NDSHS 2022–2023 Notes: Illicit Drug Use and Related Contexts (Comprehensive)

Overview

• This is a comprehensive web report of the National Drug Strategy Household Survey (NDSHS) 2022–2023 conducted in Australia, with results covering licit and illicit drug use, alcohol, tobacco, e-cigarettes, and related harms.

• The survey involved more than 21,000 participants across Australia, collected during 2022 and 2023, and is conducted every 2–3 years as part of a long-standing 1985–present program to inform policy.

• The report provides findings and traces changes over the past ~20 years, including demographic shifts and policy context.

• Cat. no: PHE 340; © AIHW 2024.

Key Findings (highlights from the Findings section)

• Daily tobacco smoking rate declined from 11.0 ext{ ext{%}} (2019) to 8.3 ext{ ext{%}} (2022–2023). This corresponds to about $2.3 ext{ million}$ daily smokers in 2019 and $1.8 ext{ million}$ in 2022–2023.

• Use of electronic cigarettes and vapes nearly tripled from 2.5 ext{ ext{%}} (2019) to 7.0 ext{ ext{%}} (2022–2023).

• Roughly 31 ext{ ext{%}} of Australians drank alcohol in ways that put health at risk in 2022–2023, equating to about $6.6 ext{ million}$ people.

• Lifetime illicit drug use is high: about 47 ext{ ext{%}} of people have used illicit drugs in their lifetime, with cannabis the most used (about 41 ext{ ext{%}}).

• The rate of illicit drug use in the past year was 17.9 ext{ ext{%}} (≈$3.9 ext{ million}$ people).

• The survey notes shifts, including increased use among young people and women for certain drugs and substances, and persistent concerns about alcohol, tobacco, and e-cigarette use.

What the report covers and policy context

• Drugs considered include: alcohol, tobacco, electronic cigarettes and vapes (e‑cigarettes), illicit drugs, and pharmaceuticals used for non-medical purposes.

• Harms considered include health harms (e.g., tobacco-related diseases, alcohol-related injury) and social/economic harms (including contact with the criminal justice system).

• The report uses results from the 2022–2023 NDSHS (the 14th survey under the National Drug Strategy). The survey was conducted prior to new vaping restrictions that took effect in 2024.

• Policy context highlights changes since 2019, including: National Tobacco Strategy 2023–2030; reforms to vaping regulation (TGA 2023); NHMRC 2020 alcohol guidelines; National Preventative Health Strategy 2021–2030; and COVID-19-related health restrictions that may have medium-term effects on drinking and drug use.

Demographics and general trends

• Historically, use of alcohol, tobacco, e-cigarettes, and illicit drugs has been higher among males, but the gap is closing, especially for youth aged 18–24.

• Young women show rising use of alcohol, e-cigarettes, and illicit drugs relative to 2019.

Page-by-page synthesis (key concepts, numbers, and context)

Page 1: Snapshot and scope

• National scope: Australia; results from >21,000 participants (2022–2023).

• Focus: illicit use of drugs within broader drug context (licit drugs included via non-medical use definitions).

• Major findings (reiterated):

  • Daily smoking: $11.0\%\to 8.3\%$ (2019 to 2022–2023).

  • E-cigarettes/vapes: $2.5\%\to 7.0\%$ (2019 to 2022–2023).

  • Risky alcohol: $31\%$.

  • Lifetime illicit drug use: $47\%$; cannabis most used at $41\%$.

Page 2: Summary and context

• 1 in 12 people smoke daily.

• E‑cigarette and vape use rises, especially among young people.

• Risky alcohol consumption remains steady (not a sharp rise or fall).

• Illicit drug use increases, driven by hallucinogens.

• Young women show higher use of alcohol and other drugs than in 2019.

• The NDSHS is the leading national survey on licit and illicit drug use; the 2022–2023 cycle is the 14th in the series (started 1985; every 3 years since 1995).

• 1 in 12 nationally smoke daily; between 2019 and 2022–2023 the national tobacco smoking rate fell from $11.0\%$ to $8.3\%$, i.e., about 1.8$ million daily smokers in 2022–2023 vs 2.3$ million in 2019.

Page 3: E‑cigarettes/vapes and age patterns

• E‑cigarettes are defined as personal vaporising devices that inhaled vapour (may or may not contain nicotine).

