Chapter 4: The Chief Public Health Officer's report on the state of public health in Canada 2008 – Health behaviours
Social and Economic Factors that Influence Our Health and Contribute to Health Inequalities
Individual behaviours, such as staying physically active and eating well, can contribute to good health. Other behaviours, such as smoking, heavy drinking and illicit drug use, can have detrimental health effects. Ultimately, health behaviours are individual choices that people make. However, these behaviours are influenced by the social and economic environments where individuals work, live and learn.7, 9
While the overall smoking rate in Canada is declining, 19% of the Canadian population (over 15 years old) still reports smoking (women 17%; men 20%).353 Smoking is responsible for high rates of disease and death. It is a risk factor for lung cancer, head, neck and throat cancers, heart disease, stroke, chronic respiratory disease and other conditions.354 It is estimated that 16.6% of all Canadian deaths are attributable to smoking.355 And the cost of smoking in Canada – in terms of services such as health care, and the loss of productivity in the workplace or at home resulting from premature death and disability – is estimated at $17 billion per year.355
Most Canadian smokers (90%) report beginning to smoke during their teens.356 However, most do not quit until later in life. Among all Canadians who have ever smoked, 59% have quit. For those smokers in their early 20s (20- to 25-year-olds), only 25% have reported quitting, while among those over the age of 45, 71% have reported quitting.353
A socio-economic gradient exists for smoking where – in general – as income and education levels drop, a larger proportion of people report daily smoking.357 The highest smoking rates can be found among Canadians with lower income, Aboriginal populations and people living in Northern Canada, which likely contributes to the higher rates of cardiovascular and respiratory diseases found in these populations.357, 358, 359 Figure 4.5 shows the proportion of daily tobacco smoking, excluding those who use tobacco solely for traditional purposes, among Aboriginal Peoples compared to the overall population in 2001.360
Figure 4.5 Daily smoking by Aboriginal status, Canada, 2001
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Aboriginal Peoples Survey, 2001
and Health Canada, Canadian Tobacco Use Monitoring System, 2001.
Figure 4.6 shows that although smoking rates have been falling for all education levels, there continues to be a marked difference between the percentage of smokers who have completed university and those who have not.361
Figure 4.6 Smoking and education, aged 15+ years, Canada, 1999-2006
Source: Public Health Agency of Canada using Health Canada, Canadian Tobacco Use Monitoring System 1999-2006.
For some, exposure to smoke is not a choice. About 9% of children under the age of 12 and 15% of Canadian households are regularly exposed to environmental tobacco smoke – often called ‘second-hand smoke’.80 Among affected children, 51% live in the lowest-income quintile households compared to 18% who live in the highest-income quintile households.362 Recent measures to protect children from second-hand smoke include legislation to ban smoking in vehicles carrying children that was recently passed in Nova Scotia. Other provinces are considering the same measures, including British Columbia, Manitoba, Ontario and New Brunswick.363 Rates of smoking during pregnancy – a known risk factor for unhealthy fetal growth and development – continue to decline in Canada. Yet, 9.8% of women who were pregnant in the last five years also reported smoking during their pregnancy.353
Research studies report a linear relationship between physical activity and health such that the most physically active are at the lowest risk of poor health.364 Physical inactivity is a modifiable risk factor for a wide range of chronic diseases including cardiovascular disease, diabetes mellitus, cancer and depression.364 Compared to people who are physically active, those who report being physically inactive are also more likely to report their mental health as fair or poor. It is estimated that $5.3 billion (2.6%) of the total direct health-care costs in Canada are attributable to physical inactivity.365
Only just over half (52%) of Canadians over age 12 reported being physically active or moderately active during leisure time in 2005. However, about 70% of those who are inactive during leisure time report some level of physical activity at non-leisure times. During normal daily activity: 8% report carrying or lifting heavy loads; 25% report frequently carrying light loads and climbing stairs; 42% report frequently standing or walking; and 24% report spending 6 or more hours a week bicycling or walking as a means of transportation.366
Leisure physical activity levels vary across different populations and income levels, which may be a product of available leisure time. The rate of leisure-time physical activity is highest among those at the highest end of the income spectrum (see Figure 4.7). About 62% of Canadians over age 12 in the highest-income quintile report being physically active compared to 44% among the lowest-income quintile.366
Figure 4.7 Percent of the general population aged 12+ years who were physically active by income, Canada, 2005
Source: Statistics Canada, Physically Active Canadians.
