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-A M — m *-~ 





APRIL 201 2 




ass. 




EVEN MORE YEARS: 

e impact of smoking, 
ol, diet, physical activity 
stress on health and life 



expectancy in Ontario 




Institute for Clinical 
Evaluative Sciences 



ICES 

Twenty Years • 1992-2012 



Public 

Hea.lth 
Ontario 



PARTNERS FOR HEALTH 



Sante 

publique 
Ontario 

PARTE N Al R E S POUR LA SANTE 



Ottawa Hospital Research Institute 

OHRI^I IRHO 

Institut de recherche de I'Hopital d'Ottawa 



TTTTT 



u Ottawa 

L'Universite canadienne 
Canada's university 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



II | SEVEN MORE YEARS: THE IMPACT OF 
SMOKING, ALCOHOL, DIET, PHYSICAL 
ACTIVITY AND STRESS ON HEALTH 
AND LIFE EXPECTANCY IN ONTARIO 

An ICES/PHO Report 

Authors: 

Douglas G. Manuel 
Richard Perez 
Carol Bennett 
Laura Rosella 
Monica Taljaard 
Melody Roberts 
Ruth Sanderson 
Meltem Tuna 
Peter Tanuseputro 
Heather Manson 



PUBLICATION INFORMATION 

© 2012 Institute for Clinical Evaluative Sciences and 
Public Health Ontario 

All rights reserved. No part of this publication maybe 
reproduced, stored in a retrieval system or transmitted 
in any format or by any means, electronic, mechanical, 
photocopying, recording or otherwise, without the 
proper written permission of the publisher. 

The opinions, results and conclusions included in this 
report are those of the authors and are independent 
from the funding sources. No endorsement by the 
Institute for Clinical Evaluative Sciences (ICES), Public 
Health Ontario (PHO) or the Ontario Ministry of 
Health and Long-Term Care (MOHLTC) is intended or 
should be inferred. 

Canadian Cataloging in 
Publication Data 

Seven more years: The impact of smoking, alcohol, 
diet, physical activity and stress on health and life 
expectancy in Ontario An ICES/PHO Report. 

Includes bibliographical references. 

ISBN: 978-1-926850-33-7 (Print) 



How to Cite This Publication 

Manuel DG, Perez R, Bennett C, Rosella L, Taljaard 
M, Roberts M, Sanderson R, Meltem T, Tanuseputro P, 
Manson H. Seven more years: The impact of smoking, 
alcohol, diet, physical activity and stress on health and 
life expectancy in Ontario. An ICES/PHO Report. 
Toronto: Institute for Clinical Evaluative Sciences and 
Public Health Ontario; 2012. 

Institute for Clinical Evaluative Sciences (ICES) 

Gl 06, 2075 Bayview Avenue 
Toronto, ON M4N 3M5 
Telephone: 416-480-4055 
www.ices.on.ca 

Public Health Ontario 

480 University Avenue, Suite 300 
Toronto, ON M5G 1V2 
Telephone: 647-260-7100 
www.oahpp.ca 



ISBN: 978-1-926850-34-4 (PDF) 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Publication Information 

Authors' Affiliations 

Acknowledgments 

Partnerships and Other Studies 

About ICES and PHO 

Glossary 

List of Exhibits 



CONTENTS 



Background 7 

About this Report 1 4 

A. Behavioural Health Risks 1 5 

B. Measurement of Life Expectancy and 
Health-Adjusted Life Expectancy 16 

C. Questions Examined 16 

D. Specific Objectives 16 

Methods 17 
Limitations and 

Interpretive Cautions 19 

Limitation 1 : Only community-dwelling adults 

were included 20 
Limitation 2: Health risks were likely under-reported 20 
Interpretative Caution 1 : Life expectancy and 

health-adjusted life expectancy 20 
Interpretative Caution 2: Selected behavioural health 

risks and the combined effect of multiple risks 20 



Findings 21 

Predictive Risk Model 22 

Life Expectancy and Health-Adjusted 

Life Expectancy for Ontarians with Different 

Levels of Risk Exposure 22 

Population Health Impact of Behavioural Risks 22 

Policy Scenarios 23 

Discussion 33 

Adding Life to Years as Well as Years to Life 34 

Understanding Individual versus Population 

Burden of Risks 34 

Comparing the Impact of Socioeconomic 

Position and Obesity 34 

Conclusion 35 

References 37 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



AUTHORS' AFFILIATIONS 

Douglas G. Manuel, MD, FRCPC, MSc 

Senior Scientist, Ottawa Hospital Research Institute / 
Adjunct Scientist, Institute for Clinical Evaluative 
Sciences / Chair in Applied Public Health Sciences, 
CIHR/PHAC / Associate Professor, University of 
Ottawa and University of Toronto / Co-lead, Population 
Health Improvement Research Network / Associate 
Scientist, C.T. Lamont Primary Health Care Research 
Centre and Bruyere Research Institute 

Richard Perez, MSc 

Research Analyst, ICES@uOttawa, Ottawa Hospital 
Research Institute 

Carol Bennett, MSc 

Research Coordinator, ICES@uOttawa, Ottawa 
Hospital Research Institute 

Laura Rosella, PhD 

Scientist, Public Health Ontario / Assistant Professor, 
Dalla Lana School of Public Health, University of 
Toronto / Adjunct Scientist, Institute for Clinical 
Evaluative Sciences 

Monica Taljaard, PhD 

Scientist, Clinical Epidemiology Program, Ottawa 
Hospital Research Institute / Professor, Department of 
Epidemiology and Community Medicine, University 
of Ottawa 

Melody Roberts, MES 

Manager, Health Promotion Capacity Building, Public 
Health Ontario / Adjunct Professor, University of 
Waterloo 



