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Modifiable Risk Factors in Cancer in First Nations in Ontario

Key findings

Commercial tobacco use, exposure to second-hand smoke, alcohol consumption, excess body weight, physical inactivity and poor diet are modifiable risk factors associated with a number of different cancers. A significantly higher proportion of First Nations adults (on- and off-reserve) smoke cigarettes compared to non-Aboriginal adults. Also of concern is the high prevalence of cigarette smoking among on- and off-reserve First Nations adolescents, with rates that are 7 and 3 times higher than non-Aboriginal adolescents, respectively. First Nations adults and adolescents (on- and off-reserve) also are more likely to be obese than their non-Aboriginal counterparts. Vegetable and fruit intake levels are concerning, particularly among First Nations adults living on-reserve, where only 12% of men and 20% of women consume enough vegetables and fruit. A significantly higher percentage of on- and off-reserve First Nations adults were food insecure compared to non-Aboriginal Ontarians.

These findings have strong implications for greater risk and burden of cancer among First Nations people in Ontario compared to the general population.

The findings related to Ontario First Nations people presented in this section are from a recently published report, Cancer in First Nations in Ontario: Risk Factors and Screening. This report was a collaboration between the Chiefs of Ontario and Cancer Care Ontario in recognition of their shared goal of reducing the burden of chronic disease, specifically cancer, among First Nations people in Ontario.

Who are the First Nations Peoples of Ontario?

First Nations Peoples are one of 3 groups recognized by Canada’s Constitution Act of 1982 as “the Aboriginal peoples of Canada,” who are explicitly defined as “the Indian [now referred to as “First Nations”], Inuit, and Métis peoples.”

Prior to contact with Europeans, First Nations in what is now defined as Ontario represented diverse and stable communities whose economy and governance were sound and thriving. The arrival of Europeans and the resulting policies of assimilation (such as the residential school system) dramatically impacted the way of life of First Nations people and all aspects of their health.

Today there are 133 First Nations communities in Ontario, 126 of which have independently recognized land bases. As of 2016, there are approximately 236,680 people residing in Ontario who identify as First Nations, of whom approximately half live on-reserve or on Crown lands [1]. According to the 2016 Census, there were 85,475 people who self-identified as First Nations but were not registered under the Indian Act [2]. Almost half of registered First Nations people in Ontario who are on-reserve live in communities that are urban (47%) [3]. Over one-quarter live in special access communities (no year-round road access to a service centre) (28%) [3]. First Nations people in Ontario are young, with an average age of 32 years (compared to 40.5 for non-Aboriginal Ontarians) [2].

* Canadian Census data may underestimate First Nations population numbers.

What are modifiable risk factors?

Modifiable risk factors are behaviours and exposures that can lower or raise a person’s risk of cancer. They can, in theory, be changed.

The specific modifiable risk factors in this section include

  • cigarette smoking
  • vegetable and fruit intake
  • excess body weight (being overweight or obese)
  • food security

 

Figure 1. Percentage of on- and off-reserve First Nations and non-Aboriginal adolescents (age 12 to 17 years) and adults (age 20+) who smoked cigarettes daily or occasionally, Ontario

More information regarding the methodology is available.

Report date: March 2018

Data source: First Nations Regional Health Survey Phase 2, 2008/10 (First Nations Information Governance Centre); Canadian Community Health Survey, 2007–2014 (Statistics Canada).

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Aboriginal Cancer Control Unit)

Note:

  1. I represent 95% confidence intervals.
  2. Symbol indicates high sampling variability. Interpret with caution.

 

Figure 2. Percentage of on- and off-reserve First Nations and non-Aboriginal adults (age 20+) who smoked cigarettes daily or occasionally, by year, 2007 to 2013, Ontario

More information regarding the methodology is available.

Report date: March 2018

Data source: First Nations Regional Health Survey Phase 2, 2008/10 (First Nations Information Governance Centre); Canadian Community Health Survey, 2007–2014 (Statistics Canada).

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Aboriginal Cancer Control Unit)

Note:

  1. Age-standardized to the 2006 Ontario Aboriginal identity population.
  2. • represents estimate for on-reserve First Nations (RHS).

 

Figure 3. Percentage of on- and off-reserve First Nations and non-Aboriginal men and women (age 18+) who consumed at least two vegetables and two fruits a day, Ontario

More information regarding the methodology is available.

