Key Words: Aboriginal; Addiction; Prevention; Spiritual; Strategies; Tobacco

PREVALENCE
The prevalence of smoking in Canada has decreased gradually from a high of approximately 35% in the mid-1980s. Data published by the Canadian Tobacco Use Monitoring Survey (3) indicated that as of June 2004, an estimated 5.1 million people, representing roughly 20% of the population aged 15 years or older, were current smokers. The prevalence of smoking in youth aged 15 to 19 years also followed a downward trend, from approximately 45% in 1981 to 20% in 2004 (3).

However, the prevalence of smoking in Aboriginal Canadians, although gradually decreasing, remains high. Recent statistics (4) indicate that the rate of smoking among First Nations people in Canada (59%) is still approximately three times the rate for the general Canadian population. Among 15- to 17-year-old adolescents, the rate of smoking among boys (47%) and girls (61%) is still three times the national rate. In a 2005 study of a First Nations community in Manitoba (5), 82% of adolescents aged 15 to 19 years were current smokers. Similarly, 70% of Inuit aged 18 to 45 years are current smokers (6).

CONSEQUENCES OF TOBACCO USE
Tobacco use continues to be a leading cause of preventable death in North America, particularly due to myocardial disease, vascular disease, chronic lung disease such as emphysema, cancer of the lung and other cancers (7). Smoking is also a risk factor for the development of type 2 diabetes (8), which is very common in Aboriginal populations. There is also evidence of faster progression of complications in diabetics who smoke (8-10). Smoking is also associated with an increased risk of fires.

Smoking during pregnancy is particularly hazardous to the fetus (11,12). Complications include an increased number of perinatal deaths, placental problems, increased preterm deliveries, fetal growth retardation (13), congenital abnormalities such as gastroschisis, sudden infant death syndrome, increased risk of miscarriage and learning disabilities (11). Smoking during pregnancy has also been associated with withdrawal symptoms in the newborn period (14) and attention deficit hyperactivity disorder symptoms in childhood (15), and is a risk factor for subsequent nicotine dependence in adolescence (16). Children of mothers who smoked a pack or more of cigarettes per day during pregnancy are at elevated risk of developing nicotine dependence as adults (17).

Postnatal exposure to second-hand smoke results in increased rates of lower respiratory infections, decreased lung growth, increased otitis media, increased risk of sudden infant death syndrome and increased risk of asthma. In 2001, regular smoking occurred in 21% of homes in Canada with children younger than 12 years of age (18).

FACTORS INFLUENCING NICOTINE USE
Nicotine addiction
Nicotine, one of the most highly addictive substances in the world, acts on the same pleasure centres of the brain as other drugs such as heroin and cocaine. It was previously thought that nicotine addiction developed over months or years of exposure. However, recent evidence suggests that even occasional use over a short period of time can be addictive. Nicotine has a positive effect on mood and performance (19), resulting in more efficient processing of information. This may be the basis for addiction. Small, frequent doses increase alertness and arousal, while larger, more prolonged doses lead to sedation and reduced anxiety. In addicted individuals, increasing doses may be necessary to achieve the same beneficial effects, and symptoms of nicotine withdrawal occur when nicotine is withdrawn.

Age at onset of tobacco use may be a significant factor in the development of addiction to tobacco. When introduced to nicotine and allowed free access to the substance, ‘adolescent’ rats showed a significantly higher ingestion of nicotine, up to eight times more than rats first introduced to nicotine as adults (20). Reduced sensitivity to taste is associated with increased risk of addiction (21). High nicotine levels associated with first-time use may result in a less than pleasant experience and discourage further smoking.

A number of genetic factors (20), including the nicotinic acetylcholine receptor, the dopamine transporter gene (22) and cytochrome P450 2A6, appear to be associated with the development of nicotine addiction (23). Polymorphism in the genes regulating nicotine metabolism is an important factor in the development of addiction. These three enzyme systems are the subject of intense study.

Although addiction is a known consequence of tobacco use, there are no data suggesting racial or genetic differences related to nicotine metabolism.

Youth access to tobacco
Although the highest prevalence of tobacco use is among youth aged 15 to 24 years (5), smoking initiation can begin as early as 11 to 13 years of age, several years before it is legal for a youth to buy tobacco in Canada. For Aboriginal youth, smoking and the use of smokeless tobacco can begin as early as seven or eight years of age, with even younger children imitating the habits of adults around them.