Ruth Sanderson, MSc 

Manager, Analytic Services, Surveillance and 
Epidemiology, Public Health Ontario 

Meltem Tuna, PhD 

Research Analyst, ICES@uOttawa, Ottawa Hospital 
Research Institute 

Peter Tanuseputro, MD, MHSc, CCFP 

Public Health and Preventive Medicine Resident, 
Ottawa Hospital Research Institute and Public 
Health Ontario 

Heather Manson, MD, FRCPC, MHSc 

Director, Health Promotion, Chronic Disease and 
Injury Prevention, Public Health Ontario / Assistant 
Professor (Status Only), Dalla Lana School of Public 
Health, University of Toronto / Adjunct Professor, 
University of Waterloo 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



ACKNOWLEDGMENTS 



PARTNERSHIPS AND OTHER STUDIES 



3 



Scientific Advisory Committee 



Mary-Jo Makarchuk (Institute of Nutrition, 
Metabolism and Diabetes, Canadian Institutes of 
Health Research) 



This report was produced through a partnership 
between the Institute for Clinical Evaluative Sciences 
(including the ICES satellite site, ICES@uOttawa) and 
Public Health Ontario (PHO). It is the second report 
in a three-part series on Ontario's burden of disease 
and ill health. The first, published in 2010, reported 
on the burden of infectious disease, and the final 
report will examine the burden of mental health 
and addiction. 



Bernard Choi (Public Health Agency of Canada) 



Majid Ezzati (School of Public Health, Imperial 
College London) 



Paulina Salamo (Public Health Division, Ministry of 
Health and Long-Term Care) 



Jeff Kwong (Institute for Clinical Evaluative Sciences, 
Public Health Ontario) 



Monir Taha (Halton Region Health Department) 



Jiirgen Rehm (Centre for Addiction and Mental 
Health) 



Statistics Canada 



David Binder 



Practice, Policy and Research 



Lenka Mach 



Advisory Committee 

Tiffany Barker (Health System Strategy and Policy 
Division, Ministry of Health and Long-Term Care) 

Bernard Choi (Public Health Agency of Canada) 

Erica DiRuggiero (Institute of Population and Public 
Health, Canadian Institutes of Health Research) 

Norman Giesbrecht (Centre for Addiction and 
Mental Health) 

Anne-Marie Holt (Epidemiology and Evaluation 
Services, Haliburton, Kawartha, Pine Ridge District 
Health Unit) 

Mary LAbbe (Department of Nutritional Sciences, 
Faculty of Medicine, University of Toronto) 

Scott Leatherdale (School of Public Health and 
Health Systems, University of Waterloo) 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



ABOUT ICES 

The Institute for Clinical Evaluative Sciences (ICES) is an independent, non-profit 
organization that produces knowledge to enhance the effectiveness of health care 
for Ontarians. Internationally recognized for its innovative use of population- 
based health information, ICES evidence supports health policy development and 
guides changes to the organization and delivery of health care services. 

Key to our work is our ability to link population based health information, 
at the patient level, in a way that ensures the privacy and confidentiality of 
personal health information. Linked databases reflecting 13 million of 33 million 
Canadians allow us to follow patient populations through diagnosis and treatment 
and to evaluate outcomes. 

ICES brings together the best and the brightest talent across Ontario. Many 
of our scientists are not only internationally recognized leaders in their fields 
but are also practicing clinicians who understand the grassroots of health care 
delivery, making the knowledge produced at ICES clinically focused and useful in 
changing practice. Other team members have statistical training, epidemiological 
backgrounds, project management or communications expertise. The variety of 
skill sets and educational backgrounds ensures a multi- disciplinary approach 
to issues and creates a real-world mosaic of perspectives that is vital to shaping 
Ontario's future health care system. 

ICES receives core funding from the Ontario Ministry of Health and Long-Term 
Care. In addition, our faculty and staff compete for peer-reviewed grants from 
federal funding agencies, such as the Canadian Institutes of Health Research, 
and receive project-specific funds from provincial and national organizations. 
These combined sources enable ICES to have a large number of projects underway, 
covering a broad range of topics. The knowledge that arises from these efforts 
is always produced independent of our funding bodies, which is critical to our 
success as Ontario's objective, credible source of evidence guiding health care. 



ICES 



Institute for Clinical 
Evaluative Sciences 



Twenty Years • 1992-2012 



Public 

Health 
Ontario 



ABOUT PHO 

Public Health Ontario (PHO) is a Crown corporation dedicated to protecting and 
promoting the health of all Ontarians and reducing inequities in health. As a hub 
organization, PHO links public health practitioners, front-line health workers and 
researchers to the best scientific intelligence and knowledge from around the world. 

Our mission is to support health care providers, the public health system and 
partner ministries in making informed decisions and taking informed action. 
PHO provides transparent and timely expert scientific advice, technical support 
and practical tools related to infection prevention and control; surveillance and 
epidemiology; health promotion, chronic disease and injury prevention; environmental 
and occupational health; health emergency preparedness; public health laboratory 
services; research; professional development; and knowledge services. 

ABOUT THE OTTAWA HOSPITAL RESEARCH INSTITUTE 

The Ottawa Hospital Research Institute (OHRI) is the research arm of The Ottawa 
Hospital and is an affiliated institute of the University of Ottawa, closely associated 
with the University's Faculties of Medicine and Health Sciences. The OHRI 
includes more than 1,500 scientists, clinical investigators, graduate students, 
postdoctoral fellows and staff conducting research to improve the understanding, 
prevention, diagnosis and treatment of human disease. 