Report date: March 2018

Data source: First Nations Regional Health Survey Phase 2, 2008/10 (First Nations Information Governance Centre); Canadian Community Health Survey, 2007–2014 (Statistics Canada).

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Aboriginal Cancer Control Unit)

Note:

  1. Age-standardized to the 2006 Ontario Aboriginal identity population.
  2. I represent 95% confidence intervals.

 

Figure 4. Percentage of on- and off-reserve First Nations and non-Aboriginal adolescents (ages 12 to 17 years) and adults (age 18+) who were obese, Ontario

More information regarding the methodology is available.

Report date: March 2016

Data source: Canadian Community Health Survey (CCHS), 2007–2013 (Statistics Canada) and First Nations Regional Health Survey (RHS) Phase 2 (2008/10) (First Nations Information Governance Centre).

Prepared by: Cancer Care Ontario, Aboriginal Cancer Control Unit and the Chiefs of Ontario, Health Research Sector.

Note:

  1. Adult estimates are adjusted to the age distribution of the 2006 Ontario Aboriginal identity population (from the 2006 Census).
  2. Symbol indicates high sampling variability. Interpret with caution.
  3. Obese adults aged 18+: BMI 30 or greater. Body Mass Index (BMI)=weight in kilograms/(height in metres) squared. Excludes pregnant women.
  4. Obese adolescents ages 12-17: using categories of BMI as specified by the Cole Classification System (Cole et. al., BMJ. 2000;210:1240-1243)

 

Figure 5. Percentage of on- and off-reserve First Nations and non-Aboriginal households that were moderately or severely food insecure, Ontario, 2007 to 2014

More information regarding the methodology is available.

Report date: March 2018

Data source: First Nations Regional Health Survey Phase 2, 2008/10 (First Nations Information Governance Centre); Canadian Community Health Survey, 2007–2014 (Statistics Canada).

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Aboriginal Cancer Control Unit).

Note:

  1. I represent 95% confidence intervals.

 

Data Table 1. Percentage of on- and off-reserve First Nations and non-Aboriginal adolescents (age 12 to 17 years) and adults (age 20+) who smoked cigarettes daily or occasionally, Ontario

Aboriginal identity Category Percentage Lower confidence interval Upper confidence interval Lower difference Upper difference Coefficient of variation
On-reserve First Nations (RHS) Adolescents 30.3% 24.8% 36.4% 5.5% 6.1% -
On-reserve First Nations (RHS) Adults 49.8% 46.6% 53.0% 3.2% 3.2% 5.06
Off-reserve First Nations (CCHS) Adolescents 13.8% 9.0% 18.6% 4.8% 4.8% -
Off-reserve First Nations (CCHS) Adults 42.7% 39.3% 46.2% 3.4% 3.5% 5.85
Non-Aboriginal (CCHS) Adolescents 4.2% 3.8% 4.7% 0.4% 0.5% -
Non-Aboriginal (CCHS) Adults 21.7% 21.2% 22.2% 0.5% 0.5% 1.43

Report date: March 2018

Data source: First Nations Regional Health Survey Phase 2, 2008/10 (First Nations Information Governance Centre); Canadian Community Health Survey, 2007–2014 (Statistics Canada).

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Aboriginal Cancer Control Unit)

Note:

  1. I represent 95% confidence intervals.
  2. Symbol indicates high sampling variability. Interpret with caution.

 

Data Table 2. Percentage of on- and off-reserve First Nations and non-Aboriginal adults (age 20+) who smoked cigarettes daily or occasionally, by year, 2007 to 2013, Ontario

Year On-reserve Off-reserve First Nations (CCHS) Non-Aboriginal (CCHS)
2007 - 50.7% 23.5%
2008 - 45.3% 22.4%
2009 - 45.3% 22.4%
2010 49.8% 44.5% 21.6%
2011 - 39.6% 21.9%
2012 - 42.6% 21.4%
2013 - 38.7% 20.5%
FN CI FN CI NA CI NA CI
43% 59% 22% 25%
36% 55% 21% 24%
36% 55% 21% 24%
35% 54% 20% 23%
30% 49% 21% 23%
34% 51% 20% 23%
31% 47% 19% 22%

Report date: March 2018

Data source: First Nations Regional Health Survey Phase 2, 2008/10 (First Nations Information Governance Centre); Canadian Community Health Survey, 2007–2014 (Statistics Canada).

