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

Health behaviours

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}

Smoking

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

Physical activity

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

Healthy eating

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}

Alcohol consumption

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

Sexual health

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