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Commercial tobacco exposure in First 

Nations, Inuit and Métis in Ontario: results 

from population-based health surveys 

and implications for cancer control 
Caroline Cawley*1, Maegan V. Mazereeuw1, Sehar Jamal1, Amanda J. Sheppard1,2, Loraine D. Marrett1,2 

1Aboriginal Cancer Control Unit, Cancer Care Ontario, Toronto, Canada 
2Dalla Lana School of Public Health, University of Toronto, Toronto, Canada 

*Corresponding author email: caroline.cawley@cancercare.on.ca 
 

ABSTRACT 
The lack of comprehensive health data is a significant barrier to better understanding and reducing the 

risk of chronic diseases among First Nations, Inuit and Métis people in Ontario. This study estimates 

commercial tobacco exposure (cigarette smoking and second-hand smoke) in First Nations (on- and 

off-reserve), Inuit and Métis in comparison to non-Aboriginal Ontarians using three health surveys. We 

measured age-standardized prevalence using the First Nations Regional Health Survey Phase 2 (for 

First Nations on-reserve), Canadian Community Health Survey (for First Nations off-reserve, Métis and 

non-Aboriginal Ontarians) and the Aboriginal Peoples Survey (for Inuit). A higher proportion of First 

Nation men, women and adolescents on- and off-reserve smoked compared to their non-Aboriginal 

counterparts. Métis adults and adolescents were more likely to smoke than non-Aboriginal adults and 

adolescents. Métis adolescents were more likely to be regularly exposed to second-hand smoke than 

non-Aboriginal adolescents, both at home and in public places. Inuit adults had a higher prevalence of 

current smoking and a higher prevalence of regular second-hand smoke exposure at home. The high 

prevalence of cigarette smoking and second-hand smoke exposure suggests that First Nations, Inuit 

and Métis people may experience a greater future burden of cancer and other chronic diseases related 

to smoking. Differences in survey questions and methodology, and the lack of ethnic identifiers in most 

Canadian health databases limit our understanding of cancer burden and other health outcomes in 

these populations. Knowledge-sharing and relationship building between First Nations, Inuit and Métis 

organizations, researchers and data custodians are essential to ensure appropriate data governance, 

meet health needs and further cancer control activities, including prevention. 

 

KEYWORDS: commercial tobacco exposure; population health survey; cancer control; Ontario 

tobacco exposure and cancer 

 

Citation: Cawley C, Mazereeuw MV, Jamal S, Sheppard AJ, Marrett LD (2018) Commercial tobacco exposure 

in First Nations, Inuit and Métis in Ontario: results from population-based health surveys and implications for 

cancer control. Cancer Health Disparities 2:e1-e12. doi:10.9777/chd.2018.10002 



 
 
 
 
 

 

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INTRODUCTION 

First Nations, Inuit and Métis are the three 

Indigenous peoples of Canada.(Government of 

Canada, 1982) There are more Indigenous people 

living in Ontario than any other province or 

territory in the country, numbering 374,395 

people, or about 3 percent of the provincial 

population (Statistics Canada, 2017). First Nations, 

Inuit and Métis are not a cultural group, but rather 

distinct, peoples whose existing aboriginal and 

treaty rights were recognized and affirmed by the 

Constitution (Government of Canada, 1982). The 

arrival of Europeans and resulting policies of 

assimilation, such as the residential school system 

and the current Indian Act (applying specifically to 

First Nations), continue to extensively impact First 

Nations, Inuit and Métis peoples’ ways of life and 

all aspects of their health. 

First Nations represent the largest of the three 

groups named in Canada’s Constitution Act of 

1982. There are approximately 236,680 First 

Nations in Ontario, of whom 94,312 live on-reserve 

or on Crown lands (Indigenous and Northern 

Affairs Canada, 2014. http://www.aadnc-

aandc.gc.ca/eng/1429798605785/1429798785836#

tbc1303). The genesis of the Métis culture and 

nation dates back to the 1600s, when European 

settlers first came into contact with local 

Indigenous communities. Early unions between 

these predominantly male fur trading European 

settlers and local First Nations women led to the 

emergence of a new and highly distinctive 

Aboriginal people with a unique identity. Ontario 

has the largest Métis population in Canada, with 

120,585 people, or 20.5 percent of all Métis 

(Statistics Canada, 2017). The word Inuit means 

“the people” in the most commonly used Inuit 

language of Inuktitut (Indigenous and Northern 

Affairs Canada). Inuit are culturally similar 

Indigenous Peoples who have lived throughout 

the Arctic for thousands of years (Public History 

Inc., 2008). Inuit in Ontario constitute a small but 

fast-growing population. About 65,025 people in 

Canada (3,860 in Ontario) identified as being Inuit. 

