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Use and misuse of tobacco among aboriginal peoples

Use and misuse of tobacco among
Aboriginal peoples
Sam Wong, Canadian Paediatric Society
First Nations, Inuit and Métis Health Committee
Paediatr Child Health 2006;11(10):681-5
Updated: Jun 1 2010
rate. In a 2005 study of a First Nations community in Mani- Abstract
toba [5], 82% of adolescents aged 15 to 19 years were current Changes in the use of tobacco by Aboriginal peoples have smokers. Similarly, 70% of Inuit aged 18 to 45 years are cur- occurred over time, from the spiritual, ceremonial use of fairly mild tobacco at the time of the first contact with Eu- ropeans to the highly addictive tobacco in use today, both Consequences of tobacco use
in ceremonies and recreationally. Although some people still have access to and are using traditional sacred tobac- co, subsequent misuse of tobacco has put the health, qual- Tobacco use continues to be a leading cause of preventable ity of life and life expectancy of a large number of adults death in North America, particularly due to myocardial dis- and children in First Nations and Inuit communities in ease, vascular disease, chronic lung disease such as emphyse- peril [1]. The present document, a revision of a 1999 ma, cancer of the lung and other cancers [7]. Smoking is also a Canadian Paediatric Society statement on smoking [2], risk factor for the development of type 2 diabetes [8], which is looks at the consequences of tobacco use and possible rea- very common in Aboriginal populations. There is also evi- sons for its high prevalence, and explores some attempts dence of faster progression of complications in diabetics who smoke [8]-[10]. Smoking is also associated with an increased risk Key Words: Aboriginal; Addiction; Prevention; Spiritual;
Strategies; Tobacco

Smoking during pregnancy is particularly hazardous to the fe- tus [11][12]. Complications include an increased number of perinatal deaths, placental problems, increased preterm deliv- eries, fetal growth retardation [13], congenital abnormalities such as gastroschisis, sudden infant death syndrome, in- Prevalence
creased risk of miscarriage and learning disabilities [11]. Smok- ing during pregnancy has also been associated with withdraw- The prevalence of smoking in Canada has decreased gradual- al symptoms in the newborn period [14] and attention deficit ly from a high of approximately 35% in the mid-1980s. Data hyperactivity disorder symptoms in childhood [15], and is a published by the Canadian Tobacco Use Monitoring Survey risk factor for subsequent nicotine dependence in adoles- [3] indicated that as of June 2004, an estimated 5.1 million cence [16]. Children of mothers who smoked a pack or more people, representing roughly 20% of the population aged 15 of cigarettes per day during pregnancy are at elevated risk of years or older, were current smokers. The prevalence of smok- developing nicotine dependence as adults [17].
ing in youth aged 15 to 19 years also followed a downward Postnatal exposure to second-hand smoke results in increased trend, from approximately 45% in 1981 to 20% in 2004 [3].
rates of lower respiratory infections, decreased lung growth, However, the prevalence of smoking in Aboriginal Canadi- increased otitis media, increased risk of sudden infant death ans, although gradually decreasing, remains high. Recent sta- syndrome and increased risk of asthma. In 2001, regular tistics [4] indicate that the rate of smoking among First Na- smoking occurred in 21% of homes in Canada with children tions 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 FIRST NATIONS, INUIT AND MÉTIS HEALTH COMMITTEE, CANADIAN PAEDIATRIC SOCIETY | 1
Factors influencing nicotine use
by the fact that there is no consistent minimum smoking age Nicotine addiction
Poverty and educational level
Nicotine, one of the most highly addictive substances in the Studies have shown a correlation among poverty, high unem- world, acts on the same pleasure centres of the brain as other ployment, low income and high rates of smoking. Parents drugs such as heroin and cocaine. It was previously thought with lower incomes and educational levels are more likely that nicotine addiction developed over months or years of ex- than higher-paid, better-educated parents to have teenage posure. However, recent evidence suggests that even occasion- children who smoke [24]. Low income levels and high unem- al use over a short period of time can be addictive. Nicotine ployment rates are problems on most reserves in Canada, and has a positive effect on mood and performance (19), resulting affect many off-reserve Aboriginal people as well.
