In my words
If my parents had taken better care of themselves, their disease probably would have been caught sooner. I would like to see more education for the prevention, detection and treatment of cancer.
Roughly one fifth of Ontario adults currently smoke cigarettes, and over one quarter are obese. While smoking rates have declined significantly since at least the 1980s, obesity rates rose significantly during the same period, and the increase appears to be continuing. The proportion of adults who drink alcohol in excess of the maximum recommended amount has remained stable since 2003. The majority of Ontario adults do not adhere to the cancer prevention recommendations for vegetable and fruit consumption or physical activity.
Exposure to some risks is concentrated in particular social, economic or geographic populations. This unequal distribution across subpopulations reflects structural inequalities in society that limit the ability of individuals to reach their optimal health.
What are modifiable risk factors?
Modifiable risk factors are behaviours and exposures that can lower or raise a person’s risk of cancer. They are modifiable because they can, in theory, be changed.
The following specific modifiable risk factors are discussed in this section:
- tobacco use (current smoking);
- alcohol consumption (in excess of the maximum amount recommended for cancer prevention);
- excess body weight (obesity);
- adequate vegetable and fruit consumption (reported as inadequate consumption in past years); and
- physical activity during leisure time and transportation (reported as inactivity in past years).
In contrast to past years, these risk factors are only examined at a high level (over time and by socio-demographic factors) in this year’s Cancer System Quality Index (CSQI). Because the distribution of modifiable risk factors generally takes a few years to change in a population, these factors will be examined in more detail on a rotating basis in future years.
What are the measures of socio-demographic status?
Socio-demographic factors—such as education, income, immigration, social status and social support networks—are well established determinants of health that work both together and independently to influence health outcomes and behaviours. Broadly categorized, these factors are all considered to be social determinants of health. The social determinants of health are described in more detail and discussed in the context of the cancer experience in Ontario in the “Context in Ontario: Social Determinants of Health” section of the CSQI.
In this section, modifiable risk factors are examined in relation to the following measures of socio-demographic status: income quintile, urban or rural residence, highest level of completed education and immigrant status. Modifiable risk factors among Ontario’s First Nations, Inuit and Métis populations are examined in more detail in the “Cancer Risk Factors among the First Nations, Inuit and Métis Peoples of Ontario” section of the CSQI.
What do the results show?
Trends over time:
- Smoking rates in Ontario have been declining for at least 2 decades1. In 2014, however, nearly one fifth (19%) of Ontarians ages 20 years or older reported that they were daily or occasional smokers (Figure 1).
- Approximately 8% of Ontario adults ages 19 years and older in 2014 (equivalent to nearly 1 million people) drank more alcohol than the maximum amount recommended for cancer prevention (i.e. more than 2 drinks per day for men and more than 1 drink per day for women). This estimate has not declined since at least 2003, and it varies substantially within the Ontario population (data not shown).
- The proportion of adults who are obese has been increasing for at least 2 decades2. The prevalence of obesity among Ontario adults (aged 18+) increased from 21% in 2003 to 27% in 2014. The increase in obesity seen in Ontario from 2003 to 2014 indicates that this trend is ongoing, and continuing increases are projected for the coming years3.
Adequate vegetable and fruit consumption
- Although eating at least 5 servings of vegetables and fruit a day is a good marker of overall diet quality4, only one third (34%) of Ontario adults currently report eating vegetables (excluding potatoes) that often or more. This figure has not changed since 2003 (Figure 2).
- The proportion of Ontario adults who are moderately active or active in their leisure time is low (52% in 2014), and it has not increased for at least the past 10 years. From 2003 to 2014, the proportion of adults ages 18 and older who were at least moderately active remained stable.
- Socio-demographic factors such as income, education and place of residence (i.e. living in urban areas vs. those that are rural-remote) have a well-established impact on health. They also are associated with risk factor prevalence.
- Prevalence of current smoking generally decreases with increasing income. Compared with adults (aged 30+) in the highest income quintile, those in the lowest income quintile had significantly higher rates of current smoking from 2012–2014 (24.7% in Q1 vs. 12.5% in Q5) (Figure 3).
- Significant variation in the prevalence of current smoking also is seen according to area of residence, highest level of education and immigration status. In general, the rate of current smoking is higher in rural areas (compared with urban ones), among people with less than secondary or secondary school education (compared to people with post-secondary education), and among Canadian-born adults (compared with immigrants to Canada).
