Health Reports
Smoking prevalence among Inuit in Canada
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by Evelyne Bougie and Dafna Kohen
Inuit are the original inhabitants of the Arctic. In 2011, the Inuit population of Canada totalled just under 60,000 individuals, 73% of whom lived in remote communities in the four regions collectively known as Inuit Nunangat: Nunatsiavut (Labrador); Nunavik (northern Quebec); Nunavut; and the Inuvialuit Settlement Region (Northwest Territories).Note 1
Inuit face unique challenges in terms of physical and mental health.Note 2Note 3 Included among these challenges is a high prevalence of smoking.Note 2Note 3Note 4Note 5Note 6Note 7 According to the 2012 Aboriginal Peoples Survey (APS), 52% of Inuit aged 15 or older smoked cigarettes daily―more than three times the rate (16%) of the total population of Canada.Note 4
Smoking-related diseases account for the largest percentage of the difference in female life expectancy between residents of Inuit Nunangat and the rest of Canada.Note 8 Lung cancer is the most common cancer in NunavutNote 9; in fact, Inuit have the highest incidence of lung cancer in the world.Note 10Note 11
Given the well-established relationship between tobacco smoking and a variety of adverse health effectsNote 12 and premature death,Note 13 smoking patterns among Inuit merit examination. Based on results of the 1991, 2001 and 2012 APS (see The data), this study examines trends in daily smoking, occasional smoking and non-smoking among Inuit aged 15 or older, by selected characteristics (inside/outside Inuit Nunangat, Inuit region, sex and age group). Change is measured by comparing estimates over 20 years (1991 to 2012) and over each 10-year interval (1991-to-2001 and 2001-to-2012). For daily smokers, the average number of cigarettes smoked per day and the average age of daily smoking initiation are also investigated.
National trends
Between 1991 and 2012, the prevalence of daily smoking among Inuit decreased significantly from 64% to 52% (Table 1). Relatively little change occurred between 1991 and 2001, but the drop thereafter was significant: from 61% in 2001 to 52% in 2012. At the same time, the percentage of all Canadians aged 15 or older who were daily smokers also declined―from 22% in 2001 to 16% in 2012.Note 14
Occasional smoking was more common among Inuit in 2012 than in 1991. The percentage did not change significantly between 1991 and 2001, but rose between 2001 and 2012.
The prevalence of non-smoking among Inuit was significantly higher in 2012 (38%) than in 1991 (29%). The percentage of non-smokers increased steadily and significantly throughout the two decades.
More prevalent inside Inuit Nunangat
During the entire period, daily smoking was consistently and significantly more prevalent among Inuit living inside than outside Inuit Nunangat. The percentage of daily smokers decreased significantly in both areas, but the decline was more pronounced outside Inuit Nunangat (down 20 percentage points versus 5 percentage points). Both inside and outside Inuit Nunangat, the percentage who smoked daily was relatively stable between 1991 and 2001, but had dropped significantly by 2012.
Daily smoking in the four Inuit regions
Over the two decades, daily smoking decreased significantly in Nunavut, the Inuvialuit Settlement Region and Nunatsiavut. However, between 1991 and 2001, daily smoking prevalence in these regions did not change significantly. During the next decade, a significant decline was apparent only in the Inuvialuit Settlement Region.
Throughout the two decades, the prevalence of daily smoking was significantly lower in Nunatsiavut than in the other Inuit regions. In 2012, daily smoking prevalence was significantly higher in Nunavik and Nunavut than in the other two Inuit regions.
In Nunavik, the percentage of daily smokers rose significantly between 1991 and 2001, but by 2012 had fallen back to the 1991 level.
Declines in most age groups
Between 1991 and 2012, daily smoking declined significantly for Inuit in all age groups except 45 to 54. Changes from 1991 to 2001 did not reach statistical significance for any age group, but from 2001 to 2012, declines were significant for those aged 15 to 24, 35 to 44, and 65 or older (Table 2). Decreases over the entire 1991-to-2012 period were greatest for the 55-to-64 and 65-or-older age groups.
In the general Canadian population, the prevalence of smoking is lowest at the extremes of the age range.Note 15 Among Inuit, in 2012, the prevalence of daily smoking was lowest at age 65 or older, followed by ages 55 to 64. Prevalence was similar among all age groups from 15 through 54, except that 25- to-34-year-olds were significantly more likely than 15- to-24-year-olds to be daily smokers (62% versus 55%).
Inuit men and women equally likely to report daily smoking
The prevalence of daily smoking was similar among Inuit men and women throughout the two decades. This contrasts with the general Canadian population, among whom men are more likely than women to smoke daily or occasionally.Note 15
Daily smoking trends among Inuit men and women followed the overall pattern, in that prevalence was significantly lower in 2012 than in 1991, with a significant decline occurring only between 2001 and 2012 (Table 2).