Over one-quarter (27 percent) of self-identifying 

Inuit in Canada live in southern Canada, outside of 

Inuit Nunangat (the Inuit homeland made up of 

four regions stretching across much of the 

Canadian Arctic) (Statistics Canada, 2017).  

 

 

Table 1. First Nations, Métis and Inuit populations in Ontario (2016 census). 

 First Nations Métis Inuit 

Population 

Total 236,680 120,585 3,860 

Male 112,835 (48%) 59,015 (49%) 1,830 (47%) 

Female 123,845 (52%) 61,570 (51%) 2,025 (53%) 

Age 

0-14 61,590 (26%) 23,775 (20%) 1,165 (30%) 

15-24 41,410 (18%) 19,250 (16%) 695 (18%) 

25-34 32,800 (14%) 16,490 (14%) 600 (16%) 

35-44 29,365 (12%) 15,765 (13%) 410 (11%) 

45-54 31,375 (13%) 18,030 (15%) 495 (13%) 

55-64 23,825 (10%) 15,905 (13%) 310 (8%) 

65+ 16,320 (7%) 11,365 (9%) 180 (5%) 

Source: Statistics Canada (2017). 2016 Census of Population, Statistics Canada Catalogue no. 98-400-X2016155. 



 
 
 
 
 

 

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Studying the prevalence of behavioural risk factors 

for cancer using routine, population-based health 

surveys where respondents are asked about their 

Indigenous (referred to as ‘Aboriginal’ by Statistics 

Canada) identity offers a timely approach to 

determining how and where prevention resources 

can be most effectively directed to reduce the 

future burden of disease. Using commercial 

tobacco products (in particular, smoking 

cigarettes) is known to account for more cases of 

cancer than any other known risk factor western 

populations (U.S. Department of Health and 

Human Services, 2004). In Ontario, about 15 

percent of all new cancer cases (and 71 percent of 

lung cancer cases specifically) are attributable to 

cigarette smoking (Cancer Care Ontario, 2014). 

 

To many First Nations and Métis peoples, tobacco 

is a plant that has cultural, ceremonial and/or 

spiritual significance. For example, it is commonly 

held in the left hand during prayer or ceremony, 

and is often given to Elders and Traditional 

Knowledge Keepers as a sign of respect (Chiefs of 

Ontario and Cancer Care Ontario, 2016). Tobacco 

holds no traditional significance to Inuit, and was 

first introduced in Arctic communities by European 

traders. The use of commercial tobacco (e.g., 

smoking cigarettes or cigars, chewing tobacco or 

snuff) has no connection to the historical or 

traditional uses of tobacco among First Nations 

and Métis (Tobacco Has No Place Here).  

In Ontario, tobacco policy is legislated by the 

provincial government. The Smoke Free Ontario 

Act regulates where cigarettes cannot be smoked 

(e.g., schools, hospitals, restaurants) or sold, and 

enforces a minimum age of 19 for such purchases 

(Government of Ontario, 2017). Under federal 

legislation, First Nations people living on reserves 

(land held by the Crown for the “use and benefit 

of [First Nations] (Government of Canada, 1982)) 

are exempt from provincial laws, and create and 

enforce their own tobacco policies within their 

jurisdictions. Individual First Nations councils can 

pass by-laws to regulate smoking in their 

communities. 

The objectives of this study were to (a) develop 

indicators of commercial tobacco exposure as a 

risk factor for cancer for First Nations (living on- 

and off-reserve), Inuit and Métis people in Ontario 

using data available from three population-based 

health surveys; and (b) compare the prevalence 

estimates for First Nations, Inuit and Métis with 

those of the non-Aboriginal population in Ontario. 

MATERIALS AND METHODS 

Data Sources 

The Canadian Community Health Survey (CCHS) is 

a population-based survey of the Canadian 

population aged 12 years and over living in all 

provinces and territories, excluding individuals 

living on First Nations reserves and Crown lands, 

institutional residents, full-time members of the 

Canadian Forces and residents of some remote 

regions (Statistics Canada, 2007-2013). 