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Aboriginal Cancer Control Unit)

Note:

  1. Age-standardized to the 2006 Ontario Aboriginal identity population.
  2. • represents estimate for on-reserve First Nations (RHS)..

 

Data Table 3. Percentage of on- and off-reserve First Nations and non-Aboriginal men and women (age 18+) who consumed at least two vegetables and two fruits a day, Ontario

Aboriginal identity Category Percentage Lower confidence interval Upper confidence interval Lower difference Upper difference Coefficient of variation
On-reserve First Nations (RHS) Men 12.0% 9.2% 14.8% 3% 3% 11.82
On-reserve First Nations (RHS) Women 19.9% 16.8% 23.0% 3% 3% 8.17
Off-reserve First Nations (CCHS) Men 21.9% 17.7% 26.1% 4% 4% 8.45
Off-reserve First Nations (CCHS) Women 27.7% 23.2% 32.2% 4% 4% 5.93
Non-Aboriginal (CCHS) Men 22.8% 22.2% 23.4% 1% 1% 1.13
Non-Aboriginal (CCHS) Women 37.0% 36.3% 37.7% 1% 1% 0.74

Report date: March 2018

Data source: First Nations Regional Health Survey Phase 2, 2008/10 (First Nations Information Governance Centre); Canadian Community Health Survey, 2007–2014 (Statistics Canada).

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Aboriginal Cancer Control Unit)

Note:

  1. Age-standardized to the 2006 Ontario Aboriginal identity population.
  2. I represent 95% confidence intervals.

 

Data Table 4. Percentage of on- and off-reserve First Nations and non-Aboriginal adolescents (ages 12 to 17 years) and adults (age 18+) who were obese, Ontario

Indicator Aboriginal identity Estimate (%) "95% confidence interval
(low, high)"
Adolescents On-reserve First Nations (RHS) 15.9% (13.3, 18.9)
Adolescents Off-reserve First Nations (CCHS) 7.5% (3.9, 11.0)
Adolescents Non-Aboriginal (CCHS) 4.8% (4.2, 5.4)
Adults On-reserve First Nations (RHS) 48.8% (45.6, 52.0)
Adults Off-reserve First Nations (CCHS) 30.4% (27.0, 33.8)
Adults Non-Aboriginal (CCHS) 17.4% (17.1, 17.9)

Report date: March 2016

Data source: Canadian Community Health Survey (CCHS), 2007–2013 (Statistics Canada) and First Nations Regional Health Survey (RHS) Phase 2 (2008/10) (First Nations Information Governance Centre).

Prepared by: Cancer Care Ontario, Aboriginal Cancer Control Unit and the Chiefs of Ontario, Health Research Sector.

Note:

  1. Adult estimates are adjusted to the age distribution of the 2006 Ontario Aboriginal identity population (from the 2006 Census).
  2. Symbol indicates high sampling variability. Interpret with caution.
  3. Obese adults aged 18+: BMI 30 or greater. Body Mass Index (BMI)=weight in kilograms/(height in metres) squared. Excludes pregnant women.
  4. Obese adolescents ages 12-17: using categories of BMI as specified by the Cole Classification System (Cole et. al., BMJ. 2000;210:1240-1243)

 

Data Table 5. Percentage of on- and off-reserve First Nations and non-Aboriginal households that were moderately or severely food insecure, Ontario, 2007 to 2014

Aboriginal identity Category Estimate (%) Upper 95% confidence interval Upper 95% confidence interval
On-reserve First Nations (RHS) Moderate 33.1 30.3 35.9
On-reserve First Nations (RHS) Severe 14.5 12.0 17.3
Off-reserve First Nations (CCHS) Moderate 13.8 11.3 16.3
Off-reserve First Nations (CCHS) Severe 6.2 4.6 7.8
Non-Aboriginal (CCHS) Moderate 4.9 4.6 5.1
Non-Aboriginal (CCHS) Severe 1.4 1.3 1.6

Report date: March 2018

Data source: First Nations Regional Health Survey Phase 2, 2008/10 (First Nations Information Governance Centre); Canadian Community Health Survey, 2007–2014 (Statistics Canada).

