Smith, G. D. (2003).

Smoking and ill health: Does lay epidemiology explain the failure of smoking cessation programs among deprived populations?

American Journal of Public Health, 93, 266–270.

Livingston, M., Laslett, A., & Dietze, P. (2008).


Individual and community corre- lates of young people’s high-risk drinking in Victoria.

Australia.

Drug and Alcohol Dependence, 98, 241–248.

Miller, P. G., Coomber, K., Staiger, P., Zinkiewicz, L., & Toumbourou, J. W. (2010).

A review of rural and regional alcohol research in Australia.

Australian Journal of Rural Health, 18, 110–117.

National Health and Medical Research Council.

(2001).

Australian Alcohol Guidelines: Health risks and beneﬁts.
Canberra: Commonwealth of Australia.

Peterson, G. M., Northeast, S., Jackson, S. L., & Fitzmaurice, K.D.

(2007).

Harm in rural and remote minimization strategies: opinions of professionals Australia.

Rehm, J., Baliunas, D., Borges, G. L. G., Graham, K., Irving, H., Kehoe, T., Parry, C. D., Patra, J., Popova, S., Poznyak, V., Roerecke, M., Room, R., Samokhvalov, A. V., & Taylor, B.

(2010).

The relation between different dimensions of alcohol consumption and burden of disease: an overview.
Addiction, 105(5), 817–843.

Shakeshaft, A., Petrie, D., Doran, C. M., Breen, C. L., & Sanson-Fisher, R. (2012).

An empirical approach to selecting community-based alcohol interventions: com- bining research evidence, rural community views and professional opinion.

BMC Public Health, 12(1), 12–25.

Spoth, R., Goldberg, C., Neppl, T., Trudeau, L., & Ramisetty-Mikler, S. (2001).

Rural–urban differences in the distribution of parent-reported risk factors for substance use among young adolescents.
Journal of Substance Abuse, 13(4), 609–623.

Toumbourou, J. W., Miller, P., Staiger, P. K., Hemphill, S. A., & Catalano, R. F. (2011).

Rural adolescent alcohol, tobacco, and illicit drug use: A comparison of students in Victoria, Australia and Washington State, United States.

The Journal of Rural Health, 27, 409–415.

United Nations Ofﬁce on Drugs and Crime.

(2011).

World Drug Report 2011.

Vienna: United Nations Ofﬁce on Drugs and Crime.

World Health Organization.

(2011).


Global status report on alcohol and health.

Geneva: World Health Organization.

Please cite this article in press as: Roxburgh, A., et al.

Patterns of alcohol, tobacco and cannabis use and related harm in city, regional and remote areas of Australia.

International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.02.001 Need for a nationally-consistent approach to alcohol-fuelled violenceSubmission 47 - Attachment 31