Respondents are asked whether they are an 

Aboriginal person, and if so whether they are First 

Nations, Inuit or Métis. Non-Aboriginal Ontarians 

were defined as respondents to the CCHS who did 

not self-identify as Aboriginal or who identified as 

Aboriginal but were born outside of Canada, the 

U.S., Germany or Greenland (in survey years prior 

to 2011).1 

The Regional Health Survey (RHS) is the only First 

Nations-governed national health survey that 

collects health-related information about First 

Nations people living on-reserve aged 12 years 

and over (First Nations Information Governance 

Centre, 2013). The RHS Phase 2 was a single 

survey completed between the spring of 2008 and 

the fall of 2010 in 24 of the 133 First Nations 

communities (reserves) in Ontario. The RHS 

includes an adult survey for respondents aged 18 

                                                           
1
As of 2011, the CCHS restricted the question about 

Aboriginal identity to those born in Canada, the United 

States, Germany or Greenland. To be consistent, we 

classified respondents in 2007 to 2010 as non-

Aboriginal if they identified as Aboriginal and reported 

being born outside one of these four countries. 



 
 
 
 
 

 

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and older and a youth survey for those aged 12 to 

17.  

Data for Inuit living in Ontario were obtained from 

the 2012 edition of the Aboriginal Peoples Survey 

(APS). The APS, administered by Statistics Canada, 

is a national survey of First Nations (off-reserve), 

Métis and Inuit aged six years and over and its 

sample is drawn from individuals who reported 

Aboriginal identity on the 2011 National Household 

Survey (Statistics Canada, 2016). The APS includes 

fewer health-related variables than the CCHS, but 

the CCHS has poorer coverage of the Inuit, 

particularly in southern Canada. Even after 

combining multiple survey cycles, the number of 

Inuit respondents captured by the CCHS was too 

small to report estimates with certainty.  

First Nations 

Data for First Nations people living on reserve 

were obtained from the Ontario portion of Phase 

2 (2008/10) of the RHS. On-reserve First Nations 

people were defined as respondents to the RHS 

who were on the band/membership list of one of 

the 24 communities selected for participation in 

the RHS Phase 2 (Chiefs of Ontario, 2012). Data for 

First Nations people living off-reserve and non-

Aboriginal Ontarians were obtained from the 

Ontario portion of the CCHS administered by 

Statistics Canada. Seven annual waves of the CCHS 

(2007–2013) were combined due to the 

consistency of the Aboriginal identity questions 

used during this time period. Off-reserve First 

Nations people were defined as respondents to 

the CCHS who self-identified as either First Nations 

only or as both First Nations and Inuit and were 

born in Canada, the United States, Germany or 

Greenland.2  

                                                           
2 

As of 2011, the CCHS restricted the question about 

Aboriginal identity to those born in Canada, the United 

States, Germany or Greenland. To be consistent, we 

classified respondents in 2007 to 2010 as non-

Aboriginal if they identified as Aboriginal and reported 

being born outside one of these four countries. 

The prevalence of current smoking in First Nations 

adults living on- and off-reserve, and non-

Aboriginal adults in Ontario, was defined as the 

proportion of respondents aged 20 years and 

older who reported smoking cigarettes daily or 

occasionally. The CCHS and RHS had equivalent 

questions and response options on the subject of 

cigarette smoking. The prevalence of second-hand 

smoke exposure in First Nations adults and 

adolescents and non-Aboriginal adults and 

adolescents was defined as the proportion of non-

smokers who reported being exposed to second-

hand smoke in their home, in a vehicle or in a 

public place every day or almost every day. The 

prevalence of second-hand smoke exposure 

among First Nations people living on-reserve 

could not be estimated, as relevant questions were 

not included in the RHS. 

Métis 

Data for Métis people living in Ontario and non-

Aboriginal Ontarians were obtained from the 

Ontario portion of the CCHS cycles 2007–2014. 

Métis people were defined as respondents to the 

CCHS who were born in Canada, the U.S., 

Germany or Greenland, and self-identified as Métis 

only or as Métis in combination with any other 

Aboriginal identity (i.e., First Nation or Inuit). The 

prevalence of current smoking in Métis adults and 

non-Aboriginal adults was defined as the 

proportion of adults aged 20 years and older who 

report smoking cigarettes daily or occasionally. 