Generally, women in all income groups report 5 to 10% lower levels of physical leisure-time activity than men and the gap between high- and low-income women is greater than it is for men. Across Canada there is regional variation in physical activity levels with a clear east-west gradient. Provinces in Western Canada report higher rates of active or moderate leisure-time physical activity (e.g. 59% in British Columbia) versus the East (e.g. 44% in Prince Edward Island). Overall, Canada’s largest cities (over 2 million in population) report lower rates of leisure-time physical activity than the national average.366
Encouraging Healthy Lifestyles
ActNow BC is a multi-year health and wellness campaign that was launched by the Government of British Columbia in March 2005. The campaign's programs and initiatives champion healthy eating, physical activity, ending tobacco use and healthy choices during pregnancy.367 Through its many partnerships, ActNow BC is present in schools, workplaces and communities throughout the province. Since the start of the program, more than 130 towns, cities and First Nations communities have registered as "Active Communities"; 100% of school districts – encompassing over 1,300 elementary and middle schools with more than 360,000 students – have additional physical activity throughout the school day through Action Schools! BC; and the Ministry of Health has piloted a Workplace Wellness initiative that extends the approach to workplaces across the province.368, 369, 370
ActNow BC is also partnering with the National Collaborating Centre for Aboriginal Health, First Nations Health Council, Métis Nation BC and the BC Association Friendship Centres to bring the healthy living approach to Aboriginal communities in the province. The goal is to 'close the gap in health' between Aboriginal Peoples and the overall population of British Columbia.371 Though early in the process, ActNow BC's uptake has been promising and it has already been highlighted by the Health Council of Canada (December 2007) as having the potential to have a positive effect on the incidence of diabetes and other chronic diseases in the province.372
The types, quantity and quality of food eaten also affect health. Aside from nutritional value, the availability and affordability of nutritious food and the individual food choices made are important. Less healthy eating, combined with inadequate physical activity, can lead to increased body weights. For adults, obesity is a risk factor for many chronic diseases including hypertension, Type 2 diabetes, gallbladder disease, coronary artery disease, osteoarthritis, and certain types of cancer.14 The annual economic burden of unhealthy eating in Canada has been estimated at $6.6 billion, including direct health-care costs of $1.3 billion.373 Only 41.2% of Canadians aged 12 years and over report consuming fruits and vegetables at least five times per day.374
Eating healthy foods – such as fresh fruit and vegetables, fibre-rich foods and those with a lower fat content – is related to their accessibility and affordability. Northern and remote communities do not have as many food choices and healthy foods are often more expensive than in more populated regions of the country. A further challenge to healthy eating is the availability of quick, less expensive and less healthy foods. A recent University of Alberta study found that more fast-food restaurants are situated in Edmonton neighbourhoods where residents have lower incomes and education levels and most people are renters rather than home owners compared to other neighbourhoods in the city.264
Parental practices such as breastfeeding can positively influence an infant’s start in life. Canada’s breastfeeding initiation rates have increased dramatically over the last four decades (25% of mothers initiated breastfeeding in 1965 compared to 87% of mothers in 2003).375 Breastfeeding initiation rates vary between populations and are generally lower for younger mothers (76% of those aged 15 to 19 years), single mothers (78%), Aboriginal off-reserve mothers (82%), First Nations on-reserve mothers (63%), and higher among immigrant mothers (92%) (see text box).376 Although more mothers are now initiating breastfeeding in Canada, many do not maintain the practice. While the Canadian Paediatric Society (2005) recommends that babies be breastfed exclusively for six months, only 39% of Canadian mothers report exclusive breastfeeding for four months and 17% report exclusive breastfeeding for six months or more.377, 378, 379 Overall, 48% of Canadian mothers breastfeed for six months or more (exclusive and non-exclusive) which is lower than rates in other countries such as Sweden (70.6% in 2003).380, 381
Promoting Healthy Eating
Canada Prenatal Nutrition Program
For more than a decade, the Canada Prenatal Nutrition Program (CPNP) has provided long-term funding to community groups to develop or enhance programs for at-risk pregnant women and their children.382 The CPNP is delivered through two separate organizations: First Nations and Inuit Health Branch of Health Canada and the Public Health Agency of Canada (PHAC).382 CPNP aims to: improve the health of both infant and mother; reduce the incidence of unhealthy birth weights; promote and support breastfeeding; build partnerships; and strengthen community supports for pregnant women.382 One way it does this is working closely with other programs and organizations to ensure that there is a continuum of community-based support for women, and their children and families.383 CPNP also provides services like food supplementations, nutritional counselling, prenatal vitamins, food and food