Studies have shown that easy access to cigarettes is one of the best predictors of a child becoming a regular smoker at a young age; in 2004, a majority (56%) of underage smokers reported obtaining tobacco from friends and family. Furthermore, despite regulations, 33.3% of retailers have continued to sell cigarettes to underaged Canadians. This is complicated by the fact that there is no consistent minimum smoking age across Canada.

Poverty and educational level
Studies have shown a correlation among poverty, high unemployment, low income and high rates of smoking. Parents with lower incomes and educational levels are more likely than higher-paid, better-educated parents to have teenage children who smoke (24). Low income levels and high unemployment rates are problems on most reserves in Canada, and affect many off-reserve Aboriginal people as well.

Cost of tobacco
Tobacco use varies inversely with price. Among youth, a 10% increase in price is associated with a 14% decrease in the prevalence of smoking (25). Tax is a major determinant of tobacco price and varies markedly across Canada. The price of a carton of cigarettes can range from a low of approximately $20 in Quebec for discount cigarettes to a high of $42 in the Northwest Territories for duty-paid cigarettes. The availability of tax-free tobacco on reserves undermines the deterrent of high price to smoking. Furthermore, because selling tax-free tobacco off-reserve can be a good source of income, there may be little incentive to discontinue the practice (26).

Cultural factors
For many First Nations people, tobacco has been used traditionally in ceremonies, rituals and prayer for thousands of years. It is used for a variety of medicinal purposes and its ceremonial use has powerful spiritual meaning, establishing a direct communication link between the person giving and the spiritual world receiving. In the traditional sense, the most powerful way of communicating with the spirits is to smoke tobacco in a sacred pipe. While tobacco is sacred, the recreational use of tobacco, with its high content of nicotine, is addictive and harmful. First Nations Elders maintain that this type of use is disrespectful of the spiritual, medicinal and traditional use of tobacco. These observations echo those of the Assembly of First Nations (6).

While tobacco has rarely been used ceremonially in Inuit culture, over seven in 10 adults now smoke daily – a rate higher than that of First Nations and Métis people. Traditional Inuit society was smoke-free. The Inuit did not use tobacco until approximately 100 years ago. At first, it was mainly men who smoked, and it was forbidden for Inuit youth to use tobacco. In the 1940s, smoking became more prevalent among all Inuit, and today, Inuit women have one of the highest rates of lung cancer in the world (27).

Until recently, smoking was accepted as a fact of life in the North, so there had been few efforts to discourage it. In the mid-1990s, nicotine use in Nunavut remained widespread and showed no obvious signs of abating. However, increasing awareness of decreased life expectancy, infant mortality rates three times the national average, and high rates of lung disease and cancer (28) spurred Nunavut to adopt fairly extensive tobacco reduction initiatives in 2003, affecting all aspects of life, school, the home and the community (29,30). Since then, a ban on smoking has been extended to all public and workplaces (31).

ADDRESSING THE PROBLEM OF HIGH TOBACCO USE

1. A number of programs have been established by provincial and territorial governments to target the broad social environment. In most cases, provincial regulations do not apply to reserves. These programs include:
   • The establishment of smoke-free public and workplaces to protect nonsmokers from second-hand smoke (31).
   • Efforts to standardize legal age limits for tobacco use and penalties for selling to minors.  
   • Keeping tobacco products out of sight – the so-called ‘shower curtain law’.  
   • Banning tobacco advertising and displays.  
   • Taxing tobacco at a high level to produce cigarette prices sufficiently high to deter regular smoking among adolescents.  
   • The use of health warnings on cigarette packages.  
     
     Success with these measures has been variable. In January 2005, during National Non-Smoking Week, the Canadian Council for Tobacco Control brought out a ‘Report Card’, which graded the antismoking legislation accomplishments of all Canadian provinces and territories. Six categories were selected for grading. Results were variable. For example, in the area of tobacco pricing, marks ranged from an A+ for the Northwest Territories to Fs in Ontario, Quebec and the Yukon (31).  
     
     
2. Health Canada and national Aboriginal organizations have become proactive in dealing with the issue of tobacco misuse.  
   
   National programs to increase awareness of the problems of tobacco misuse  
   The First Nations and Inuit Health Branch works in partnership with national Aboriginal organizations, such as Assembly of First Nations and Inuit Tapiriit Kanatami, to raise awareness of tobacco misuse as a serious health issue to communities (32).

   Among First Nations, tobacco control programs are being developed for, and delivered to, community health representatives (CHRs) and tobacco cessation counsellors. Strategies include capacity building; developing and delivering comprehensive, culturally sensitive and effective tobacco control programs; promoting the health of First Nations and Inuit peoples by decreasing the prevalence of tobacco smoking and smokeless tobacco use; and engaging leadership of First Nations and Inuit in learning to voice opinions and support tobacco control strategies (33).  