The prevalence of second-hand smoke exposure 

in Métis adults and adolescents and non-

Aboriginal adults and adolescents was defined as 

the proportion of non-smokers who reported 

being exposed to second-hand smoke in their 

home, in a vehicle or in a public place every day or 

almost every day.  

Inuit 

Inuit living in Ontario were defined as respondents 

of the APS who identified as Inuit and reported 

residing in Ontario at the time of the 2011 National 



 
 
 
 
 

 

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Household Survey. Due to small numbers of Inuit 

respondents to the APS in Ontario, Inuit living in 

southern Canada more broadly (outside of the 

traditional Inuit homeland of Inuit Nunangat (Inuit 

Tapiriit Kanatami, 2008)) were used as a proxy for 

Inuit living in Ontario for some indicators. The APS 

includes a variable that indicates whether a 

respondent lives in one of the four constituent 

regions of Inuit Nunangat (Nunatsiavut in 

Labrador, Nunavik in northern Quebec, the 

territory of Nunavut, or Inuvialuit in the Northwest 

territories) or outside of Inuit Nunangat. A study of 

cancer risk factors among Inuit demonstrated that 

prevalence estimates for Inuit in Ontario are 

largely similar to those of Inuit living outside 

Nunangat, across indicators of cancer risk 

(Tungasuvvingat Inuit and Cancer Care Ontario, 

2017).  

The prevalence of current smoking in Inuit adults, 

and non-Aboriginal adults in Ontario, was defined 

as the proportion of respondents aged 20 years 

and older who reported smoking cigarettes daily 

or occasionally. The CCHS and APS had equivalent 

questions and response options on the subject of 

smoking. Second-hand smoke exposure could not 

be reported for Inuit living in Ontario due to small 

sample size. 

Analysis 

Sampling weights assigned by Statistics Canada 

(for the CCHS and APS) or the First Nations 

Information Governance Centre (for the RHS) were 

used for all estimates. First Nations and Métis 

estimates (and non-Aboriginal estimates for 

comparison) were age-standardized using the 

2006 Ontario Aboriginal identity population. Inuit 

estimates (and non-Aboriginal estimates for 

comparison) were age-standardized using the 

Inuit identity population in Canada outside Inuit 

Nunangat (the traditional Inuit homeland in 

northern Canada) in the 2006 census. We used 

bootstrapping techniques, with the appropriate 

multiplicative factor (Fay adjustment) in the case of 

Inuit analyses, to calculate the coefficient of 

variation (CV) and 95% confidence intervals (CIs). 

Estimates with a CV ranging from 16% to 33% 

were flagged to be interpreted with caution 

(Statistics Canada). Two percentages were 

determined to be statistically significant if the 95 

percent confidence intervals of the two estimates 

did not overlap. 

Where possible, results were reported by age 

group, sex and educational attainment. 

Respondents ages 12 to 19 were considered to be 

adolescents, except for in First Nations analyses, as 

the RHS youth survey was limited to respondents 

ages 12 to 17. Highest reported level of attained 

education was classified into three categories: less 

than secondary school graduation, secondary 

school graduation or some post-secondary school, 

and post-secondary graduation. Only respondents 

aged 25 years and older were included in 

education analyses.  

RESULTS 

First Nations 

The RHS included 1500 First Nations adults and 

600 First Nations adolescents living on-reserve, 

while the CCHS (2007 to 2013) included 2119 First 

Nations adults and 376 adolescents living off-

reserve, and 123 105 non-Aboriginal adults and 11 

636 adolescents in Ontario. First Nations adults 

living on-reserve (50 percent of men and 49 

percent of women) and off-reserve (44 percent of 

men and 41 percent of women) had a significantly 

higher prevalence of current smoking than non-

Aboriginal adults (26 percent of men and 18 

percent of women). First Nations adolescents (both 

sexes combined) living on-reserve (30 percent) 

and off-reserve (14 percent) were also significantly 

more likely to smoke cigarettes compared to non-

Aboriginal adolescents (4 percent). The prevalence 

of smoking significantly declined from 2007 to 

2013 for off-reserve First Nations and for non-

Aboriginal adults. The proportion of off-reserve 

First Nations adults who reported smoking 

decreased from 51 percent in 2007 to 39 percent 



 
 
 
 
 

 

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in 2013 (Figure 1). No time trend data were 

available for on-reserve First Nations adults, as the 

RHS Phase 2 was a one-time survey in the time 

period of interest. 