• Regulatory context: From early 2024, new vape restrictions (import restrictions on vapes, including non-nicotine products) were introduced; the 2022–2023 results reflect prevalence before these restrictions.

• Age-specific trends in e‑cigarette use (2019 → 2022–2023):

  • 18–24: from $5.3\%$ to $21\%$.

  • 14–17: from $1.8\%$ to $9.7\%$.

  • 60–69: $1.6\%$; 70+: $0.4\%$.

• This contrasts with tobacco smoking, which is more prevalent among older age groups.

• About 54% of ever users reported their last e-cigarette contained nicotine; about 73% of current e-cigarette users used nicotine; about 87% obtained them without a prescription.

• No evidence that e‑cigarettes are an effective cessation aid or gateway to tobacco smoking from the NDSHS data (i.e., results do not support a causal cessation or gateway conclusion).

Page 4–5: E‑cigarette reasons, nicotine, and risky alcohol context

• Reasons for e‑cigarette use differ by age: younger users: curiosity or better taste; older users: to quit smoking.

• The majority of nicotine-containing e‑cigarettes were obtained without a prescription, reflecting regulatory context during the survey period.

• Risky drinking remains a stable issue; see figures and later sections for detail on individual behaviours.

Page 6–7: Underage drinking and pregnancy-related limits

• Under 18 drinking: stable over time; 14–17-year-olds who drank in the past year fell to about 31% in 2022–2023 (down from 69% in 2001).

• 16–17-year-olds: attitudes toward underage drinking showed mixed beliefs about safety; e.g., 32% agreed that a 16–17-year-old can occasionally drink 1–2 standard drinks without health risk; 24% agreed it is beneficial to provide some alcohol to a 16–17-year-old; 33% of 14–17-year-olds held similar beliefs.

• Pregnancy and drinking: Around $28\%$ of women aged 14–49 who were pregnant at some point in the previous 12 months consumed alcohol while pregnant; among those who had been pregnant but did not know they were pregnant, about $64\%$ drank before knowing; once aware, about $14.9\%$ drank during pregnancy.

Page 7–8: Illicit drug use and gender differences

• Illicit drug use in the previous 12 months: $17.9\%$ (~3.9$ million).

• Hallucinogens rose notably: 2019 $1.6\%$ (≈$300,000$) to 2022–2023 $2.4\%$ (≈$500,000$).

• Mushrooms/psilocybin rose to roughly $1.8\%$ by 2022–2023; LSD/acid/tabs remained elevated relative to 2019.

• Ecstasy use declined between 2019 and 2022–2023 (likely due to COVID-19 related disruptions to events), with early signs of rebound in 2023.

• Cannabis remained the most-used illicit drug (~$11.5\%$ in the past 12 months; ≈2.5$ million).

• Cocaine use remained high (~$4.5\%$ in the past 12 months; ≈1.0$ million).

• Other drugs with notable prevalence: inhalants $1.4\%$; heroin $0.1\%$; non-medical use of tranquillisers/sleeping pills $1.6\%$; non-medical use of pain-killers/opioids declined from $3.6\%$ to $2.2\%$.

• Ketamine use increased to ~$1.4\%$; about 300,000 people used it in the past 12 months; higher use among people in their 20s and notable increases in 30s.

Page 8–9: Gender and age patterns in illicit drug use

• Young women (18–24) show increases in recent use of the most commonly used substances: any illicit drug rose from $27\%$ (2019) to $35\%$ (2022–2023); men remained at $35\%$ across both years.

• Cannabis use among young people is now comparable between genders: the 18–24 cohort reported cannabis use around $26\%$ for both sexes in 2022–2023.

• Cocaine use among young women rose from $8.0\%$ (2019) to $11.9\%$ (2022–2023), close to the male rate of $11.2\%$.

• Overall, shifts indicate a narrowing gender gap in illicit drug use among young people, with increases among young women in several categories.

Page 9: Figures on tobacco/e-cigarettes and risky drinking by gender (Figure 9–10 context)

• Gender comparisons show trends in tobacco, e-cigarette use, and risky drinking, with reductions in some male-dominated patterns and increases among young women in some domains (e.g., e-cigarette use and certain drugs).

• Among 14–17-year-olds, recent alcohol consumption increased among young females (from 28% in 2019 to 35% in 2022–2023), while among young males it was 27% in 2022–2023.

