The Story Behind the Data: Addressing Broader Social Determinants in Harm Reduction Policy for Rural Alcohol, Vaping, Smoking and Other Drug Use

Abstract

The complexity of problematic alcohol, smoking, vaping and other drug use is compounded in rural, regional and remote Australia (hereafter rural), which makes up more than 30% of the population or 7.3 million people. Substance misuse in rural Australian communities intersects with historic social and economic disadvantage characterised by the tyranny of distance and the implementation of metrocentric policies and inflexible funding that do not translate into positive outcomes for rural communities. With a limited healthcare workforce and inadequate investment in supportive infrastructure, the flow-on effects to community wellbeing are prominent.

The National Rural Health Alliance has recently published a fact sheet on Alcohol, Smoking, Vaping and Other Drugs as an outcome of research collated for a Parliamentary Inquiry into the Health Impacts of Alcohol and Other Drugs in Australia. The data presented in the fact sheet and the submission support the broader implications that the social determinants of health and the historic disadvantages faced by rural Australians are intrinsically linked to outcomes of alcohol, smoking, vaping and other drug use.

Current data continues to highlight the need for rural Australia to be considered a priority area for investment for alcohol, smoking and other drug use. Rural Australians face higher rates of alcohol related harm, with residents aged over 14 living in Remote and Very Remote areas being approximately 1.4 times more likely to consume alcohol at risky levels compared to their urban counterparts [1]. People living in Very Remote areas had the highest rates of alcohol-related injury hospitalisations in the country, over 8 times the national rate and almost 11 times the rate for people living in Major Cities [1].

Tobacco smoking rates in rural Australia are also higher than those living in Major Cities. While tobacco use in rural areas remains high, the use of e-cigarettes is lower. Given the emerging public health concerns surrounding e-cigarette usage, research as to why these rates are lower must be considered to maintain lower uptake in rural communities. Rates of illicit drug use in remote areas remained the highest in recent data collection compared to other geographic areas [1].

These higher rates in rural Australia do not happen in isolation, nor out of coincidence. Rather, the direct cause of these elevated poor health outcomes is intrinsically linked to the social determinants of health, a historical lack of investment in rural health and a limited health workforce. For example, rural Australians are 24 times more likely to be hospitalised due to domestic violence than people in Major Cities [2]. Co-occurring alcohol misuse can be correlated with elevated risks of family and domestic violence, with approximately one-third of all violent incidents experienced (as victim or perpetrator) being alcohol related. Research indicates that the combination of heavy drinking and limited access to support services can create an environment where domestic violence becomes more prevalent [3].

The correlation between rurality and elevated alcohol use is often linked with self-medication due to the absence of adequate health care and support services to assist rural Australians with their complex and unique challenges, including isolation. Similarly, there is a strong link between chronic pain and substance use. Approximately 80% of people with chronic pain miss out on treatment and often wait for over a year to access support services, with rural Australians facing even higher wait times [1]. There is also a well-recognised relationship between substance use and mental illness, particularly severe mental illness, with over 55% of individuals experiencing alcohol and other drug issues experiencing co-occurring ill mental health [3].

Recovery from problematic alcohol, smoking, and other drug use is reliant on an effective ecosystem of support [4]. For rural Australians, accessing support services can be a major help-seeking barrier. Only 2.7% of the available alcohol and other drug treatment services available are in Remote areas, which often results in people having to travel significant distances at their own personal expense, away from work and families, to seek treatment [1]. This poses a significant barrier as, on average, Australians living in rural areas have lower incomes and leaving communities and positive familial relationships can have a significant impact on a person's engagement in recovery [2]. In addition, integrating alcohol and mental health services would deliver more streamlined and effective care for individuals dealing with harmful drinking habits, complement broader efforts to reduce alcohol-related harm and provide person-centred support.

While rural communities face these issues, they are also at the forefront for developing innovative solutions for supporting people through alcohol, smoking and other drug issues.

Rural programs often focus on diversion through pro-social community activities that simultaneously address the broader socioecological issues associated with substance misuse and harm. There is a growing body of evidence to suggest that properly resourced community-controlled models of care yield better outcomes for people who are experiencing problematic substance use [5]. Examples such as the Central Australian Youth Link Up Service (CAYLUS) demonstrate this. CAYLUS is a community initiative based in Alice Springs which focuses on improving the quality of life for young people in remote Central Australian communities. CAYLUS addresses substance misuse issues by offering youth programs, educational opportunities and employment pathways. Through providing resources and infrastructure to local communities, CAYLUS delivers programs that promote healthy lifestyles and reduce harm associated with substance misuse and has produced tangible harm-reduction results [6].

The success of the CAYLUS model demonstrates scalable impact and should be examined and adapted for other at-risk communities. Such models demonstrate the importance of focusing on factors beyond cessation when discussing long-term solutions for problematic alcohol, smoking, and other drug use in rural Australia [3].

In March 2025, the Australian Government Parliamentary Standing Committee on Health, Aged Care and Sport released an Issues Paper following their Inquiry. It was recommended that the successive Standing Committee consider completing a full inquiry report into the health impacts of alcohol and other drugs in Australia based on evidence supplied for the Inquiry. This includes addressing the persistent healthcare workforce shortage in rural Australia, and the limited services and infrastructure that impact this demographic. Investment in equitable, accessible, comprehensive and long-term support services is necessary to shift cultural perceptions and address the broader context of risky substance use, particularly in rural communities.