 

Figure 1. Percentage of First Nations and Non-Aboriginal 

adults (age 20+) who were current smokers, by year, 2007–

2013, Ontario. 

First Nations adults (both on- and off-reserve) with 

less than secondary education were significantly 

more likely to smoke than those with a post-

secondary degree. The prevalence of cigarette 

smoking was significantly higher among First 

Nations adults living on- and off-reserve for all 

levels of education. 

Non-smoking First Nations adults living off-reserve 

(18 percent) were more likely to be exposed to 

second-hand smoke in their home or vehicle than 

non-smoking non-Aboriginal adults (8 percent). 

Similar percentages of non-smoking First Nations 

and non-Aboriginal adults were regularly exposed 

to second-hand smoke in public. 

Métis 

The CCHS (2007 to 2014) included 1592 Métis 

adults and 285 Métis adolescents. There were also 

135 817 non-Aboriginal adults and 17 383 

adolescents surveyed in Ontario. The prevalence 

of current smoking was significantly higher for 

Métis adults (36 percent) and adolescents (16 

percent) than it was for non-Aboriginal adults (21 

percent) and adolescents (7 percent). The 

proportion of Métis adults who reported smoking 

decreased significantly over time (Figure 2), from 

44 percent in 2007 to 32 percent in 2014. 

 

Figure 2. Percentage of Métis and Non-Aboriginal adults (age 

20+) who were current smokers, by year, 2007–2014, Ontario. 

The prevalence of smoking was significantly higher 

for Métis adults with less than secondary education 

(57 percent), compared to those with a post-

secondary degree (29 percent).  

Non-smoking Métis adults (15 percent) were 

significantly more likely to be exposed to second-

hand smoke in private vehicles or at home than 

non-smoking non-Aboriginal adults (8 percent). 

Second-hand smoke exposure at home or in 

vehicles was also significantly higher for Métis 

adolescents (37 percent) than for non-Aboriginal 

adolescents (17 percent) and Métis adults (15 

percent). Métis adolescents (30 percent) were 

significantly more likely to be exposed to second-

hand smoke in public places than Métis adults (16 

percent). 

Inuit 

The prevalence of current smoking was higher in 

Inuit adults living in Ontario (34 percent) than in 

non-Aboriginal adults (23 percent), although not 

significantly. There is also high variability in the 

estimate for Inuit adults due to small sample sizes. 

Inuit living outside the traditional territories of Inuit 

Nunangat (i.e., living in southern Canada) were 

significantly more likely to smoke cigarettes, 

compared to non-Aboriginal adults. A significantly 

higher proportion of Inuit women living outside 

Inuit Nunangat (41 percent) than non-Aboriginal 

Ontario women (18 percent) smoked; among men,  



 
 
 
 
 

 

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33 percent of Inuit living outside Inuit Nunangat smoked, compared to 27 percent of non-Aboriginal men in Ontario (Figure 3).  

 

Figure 3. Percentage of Inuit adults in Canada and non-Aboriginal adults in Ontario (age 20+) who were current smokers, by sex, 2012. 

Inuit living outside Inuit Nunangat who had completed less than secondary education (60 percent) were more likely to smoke than those who had 

completed a post-secondary degree (21 percent). The proportion of non-smoking Inuit living outside Inuit Nunangat regularly exposed to second-hand 

smoke in the home (19 percent) was significantly higher than the proportion of non-Aboriginal non-smoking Ontarians exposed to second-hand smoke 

in the home (7 percent). 

 



 
 
 
 
 

 

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Table 2. Age-standardized prevalence (%) of commercial tobacco exposure in First Nations, Métis, and Inuit populations and corresponding 95% 

confidence intervals. 