Prepared by: Cancer Care Ontario, Prevention and Cancer Control (Aboriginal Cancer Control Unit).

Note:

  1. I represent 95% confidence intervals.

 

What do the results show?

Cigarette smoking

  • First Nations adults and adolescents living on-reserve reported a high prevalence of cigarette smoking (50% and 30%, respectively). This was followed closely by First Nations adults and adolescents living off-reserve (43% and 14%, respectively). These numbers are significantly greater than those among their non-Aboriginal counterparts (22% in adults and 4% in adolescents) (Figure 1).
  • The prevalence of cigarette smoking significantly declined from 2007 to 2013 for off-reserve First Nations and non-Aboriginal adults. For instance, a similar proportion of on-reserve and off-reserve First Nations adults were cigarette smokers in 2010 (Figure 2).

Vegetable and fruit consumption

  • On-reserve First Nations adult males (12%) and females (20%) were significantly less likely to consume at least 2 vegetables and 2 fruit per day than First Nations adult males (27%) and females (40%) living off-reserve. Values for both groups are significantly lower than for non-Aboriginal adult males (35%) and females (52%) (Figure 3).

Overweight and obesity

  • Almost half of First Nations adults (age 18 years and older) living on reserve were classified as obese (49%), a significantly greater proportion than First Nations adults living off-reserve (30%). Both on- and off-reserve First Nations adults were significantly more likely to be obese than non-Aboriginal adults (17%). Among adolescents, First Nations people living on-reserve were more than 3 times as likely to be obese than their non-Aboriginal counterparts (18% compared to 5%). The prevalence of obesity among First Nations adolescents living off-reserve and non-Aboriginal adolescents was similar (8% and 5%, respectively) (Figure 4).

Food insecurity

  • From 2007 to 2014, a significantly higher percentage of on- and off-reserve First Nations adults were food insecure than were non-Aboriginal Ontarians. About one-third (33%) of First Nations adults living on-reserve were in moderately food insecure households, compared to 14% of adults living off-reserve and 5% of non-Aboriginal adults. On- and off-reserve First Nations adults were significantly more likely to be living in households classified as severely food insecure (15% and 6%, respectively) than non-Aboriginal adults (1%) (Figure 5).

Why is this important to Ontarians?

Healthier behaviour reduces cancer risk.

  • Very little is currently known about cancer rates among First Nations people in Ontario. Information about the prevalence of cancer risk factors therefore offers perhaps the best approach for determining where cancer prevention resources can be directed most effectively in order to reduce the future burden of cancer and other chronic diseases.
  • With their current high rates of cigarette smoking, First Nations people are expected to experience a substantial future burden of tobacco-related chronic disease. Strategies, policies and programs to reduce tobacco use should therefore be a priority.
  • While traditional tobacco plays an important medicinal and ceremonial role in many First Nations communities, the spiritual use of traditional tobacco has no connection to the recreational use of commercial tobacco [4].
  • Exposure to tobacco through cigarette smoking and second-hand smoke is associated with an increased risk of many types of cancer (especially lung cancer), chronic respiratory diseases and other serious chronic conditions (including cardiovascular disease and possibly diabetes).
  • While eating a diet rich in vegetables and fruits contributes to maintaining a normal body weight, it also confers independent health benefits for prevention of chronic disease and several types of cancer. Evidence shows that while plant-based foods (such as non-starchy vegetables and fruit, or dietary fibre) have protective effects, red and processed meats and salted or salty foods increase cancer risk.
  • So-called convenience foods that are higher in fat and lower in nutritional value are increasingly being integrated into modern First Nations diets, partly because they are less expensive and partly because access to traditional foods from the land (such as plants, berries, beans, vegetables, birds, wild game meat and fish) has become more limited.
  • Given the relatively low intake of vegetables and fruit and the high levels of obesity among First Nations people compared to non-Aboriginal Ontarians, an increased burden of cancers and other chronic diseases related to these factors may be anticipated.

Healthy eating behaviours are influenced by economic resources for obtaining sufficient and nutritious food.

  • Individuals or households are defined as food secure when they “at all times have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life” [5]. Food insecurity occurs when access to healthy food is compromised due to limited financial resources. Food insecurity is a strong determinant of health because it directly influences the quality and quantity of food eaten. Levels of food insecurity also relate to the food access and affordability issues facing many remote First Nations communities.
  • The high prevalence of food insecurity among First Nations communities in Ontario suggests that First Nations people face more difficulty in accessing and affording food than non-Aboriginal people in Ontario, which has implications for adequate nutrition.