PARTNERS FOR HEALTH 



Sante 

publique 
Ontario 

PARTEN A IRES POUR LA 5 ANTE 



Ottawa Hospital Research Institute 

OHRI^j IRHO 

Institut de recherche de I'Hopital d'Ottawa 



TTTTT 



u Ottawa 

I.'Univcrsite canadienne 
Canada's university 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



GLOSSARY 

Body mass index (BMI) 

A weight-to-height ratio used as an indicator of obesity and underweight. BMI is 
calculated by dividing an individual's body weight in kilograms by the square of 
height in metres (kg/m 2 ). In this report, we define obesity as BMI > 30 and normal 
weight as BMI of 18.5 to 25. 

Burden 

The impact or size of a health problem in an area, measured by cost, mortality, 
morbidity or other indicators. 1 This report examines the burden of unhealthy 
behaviour by calculating differences in life expectancy and health-adjusted life 
expectancy in Ontario based on individuals' exposure to five behavioural risks for 
poor health. 

Compression of morbidity 

A reduction in the proportion of life spent in ill health. Compression of morbidity 
can occur regardless of the age distribution of a population. For example, even 
in populations with an increasing proportion of older people (as in Ontario), 
compression of morbidity will result if health-related quality of life improves more 
rapidly than life expectancy. 

Health behaviour 

Actions people do that may affect their health, positively or negatively. Health 
behaviours are among the determinants of health and are influenced by the social, 
cultural and physical environments in which people live and work. 2 They are also 
shaped by individual choices and external constraints. 2 This report examines five 
health behaviours — smoking, alcohol consumption, diet, physical activity and 
stress. 

Health-adjusted life expectancy 

Health-adjusted life expectancy combines life expectancy with a measure of 
health-related quality of life to estimate the number of years people can be 
expected to live in good health. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life 



Health-related quality of life 

A concept that includes a person's level of functioning, activities of daily living 
and ability to participate in society. To measure health-related quality of life 
for this study, we used the Health Utilities Index, which combines a number of 
attributes to summarize health status as a single score. Additional measures of 
health-related quality of life are described in the Appendix. 

Health Utilities Index (HUI) 

Developed by McMaster University's Centre for Health Economics and Policy 
Analysis, the HUI is a summary measure of an individual's health comprising six 
attributes: sensation (vision, hearing and speech), mobility, dexterity, emotion, 
cognition and pain. Each attribute has a number of levels. The six attributes are 
then combined into a single score which falls somewhere between -0.36 (state 
worse than death) and 1 (perfect health). 

Life expectancy 

Life expectancy is a calculation of how long a person or population would be 
expected to live, on average, given unchanging risk of death from a specific point 
in time. This report estimates life expectancy for Ontarians in 2007. 

Socioeconomic position 

People in poorer socioeconomic circumstances generally have poorer health. 
Deprivation measures identify those who experience material or social 
disadvantage compared to others in their community. 3 In this report, we used 
the Deprivation Index for Health in Canada developed by the Institut national de 
sante publique du Quebec (INSPQ). 4 The index includes education, employment 
and income as measures of material deprivation; and single-parent families, living 
alone, or being divorced, widowed or separated as measures of social deprivation. 
The deprivation index was used to assign geographical areas into socioeconomic 
position groups (low, middle and high) based on material and social quintiles. 
High-deprivation neighbourhoods were those in the top two quintiles for both 
social and material deprivation. Low- deprivation neighbourhoods were those 
in the bottom two quintiles. Additional measures of socioeconomic position, 
including income and education, are examined in the Appendix. 



in Ontario 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



LIST OF EXHIBITS 



Exhibit 1 Life expectancy for Canadian provinces 
(highest, lowest, British Columbia, 
Ontario), 1986-2006 

Exhibit 2 Prevalence of selected risk factors 
(smoking, unhealthy alcohol 
consumption, poor diet, physical 
inactivity and high stress) among adults 
aged 20 and older in British Columbia 
and Ontario, 2001-2009 



Exhibit 3 



Definitions of behavioural health risks 



Exhibit 4 Spectrum of risk factors leading to 
disease outcomes 

Exhibit 5 Gain or loss in life expectancy for 
Ontarians aged 20 and older with 
healthy versus high level of unhealthy 
exposure for selected behaviours, 
relative to average Ontario life 
expectancy, 2007 

Exhibit 6 Effect of behavioural risk exposure on 
predicted deaths in Ontario, 2007 



Exhibit 7 Impact of eliminating five behavioural 
risks on life expectancy and health- 
adjusted life expectancy for Ontarians 
aged 20 and older, 2007 

Exhibit 8 Differences in life expectancy by 
socioeconomic position (SEP) and 
body mass index (BMI) and reductions 
in these gaps after eliminating five 
behavioural risks in Ontario, 2007 

Exhibit 9 If Ontarians aged 20 and older were 

each to improve their worst behavioural 
risk, which would they tackle? 

Exhibit 10 Life expectancy gains with two policy 
scenarios: Ontarians aged 20 and older 
(1) optimizing their worst behavioural risk 
and (2) meeting British Columbia's targets 
for smoking, diet and physical activity 

Exhibit 1 1 Change required in order for Ontario 
to meet British Columbia's healthy 
living targets 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



7 



Background 



The 2009 report, What Does It Take 
to Make a Healthy Province?, 5 raised 
concern that Ontario was lagging 
behind Canada's healthiest provinces. 



Since the mid-1990s, British Columbia has been the 
healthiest province with the highest life expectancy 
(Exhibit 1) and, compared to Ontario, the smallest 
proportion of residents who smoke, have poor fruit 
and vegetable consumption or are physically inactive 
(Exhibit 2). Despite improvements in the rates of 
some unhealthy behaviours in the past decade, 
Ontario continues to lag behind British Columbia in 
healthy living. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Background 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



8 I Exhibit 1 

Life expectancy for Canadian provinces (highest, lowest, British Columbia, Ontario), 1986-2006 



Life expectancy 
at birth (years) 



85 _ 




70 i i i i i 

1986 1991 1996 2001 2006 

Year 

— Highest province — British Columbia — Ontario Lowest province 



Key messages 

• British Columbia has had the highest life expectancy in Canada since the early 1990s. 