Pages 10–12: Policy changes, vaping regulation, and survey methodology basics

• Policy changes since 2019 (illustrative list):

  • National Tobacco Strategy 2023–2030 with targets to reduce daily smoking to <10% by 2025 and <5% by 2030.

  • 2024 tightening of e-cigarette access, including import restrictions for many vapes; nicotine-containing products often require prescription.

  • NHMRC 2020 alcohol guidelines; adult and youth recommendations reinforced.

  • National Preventative Health Strategy 2021–2030 with goals to reduce harmful alcohol consumption (10% reduction by 2025) and reduce recent illicit drug use by 15% by 2030.

• Fieldwork and methodology:

  • Two fieldwork periods: 2022 (20 July–18 December) and 2023 (20 March–31 May).

  • The timings were chosen to mitigate holiday-season effects on alcohol and drug use data.

  • Results indicate most drug types were comparable across the two periods, though methamphetamine/amphetamine and ecstasy showed some period effects (seasonality) as discussed in the fieldwork comparison (see Fig. in Page 37–37 Table 5).

• Two-step sex/gender data approach: to improve representation of cisgender and trans/gender-diverse populations, replacing the single ‘sex’ question with two questions: sex recorded at birth and gender description. This influences weighting and time-series comparability.

• Fieldwork adjustments and response-rate considerations:

  • Interim Placement Follow-Up (IPF) used to re-contact non-respondents within households; respondents could switch survey mode if desired.

  • QR codes on paper forms to link to online surveys; online response rate rose to 28% in 2022–2023 from 25% in 2019.

  • Online vs paper mode effects were analyzed with logistic regression controlling for demographics; some differences persisted by mode, particularly for heavy alcohol use and certain drug-use indicators when not adjusting for demographics.

Page 13–14: Socioeconomic patterns and e-cigarette use by SES

• E-cigarette use is more common in areas of higher socioeconomic advantage, whereas tobacco smoking remains higher in more disadvantaged areas.

• People who use both smoking and e-cigarettes tend to have similar prevalence across SES strata, indicating vaping may attract different demographic groups than smoking alone.

• Implications: e-cigarettes might not be reaching high-smoking populations (older adults and those in high-disadvantage areas) where cessation support could be most needed.

Page 15–17: Alcohol risk, underage drinking, pregnancy, and women’s harms

• Risky drinking: similar prevalence from year to year across the period; 2016–2023 trends show a general long-term decline (with a plateau around 2013–present). The overall percentage at risky levels was $31\%$ in 2022–2023, with about 6.6$ million people at risk.

• More detailed risky drinking indicators: more than 10 standard drinks per week (≈$25\%$) and more than 4 standard drinks on a single day at least monthly (≈$24\%$), with changes relatively modest since 2019.

• Awareness of guidelines: about $62\%$ of respondents were aware of Australia’s alcohol guidelines; among those at risky levels, awareness was higher at $69\%$.

• Under-18 drinking: declines in past-year alcohol use among 14–17-year-olds (down from historic highs); by 2022–2023, 31% had consumed alcohol in the past year.

• Pregnant women: around $28\%$ drank alcohol while pregnant at some point in the past 12 months; among those who had been pregnant but did not know they were pregnant, about $64\%$ drank before knowing; once aware of pregnancy, the figure dropped to around $14.9\%$.

• Harms from alcohol influence: national estimates show growth in harms experienced by women from others under the influence of alcohol (2019: 2.2 million; 2022–2023: 2.4 million), while harms to men slightly declined (2019: 2.3 million; 2022–2023: 2.2 million).

Page 18–21: Illicit drugs—definitions, scope, and trends

• Illicit drugs are defined as: illegal drugs (e.g., cocaine, ecstasy), pharmaceuticals used non-medically (e.g., opioids, benzodiazepines), and other substances used non-medically (e.g., inhalants).

• ASSIST-Lite: a WHO-developed screener used in NDSHS to assess risk of substance use disorders. Categories: low risk, moderate risk, high risk. High risk suggests possible dependence; moderate risk suggests hazardous use. The ASSIST-Lite was integrated in 2019.

• New sections introduced in 2022–2023: pharmaceutical stimulants for non-medical use (e.g., methylphenidate, lisdexamfetamine), and kava introduced as a separate section.