- The proportion of adults (aged 30+) who drink in excess of the cancer prevention recommendations for alcohol generally rises with increasing income (Figure 3). Compared with those in the highest income quintile, those in the lowest income quintile had significantly lower rates of exceeding the alcohol consumption recommendation during 2012–2014 (4.7% in Q1 vs. 11.9% in Q5). This is in contrast to patterns seen for several other behavioural risk factors for cancer (such as tobacco smoking), which are more common in lower income groups.
- From 2012 to 2014, the prevalence of drinking in excess of the cancer prevention recommendations was significantly higher among adults living in rural areas than it was in urban ones. It also was more prevalent among Canadian-born adults than immigrants who have been in Canada for more than 10 years. The proportion of adults who exceeded the recommendations did not differ significantly among levels of education.
- The prevalence of adult obesity does not vary across income quintiles (Figure 3). However, variation in the prevalence of obesity from 2012 to 2014 was seen across levels of other socio-demographic factors, including immigrant status and education. The prevalence of obesity was higher in rural areas (compared to urban ones), among people with less than secondary or secondary school education (compared to people with post-secondary education), and among Canadian-born adults (compared with immigrants to Canada).
Adequate vegetable and fruit consumption
- Compared with adults (aged 30+) in the highest income quintile, a significantly lower proportion of adults in the lowest income quintile reported consuming vegetables and fruit 5 or more times per day during 2012–2014 (30.5% in Q1 vs. 38.6% in Q5) (Figure 3).
- The prevalence of consuming vegetables and fruit 5 or more times per day was significantly higher among adults living in urban areas than in rural ones; it also was more common among adults who have graduated from post-secondary education than adults who have attained lower levels of education. The proportion of adults consuming vegetables and fruit 5 or more times per day was significantly higher among immigrants who have been in Canada for more than 10 years than Canadian-born adults. Individuals with less education and in the lower income quintiles may experience affordability and availability barriers to accessing fresh vegetables and fruit.
- Compared with Ontario adults (aged 30+) in the highest income quintile, a significantly lower proportion of adults in the lowest income quintile were at least moderately active or active during leisure time and transportation during 2012–2014 (39.4% in Q1 vs. 64.0% in Q5) (Figure 3).
- From 2012 to 2014, the prevalence of being either moderately active or active was significantly higher among adults living in rural areas (compared to those in urban ones), among post-secondary graduates (compared to adults with lower levels of education), and among Canadian-born adults (compared to immigrants to Canada).
Why is this important to Ontarians?
Healthier behaviour reduces cancer risk.
- Consumption of non-starchy vegetables and fruit probably protects against cancers of the mouth, pharynx, larynx, esophagus and stomach, and consuming fruit may protect against lung cancer5. Consumption of vegetables and fruit also is a good marker of overall diet quality6. Vegetables and fruit contain a number of nutrients, including vitamins and antioxidants, which may lower the risk of several cancers7. Regular moderate to vigorous physical activity has been shown to reduce the risk of colon cancer, and it probably protects against cancers of the breast and endometrium5.
- Obesity is a complex issue with multiple causes and contributors. While eating a diet rich in vegetables and fruit and participating in moderate-to-vigorous physical activity contribute to maintaining a healthy weight, they also confer independent health benefits for the prevention of chronic disease, specifically cancer.
- Excess body weight (i.e. overweight and/or obesity) increases the risks of cancers of the esophagus (adenocarcinoma), colon and rectum, pancreas, breast (post-menopausal), endometrium and kidney.5,8,9,10,11 Cancer risk is influenced by degrees of body fatness consistent with obesity, overweight and even within a range that is generally considered to be healthy5.
- Tobacco use (active cigarette, cigar and cigarillo smoking, and exposure to second-hand smoke and smokeless tobacco) is a major preventable cause of morbidity and mortality. Active tobacco smoking causes cancers of the lung, upper aerodigestive tract, esophagus, stomach, colon and rectum, liver, pancreas, cervix, ovary, kidney, bone marrow (myeloid leukemia), and bladder and other urinary organs5.