• This report examines the behavioural risks that might account for the gap in life expectancy between Ontario and British Columbia. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Background 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Exhibit 2a I 9 

Prevalence of selected risk factors (smoking, unhealthy alcohol consumption, poor diet, physical inactivity and high stress) 
among adults aged 20 and older in British Columbia and Ontario, 2001-2009 

CURRENT SMOKING (HEAVY AND LIGHT SMOKERS) 
Percent of population 

70 - 

60 - 
50 - 
40 - 
30 - 

20 - " • ■ • 

10 - 



2001 2003 2005 2007 2009 

— •— British Columbia Ontario 



Data source: Canadian Community Health Survey 

Key messages 

• Despite improvements in some health behaviours over time, Ontario continues to lag behind British Columbia in key factors for healthy living. 

• Poor diet and physical inactivity account for the most notable gaps in health behaviour between Ontario and British Columbia. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Background 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Exhibit 2b 

Prevalence of selected risk factors (smoking, unhealthy alcohol consumption, poor diet, physical inactivity and high stress) 
among adults aged 20 and older in British Columbia and Ontario, 2001-2009 



BINGE DRINKING* 



Percent of population 

70 - 



60 
50 
40 
30 
20 
10 



2001 

■ British Columbia 



Ontario 



2003 



2005 



2007 



2009 



*Data missing for British Columbia, 2009 

Data source: Canadian Community Health Survey 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Background 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Exhibit 2c 

Prevalence of selected risk factors (smoking, unhealthy alcohol consumption, poor diet, physical inactivity and high stress) 
among adults aged 20 and older in British Columbia and Ontario, 2001-2009 



POOR DIET (POOR AND VERY POOR DIET) 
Percent of population 

70 - 




30 - 
20 - 
10 - 



2001 2003 2005 2007 2009 

— •— British Columbia Ontario 



Data source: Canadian Community Health Survey 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Background 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Exhibit 2d 

Prevalence of selected risk factors (smoking, unhealthy alcohol consumption, poor diet, physical inactivity and high stress) 
among adults aged 20 and older in British Columbia and Ontario, 2001-2009 



PHYSICAL INACTIVITY 



Percent of population 

70 - 




30 - 
20 - 
10 - 



2001 2003 2005 2007 2009 

— •— British Columbia Ontario 



Data source: Canadian Community Health Survey 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Background 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Exhibit 2e 

Prevalence of selected risk factors (smoking, unhealthy alcohol consumption, poor diet, physical inactivity and high stress) 
among adults aged 20 and older in British Columbia and Ontario, 2001-2009 



HIGH STRESS 
Percent of population 

70 - 

60 - 
50 - 
40 - 
30 - 

20 - 

10 - 



2001 2003 2005 2007 2009 

— •— British Columbia Ontario 



Data source: Canadian Community Health Survey 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Background 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



I 



About this report 

This report expands our understanding of the 
benefits of healthy living by quantifying the impact 
of behavioural risks on Ontarians' life expectancy 
and health-related quality of life. Key terms are 
defined in the Glossary. More details on study 
methods and results are found in the Appendix. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life 
About this report 



lectancy in Ontario 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



A. BEHAVIOURAL HEALTH RISKS 

Five behavioural health risks are examined: smoking, 
unhealthy alcohol consumption, poor diet, physical 
inactivity and high stress. These risks are defined 
briefly in Exhibit 3 and in more detail in the 
Appendix. 

The focus on behavioural risks — rather than 
intermediate risks such as obesity, or proximal risks 
such as blood pressure and cholesterol (Exhibit 
4) — draws attention to these preventable causes of 
poor health in Ontario. We also chose to focus on 
behavioural risks to make it possible to calculate their 
contributions to overall health. If we had included 
a greater range of risks, we would undoubtedly 
have found a larger collective burden on the health 
of Ontarians, but it would have been difficult to 
untangle the contribution of each individual risk. 



Diet Very poor diet Index score <1 





Poor diet 


Index score of 2 to 3 




Fair diet 


Index score of 4 




Adequate diet 


Index score of 5 


Stress 


High stress 


Self-perceived stress: 'quite a bit' or 'extremely' 




Low stress 


Self-perceived stress: 'not at all', 'not very' or 'a bit' 



* Highest risk levels are in boldface and lowest risk levels (reference group) are in italics. 

**Bingeing was defined as a5 drinks/day (men) or a4 drinks/day (women) on any day in the previous week or weekly bingeing behaviour 
in the previous month. 



MET = metabolic equivalent of task; a measure of calories burned by type, duration and frequency of physical activity. 

Index score = the healthiness of diet based on consumption of fruit and vegetables. Index points are awarded for the average number 
of daily servings of fruits/vegetables consumed (1 point for to <1 servings; 2 points for 1 to <2, 3 points for 2 to <3, 4 points for 3 to 
<4 and 5 points for 4 or more servings). The following factors can also cause loss of 1 index point each (up to 3 points) : >1 serving of 
potato, >1 serving of fruit juice or no weekly servings of carrots. 