 First Nations and comparison population 

(2007-2013) 

Métis and comparison population 

(2007-2014) 

Inuit and comparison population 

(2012) 

 First Nations 

on-reserve in 

Ontario (RHS) 

First Nations 

off-reserve in 

Ontario (CCHS) 

Non-Aboriginal 

in Ontario 

(CCHS)  

Métis in 

Ontario  

(CCHS) 

Non-Aboriginal 

in Ontario   

(CCHS) 

Inuit outside 

Nunangat  

(APS) 

Non-Aboriginal 

in Ontario  

(CCHS) 

Current smoking by age (years) 

Men (20+) 50% (45, 55) 44% (39, 49) 26% (25, 26) 41% (35, 46) 25% (25, 26) 33%* (21, 44) 27% (24, 29) 

Women (20+) 49% (45, 54) 41% (36, 46) 18% (17, 18) 33% (28, 38) 17% (17, 18) 41% (31, 50) 18% (16, 21) 

Adolescents (12-17) 30% (25, 36) 14%* (9, 19) 4% (4, 5)     

Teens (12-19)    16%* (10,21) 7% (7, 8)   

Current smoking by education (both sexes combined, adults 25+) 

Less than secondary 58% (51, 64) 60% (53, 67) 34% (33, 36) 57% (47, 67) 38% (36, 40) 60%* (44, 76) 43% (36, 51) 

Secondary or some post-secondary 47% (41, 53) 41% (34, 47) 27% (26, 28) 40% (31, 48) 29% (28, 30) 50%* (31, 69) 29% (25, 32) 

Post-secondary 41% (35, 46) 30% (25, 34) 16% (15, 16) 29% (25, 34) 17% (16, 17) 22%* (13, 31) 16% (15, 17) 

Second-hand smoke by location (both sexes combined, adults 20+) 

Home only      19% (14, 25) 7% (6, 8) 

Home and vehicle  18% (15, 21) 8% (8, 9) 15% (10, 20) 8% (8, 9)   

Public places  14% (11, 17) 12% (12, 13) 16% (12, 20) 13% (12, 13)   

 



 
 
 
 
 

 

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DISCUSSION 

Implications 

First Nations, Inuit and Métis people in Ontario 

generally had higher rates of exposure to 

commercial tobacco than non-Aborigi¬nal 

Ontarians. The high prevalence of cigarette 

smoking and second-hand smoke exposure 

suggests that First Nations, Inuit and Métis people 

may expe¬rience a greater future burden of 

cancer and other chronic diseases related to 

smoking. In addition to lung cancer, smoking 

ciga¬rettes is an established cause of many other 

types of cancer including mouth and throat, 

stomach, colorectal, pancreas, liver, cervix, ovary, 

kidney and bladder, and leu¬kemia (Gandini et al., 

2008). Smoking also increases the risk of many 

other serious health conditions, including 

cardiovascular disease (e.g., heart attack) and 

chronic respiratory diseases (e.g., COPD) (U.S. 

Department of Health and Human Services, 2004). 

Of particular concern among the findings of this 

study is the proportion of First Nations, Inuit and 

Métis adolescents who reported smoking 

cigarettes. Lung cancer risk is closely linked to 

duration of smoking (Peto, 1986). Therefore, 

initiating cigarette use as an adolescent can 

increase the total number of years a person 

spends smoking and their risk of developing 

cancer. Studies of First Nations youth show very 

early smoking initiation (age 12 and younger) and 

easy access to cigarettes (Elton-Marshall et al., 

2011; Lemstra et al., 2011). 

Although few studies of cancer incidence in 

Indigenous populations have been conducted in 

Ontario (and in Canada), recent research has 

demonstrated increasing rates of smoking-related 

cancers in the First Nations population of the 

province. Among registered First Nations people 

(individuals who have status under Canada’s Indian 

Act) in Ontario, the incidence of numerous cancers 

associated with tobacco exposure (including lung, 

colorectal and kidney cancers) is significantly 

higher than in the rest of the population (Chiefs of 

Ontario et al., 2017). Data on cancer patterns in 

Métis populations are even more limited. In 

Manitoba, the Métis population was found to have 

higher rates of lung cancer compared to all other 

Manitobans. Métis women also had higher lung 

cancer mortality rates than non-Aboriginal women 

in Canada (Tjepkema et al., 2009). There are no 

data available on cancer rates among Inuit living 

outside the traditional homeland, but studies of 

Inuit Nunangat and Inuit in the circumpolar region 

indicate lung cancer rates that are the highest in 

the world (Carrière et al., 2012; Circumpolar Inuit 

Cancer Review Working Group et al., 2008). 