Cigarettes smoked per day
Smoking can be classified as “heavy,” “moderate” or “light,” based on the number of cigarettes smoked per day. Throughout the two decades, Inuit who were daily smokers were significantly more likely to be “moderate” (10 to 24 cigarettes per day) than “heavy” (25 or more) or “light” (1 to 9) smokers (Figure 1). Among those who smoked daily, women were significantly more likely than men to be light smokers, while men were significantly more likely to be heavy smokers.
The number of cigarettes smoked per day has been shown to be negatively associated with cessation―heavy smokers are less likely than light smokers to quit.Note 16 The average number of cigarettes smoked per day by Inuit daily smokers fell significantly from 14.9 in 1991 to 13.3 in 2001 and to 12.3 in 2012. The decrease was significant among those living inside Inuit Nunangat, among men and women, and among all age groups from 15 through 54. The average number of cigarettes smoked per day did not change significantly among those living outside Inuit Nunangat or in Nunavik, or among Inuit aged 55 or older (Table 3).
Age of daily smoking initiation
For most smokers, smoking begins in their teens.Note 17 The average age of daily smoking initiation reported by Inuit daily smokers remained stable at 15.1 in 2001 and 15.2 in 2012 (data not available for 1991). A change was apparent in Nunavut, where daily smokers reported starting smoking daily at a significantly older age in 2012 (15.4) than in 2001 (14.9). As well, in 2012, 15- to 24-year-olds who were daily smokers reported that they started smoking daily at an average age of 14.2, which was significantly older than the average reported by daily smokers who had been aged 15 to 24 in 2001―13.7 (Table 3).
Conclusions
Aboriginal Peoples Survey data show that the prevalence of daily smoking among Inuit, while much higher than among the Canadian population overall, decreased between 1991 and 2012. Nonetheless, the prevalence of daily smoking was particularly elevated in Inuit Nunangat. Inuit men and women were equally likely to report smoking daily, but Inuit men were more likely to report heavy smoking. Research seeking to understand smoking initiation and smoking behaviour among Inuit from a social determinants perspectiveNote 3 could further inform cessation and prevention programs for this population group.
Acknowledgments
This study was sponsored by the First Nations and Inuit Health Branch (FNIHB), Health Canada.
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The data
The data are from the 1991, 2001 and 2012 Aboriginal Peoples Survey (APS), a national cross-sectional survey of First Nations people, Métis and Inuit conducted by Statistics Canada. Residents of institutions are excluded. The response rates were 79% in 1991, 84% in 2001, and 76% in 2012.
The survey methodology differed. The 1991 and 2001 APS were conducted in selected First Nations communities (reserves), whereas the 2012 APS excluded people living on Indian reserves and settlements as well as in certain First Nations communities in Yukon and the Northwest Territories. The 1991 sample was from the census population who self-reported Aboriginal origins and who also self-identified as Aboriginal in the APS. The 2001 and 2012 samples were derived from the census (or National Household Survey in 2012) population who self-reported Aboriginal identity or ancestry, and who also self-identified as Aboriginal in the APS. It is not known if differences in survey methodology affected trends in results.
The sample for the present study consisted of APS respondents who: self-identified as Inuit, were aged 15 or older, and provided smoking data. The percentages with missing smoking data were about 1% in 1991, 2% in 2001 and 7% in 2012. To overcome differences in survey methodology, respondents who self-identified as Inuit, but who lived on a reserve in 1991 or 2001, were excluded from the analysis. Inuit of the Western Arctic are known as “Inuvialuit”; in this report, the term “Inuit” includes Inuvialuit. The study sample sizes were 6,669 in 1991; 4,993 in 2001; and 3,429 in 2012.
The smoking status question was the same in all survey years: “At the present time do you smoke cigarettes daily, occasionally, or not at all?” Daily smokers were asked: “How many cigarettes do you smoke each day now?” In 2001 and 2012, daily smokers were also asked: “At what age did you begin to smoke cigarettes daily?”
Sampling weights were applied to all analyses, and a bootstrapping technique was used when calculating estimates of variance for the 2001 and 2012 APS. No bootstrap weights were developed for the 1991 APS; variance was calculated using a design effect adjustment of 1.5 for Inuit.Note 18 Significance tests (z-tests at p < 0.05) were performed to evaluate change over time by comparing estimates in 1991 with those in 2001; 2001 with 2012; and 1991 with 2012. Estimates with coefficients of variation greater than 16.6% but less than or equal to 33.3% should be interpreted with caution; these are noted (E) in the tables. Estimates with coefficients of variation greater than 33.3% or with small counts (less than 10) were suppressed.
Accurate estimates of the prevalence of cigarette smoking among Canadians overall can be derived from self-reported data,Note 19 but the validity of self-reported smoking data has not been determined for Inuit specifically. It is not known if smoking trends over time would be affected by social desirability biases. Another source of bias in self-reported smoking status could have been introduced by proxy reporting. Finally, because the data are based on three separate cross-sectional surveys, differences in smoking behaviour over time may reflect differences between cohorts.
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