Exhibit 3 

Definitions of behavioural health risks* 



BEHAVIOUR 


CATEGORY 


DEFINITION 


Smoking 


Heavy smoker 


Daily current smoker (>1 pack/day) 




Light smoker 


Daily current smoker (<1 pack/day) 




Former smoker 


Former daily smoker 




Non-smoker 


Former occasional smoker or never smoker 


Alcohol 


Binge drinker 


Bingeing**: >24 (men) or >17 (women) drinks/week in previous month 




Heavy drinker 


10 to 24 (men) or 6 to 17 (women) drinks/week 




Moderate drinker 


5 to 9 (men) or 3 to 5 (women) drinks/week 




Light drinker 


to 4 (men) or to 2 (women) drinks/week 




Occasional drinker 


<1 drink/month 




Current non-drinker 


No alcohol consumption in the last 12 months 


Physical 


Inactive 


Oto <1.5 METs/day 


activity 


Moderately active 


1.5to<3METs/day 



Active >3 METs/day 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
About this report 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



B. MEASUREMENT OF LIFE 
EXPECTANCY AND HEALTH- 
ADJUSTED LIFE EXPECTANCY 

The main measures in the report are life expectancy 
and health-adjusted life expectancy. 

Life expectancy is a calculation of how long a person 
or population would be expected to live, on average, 
given unchanging risk of death from a specific point 
in time. This report estimates life expectancy for 
Ontarians in 2007. 

Health-adjusted life expectancy combines life 
expectancy with a measure of health-related quality 
of life — a concept that includes a person's level of 
functioning, activities of daily living and ability to 
participate in society. To measure health-related 
quality of life, we used the Health Utilities Index 
(HUI), which combines a number of attributes to 
summarize health status as a single score. 6 

Reporting on these broad measures of health — as 
opposed to illness from specific diseases — focuses 
discussion on the collective or net effect of 
behavioural risks. The five unhealthy behaviours 
examined are well-established risks for more than 
50 diseases. 7 9 However, the relationship between 
behaviour and health is complex. Not all unhealthy 
behaviour carries the same risk for everyone, and 
healthy behaviour is not universally beneficial. 
Moderate alcohol intake (1 to 2 drinks per day) 
has a net health benefit, with a 15% reduced risk of 
death from all causes, but is also associated with an 
increased risk of breast and other cancer. 10 12 



C. QUESTIONS EXAMINED 

The report examines two questions: 

1/ What is the health of Ontarians who 
have various kinds of healthy versus 
unhealthy living? 

To answer this question, we examined how life 
expectancy and health-adjusted life expectancy vary 
by people's level of exposure to the behavioural risks. 
For example, we calculated the life expectancy of 
Ontarians who smoke and compared their length of 
life to Ontarians who have never smoked. Ontarians 
who have never smoked may have more favourable 
health behaviour in other areas as well, such as 
physical activity and eating, and so we interpret the 
life expectancy estimates as the collective influence of 
all health risks of smokers or non-smokers, including 
risks not examined in this report. 

21 How much would Ontarians' health 
improve if we collectively reduced our 
behavioural risks? 

The second question addresses the role of each 
behavioural risk on the health of Ontarians. The 
report estimates how life expectancy and health- 
adjusted life expectancy would increase in Ontario if 
no one was exposed to each behavioural risk. We also 
assess the collective impact of all risks combined. 



D. SPECIFIC OBJECTIVES 

1. To describe the overall trend in the proportion of 
Ontarians with one or more of five behavioural 
health risks: smoking, unhealthy alcohol 
consumption, poor diet, physical inactivity 

and high stress; and to compare Ontario to the 
healthiest province (British Columbia). 

2. To calculate the contribution of these five 
behavioural health risks on Ontarians' life 
expectancy and health-adjusted life expectancy in 
2007, including Ontarians ranked by: 

i. Neighbourhood (socioeconomic position); 

ii. Weight (body mass index [BMI]). 

3. To calculate the health gains that would be 
achieved in Ontario through different preventive 
scenarios, including: 

i. Incremental improvements in the health 
behaviour of all Ontarians; 

ii. Achieving British Columbia's improvement 
targets for health behaviour. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
About this report 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Methods 

The study base was all community-dwelling 
Ontarians aged 20 and older. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Methods 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Our methodology included two main components: 

1. We examined the relationship between the 

behavioural risks and mortality using the Ontario 
sample of three population health surveys — the 
Canadian Community Health Survey (CCHS) 
cycles 1.1, 2.1 and 3.1, conducted biannually by 
Statistics Canada between 2001 and 2005. These 
data were individually linked to death records 
from 2001 to 2010. As well, the survey data were 
used to examine the relationship between the 
behavioural risks and health-related quality of life. 
The output of this component was a multivariable 
model that was used to predict the risk of death 
based on exposure to unhealthy behaviours, and 
to assess the contribution of each behavioural risk 
and combinations of risks toward the risk of death. 



2. We applied the risk model to the most current 
CCHS survey (2007) to estimate the one-year 
probability of death for each respondent. Using a 
period life table approach, we used the probability 
of death to estimate life expectancy and health- 
adjusted life expectancy for respondents based 
on their exposure to each of the five behavioural 
risks and to selected socioeconomic and personal 
factors, including age, sex, ethnicity, education and 
neighbourhood characteristics that reflect material 
and social infrastructure. A second calculation 
assessed the contribution of behavioural risks 
to risk of death, by estimating the probability of 
death for each respondent after recoding their risk 
exposure variable as "no exposure." For example, 
we first estimated the risk of death for current 
smokers, and then re- estimated their risk of death 
assuming they had never smoked. The difference 
between the two calculations creates an estimate 
of the contribution of smoking to the risk of death. 



The impact on health-related quality of life was 
calculated by comparing Health Utilities Index 
scores of people with a behavioural risk to the scores 
from the remaining Ontario population. The burden 
associated with a health risk was the difference in 
health-related quality of life between these two 
groups. 