   Smoking cessation programs
   The First Nations and Inuit Health Branch recently updated its suggestions on quitting smoking. Their Web site (34) lists toll-free smoking lines, a list of nicotine replacements and medications to assist in smoking cessation, a list of community-based cessation programs and counselling services, and detailed self-help suggestions such as the “5 steps to quitting”.  

   These steps, which are expanded upon on their Web site, include:  

   • Get ready.  

   • Get support.  

   • Learn new skills and behaviours.  

   • Get medication and use it correctly.  

   • Be prepared for relapse or difficult situations.  

   A number of links to cessation resources are also available on their Web site.  

   Antismoking measures  
   Antismoking measures include messages, spread by multiple routes and repeated over time, that aim to:  

   • promote smoke-free spaces (public, private and work places), and are aimed mainly at adults under the age of 35 years (current prevalence for those aged 20 to 34 years is 27%, which is higher than the smoking rate of the general population [3]);
   • target pregnant and postpartum women;
   • target third-party suppliers of tobacco products to youth (eg, parents, siblings, older teens and other adults) with the goal of curtailing the supply of tobacco to youth; and
   • continue bans on smoking advertisements and tobacco company sponsorship.  

   Bans on smoking in the workplace  
   A number of provinces and territories have smoking bans in the workplace and in public areas to decrease exposure to second-hand smoke (31). The success of bans aimed at decreasing smoking in restaurants, bars, indoor recreational areas (including bingo halls) and public buildings has been variable (35). In Manitoba, the smoking ban legislation exempts reserves and, therefore, there is no smoking ban to follow.  

   Although it is true that some communities are passing bylaws that provide less protection than provincial smokefree legislation, other communities are passing bylaws that not only support provincial legislation but in some cases surpass it.  

3. Other measures designed to address the individual misuse of tobacco

   • Teaching and practicing ‘resistance’ skills.

   • The use of antismoking medication, either nicotine substitution (eg, the ‘patch’) or non-nicotine drugs such as bupropion (Zyban, Biovail Pharmaceuticals, Canada) (36).

   • The enforcement of age limits on tobacco sales and measures to remove cigarettes from public view.

   • Emphasis on the role of the physician and health care professional in smoking control. This includes counselling patients to help prevent and stop smoking. This emphasis should be part of routine preventive care at each office or community health visit (37). The five ‘As’ should be used routinely:

     • ASK about tobacco use  

     • ADVISE urge to quit  

     • ASSESS willingness to attempt quitting  

     • ASSIST – counselling and pharmacological therapy  

     • ARRANGE follow-up  

   • Taking advantage of educational opportunities; for example, use the experience of a smoking-related illness of a family member to educate family and community members about the dangers of tobacco, emphasizing control measures, cessation strategies and the use of nicotine substitution therapy such as the ‘patch’.  

   • Advocacy: Actively promote school-based prevention programs and be actively involved in policy interventions related to smoking.

SUMMARY
The high prevalence of tobacco use and misuse among Aboriginal people compared with their non-Aboriginal counterparts, as well as the resultant health consequences, continue to be of concern not only to the individuals using tobacco but also to others, especially infants, children, youth and pregnant women exposed to second-hand smoke.

Recently proposed solutions by First Nations and Inuit groups, federal, provincial and territorial governments, and other interested organizations need to be implemented. Difficulties in implementation include acceptance of these measures by the large numbers of jurisdictions involved, often with competing priorities. These include economic factors, such as a conflict between the perceived need to raise money by selling tax-free tobacco for communities and the desirability of using a high price to discourage tobacco use. There is also no coordination of minimum smoking ages across Canada and no means to decrease exposure to tobacco products, especially to youth.

A number of recommendations have been formulated as a guide to groups interested in decreasing tobacco use. These recommendations were generated through consensus, and were prepared with the participation of a number of Aboriginal and non-Aboriginal groups.