- All types of alcoholic beverages increase the risk of cancers of the oral cavity and pharynx, esophagus (primarily squamous cell carcinoma), larynx, liver, colon and rectum, and breast. Pancreatic cancer also may be caused by alcohol consumption, although more research is needed to confirm this association8.
What’s happening in Ontario?
Support for healthy behaviours
- In 2012, Cancer Care Ontario and Public Health Ontario partnered to create a set of evidence-based, policy intervention recommendations to address 4 major risk factors for chronic disease: tobacco, alcohol, physical activity and healthy eating. The report, Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario, outlines 22 recommendations to reduce population-level exposure to those 4 major risk factors, build capacity for chronic disease prevention and work towards health equity12.
- Some related actions have already been undertaken by the government of Ontario, Cancer Care Ontario and other chronic disease prevention partners. For example, working toward broadening and extending the integrated tobacco cessation system, Cancer Care Ontario has been collaborating with regional cancer centres to screen new ambulatory care patients for tobacco use, advise people who smoke on the benefits of quitting, and refer smokers to cessation services for support.
- Furthermore, the Government of Ontario’s Making Healthier Choices Act, 2015 will require food chains with 20 or more locations in Ontario to display calories on menus by January 1, 2017, in conjunction with a contextual statement about the calories of an average diet13. Menu labelling will not only inform Ontarians about the nutritional value of the food they are selecting, but it may potentially have the benefit of influencing food service operations to offer healthier products in their restaurants14.
- The Making Healthier Choices Act, 2015 also bans the sale of all flavoured tobacco, including menthol, and it controls the sale, use and promotion of electronic cigarettes. The Act is predicted to have an impact on smoking prevalence among youth in Ontario15. Additionally, amendments in 2016 to the Smoke-Free Ontario Act banned smoking on hospital grounds, with the exception of outdoor designated smoking areas. This exception is only for a limited time: by January 1, 2018, all outdoor grounds of hospitals must be completely smoke-free16.
- Another notable advancement includes an initial increase in the tobacco tax rate of 1.5 cents per cigarette and per gram of other tobacco products (except cigars) which came into effect on February 26, 2016. Tobacco tax rates on cigarettes and other tobacco products (except cigars) also will increase each year for the next 5 years by an amount based on inflation. These inflation-linked increases begin in June 201717.
- Although the Government of Ontario has increased the availability of alcohol by permitting sales in some grocery stores (for beer, cider and wine) and farmers markets (for cider and wine), it also has announced the development of a comprehensive provincial alcohol policy to support the safe and responsible consumption of alcohol18,19.
- In 2015, Cancer Care Ontario began monitoring and assessing the cancer prevention system in Ontario through its Prevention System Quality Index (PSQI) report. Scheduled to be updated and released on an annual basis, the PSQI reports on the system-level policies and programs that have the potential to reduce the prevalence of cancer risk factors and exposures in Ontario.
- This focus on system-level policies and programs is supported by evidence that shows that healthy public policy and community-wide programs are more effective in reducing the prevalence of modifiable risk factors at a population-level than those that focus on changing behaviours of individuals. Levels of physical activity in the population, for example, may be influenced more by urban planning and land use polices (such as those related to the development of walkable neighbourhoods and the availability of bike paths) than they are by health promotion programming that attempts to get individuals to exercise more often.
Focus on children and youth.
- Children and youth are an important target population for public health interventions related to overweight, obesity, healthy eating and physical activity. Children who are obese are more likely to remain obese as adults 20.
- The Ministry of Health and Long-Term Care’s Healthy Kids Panel identified reducing childhood obesity as a priority21. Ontario is taking action to implement recommendations from the Healthy Kids Panel by focusing on 3 pillars: healthy start, healthy food and healthy active communities.
- In the Healthy Kids Community Challenge, a cross-government initiative of Ontario’s Healthy Kids Strategy, 45 Ontario communities are delivering local programs and activities to support children and youth in healthy living, including healthy eating and physical activity to promote children’s health22.
- My CancerIQ is a confidential online tool that allows Ontarians to determine their risk for melanoma, breast, cervical, colorectal, kidney and lung cancer. Launched in February 2015, My CancerIQ was created by Cancer Care Ontario, in partnership with the Ministry of Health and Long-Term Care, to encourage Ontarians to be more proactive about their health.
