EXPERT REACTION: Smoking down, vaping up, and 1 in 5 of us use drugs illicitly - Australia's National Drug Strategy Household Survey

Over the past two decades, Australia has experienced a concerning rise in levels of psychological distress, a trend that has been closely linked to persistently high levels of risky drinking behaviours. This raises pressing questions about the role of alcohol as a coping mechanism for emotional symptoms.

For many individuals, alcohol serves as a temporary escape from life stressors and mental health challenges. The current global landscape, marked by ongoing crises and environmental concerns, further exacerbates feelings of anxiety, uncertainty, and distress. These external stressors can leave people feeling despondent, and alcohol can seem like an easy way to cope.

However, this coping strategy often proves counterproductive. Instead of alleviating distress, alcohol can worsen underlying mental health issues, leading to a vicious cycle of risky drinking and deteriorating wellbeing. 

Providing accessible support resources and encouraging open discussions about psychological distress, mental health, and drinking behaviours may empower individuals to develop healthier coping mechanisms and seek appropriate assistance when needed.

Results from the 2022-2023 National Drug Strategy Household Survey are reflective of the cultural shifts we are seeing for young Australians’ drinking habits. Among young people aged 18-24 the most recent survey saw an uptick in the number individuals who had never had a glass of alcohol (16.3%) or drink alcohol less than monthly (20%). These results aren’t surprising as recent years have seen a substantial rise in the number of sober curious individuals as well as non-alcoholic alternatives stocked at pubs and bottle shops.

Despite these positive developments, there persists a concerning prevalence of risky drinking behaviour among 18-24 year olds. Consistent with findings from the 2019 survey, 42% of respondents in this age group continue to engage in alcohol consumption at levels deemed risky. Notably though, the latest survey saw a greater proportion of females engage in risky drinking when compared to previous years.

Overall, there are positives which can be taken from these new survey results with the increase in the number of young people abstaining from drinking, however, there is still a concerning number of young people who are drinking at levels which put both themselves and others at risk of harm.

Overall support for drug checking services (also known as ‘pill testing’) increased from 57% in 2019 to 64% in 2022-23. This suggests that now almost two-thirds of people support the policy. Since 2019, drug checking has been trialled in the ACT and has received positive evaluations.

There have also been multiple drug-related deaths at Australian music festivals, leading to calls to implement drug checking among advocates, professionals and community members. This may have influenced public perceptions and increased support for drug checking services.

The nicotine use data reported in the 2022-2023 National Drug Strategy Household Survey report is primarily a story of two different cohorts. The first is comprised of approximately half of younger Australians (under 30 years of age), who have tried vaping at least once in their life, typically out of curiosity. The second cohort is comprised of older Australians who reported that they have mainly taken up vaping as a way to reduce or quit their use of tobacco.

The newly introduced legislation, making prescriptions a requirement for any purchase of vaping products, is likely to result in a decrease in overall vaping rates, particularly among people who are not currently addicted to nicotine, which will include most of the younger cohort. However, it is evident that a small portion of this group have progressed to daily vaping, which may be indicative of nicotine addiction or dependence.

For the older cohort, using vaping as a way to cease tobacco use is supported by a recent Cochrane Systematic Review, which concluded that there is a ‘high level of certainty’ that e-cigarette use increases rates of quitting tobacco, when compared to other nicotine replacement products, like gums and patches. While it is clearly healthier to not use any nicotine products, and the long-term health effects of vaping are still unclear, it is generally agreed that this is a healthier method of using nicotine than smoking tobacco.

The results relating to e-cigarette use in Australia are shocking if taken at face value.  Any use of e-cigarettes, and any increase in the number of users, will have dramatic effects on the health of Australians in years to come.

Data from the report shows that current use has markedly increased, especially in young people.  However, current use is defined as use of “e‑cigarettes ‘daily’, ‘at least weekly (but not daily)’, ‘monthly (but not weekly)’, or ‘less than monthly’”. If the high level reporting (current use) is used there is an over-estimation of the number of actual daily users of electronic cigarettes, and perhaps more importantly the number of people addicted to nicotine.  If we look closer at the data, the 18-24 year old people were the group most likely to use e-cigarettes (21%), but less than half of these used them on a daily basis.  This means that 90% of young adults are not daily users of e-cigarettes.
 
 Why is it important to get the reporting correct? The shock value of such reporting may have the unintended effect of normalising electronic cigarette use. Most young people in Australia are not e-cigarette users no matter how the data is presented. 
 