Data challenges 

The lack of good-quality and comprehensive 

health data is a significant barrier to better 

understanding and reducing the risk of chronic 

diseases, including cancer, among First Nations, 

Inuit and Métis people in Ontario. A lack of ethnic 

identifiers in health administrative databases in 

Canada limits our understanding of the burden of 

cancer and health outcomes in these populations. 

In Ontario, the few studies that have estimated 

cancer incidence, mortality or survival in 

Indigenous populations have involved complex 

and costly data linkages between the Ontario 

Cancer Registry and registers of qualifying First 

Nations and Métis people (Marrett and Chaudhry, 

2003; Withrow et al., 2012. 

http://www.metisnation.org/media/229177/mno%2

0cancer%20clinical%20significance%20report%20(

29-mar-2012).pdf). These studies are limited in 

their generalizability, small population sizes 

(especially for Inuit) and relatively dated results; all 

of which convolute their ability to inform cancer 

control programming.  

Differences in survey questions and methodology 

limit our ability to assess certain indicators, for 

instance, second-hand smoke exposure and 

smoking time trends for First Nations people living 

on-reserve. In addition, small sample sizes mean 

that some risk factor prevalence estimates for Inuit 

living in Ontario could not be reported (e.g., 



 
 
 
 
 

 

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second-hand smoke exposure), and we could not 

stratify by the same sociodemographic factors 

across First Nations, Inuit and Métis populations. 

The need to use three different surveys (CCHS, 

RHS and APS), and three different time periods of 

observation is indicative of the challenges faced in 

this type of research. No one survey could be used 

to assess the prevalence of tobacco exposure 

across all three groups in Ontario. Access to data 

also varies by survey. The RHS is not publicly 

available, in keeping with the First Nations 

principles of OCAP™, or Ownership, Control, 

Access and Possession. Partnerships and 

knowledge-sharing between First Nations, Inuit 

and Métis groups, researchers and data custodians 

are essential to ensuring appropriate data use and 

governance.  

Given that the CCHS, RHS and APS collect 

information through self-report, there may be a 

risk of social desirability bias, where survey 

respondents tend to under-report behaviours that 

are socially undesirable (i.e. smoking). It is unlikely 

that there would be a major difference in this 

effect across First Nations, Inuit, Métis and non-

Aboriginal populations, and the effect on the 

relative estimates of prevalence for any given risk 

factor would be minimal.  

What is being done in Ontario? 

The Path to Prevention report, published by 

Cancer Care Ontario in 2015, summarizes the 

many organizations that are involved in chronic 

disease prevention activities—including tobacco 

control activities—specific to First Nations, Inuit 

and Métis populations in Ontario. The report 

presents four main recommendations to reduce or 

eliminate smoking and commercial tobacco use: 

develop a coordinated plan to prevent commercial 

tobacco use among First Nations, Inuit and Métis 

children and youth; establish commercial tobacco 

cessation programs and services in First Nations, 

Inuit and Métis communities; support the 

development of resources to address second- and 

third-hand smoke (residue from tobacco smoke 

on indoor surfaces) and support community-

initiated and managed tobacco control measures, 

while respecting First Nations’ rights. These 

recommendations were developed based on the 

knowledge and experience shared by First Nations, 

Inuit and Métis communities, organizations and 

individuals in a series of focus groups and 

interviews.  

Building productive relationships is a strategic 

priority of the Aboriginal Cancer Strategy III. The 

Aboriginal Cancer Control Unit works closely with 

First Nations, Inuit, Métis and other organizations 

to better address their cancer issues and needs by 

formalizing relationships through Protocols or 

Memoranda of Understanding. This relationship 

building is key to building to kind of respect, trust 

and partnerships essential to further cancer control 

activities, including prevention. 

Acknowledgements 

The authors thank Michelle Rand for her assistance 

in reviewing the Path to Prevention content. We 

also thank the Aboriginal Cancer Control Unit and 

Aboriginal Tobacco Program of Cancer Care 

Ontario for their support. 

 

Conflict of interest statement 
The author has declared that no competing or 

conflict of interests exist. The funders had no 

role in study design, writing of the manuscript 

and decision to publish.    
 

Authors’ contributions 

CC and SJ performed the data analysis. LM, AS 

and MM conceptualized and implemented the 

study. CC drafted the article, all authors critically 

reviewed it for important intellectual content. All 

authors gave final approval of the version to be 

published.  

 

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