- My CancerIQ includes a series of risk assessments that estimate a person’s risk compared with other Ontarians of the same age and sex. At the end of each assessment, individuals receive a personalized risk assessment and action plan with tips and resources based on their individual risk factors. The risk assessments include what factors help reduce the risk of cancer, what factors increase a person’s risk of developing cancer and what can be done to reduce the risk. Links to additional resources are also provided.
- Since its launch, more than 176,000 cancer risk assessments have been completed at MyCancerIQ.ca.
Consideration of socio-demographic disparities.
- Significant disparities exist across several socio-demographic factors that must be considered when developing programs and policies to address chronic disease risk modifiers.
- For example, while vegetable and fruit consumption and physical activity are lowest in the lowest income quintile, the relationship between income and obesity is more complicated.
- To avoid exacerbating differences between income groups and the underlying system-level barriers that may be driving them, the complexity of these relationships must be considered—and possibly further investigated with qualitative data—during the design of prevention programs and policies.
- The Health Equity Impact Assessment Tool, developed by the Ministry of Health and Long-Term Care, can assist planners in assessing socio-demographic inequities that might result from a new program or policy, thus helping to mitigate those impacts23.
- For more information on social determinants of health in Ontario, see the “Context in Ontario: Social Determinants of Health” section of the CSQI.
Prevention efforts in Ontario’s First Nations, Inuit and Métis populations
- Cancer Care Ontario’s Aboriginal Cancer Control Unit released the Aboriginal Cancer Strategy III (ACS III) in 2015. Created through engagement with First Nations, Inuit and Métis organizations and communities across the province, this document identified priority prevention policies in the area of smoking cessation.
- It also called for work to begin to address other modifiable risk factors. (i.e. excess body weight and inadequate fruit and vegetable consumption) . The Path to Prevention—Recommendations for Reducing Chronic Disease in First Nations, Inuit and Métis, which will be released in 2016, fulfills a commitment that was made in the Taking Action report to outline recommendations to government and other stakeholders to work together to prevent chronic disease among First Nations, Inuit and Métis populations in Ontario12.
To see how Ontario compares to other jurisdictions, see the Comparison of Modifiable Risk Factors section of CSQI.
- Ialomiteanu AR, Adlaf EM, Mann RE, Rehm J. CAMH monitor eReport: addiction and mental health indicators among Ontario adults, 1977–2009 (CAMH research document series no. 31) [Internet]. Toronto: The Centre for Addiction and Mental Health; c2012. Available from: http://www.camh.ca/en/research/news_and_publications/Pages/camh_monitor.aspx.
- Chief Medical Officer of Health of Ontario. 2004 Chief Medical Officer of Health report. Healthy weights, healthy lives [Internet]. Toronto: Queen’s Printer for Ontario; 2004 [cited 2013 Feb 19]. Available from: http://www.health.gov.on.ca/en/common/ministry/publications/reports/cmoh04_report/healthy_weights_112404.pdf.
- Twells LK, Gregory DM, Reddigan J, Midodzi WK. Current and predicted prevalence of obesity in Canada: a trend analysis. CMAJ Open 2014 Jan; 2(1):E18–E26.
- Garriguet D. Diet quality in Canada. Health Rep. 2009 Sep; 20(3):41–52.
- World Cancer Research Fund (WCRF), American Institute for Cancer Research (AICR). Food, nutrition, physical activity, and the prevention of cancer: a global perspective. Washington, DC: AICR; 2007.
- Garriguet D. Diet quality in Canada. Health Rep. 2009 Sep; 20(3):41–52.
- Norat T, Aune D, Chan D, Romaguera D. Fruits and vegetables: updating the epidemiologic evidence for the WCRF/AICR lifestyle recommendations for cancer prevention. Cancer Treat Res. 2014; 159:35–50.
- WCRF, AICR. Continuous update project report summary. Food, nutrition, physical activity and the prevention of breast cancer [Internet]. Washington, DC: AICR; 2010 [cited 2014 Dec 1]. Available from: http://www.dietandcancerreport.org/cancer_resource_center/downloads/cu/cu_breast_cancer_report_2008_summary.pdf.
- WCRF, AICR. Continuous update project. Colorectal cancer report 2010 summary. Food, nutrition, physical activity, and the prevention of cancer [Internet]. Washington, DC: AICR; 2011 [cited 2014 Dec 1]. Available from: http://www.dietandcancerreport.org/cancer_resource_center/downloads/cu/CUP_CRC_summary_2011.pdf.