 What does this mean? Whilst all scientific evidence shows that any use of electronic cigarettes will increase the risk of developing serious diseases in the future, unlike  cigarettes, it is difficult to estimate actual e-cigarette usage. With cigarettes where a person can recall how many packs of cigarettes they smoke a day, with vaping there is no standard unit of usage, meaning that actual usage for daily users is known to vary by 10 –to 100 fold. Another complication is what is being vaped (estimations of at least 7000 variants of e-liquids (flavours and composition), and how the machines are being used (hotter temperatures result in more toxic by-products)). Furthermore, vaping can expose the user to more nicotine than smoking, with some reports suggesting that it is more difficult to quit than smoking.
 
Looking to the future? The intended effects of the new restrictions on e-cigarettes is to drive down usage and stop new generations of Australians from becoming addicted to nicotine. It may take some time for this to be reflected in the number of users, as people have stockpiled supplies, and the government needs to be able to stop the illegal importation of vapes.

After several years of stagnation, the latest National Drug Strategy Household Survey has reported an unprecedented 34% decline in adult daily smoking, from 11% of the adult population in 2019 to 8.3% in 2022/23. This is a huge public health victory in combatting the leading preventable cause of death and illness in Australia.

This remarkable decline in smoking is strongly associated with a substantial increase in vaping. Now 3.5% of the adult population vapes daily (1.1% in 2019). Vaping was the most popular quitting aid used by smokers, twice as popular as nicotine patches and gum, and is also the most effective quitting aid. There have been no other changes in tobacco control since 2019 that would explain the rapid decline in smoking.

Despite concerns to the contrary, the uptick in youth vaping has not led to increased smoking by youth (14-17-year-olds). In fact, daily youth smoking fell from 1.9% in 2019 to 1.5% in 2023. This provides further evidence that, rather than being a gateway to smoking for youth, vaping is more likely diverting them away from smoking.

Declines in smoking were reported across all disadvantaged groups including Indigenous people (20%) and the lowest socio-economic group (13.4%). However, smoking rates remain much higher in these groups than in the general population and more needs to be done to reduce the gap.

As daily smoking rates have dropped to 8.3% of the population, it can be tempting to think that “no one really smokes anymore.” There is no room for complacency, tobacco use continues to have devastating consequences across Australia, and the tobacco industry continues to have a presence in all our communities – with cigarettes being sold in virtually every neighbourhood in Australia. With the staggering rise in young people vaping, it is essential that the proposed reforms to restrict the availability of all vaping products to prescription only access in pharmacies are urgently adopted. We have a window of opportunity to cut vaping rates by ending the easy access to these products.

Smoking is the most important preventable cause of death in Australia as it also is internationally. The fall in adult daily smoking reported by the National Drug Strategy Household Survey from 11% in 2019 to 8.3% in 2022/23 is very welcome. Daily vaping increased more than three fold from 1.1% in 2919 to 3.5% in 2022/23 and can be assumed to have made a major contribution to this decline in smoking. As vaping and smoking are economic substitutes, smoking generally declines when vaping increases.

Vaping rates increased despite strenuous and misguided efforts to restrict this much safer way of ingesting nicotine. The overwhelming majority of Australia’s vaping supply has been provided by the black market as the barriers to legal supply have been made extremely high. Rival criminal gangs now fight to control the lucrative cigarette-vaping black market and resort to firebombings and some killings.

New Zealand has achieved a faster decline in smoking rates by regulating vaping proportionately and has also avoided a vaping black market. The decline in smoking in Australia would likely have been somewhat greater if the government had nudged rather than obstructed smokers wanting to switch to vaping.

Observed reductions in smoking are testament to Australia’s ongoing commitment to a range of tobacco cessation assistance programs. By comparison, substantial increases in vaping rates, especially among young people, are the result of an insidious industry finding innovative methods of keeping youth addicted to nicotine to assure long-term sales. It is no coincidence that one of the age groups with the highest rates of increase in e-cigarette use is 14-17 year olds.

Smoking rates have drastically reduced for this group in recent decades, making them an important target market for alternative nicotine products designed to re-engage them with the industry. A compelling body of evidence shows the critical importance of flavours and convenient disposable product designs in attracting and maintaining youth e-cigarette users.

The Government’s new laws banning flavours and disposable devices are a critically important component of Australia’s comprehensive approach to the vaping epidemic. Scaled up monitoring and enforcement is needed to ensure the new regulations achieve their potential.

The rise in vaping among young people is likely influenced by significant cost savings. For instance, a daily smoker might spend approximately $14,000 a year, assuming a cost of $40 for popular cigarette brands each day, whereas a daily vaper could incur just $1,400 annually by using a few $80 vaping pens and purchasing 40 bottles of e-liquid at $20 each.