RECOMMENDATIONS

• Aboriginal communities should adopt a minimum age for the sale of cigarettes.
• Aboriginal communities should encourage dialogue in the community to help change attitudes toward the acceptability of recreational tobacco use.  
• Aboriginal communities should continue to discourage smoking in the workplace and institute bans of nontraditional use of tobacco in public places such as restaurants, recreational facilities, bingo halls and casinos.  
• First Nations reserves should focus on continuing to educate retailers on-reserve about the Tobacco Act and discourage the sale of tax-free tobacco products, especially to non-Aboriginals.  
• Because cost influences tobacco use (25), Aboriginal communities should be encouraged to place their own surcharge on tobacco products (when purchased for nontraditional use) to increase the price to match off-reserve prices; the increased revenue should then be directed to smoking prevention programs in the community.  
• A well-defined system should be established within a community to enforce all tobacco laws. The consequences of breaking these laws should be well defined.
• Cigarettes and other tobacco products should remain behind counters and out of sight in all stores.
• Aboriginal communities should encourage community members to establish smoke-free homes to diminish exposure of children to second-hand smoke.
• Nicotine replacements such as the ‘patch’ and nicotine-free tablets such as bupropion should be encouraged as part of a smoke cessation program. While at present there is limited availability of these drugs under the Non-Insured Health Benefits Program, it is recommended that these drugs be readily available when clinically appropriate.  
• Physicians and health care workers should use the opportunity afforded by clinic visits to explore smoking and tobacco use habits, to educate about the dangers to individuals directly or through second-hand smoke, and to introduce smoking-cessation strategies.  
• All Aboriginal communities should discourage nontraditional use of tobacco products.  

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FIRST NATIONS AND INUIT HEALTH COMMITTEE (2005-2006)
Members: Drs James Irvine, La Ronge, Saskatchewan; Heather Onyett, Queen’s University, Kingston, Ontario (board representative); Kent Saylor, Montreal Children’s Hospital, Montreal, Quebec (chair); Sam Wong, Edmonton, Alberta; Michael Young, Stanton Territorial Hospital, Yellowknife, Northwest Territories; Sam Wong, Edmonton, Alberta
Consultants: Drs James Carson, University of Manitoba, Winnipeg, Manitoba; John C Godel, Heriot Bay, British Columbia
Liaisons: Dr George Brenneman, Baltimore, Maryland, USA (American Academy of Pediatrics, Committee on Native American Child Health); Ms Kelly Butler, Ottawa, Ontario (First Nations and Inuit Health Branch, Health Canada); Ms Debbie Dedam-Montour, Kahnawake, Quebec (National Indian and Inuit Community Health Representatives Organization); Ms Elizabeth Ford, Ottawa, Ontario (Inuit Tapiriit Kanatami); Ms Carolyn Harrison, Ottawa, Ontario (First Nations and Inuit Health Branch, Health Canada); Ms Margaret Horn, Kahnawake, Quebec (Aboriginal Nurses Association of Canada); Ms Kathy Langlois, Ottawa, Ontario (First Nations and Inuit Health Branch, Health Canada); Ms Melanie Morningstar, Ottawa, Ontario (Assembly of First Nations); Mr Mark Schindel, Ottawa, Ontario (First Nations and Inuit Health Branch, Health Canada)
Principal author: Dr John C Godel, Quadra Island, British Columbia

FIRST NATIONS, INUIT AND MÉTIS HEALTH COMMITTEE (2009-2010)
Members: Drs William H Abelson, Prince George, British Columbia (Board Representative); Anna Banerji, St. Michael’s Hospital, Toronto, Ontario; Lola T Baydala, University of Alberta, Edmonton, Alberta; Darcy L Beer, Winnipeg, Manitoba; Heidi Schröter, Calgary, Alberta; Sam K Wong, Edmonton, Alberta (Chair)
Liaisons: Ms Debbie Dedam-Montour, Kahnawake, Quebec (National Indian and Inuit Community Health Representatives Organization); Ms Carolyn Harrison, Ottawa, Ontario (Health Canada, First Nations and Inuit Health Branch); Ms Kathy Langlois, Ottawa, Ontario (Health Canada, First Nations and Inuit Health Branch); Ms Heather McCormack Ottawa, Ontario (Health Canada, First Nations and Inuit Health Branch); Dr Kelly Moore, Albuquerque, New Mexico, USA (American Academy of Pediatrics, Committee on Native American Child Health); Ms Rena Morrison, Ottawa, Ontario (Assembly of First Nations); Ms Anna C Ryan, Ottawa, Ontario (Inuit Tapiriit Kanatami); Ms Barbara Van Haute, Ottawa, Ontario (Métis National Council); Ms Cheryl Young, Ottawa, Ontario (Aboriginal Nurses Association of Canada)
Consultants: Drs James Irvine, La Ronge, Saskatchewan; Kent Saylor, Montreal Children’s Hospital, Montreal, Quebec  
Revision Author: Dr Sam K Wong, Edmonton, Alberta (April 2010)

Last updated: June 2010