• Cannabis: remains the most-used illicit drug; lifetime prevalence remains high, and recent use (past 12 months) around 11.5% (≈2.5 million people).

• Hallucinogens: strong growth driven by psilocybin/mushrooms; mushrooms accounted for a notable share of the growth in hallucinogen use in 2022–2023.

• Methamphetamine/amphetamine: new defined categories show around 200,000 people (1.0%) used them in the past 12 months; most used crystal/ice (43%) vs powder/speed (31%).

• Pharmaceutical stimulants: about 400,000 people (2.1%) used non-medically in the past 12 months; lifetime use around 1.2 million.

• Ecstasy: declined in 2019–2022–2023, with early 2023 rebound; the data across 2022–2023 reflect two fieldwork periods with potential seasonality effects.

• Cocaine and other drugs: cocaine use remains around 4.5% in the past 12 months; 1.0 million people; gender and age differences exist with women in 18–24 reporting upticks in several substances.

• Non-medical opioid/pain-reliever use declined from 3.6% to 2.2% since 2016.

• Ketamine: usage rose to ≈0.9–1.4% in 2022–2023, with higher uptake among people in their 20s and 30s.

• Other low-prevalence drugs (e.g., GHB/GBL, 1,4-BD) were tracked; emerging synthetic drugs section re-labeled to “Other synthetic drugs” to capture EPS trends.

Page 22–23: Data access and detailed questionnaire changes

• Data access: CURF (public-use Confidentialised Unit Record File) will be available through ADA at Australian National University from May 2024; some transformations will be applied to protect confidentiality.

• Detailed questionnaire changes (2022–2023): major changes across sections (A–Z and beyond) including updated sex/gender questions, reclassification of sections, added questions on Kava, new pharmaceutical stimulants section, re-labelling of several illicit drug categories (e.g., meth/amphetamine, cocaine, ecstasy), and changes to alcohol (E section).

• Demographic and weighting changes: shift to standard ABS sex and gender variables; weighting against ABS population data (2021 Census) using a binary gender variable with reconciliations; population estimates based on latest ABS ERP data.

• Sample design: stratified, multistage random sampling across 15 strata with oversampling in Tasmania, ACT, and NT to ensure reliable estimates in smaller jurisdictions. Some under-sampling occurred in NSW, VIC, and QLD due to allocation fractions.

Page 24–25: Methodology details (sampling, fieldwork, and QoS)

• Cognitive testing and pilot work were conducted in early 2022 to refine questions and fieldwork processes.

• Fieldwork timing adjustments were made to ensure enough sample for 14–15 year-olds and to reduce holiday-season biases.

• Interventions to maximize response and quality included IPF, social media awareness in certain regions, QR codes on paper forms, translation options (Arabic, Mandarin/Simplified Chinese, Cantonese/Traditional Chinese, Greek, Italian, Vietnamese), gated access strategies for hard-to-reach housing, and a prize draw incentive ($500 EFTPOS; 30 winners).

• Table 12.1 in the report summarizes data collection methodologies and fieldwork timing from 1998 onward.

Page 26–27: Data collection modes, weighting, and response modeling

• Mode effects: online vs paper responses show demographic differences; logistic regression indicated that after adjusting for demographics, most drug-use indicators did not differ by mode, but some differences remained for alcohol and certain illicit drugs (e.g., paper respondents slightly more likely to report heavy drinking, methamphetamine/amphetamine use, tranquiliser use, current smoking, and some drug-use indicators).

• Online share of responses rose to 28% in 2022–2023 (from 25% in 2019); paper form share declined from 74% to 72% over time; telephone remained minimal (~0.1–0.3%).

• Weighting: two main weights are used: (i) person-level weighting accounting for geography, household size, age, gender; (ii) household-level weighting for the sampling frame that accounts for geographic stratification but not respondent-specific factors (e.g., household size). Weights are calibrated to match population estimates.

• Weights reflect updated sex/gender questions and population estimates (ABS 2021–2022 data).

Page 28–29: Response rates and non-response bias

• Overall response: contact made with 49,389 in-scope households; 21,663 questionnaires completed and usable; response rate (RR) = $43.9\%$ (Table 12.3).

• The RR for 2022–2023 is the lowest among waves since 2010 (previous low was 47.8% in 2004).