in more efficient processing of information. This may be the basis for addiction. Small, frequent doses increase alertness Cost of tobacco
and arousal, while larger, more prolonged doses lead to seda- Tobacco use varies inversely with price. Among youth, a 10% tion and reduced anxiety. In addicted individuals, increasing increase in price is associated with a 14% decrease in the doses may be necessary to achieve the same beneficial effects, prevalence of smoking [25]. Tax is a major determinant of to- and symptoms of nicotine withdrawal occur when nicotine is bacco 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 Age at onset of tobacco use may be a significant factor in the Northwest Territories for duty-paid cigarettes. The availability development of addiction to tobacco. When introduced to of tax-free tobacco on reserves undermines the deterrent of nicotine and allowed free access to the substance, ‘adolescent’ high price to smoking. Furthermore, because selling tax-free rats showed a significantly higher ingestion of nicotine, up to tobacco off-reserve can be a good source of income, there may eight times more than rats first introduced to nicotine as be little incentive to discontinue the practice [26].
adults [20]. Reduced sensitivity to taste is associated with in- creased risk of addiction [21]. High nicotine levels associated Cultural factors
with first-time use may result in a less than pleasant experi- ence and discourage further smoking.
For many First Nations people, tobacco has been used tradi- tionally in ceremonies, rituals and prayer for thousands of A number of genetic factors [20], including the nicotinic years. It is used for a variety of medicinal purposes and its cer- acetylcholine receptor, the dopamine transporter gene [22] and emonial use has powerful spiritual meaning, establishing a di- cytochrome P450 2A6, appear to be associated with the devel- rect communication link between the person giving and the opment of nicotine addiction [23]. Polymorphism in the genes spiritual world receiving. In the traditional sense, the most regulating nicotine metabolism is an important factor in the powerful way of communicating with the spirits is to smoke development of addiction. These three enzyme systems are tobacco in a sacred pipe. While tobacco is sacred, the recre- ational use of tobacco, with its high content of nicotine, is ad- dictive and harmful. First Nations Elders maintain that this Although addiction is a known consequence of tobacco use, type of use is disrespectful of the spiritual, medicinal and tra- there are no data suggesting racial or genetic differences relat- ditional use of tobacco. These observations echo those of the Youth access to tobacco
While tobacco has rarely been used ceremonially in Inuit cul- ture, over seven in 10 adults now smoke daily – a rate higher Although the highest prevalence of tobacco use is among than that of First Nations and Métis people. Traditional Inuit youth aged 15 to 24 years [5], smoking initiation can begin as society was smoke-free. The Inuit did not use tobacco until early as 11 to 13 years of age, several years before it is legal for approximately 100 years ago. At first, it was mainly men who a youth to buy tobacco in Canada. For Aboriginal youth, smoked, and it was forbidden for Inuit youth to use tobacco. smoking and the use of smokeless tobacco can begin as early In the 1940s, smoking became more prevalent among all Inu- as seven or eight years of age, with even younger children imi- it, and today, Inuit women have one of the highest rates of tating the habits of adults around them.
Studies have shown that easy access to cigarettes is one of the Until recently, smoking was accepted as a fact of life in the best predictors of a child becoming a regular smoker at a North, so there had been few efforts to discourage it. In the young age; in 2004, a majority (56%) of underage smokers re- mid-1990s, nicotine use in Nunavut remained widespread ported obtaining tobacco from friends and family. Further- and showed no obvious signs of abating. However, increasing more, despite regulations, 33.3% of retailers have continued awareness of decreased life expectancy, infant mortality rates to sell cigarettes to underaged Canadians. This is complicated 2 | USE AND MISUSE OF TOBACCO AMONG ABORIGINAL PEOPLES
three times the national average, and high rates of lung dis- clude capacity building; developing and delivering compre- ease and cancer [28] spurred Nunavut to adopt fairly extensive hensive, culturally sensitive and effective tobacco control pro- tobacco reduction initiatives in 2003, affecting all aspects of grams; promoting the health of First Nations and Inuit peo- life, school, the home and the community [29][30]. Since then, ples by decreasing the prevalence of tobacco smoking and a ban on smoking has been extended to all public and work- smokeless tobacco use; and engaging leadership of First Na- tions and Inuit in learning to voice opinions and support to- Address the problem of high tobacco
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 A. A number of programs have been established by provincial
medications to assist in smoking cessation, a list of communi- and territorial governments to target the broad social
ty-based cessation programs and counselling services, and de- environment. In most cases, provincial regulations do not
tailed self-help suggestions such as the “5 steps to quitting”.
apply to reserves. These programs include:
These steps, which are expanded upon on their Web site, in- • 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 • Keeping tobacco products out of sight – the so-called • Learn new skills and behaviours.