- WCRF, AICR. Continuous update project report. Food, nutrition, physical activity, and the prevention of endometrial cancer [Internet]. Washington, DC: AICR; 2013 [cited 2014 Nov 5]. Available from: http://www.wcrf.org/sites/default/files/Endometrial-Cancer-2013-Report.pdf.
- WCRF, AICR. Continuous update project report. Food, nutrition, physical activity, and the prevention of pancreatic cancer [Internet]. Washington, DC: AICR; 2012 [cited 2014 Nov 5]. Available from: http://www.wcrf.org/sites/default/files/Pancreatic-Cancer-2012-Report.pdf.
- Cancer Care Ontario, Ontario Agency for Health Protection and Promotion (Public Health Ontario). Taking action to prevent chronic disease: recommendations for a healthier Ontario. Toronto: Queen's Printer for Ontario; 2012.
- Legislative Assembly of Ontario. Bill 45, Making Healthier Choices Act, 2015 [Internet]; [cited 2016 Feb 26]. Available from: http://www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=3080 .
- Bleich SN, Wolfson JA, Jarlenski MP. Calorie changes in chain restaurant menu items: implications for obesity and evaluations of menu labeling. Am J Prev Med. 2015; 48(1):70–5.
- Canadian Cancer Society [Internet]. Toronto: the Canadian Cancer Society; c2016. Canadian Cancer Society celebrates the successful end to their #endtheflavour campaign; 2015 May 26 [cited 2016 Feb 26]. Available from: https://www.cancer.ca/en/about-us/for-media/media-releases/ontario/2015/may/bill-45-passing/?region=on.
- The Province of Ontario [Internet]. Queen’s Printer for Ontario; c2012–2016. Smoke-free Ontario; 2015 Dec 21 [cited 2016 Mar 2]. Available from: https://www.ontario.ca/page/smoke-free-ontario.
- Ontario Ministry of Finance. 2016 Budget: tax and benefit related measures [Internet]. Toronto: Queen’s Printer for Ontario; 2016. Available from: http://www.fin.gov.on.ca/publication/budget-highlights-2016-en.pdf.
- News.Ontario.ca [Internet]. Toronto: Queen’s Printer for Ontario; c2016. Wine, cider and fruit wines coming to grocery stores and farmers markets across Ontario: Province supporting producers and increasing consumer choice and convenience; 2016 Feb 19 [cited 2016 Feb 29]. Available from: https://news.ontario.ca/omafra/en/2016/02/wine-cider-and-fruit-wines-coming-to-grocery-stores-and-farmers-markets-across-ontario.html.
- The Province of Ontario [Internet]. Toronto: The Office of the Premier; c2016. Ontario developing policy to support responsible alcohol use—stay safe this holiday season and drink responsibly; 2016 Feb 19 [cited 2016 Feb 29]. Available from: https://news.ontario.ca/opo/en/2015/12/ontario-developing-policy-to-support-responsible-alcohol-use.html.
- Freedman DS, Khan LK, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS. The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics. 2005 Jan; 115(1):22–7.
- The Province of Ontario [Internet]. Toronto: Ontario Ministry of Health and Long-term Care; c2016. Backgrounder: Ontario's healthy kids strategy [Internet]; 2014 Feb 24 [cited 2014 Aug 31]. Available from: http://news.ontario.ca/mohltc/en/2014/02/ontarios-healthy-kids-strategy-1.html.
- Ontario Ministry of Health and Long-term Care [Internet]. Toronto; Queen’s Printer for Ontario; c2009–2010. Healthy kids community challenge. 2015 Sep 9 [cited 2014 Oct 31]. Available from: http://www.health.gov.on.ca/en/public/programs/healthykids/.
- Ontario Ministry of Health and Long-term Care [Internet]. Toronto: Queen’s Printer for Ontario; c2008. Health equity impact assessment; 2013 Apr 19 [cited 2014 Dec 1]. Available from: http://www.health.gov.on.ca/en/pro/programs/heia/.
- Cancer Care Ontario. Aboriginal cancer strategy III 2015–2019: together we will. Toronto; Cancer Care Ontario; 2015.