What is happening in Ontario?

Chiefs of Ontario

  • The Chiefs of Ontario continue to advocate for better health outcomes for First Nations people by partnering with organizations such as Cancer Care Ontario to build knowledge and evidence that can be used by First Nations people, both for taking control of their health and for planning and prioritizing programs.
  • The Chiefs of Ontario Health Department has developed the COO Health Portal, an online resource that outlines health priorities of the Chiefs of Ontario and amalgamates resources available to health practitioners and organizations serving Ontario First Nations communities.
  • The Chiefs of Ontario and Cancer Care Ontario have collaborated to produce Cancer in the First Nations in Ontario: Risk Factors and Screening. The report provides essential evidence that First Nations can use to support cancer prevention and screening.
  • Data collection for Phase 3 of the Regional Health Survey (health survey for on-reserve First Nations) is now complete at the national level. The national data are currently being processed for future use at the provincial/territorial level.

Cancer Care Ontario

  • The Aboriginal Cancer Strategy III (ACS III), released by Cancer Care Ontario in 2015, aims to help cancer control stakeholders in Ontario jointly develop, fund and implement Aboriginal cancer control policies and programs that improve the performance of the cancer system for First Nations, Inuit and Métis people in a way that honours the Aboriginal Path of Well-being.
  • The Aboriginal Tobacco Program at Cancer Care Ontario addresses the high prevalence of non-traditional tobacco use and second-hand smoke exposure in First Nations, Inuit and Métis communities through culturally appropriate awareness and education initiatives that support capacity-building with (and in) these communities in order to address commercial tobacco prevention, cessation and protection.
  • Cancer Care Ontario’s Path to Prevention: Recommendations for Addressing Chronic Disease in First Nation, Inuit and Métis outlines evidence-based policy recommendations to guide decision-making related to chronic disease prevention policy for First Nations, Inuit and Métis groups. The report focuses on the 4 major risk/protective factors for chronic disease: commercial tobacco use, alcohol consumption, physical activity and healthy eating. While the recommendations are aimed at the Government of Ontario, their implementation will involve full participation by First Nations, Inuit and Métis partners, as well as collaboration with relevant organizations.

Other organizations

  • The Ontario Federation of Indigenous Friendship Centres, with funding from the Ontario Ministry of Health and Long-Term Care, coordinates the Urban Aboriginal Healthy Living Program, which provides support to the urban First Nations, Inuit and Métis communities in the areas of nutrition, physical activity and smoking cessation.
  • The Ontario Ministry of Health and Long-Term Care supports a number of initiatives designed to address the specific health needs of First Nations, Inuit and Métis people, including the Northern Fruit and Vegetable Program, which provides no-cost fresh fruit and vegetables alongside healthy eating and physical activity education for school-aged children in Northern Ontario.
  • Aboriginal Health Access Centres are community-based health centres that provide primary care, cultural support and health promotion programs to First Nations, Inuit and Métis communities at 10 sites across Ontario.
  • The Ontario Native Women’s Association hosts programs that support the well-being of Aboriginal women and their families in Ontario, including Community Health Outreach and the Aboriginal Diabetes Education Project. The Association’s Policy and Research department also participates in advocacy to promote the “health, healing and wellness” of Aboriginal women.

Notes

  1. Registered Indian Population by Sex and Residence 2014 – Statistics and Measurement Directorate [Internet]. Ottawa: Indigenous and Northern Affairs Canada; 2015 May 21 [cited 2015 Sep 4]. Available from here.
  2. Statistics Canada. Data tables, 2016 Census. Catalogue no. 98-400-X2016155 [Internet]. Ottawa: Statistics Canada; 2017. Available from here.
  3. Chiefs of Ontario; Cancer Care Ontario. Cancer in First Nations in Ontario: risk factors and screening. Toronto: Chiefs of Ontario; 2016.
  4. First Nations and Inuit Health: Tobacco [Internet]. Ottawa: Health Canada; 2016 [cited 2017 Feb 17]. Available from here.
  5. Kirkpatrick SI, Tarasuk V. Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents. J Nutr. 2008;138(3):604–612.