• Get medication and use it correctly.
• Banning tobacco advertising and displays.
• Be prepared for relapse or difficult situations.
• Taxing tobacco at a high level to produce cigarette prices sufficiently high to deter regular smoking among adoles- A number of links to cessation resources are also available on • The use of health warnings on cigarette packages.
Antismoking measures
Success with these measures has been variable. In January Antismoking measures include messages, spread by multiple 2005, during National Non-Smoking Week, the Canadian routes and repeated over time, that aim to: Council for Tobacco Control brought out a ‘Report Card’, which graded the antismoking legislation accomplishments of • promote smoke-free spaces (public, private and work all Canadian provinces and territories. Six categories were se- places), and are aimed mainly at adults under the age of lected for grading. Results were variable. For example, in the 35 years (current prevalence for those aged 20 to 34 years area of tobacco pricing, marks ranged from an A+ for the is 27%, which is higher than the smoking rate of the gen- Northwest Territories to Fs in Ontario, Quebec and the • target pregnant and postpartum women; B. Health Canada and national Aboriginal organizations have
• target third-party suppliers of tobacco products to youth become proactive in dealing with the issue of tobacco
(eg, parents, siblings, older teens and other adults) with the goal of curtailing the supply of tobacco to youth; and National programs to increase awareness of the problems
• continue bans on smoking advertisements and tobacco of tobacco misuse
The First Nations and Inuit Health Branch works in partner-
ship with national Aboriginal organizations, such as Assem- bly of First Nations and Inuit Tapiriit Kanatami, to raise Bans on smoking in the workplace
awareness of tobacco misuse as a serious health issue to com- A number of provinces and territories have smoking bans in the workplace and in public areas to decrease exposure to sec- ond-hand smoke [31]. The success of bans aimed at decreasing Among First Nations, tobacco control programs are being de- smoking in restaurants, bars, indoor recreational areas (in- veloped for, and delivered to, community health representa- cluding bingo halls) and public buildings has been variable tives (CHRs) and tobacco cessation counsellors. Strategies in- . In Manitoba, the smoking ban legislation exempts re- serves and, therefore, there is no smoking ban to follow.
FIRST NATIONS, INUIT AND MÉTIS HEALTH COMMITTEE, CANADIAN PAEDIATRIC SOCIETY | 3
Although it is true that some communities are passing bylaws sures by the large numbers of jurisdictions involved, often that provide less protection than provincial smokefree legisla- with competing priorities. These include economic factors, tion, other communities are passing bylaws that not only sup- such as a conflict between the perceived need to raise money port provincial legislation but in some cases surpass it.
by selling tax-free tobacco for communities and the desirabili- ty of using a high price to discourage tobacco use. There is al- C. Other measures designed to address the individual misuse
so no coordination of minimum smoking ages across Canada of tobacco
and no means to decrease exposure to tobacco products, espe- • Teaching and practicing ‘resistance’ skills.
A number of recommendations have been formulated as a • The use of antismoking medication, either nicotine sub- guide to groups interested in decreasing tobacco use. These stitution (eg, the ‘patch’) or non-nicotine drugs such as recommendations were generated through consensus, and bupropion (Zyban, Biovail Pharmaceuticals, Canada) [36].
were prepared with the participation of a number of Aborigi- • The enforcement of age limits on tobacco sales and mea- sures to remove cigarettes from public view.
Recommendations
• Emphasis on the role of the physician and health care professional in smoking control. This includes coun- selling patients to help prevent and stop smoking. This • Aboriginal communities should adopt a minimum age for emphasis should be part of routine preventive care at each office or community health visit [37] The five ‘As’ • Aboriginal communities should encourage dialogue in the community to help change attitudes toward the ac- ceptability of recreational tobacco use.