coupons, prenatal health and lifestyle counselling (including smoking cessation), breastfeeding education and support, food preparation training, infant care and child development, as well as referrals to other services and agencies.382 The PHAC stream of CPNP now serves about 50,000 women annually through more than 330 projects in over 2,000 communities across Canada.384 In addition, more than 9,000 women take part in the First Nations and Inuit Health Branch stream of the program each year.382 Initial program evaluation results indicate that compared to similar high-risk populations, CPNP program participants had higher birth weights with increased program participation and higher breastfeeding rates than the general population.382, 385 Participants also reported that, as a result of the programs, they experienced improved access to services and information on better nutrition and parenting, felt less isolated and stressed, and had greater self-confidence.382
The majority of Canadians over the age of 15 drink alcohol (77%).386 Some epidemiological evidence indicates that there are protective health effects from moderate alcohol consumption, specifically in relation to circulatory diseases.355 However, excess alcohol consumption over both the short and long term can negatively influence health.386 Alcohol abuse also has high economic and social costs. Alcohol-related acute-care hospitalizations totalled 1.6 million days in 2002. That same year, there were 4,258 deaths attributable to alcohol, of which 1,246 were due to cirrhosis, 909 to motor vehicle crashes and 603 to suicides.355
Deaths related to alcohol dependence have declined over time, but remain higher for low-income men (see Figure 4.8).144 Differences between income levels exist for both men and women but are greater for men. Overall, the age-standardized mortality rate for alcohol dependence has declined in all groups, with the greatest decline for low-income men.144
Approximately 641,000 Canadians − roughly 3% of the total population − are considered alcohol-dependent and about 21% of all adult Canadians over the age of 19 reported engaging in heavy drinking (five or more drinks on one occasion, 12 or more times a year) in 2005.386, 387
A greater share of individuals at the lowest income level (about 5%), report behaviours consistent with being dependent on alcohol.386 Because alcohol dependence is a chronic condition that takes many years to cause death from disease, and during that period an alcoholic’s earning power may be reduced by the condition, some of the gaps in these death rates among income levels may be due to ‘reverse causation’ where the disease can reduce income before it kills.
Figure 4.8 Age-standardized mortality rates for alcohol dependence, by sex and income quintile, urban Canada, 1971-2001
ASMR – Age-standardized mortality rate.
Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.
First Nations on reserve report lower rates of alcohol use (65.6%) but higher rates of heavy drinking than the overall population. More than 42% of First Nations youth on reserve report using alcohol and 27% report heavy drinking at least once a month. In addition, approximately 64% of First Nations reported that no progress was being made within these communities on reducing both frequent alcohol and drug use.161
Drinking during pregnancy can result in serious health and development problems for children as a result of Fetal Alcohol Spectrum Disorder (FASD) – a preventable life-long disability. It is estimated that 1% of children born in Canada have FASD.388
Illicit drug use
In 2002, 12.6% of Canadians over the age of 15 reported using illicit drugs in the previous 12 months (9.4% of women and 15.9% of men). Approximately 1% of Canadians self-reported behaviours consistent with being dependent on illicit drugs, with the proportion being the highest among those with the lowest incomes (3%). However, as with alcohol dependence, illicit drug dependence among low-income Canadians could be related to reverse causation.386 Although fewer people die directly from higher levels of illicit drug use than from alcohol and tobacco use, such deaths generally occur at a young age making years of life lost due to early death high (62,110 years in 2002).355 These deaths are primarily due to overdose, drug-attributable suicide and infectious diseases (hepatitis C and HIV infections) acquired as a result of drug-use activities.355
Unsafe sexual practices – including early initiation, infrequent use of condoms and multiple partners – increase the risk of acquiring STIs and unplanned pregnancies.122 Youth and young adults have the highest rates of STIs in Canada, particularly street youth who have rates 10 to 12 times higher than their peers in the general population and a greater susceptibility to the hepatitis B virus (i.e. 40% are not vaccinated against it).204, 286
Overall, Canadian youth are becoming sexually active at younger ages than previous generations.389 About 90% of 14- to 17-year-olds surveyed believe they are knowledgeable about sexual health; however, one quarter of Grade 9 and 10 students who reported being sexually active also reported not using contraceptives.337, 390 A second cross-Canada survey also found that two thirds of Grade 9 students incorrectly believed there is a vaccine to prevent HIV-AIDS.390 A recent increase in officially reported STI rates may therefore partially be a result of major misconceptions about these diseases. Despite inconsistent contraception use and an increase in STIs, teen pregnancy rates (including live births, fetal losses and induced abortions) are decreasing.391
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