More women and fewer men experienced harm from others' drinking, this could be attributed to changes in drinking settings during the COVID-19 pandemic. With a shift towards more men consuming alcohol at home instead of in on-premise locations such as pubs, clubs, and other venues, there has been an increase in alcohol-related harms to women at home and a decrease in harms experienced by men in public settings.

Methamphetamine continues to remain the drug of most concern to Australians, despite recent use declining in the latest survey (35% in 2022-2023 compared to 40% in 2019). It also continues to be nominated by 42% of Australians as “the drug most likely to be associated with a drug problem” (compared to 49% in 2019). This high level of concern highlights the need to ensure that all Australians, especially those impacted by methamphetamine, have access to free evidence-based information and resources like Cracks in the Ice online portal (cracksintheice.org.au). 

Importantly, among people who reported methamphetamine use, 44% also reported being diagnosed or treated for a mental health disorder which shows the importance of addressing the overlap between mental health and drug use.

The most recent Australian National Drug Survey shows several interesting trends in drug use. 

Australians continue to be one of the world’s highest consumers of cocaine, yet there is little public awareness about the use of this drug since it is perceived to be an upper-class drug despite the significant impact that the production of the drug and trafficking has on the South American rainforest and indigenous communities. 

Use of psychedelic drugs has significantly increased making them the third most popular illegal drugs in Australia after cannabis and cocaine. The increased popularity of psychedelic drugs is likely due to increased media hype regarding the potential for these drugs to be used to treat mental health conditions. Last year the TGA announced that authorised psychiatrists can now prescribe these drugs to patients with treatment-resistant depression and PTSD. Given that these treatments are still very expensive and difficult to access, desperate people will do desperate things to treat their mental health conditions. However, without the support of trained professionals, Australians who attempt to treat their mental illness using illicit drugs could unwittingly make their mental health worse or place themselves at risk of harm from underground psychedelic treatment providers.

According to new findings from the AIHW, Australia remains one of the leading cannabis using nations. The number of Australians ever using cannabis is now at its highest since the survey began, and over 1 in 10 people reported use in the past year.  Although rates are high, this certainly isn’t due to permissive cannabis policies. The Australian Capital Territory (ACT), which decriminalised possession and cultivation of the drug, reported lower cannabis use rates compared to Australian states where it is criminalised. These findings should be discussed in the conversation around Australian cannabis laws.

It is concerning to see such a significant increase in e-cigarette use among young Australians, especially those who have never smoked. These figures suggest that e-cigarettes are being used recreationally and not for smoking cessation purposes. Furthermore, the number of older Australians quitting smoking has not shifted substantially, indicating that e-cigarettes are not the panacea for quitting that industry actors keep promising. We need to intensify our efforts to assist people to quit smoking using approved and effective methods.
 
Pro-vaping groups, funded by the tobacco and e-cigarette industries, will claim that the latest results suggest e-cigarette use is displacing smoking. The truth is that behind every statistic is a young Australian who had an opportunity to live a healthy life; an opportunity that was denied by the tobacco and e-cigarette industries and other vested interests – owners of convenience, vape, and tobacco shops. These stores are illegally selling e-cigarettes to children and cannot be trusted. It is critical that legislation be passed urgently to prohibit the sale of nicotine and non-nicotine e-cigarette products by these untrustworthy retail groups. It will take some time to see a reduction in prevalence rates, and industry actors will argue that this means the laws aren’t working. We need to be patient and give these laws time to work.

Vaping has been promoted as a peerless way to quit smoking. While vaping has been skyrocketing – particularly in the young -  smoking has continued to fall as it has done for decades before vapes became available. 8.3% smoking daily is the lowest rate ever recorded in Australia. Some who attribute their quitting to their vaping may well have quit unaided or via other methods had vaping never emerged.
 
But these new data put 10,000 watt lights on the fact that vaping is now most obviously a peerless way of introducing young people to nicotine, being by far highest in young age groups who have long had the lowest smoking rates. So the typical vaper is not a smoker trying to quit, but a “recreational vaper” who was nicotine naïve before starting to vape.
 
Many studies show that young people who start vaping have a 3-5 fold probability of smoking down the track. All tobacco companies know this, which explains much of why all the major companies now sell vapes as well as cigarettes.

It is good news that the prevalence of daily cigarette smoking among Australians is now under 10% among persons over the age of 14 for the first time.
 
Vaping has continued to increase among young people despite restrictions introduced in 2021 to discourage it. Nonetheless, there has not been any increase in smoking among young adults who have shown the largest increase in vaping. Indeed, the prevalence of smoking among young adults is also now under 10%.
 