• Aboriginal communities should continue to discourage – ASSESS willingness to attempt quitting smoking in the workplace and institute bans of nontradi- tional use of tobacco in public places such as restaurants, – ASSIST – counselling and pharmacological therapy recreational facilities, bingo halls and casinos.
• First Nations reserves should focus on continuing to edu- cate retailers on-reserve about the Tobacco Act and dis- • Taking advantage of educational opportunities; for exam- courage the sale of tax-free tobacco products, especially to ple, use the experience of a smoking-related illness of a family member to educate family and community mem- • Because cost influences tobacco use (25), Aboriginal com- bers about the dangers of tobacco, emphasizing control munities should be encouraged to place their own sur- measures, cessation strategies and the use of nicotine sub- charge on tobacco products (when purchased for nontra- stitution therapy such as the ‘patch’.
ditional use) to increase the price to match off-reserve • Advocacy: Actively promote school-based prevention pro- prices; the increased revenue should then be directed to grams and be actively involved in policy interventions re- smoking prevention programs in the community.
• A well-defined system should be established within a com- munity to enforce all tobacco laws. The consequences of breaking these laws should be well defined.
• Cigarettes and other tobacco products should remain be- The high prevalence of tobacco use and misuse among Abo- hind counters and out of sight in all stores.
riginal people compared with their non-Aboriginal counter- parts, as well as the resultant health consequences, continue • Aboriginal communities should encourage community to be of concern not only to the individuals using tobacco members to establish smoke-free homes to diminish expo- but also to others, especially infants, children, youth and sure of children to second-hand smoke.
pregnant women exposed to second-hand smoke.
• Nicotine replacements such as the ‘patch’ and nicotine- free tablets such as bupropion should be encouraged as Recently proposed solutions by First Nations and Inuit part of a smoke cessation program. While at present there groups, federal, provincial and territorial governments, and is limited availability of these drugs under the Non-In- other interested organizations need to be implemented. Diffi- sured Health Benefits Program, it is recommended that culties in implementation include acceptance of these mea- 4 | USE AND MISUSE OF TOBACCO AMONG ABORIGINAL PEOPLES
these drugs be readily available when clinically appropri- 15. Thapar A, Fowler T, Rice F, et al. Maternal smoking during pregnancy and attention deficit hyperactivity disorder symp- toms in offspring. Am J Psychiatry 2003;160:1985-9.
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FIRST NATIONS, INUIT AND MÉTIS HEALTH
36. Drugs Approved by the FDA. Drug Name: Zyban Sustained- COMMITTEE (2009-2010)
Release Tablets. www.centerwatch.com/patient/drugs/ Members: William H Abelson MD (Board Representative);
dru261.html (Version current at November 9, 2006).
Anna Banerji MD; Lola T Baydala MD; Heidi Schröter MD; 37. Canadian Paediatric Society, Psychosocial Paediatrics Com- mittee. [Principal author: Anne C Bernard-Bonnin]. Role of the physician in smoking prevention. Paediatr Child Health Liaisons: Debbie Dedam-Montour, National Indian and
Inuit Community Health Representatives Organization; Carolyn Harrison, Health Canada, First Nations and Inuit FIRST NATIONS AND INUIT HEALTH
Health Branch; Kathy Langlois, Health Canada, First Nations COMMITTEE (2005-2006)
and Inuit Health Branch; Heather McCormack, Health Canada, First Nations and Inuit Health Branch; Kelly Moore Members: James Irvine MD; Heather Onyett MD (board
MD, American Academy of Pediatrics, Committee on Native representative); Kent Saylor MD (chair); Sam Wong MD; American Child Health; Rena Morrison, Assembly of First Nations; Anna C Ryan, Inuit Tapiriit Kanatami; Barbara Van Consultants: James Carson MD; John C Godel MD
Haute, Métis National Council; Cheryl Young, Aboriginal Liaisons: George Brenneman MD, American Academy of
Pediatrics, Committee on Native American Child Health; Consultants: James Irvine MD; Kent Saylor MD
Kelly Butler MD, First Nations and Inuit Health Branch, Revision Author: Sam K Wong MD (April 2010)
Also available at www.cps.ca/en
Canadian Paediatric Society 2013

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exclusive course of treatment or procedure to be followed. Variations, taking in-to account individual circumstances, may be appropriate. Internet addresses are current at time of publication.

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