More details on study methods are available in the 
Appendix. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Methods 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Limitations and interpretive cautions 

In general, the study approach will 
underestimate the actual burden attributable 
to the five behavioural risks in Ontario. We 
note two main limitations to this study and 
two cautions in interpreting the findings. 
The Appendix provides further details of the 
limitations and interpretative cautions and 
how they affect the study findings. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Limitations and interpretive cautions 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



LIMITATION 1: 

Only community-dwelling adults 
were included 

One of the most important study limitations is the 
omission of people living in long-term care (LTC) 
settings. Of the approximately 80,000 deaths each 
year in Ontario, 12% occur among people living 
in LTC institutions. Had the report included LTC 
residents, deaths attributable to the five risks would 
have increased by approximately 12%. 

The study also excluded people younger than 20 years 
of age. This did not likely have a large impact on 
overall burden estimates because few young people 
die, and most report excellent health-related quality 
of life. However, alcohol burden for younger ages 
is a notable omission. Alcohol use is an important 
attribution of injury, suicide and other social 
burdens that occur disproportionately among young 
people. Each death in this age group represents a 
proportionally greater loss in life expectancy or 
health-adjusted life expectancy compared to people 
whose burden from alcohol begins at older ages. 

LIMITATION 2: 

Health risks were likely 
under-reported 

The study used self-reported exposure to health 
risks, which generally results in an underestimation 
of risk burden. Survey respondents tend to over- 
report what they perceive as healthy behaviour and 
under-report unhealthy behaviour. For example, 
in Ontario the sum of self-reported alcohol 
consumption is about half the volume of alcohol 



sold. 10 Reporting accuracy affects all risks in this 
study. Burden estimates are mostly affected when 
people report that they are in the healthiest category 
(e.g., non-smoker or moderate drinker), when they 
are actually in an unhealthy category. 

Similarly, respondents were asked brief questions 
about risks that may not capture the full spectrum 
of behaviour. For example, the study's measure of 
physical activity considered only leisure-time physical 
activity; not included were active transportation 
(such as walking and bicycling to work), activity at 
work, or sedentary time (time spent sitting). Our 
measure of diet was based on fruit and vegetable 
consumption, without specifically ascertaining the 
intake of sodium, trans fats, calories or other aspects 
of healthy and unhealthy eating. 

INTERPRETATIVE CAUTION 1: 

Life expectancy and health-adjusted 
life expectancy 

The study estimated life expectancy and health- 
adjusted life expectancy because these measures 
provide an intuitive perspective on Ontarians' health. 
However, the results should not be interpreted as 
representing how long people can be expected to 
live as of 2007, given their different levels of healthy 
living. Rather, the life expectancy and health- 
adjusted life expectancy findings summarize the 
health experience of Ontarians living in 2007 based 
on their current healthy or unhealthy behaviours, 
the associated mortality risks and their self-reported 
health-related quality of life. For example, the life 
expectancy for physically active people was based 



on observed deaths from 2001 to 2010 for Ontarians 
who were physically active in the year prior to their 
participation in one of the surveys. This calculated 
risk of death was then applied to a hypothetical 
person who was assumed to be physically active from 
the age of 20 onward. 

INTERPRETATIVE CAUTION 2: 

Selected behavioural health risks and 
the combined effect of multiple risks 

The study examined five behavioural risks. 
Additional behavioural risks that were not examined 
include sexual health risks, drug misuse and 
unintentional injuries from risk behaviour (e.g., 
unsafe driving). Also missing from our estimates was 
the burden attributable to second-hand exposure to 
health risks, such as deaths of passengers in motor 
vehicle collisions where the driver was drinking. 

The estimate of deaths attributable to a behavioural 
risk is subtracted from total deaths to calculate how 
many fewer deaths would occur if Ontarians were 
never exposed to the risk. Because these behaviours 
rarely occur in isolation (i.e., someone who smokes 
may also have a low level of physical activity and/ 
or a poor diet), the deaths from the individual 
behavioural causes should not be combined, except 
when reported as combined estimates. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Limitations and interpretive cautions 



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Public Health Ontario 



Findings 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



PREDICTIVE RISK MODEL 

The risk of death from the five behavioural risk 
factors was calculated using responses from 78,597 
people surveyed between 2001 and 2005 and followed 
until 2010. In total, there were 568,997 person-years of 
follow up and 6,399 deaths. The health behaviour and 
mortality risk model showed excellent discrimination 
and accuracy/calibration. Mortality in the highest- 
risk decile was approximately 253 times higher 
for men and 335 times higher for women than the 
lowest-risk decile (c-statistic: 0.87 for both models). 
Estimates of predictive and observed deaths were 
compared with good agreement overall (6,399 
predictive versus 6,399 observed deaths) and across 
subgroups, including several not examined during 
algorithm development (e.g., subgroups by income, 
BMI or health region). The Appendix provides 
details of the development and validation of the 
predictive model. 



LIFE EXPECTANCY AND HEALTH- 
ADJUSTED LIFE EXPECTANCY FOR 
ONTARIANS WITH DIFFERENT LEVELS 
OF RISK EXPOSURE 

Exhibit 5 shows the life expectancy in 2007 for 
Ontarians with the unhealthiest risk exposure 
compared to those with healthy behaviour. Heavy 
smokers had a life expectancy approximately 11.5 
years lower than non-smokers (71.1 versus 82.9 years 
for men; 75.0 versus 86.2 years for women). People 
with exposure to all five risks had a life expectancy 
more than 20 years lower than people with no health 
risks (68.5 versus 88.6 years for men; 71.5 versus 
92.5 years for women). (See also Exhibit A-10 in 
the Appendix.) 

We also predicted mortality, life expectancy, health- 
adjusted life expectancy and health-related quality of 
life for Ontarians at different levels of risk exposure. 
For all risks except alcohol, we found gradients in 
each of these measures — people with the highest risk 
exposure had the poorest health. (See Exhibit A-ll 
in the Appendix.) 