Surveys conducted since 2016 have shown a steep increase in vaping among young people accompanied by a decline in cigarette smoking. This mirrors experience in the USA, UK and NZ where e-cigarettes seem to be replacing cigarette smoking among young adults.

Educational campaigns emphasising the harms of vaping (including the false claim that “vaping is at least as harmful as smoking”) have not discouraged vaping among adolescents and young adults. A different educational approach is needed to discourage experimentation that is largely driven by curiosity.

The changes made to the prescription system in 2021 have very marginally increased the percentage of vapers who have a prescription (from 8% to 10%). It is of concern that the rate of e-cigarette use is lowest among older adults whose smoking prevalence has not changed since 2019.

It is unfortunate that the report uses different standards for who counts as a smoker and a vaper. Only daily smoking counts in the case of cigarettes. But “recent” vaping includes anyone who has vaped even once in the past year as well as those who have vaped daily. The limited data on the frequency of vaping suggests that daily use is not the most common pattern among young people. Data on daily vaping is critical in formulating effective policies to discourage vaping among people who do not smoke while increasing the number of smokers who use vaping as a cessation aid.

A healthy generation of young Australians is important not just for young Australians themselves but for everyone. Young people are 20% of the population and 100% of our future. Their health matters. 
 
The most recent National Drug Strategy Household Survey 2022–2023 includes information on more than 21,000 people in Australia aged 14 and over and their use of, and attitudes toward, tobacco, e-cigarettes, alcohol, and illicit drugs.
 
The most recent survey has some real indicators for concern. Vaping was most common among people aged 18–24. Concerning is that current use has increased substantially between 2019 (5.3%) and 2022–2023 (21%). Almost half (49%) of people aged 18–24 reported having tried an e-cigarette in their lifetime. We need to take the health of young people seriously. We urgently needed prevention measures, to ensure more young people are not vaping.

When vapes first emerged on the Australian market many initially believed that young people would only use these devices on a 'transient' basis – that they would try them and then stop. Many stated that the (then) low rates of current use among young people were a sign that these devices posed little risk to young people and would be a beneficial new quit aid for smokers. These latest data from AIHW indicate this has not been the case. Current use of vapes has increased five-fold among those aged 14-17 and quadrupled among 18-24 year olds between 2019 and 2022/3. Further, the use of e-cigarettes is lowest amongst the age group where smoking is highest (60+).

These data tell a compelling story that:
*    Urgent investment in prevention and early intervention programs to prevent vaping uptake is needed if we are to dampen this rapid rise in use; 
*    We need to intervene before age 14 to ensure we catch young people before nicotine addiction develops; 
*    Efforts now need to be directed towards helping young people quit e-cigarettes and develop healthy coping strategies and mechanisms.

The new data from the National Drug Strategy Household Survey showing that daily smoking prevalence in Australia has dropped below 10%, to an estimated 8.3%, is extremely good news for those of us working in tobacco control and the community more generally.

It is notable that the decline in smoking has been accompanied by a similar sized rise in vaping. Further the groups where vaping is increased most (younger people and those more socioeconomically advantaged) are where smoking has declined most. This provides more compelling evidence against the so-called Gateway effect that the introduction of vaping would lead to an increase in smoking; clearly the opposite is occurring.

Of themselves, these data are not strong evidence that vaping is causing some of the decline in smoking, but given other evidence demonstrates that vaping is a particularly effective smoking cessation strategy and behavioural economic studies show it to be a substitute for smoking; that is, something that people use when cigarettes are not available, all points to vaping playing an important contributory role to the welcome decline in smoking.

If this is true, one can only wonder what the decline in smoking would be if the government encouraged vaping as a substitute for smoking rather than making it increasingly illegal or hard to access.

In terms of products containing nicotine, the most significant takeaway from this report is that the record declines in cigarette smoking amongst young people provide strong evidence that the so-called ‘gateway effect’ that vaping leads to smoking is without substance. Indeed, the opposite seems to be the case, with decreasing rates of tobacco use accelerating as vaping has increased. This indicates that vaping has already begun to displace cigarette smoking, particularly amongst younger Australians.

However, the displacement of smoking in favour of vaping underscores the importance of having a legal, regulated, and accessible market for adult users of these products. This means abandoning the prescription-only model which has already been rejected by the overwhelming majority of people who vape and who are already sourcing their products from the black market. If the trend towards vaping over smoking continues (a trend actively encouraged by many governments including those in the UK, New Zealand, and Canada), we will likely see even more Australians sourcing vaping products from the black market, with all of the crime, violence, and dodgy consumer products that this entails.