• Disposition details: examples include refusals, foreign/no English, incapacity, other non-response; total eligible respondents who did not complete = 19,320; total completes = 21,663.

• State-by-state differences in response rates were substantial: e.g., Sydney around 33%, Remain Northern Territory around 54%; NSW 37%, VIC 41%, QLD 47%, WA 41%, TAS 50%, NT 54%, ACT 55% (Table 12.4).

Page 30–31: Non-sampling error, significance testing, and representativeness

• Non-sampling error considerations: self-report bias, recall bias, privacy concerns, stigmatisation effects on reporting illicit drug use, and social desirability bias.

• Sampling error remains an inherent limitation of survey data; estimates include relative standard error (RSE) and margin of error (MoE). RSE categories:

  • RSE 25%–50%: marked with * in supplementary tables.

  • RSE 50%–90%: marked with **.

  • RSE > 90%: not published.

  • Generally, estimates with RSE < 25% are considered sufficiently reliable for most purposes.

• Significance testing: a difference is considered statistically significant if p < 0.05; most 2019 vs 2022–2023 year-on-year changes described in the report are significant at the 95% level unless specified otherwise.

• Fieldwork timing and mode effects: two-fieldwork periods (2022 and 2023) require cautious interpretation of trend data for drugs with seasonal variation (notably methamphetamine/amphetamine and ecstasy).

Page 31–33: Representativeness and data quality awareness

• Comparison to the 2021 Census shows some over- and under-representation in key demographics (employment status, education level, household type, English-language at home, and geographic SES indicators).

• Comparison to the 2019 sample indicates shifts in response likelihood by employment, education, and SES; improvements in representativeness attempted via weighting and targeted sampling.

• Data weighting and standardisation aimed to align the sample with population benchmarks while allowing for robust trend analysis.

Page 34–36: Questionnaire changes and methodological updates (highlights)

• Major structural updates across multiple sections to reflect contemporary drug-use patterns and policy priorities, including:

  • Section reconfigurations: tobacco questions moved to a Tobacco/Section C; e-cigarette questions reorganised (Section D).

  • New sections: H (Pharmaceutical stimulants) and J (Kava) introduced in 2022–2023; Section L (Marijuana/Cannabis) reorganised with updated questions about main form and other forms used.

  • Re-labelling: drug response options updated (e.g., Methamphetamine/Amphetamine; GHB/GBL/1,4-BD; Pain-relievers/Opioids for non-medical use).

  • Section YY (Policy Support): expanded to include electronic cigarette/vape measures and broader tobacco/alcohol policy supports.

• Questionnaire changes aimed at improving comparability with 2019 while modernising questions to capture newer substance-use patterns and changing social norms.

• Several safety, consent, and accessibility adjustments (translations, gating for inaccessible housing, and a QR link) were implemented to improve participation.

Page 37–38: Fieldwork integrity and reporting guidance

• Fieldwork integrity recommendations emphasize combining 2022 and 2023 results for major drug-use statistics to capture the full spectrum of the two periods.

• Ecstasy reporting should be treated with care given fieldwork period differences; guidance suggests aggregating 2022 and 2023 data for major reporting, with caveats and footnotes where appropriate.

• The measure for risky alcohol consumption follows NHMRC 2020 guidelines and uses the two components of Guideline 1: (i) no more than $10$ standard drinks per week on average; (ii) no more than $4$ standard drinks on any single day.

Page 39–40: Illicit use definition and ASSIST-Lite details

• The report clarifies what is included in “illicit use of drugs”: illegal drugs, pharmaceuticals used non‑medically, and other substances used illicitly (e.g., inhalants).

• Medical cannabis is treated separately from illicit cannabis; cannabis used for medical purposes is not included in the illicit-use results unless used for non-medical purposes.

• ASSIST-Lite: 3–4 items per substance; used to screen for potential dependence and to identify those who may benefit from brief intervention or referral.

• The report notes that cannabis scoring thresholds in ASSIST-Lite were adjusted (increase the moderate-risk threshold from 1 to 2) for 2022–2023, affecting cross-study comparisons with other ASSIST/ASSIST-Lite results.

Page 41–42: CURF, access, and references

• CURF access to researchers via ADA (Australian Data Archive) from May 2024; data transformations applied to protect confidentiality.