POPULATION HEALTH IMPACT OF 
BEHAVIOURAL RISKS 

The population health impact of each behavioural 
risk is a combination of the number of people 
exposed to a risk and the individual increase in 
mortality associated with that risk. These two 
components can result in some unexpected findings. 
For example, heavy smokers had a much greater 
increased risk of death than people who were 
physically inactive (2.8 versus 1.4 times higher for 
men; 2.9 versus 1.5 times higher for women). (See 
Exhibit A- 14 in the Appendix.) However, many more 
Ontarians were inactive than were heavy smokers in 
2007 (49.3% versus 8.4% for men; 56.6% versus 3.8% 
for women). (See Exhibit A-14 in the Appendix.) As 
a result, physical inactivity had a high impact on 
Ontarians' health overall. The combined impact of 
all behavioural risks accounted for 59.9% of deaths in 
2007 (Exhibit 6). 

Exhibit 7 shows the population health impact of 
eliminating behavioural risks. Smoking, physical 
inactivity and inadequate diet had the greatest 
impact on life expectancy (2.5, 2.4 and 2.0 years, 
respectively). For each behavioural risk, reducing 
the unhealthy behaviour would add years to life (life 
expectancy) and even more life to years (health- 
adjusted life expectancy). Combined, the five risk 
factors represent a loss of 7.5 years of life expectancy 
and 9.8 years of health-adjusted life expectancy. (See 
also Exhibit A- 15 in the Appendix.) 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



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Public Health Ontario 



Life expectancy differs by socioeconomic position 
in Ontario — with an approximately 4.5-year gap 
between the least- deprived and most- deprived 
neighbourhoods. Exhibit 8 illustrates this equity gap 
and the contribution of behavioural risk exposure. 
The gap would be reduced by almost 50% (two 
years) if behavioural risks were the same across 
neighbourhoods. Of the five risks examined, smoking 
was the biggest contributor to the equity gap in both 
life expectancy and health-adjusted life expectancy. 
(See Exhibits A-16 and A-17 in the Appendix.) 

A smaller difference (about one year) in life 
expectancy exists for BMI. The effect of risk factor 
exposure on the gap in life expectancy across BMI 
levels is also shown in Exhibit 8. Behavioural risks 
account for 68% of the life expectancy gap between 
obese Ontarians and people of normal weight. 
Eliminating all five risks would reduce this gap to 
0.3 years. The gap in health-adjusted life expectancy 
would also be reduced to 0.3 years. 



POLICY SCENARIOS 

Two policy scenarios were examined. In the first 
scenario we asked, if Ontarians were to individually 
improve their highest risk behaviour, where would 
they focus their efforts and what collective health 
impact would result? 

We ranked the five health behaviours by risk of 
death (Exhibit 9, Step 1). Smoking is by far the most 
hazardous health behaviour and, for the 22% of 
Ontarians who smoke, would be the most important 
behaviour to improve (Exhibit 9, Step 2). For most 
people, however, physical inactivity is their biggest 
health challenge; 37% need to become more active. 
Poor diet would have to be corrected by 29%. Twice as 
many women need to increase their exercise as need 
to tackle smoking (43.2% versus 18.4%). (See Exhibit 
A- 18 in the Appendix.) 

Nearly all Ontarians reported at least one of the five 
unhealthy behaviours. Only 1.4% had none. If each 
person optimized his or her single most important 
unhealthy behaviour (for example, if people who were 
physically inactive became active), life expectancy in 
Ontario would increase by 3.7 years (Exhibit 10). 



In the second scenario we asked, what the potential 
impact would be for Ontarians if we were to achieve 
British Columbia's targets for improved health 
behaviour? (We used British Columbia's targets 
because Ontario does not have well-defined targets 
for the five health behaviours.) BC, Canada's 
healthiest jurisdiction, has set the following targets: 
nine out of 10 residents will not smoke, seven out of 
10 will eat at least five fruits and vegetables each day, 
and seven out of 10 will be physically active. 

Collectively, by reaching these goals, Ontarians 
would gain 3.0 years of life expectancy (Exhibit 10). 
Ontarians are closer to achieving the target for 
smoking than for either physical activity or diet, 
where they lag considerably behind (Exhibit 11). For 
Ontario to achieve all three of the targets, 77% of us 
would need to change at least one behaviour. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



. Intermediate ^ 
' risk factors 



^ Proximal ^ 



risk factors 



A 



^ Diseases and ^ 



other outcomes 



A 



24 I Exhibit 4 

Spectrum of risk factors leading to disease outcomes* 



Distal risk factors 



1 

A 



Background 
risk factors 



•Age 

• Sex 

• Immigrant status 

• Education 

• Socioeconomic position 



A 



• Smoking 

• Alcohol 

• Diet 

• Physical activity 

• Psychosocial stress 



• Body mass index 



Blood pressure 
Lipid levels 

Glucose levels (diabetes) 



• Disease 

• Health care use 

• Health-related quality of life 

• Death 



'Adapted from Cecchini et al. Lancet. 2010. 



Key messages 

• Behavioural risks are the focus of public health programs in Ontario. 