• References include ABS sources (Population and Sex/Gender standards) and WHO ASSIST-Lite literature; multiple government and health authority citations support policy context and guidelines.

Page 43–44: Glossary highlights (selected terms)

• Abbreviations and terms such as ASSIST, ASSIST-Lite, CALD, First Nations, illicit drugs, unbranded illicit tobacco, standard drink, and explicit definitions for terms used in the report (e.g., “current use,” “ever use,” “non-medical use”).

• Standard drink defined as 10 g of alcohol (equivalent to 12.5 ml of alcohol).

• Unbranded tobacco (chop-chop) defined; illicit tobacco includes both unbranded and branded products sold without payment of applicable duties.

• E-cigarettes defined with emphasis on nicotine content and delivery systems; mentions that heated tobacco products are outside the e-cigarette definition.

• Sleepers/benzos and other pharmaceuticals included under non-medical use in various sections; includes ASSIST-Lite scoring notes and interpretation caveats.

Page 45–46: Data tables and data access references

• Data tables are provided for tobacco, e-cigarettes, alcohol consumption, illicit drugs, non-medical pharmaceuticals, kava, medical cannabis, geographic areas, states and territories, priority population groups.

• Data tables are linked as downloadable Excel files for detailed numerical exploration.

Page 47–48: Editions and related material

• This release is the 2022–2023 NDSHS web report (29 Feb 2024).

• Related materials include the 2022 National Drug Strategy Household Survey questionnaire (Resource PDF) and topics such as Alcohol and Illicit use of drugs.

Key definitions and formulas (quick-reference)

• Risky alcohol consumption (NHMRC 2020):

  • No more than $10$ standard drinks per week on average, and no more than $4$ standard drinks on any single day (never exceeding these values).

  • If either threshold is exceeded, consumption is classified as risky.

  • In formulas: if weekly drinks > $10$ or daily drinks > $4$ (at least once a month), then risky.

• Standard drink: $10\text{ g of alcohol}$ (equivalently, about $12.5\text{ mL}$ of pure ethanol).

• ASSIST-Lite risk categories:

  • Low risk, Moderate risk, High risk (High risk indicates potential dependence; Moderate risk indicates hazardous use).

• Relative Standard Error (RSE) interpretation:

  • If $25\% \le ext{RSE} \le 50\%$, mark with *.

  • If 50\% < \text{RSE} \le 90\%, mark with **.

  • If ext{RSE} > 90\%, data are not published.

  • Generally, estimates with RSE < 25% are considered reliable for most purposes.

Connections to broader themes (from the transcript)

• The NDSHS tracks shifts in public health priorities, including reducing daily tobacco smoking, limiting access to e‑cigarettes for non-smokers, and curbing risky drinking, while monitoring illicit drug use to inform harm-reduction and treatment policy.

• The data illustrate changing demographics in drug and alcohol use, particularly widening usage among young women and older adults, and SES-related patterns in tobacco and e‑cigarette use.

• Methodological notes (dual-fieldwork periods; mode effects; sex/gender reconfiguration) emphasize the importance of robust weighting and careful interpretation when comparing across years or across survey modes.

Practical implications for exams and discussions

• Expect questions on: recent trends in smoking and e-cigarette use, age- and gender-specific patterns, SES differences in tobacco/e-cigarette use, risky drinking prevalence and guideline awareness, changes in illicit drug trends (especially hallucinogens and methamphetamine/amphetamine), and the policy landscape (tobacco, vaping, alcohol guidelines).

• Be prepared to discuss how methodological changes (two-fieldwork periods, mode effects, sex/gender standardisation) affect trend interpretation and comparability over time.

• Understand the definitions used (illicit drugs vs. pharmaceuticals used non-medically, ASSIST-Lite scoring, standard drink, etc.) and how they influence reported prevalence.

Summary takeaways

• Smoking is at its lowest in the series, but e-cigarette use is rising sharply, especially among youth.

• Risky alcohol consumption remains a public health concern with about a third of the population affected, though the trend is relatively stable since 2013.

• Illicit drug use shows important shifts, with hallucinogens and meth/amphetamine evolving notably, and gender- and age-specific patterns emerging in young populations.

• Policy changes in tobacco, vaping, and alcohol contexts interact with evolving social norms and market availability, underscoring the need for ongoing surveillance and adaptable public health strategies.

End of notes