• This report focuses on the combined burden of the five distal risk factors shown in boldface and calculates health-related quality of life and death as disease outcomes. 
Burden calculations were adjusted for all background risk factors. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



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Public Health Ontario 



Exhibit 5 

Gain or loss in life expectancy for Ontarians aged 20 and older with healthy versus high level of unhealthy exposure for selected behaviours, 
relative to average Ontario life expectancy, 2007 

Life expectancy 
(years) 

92 - 



87 



82 



77 



72 




67 

Smoking Alcohol Physical activity Diet Stress All five risk factors 

Ontarians' life expectancy ■ Life expectancy loss for individuals with high level of unhealthy behaviour ■ Life expectancy gain for individuals without unhealthy behaviour 



Key message: 

• A 20-year difference in life expectancy existed between people who have all five behavioural risks and those with none of the five risks. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



26 I Exhibit 6 

Effect of behavioural risk exposure on predicted deaths in Ontario, 2007 



BEHAVIOURAL RISK 


INCREASED RISK OF DEATH* 


PERCENT REDUCTION IN DEATHS IF RISK FACTOR WERE 
ELIMINATED (Total Deaths) 




Men 


Women 


Men 
(37,500) 


Women 
(30,700) 


Overall 
(68,200) 


Smoking 


1.9 


2.0 


26.1 


21.4 


23.7 


Unhealthy alcohol consumption 


1.2 


1.2 


12.3 


13.3 


12.8 


Physical inactivity 


1.3 


1.4 


19.3 


26.6 


23.0 


Inadequate diet 


1.3 


1.3 


21.3 


18.7 


20.0 


High stress 


1.3 


1.2 


3.1 


2.3 


2.7 


All risk factors 


59.7 


60.0 


59.9 



'Weighted hazard — average across risk exposure categories relative to the healthiest (reference) category (see Exhibit 3 ). 



Key messages 

• The combined impact of all five behavioural risks accounted for 60% of deaths in Ontario in 2007. 

• Smoking, physical inactivity and inadequate diet were the three leading behavioural causes of death in Ontario. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



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Public Health Ontario 



Exhibit 7 

Impact of eliminating five behavioural risks on life expectancy and health -adjusted life expectancy for Ontarians aged 20 and older, 2007 



Years 

12 - 



10 



■ ■ ■ ■ 



Smoking Alcohol Physical activity Diet Stress All five risk factors 

■ Life expectancy gain Health-adjusted life expectancy gain 

'Considers all risk exposure categories compared to healthiest (reference) category ( Exhibit 3) 

Key messages 

• Smoking, physical inactivity and inadequate diet each accounted for about two years of life expectancy lost. 

• Combined, the five risk factors reduced life expectancy by 7.5 years. 

• Reducing or eliminating behavioural risks resulted in even greater gains in health-adjusted life expectancy (up to 9.8 years) — adding life to years as well as years to life. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



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Public Health Ontario 



28 I Exhibit 8 

Differences in life expectancy by socioeconomic position (SEP) and body mass index (BMI) and reductions in these gaps after eliminating 
five behavioural risks in Ontario, 2007 



Life expectancy 
(years) 



92 



87 



High SEP with low behavioural risks 



Low SEP with low behavioural risks 



Normal BMI with low behavioural risks 



Obese with low behavioural risks 



82 



77 



72 



High SEP overall 



Low SEP overall 



Normal BMI overall 



Obese overall 



67 



Ontarians' life expectancy ■ Life expectancy loss for individuals with high level of unhealthy behaviour ■ Life expectancy gain for individuals without unhealthy behaviour 



Key messages 

• Health behaviour risks accounted for about half of the equity gap — the difference in life expectancy for people with high versus low socioeconomic position. 

• There was little difference in life expectancy between individuals who were obese and those with a normal body mass index. Health behaviour risks accounted for 
more than 60% of that difference. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Exhibit 9 

If Ontarians aged 20 and older were each to improve their worst behavioural risk, which would they tackle? 



STEP 1: FIND YOUR MOST IMPORTANT RISK. (See Exhibit 3 for risk definitions.) 



Risk of death* 

2.8 



2.3 



1.3 




Heavy smoker 



Start at the top of the list and 
work your way down. If you are 
not a heavy smoker, continue 
moving down the list to find your 
highest risk behaviour. 



Light smoker 



Very poor diet 
Inactive 

Binge drinker, poor diet 

Heavy drinker, light drinker, high stress, fair diet 
Moderately active 



*Risk of death relative to lowest risk level 



Life Expectancy Calculator 

Individuals can calculate their own life expectancy with a new Life Expectancy Calculator 
( http://www.rrasp-phirn.ca/risktools) based on smoking, alcohol, food, exercise and stress level. 
This tool is also accessible from the ICES and PHO websites. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 

30 I Exhibit 9 (CONTINUED) 

If Ontarians aged 20 and older were each to improve their worst behavioural risk, which would they tackle? 



STEP 2: HOW MANY ONTARIANS SHARE YOUR MOST IMPORTANT RISK? 
Percent of population 

100 - 

80 - 

60 - 



40 



20 








Physical activity Diet Smoking Alcohol Stress No behavioural risks 



Key messages 

• Physical inactivity is the most important behavioural risk in Ontario, followed by inadequate diet and current smoking. 

• Very few Ontarians have healthy behaviour for all five risk factors. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



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Public Health Ontario 



Exhibit 10 

Life expectancy gains with two policy scenarios: Ontarians aged 20 and older (1) optimizing their worst behavioural risk and 
(2) meeting British Columbia's (BC's) targets for smoking, diet and physical activity 

Years 

4.0 - 



3.0 - 



2.0 - 



1.0 - 



0.0 




Optimize highest risk Meet BC smoking target Meet BC diet target Meet BC activity target Meet all 3 BC targets 



Key messages 

• If each Ontarian optimized his or her most important unhealthy behaviour, life expectancy in Ontario would increase by 3.7 years. 

• If Ontario were to achieve all three of BC's healthy living targets, life expectancy would increase by three years. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



32 I Exhibit 11 

Change required in order for Ontario to meet British Columbia's (BC's) healthy living targets 



Percent of population 

100 - 




Not smoking Adequate diet Physically active 

■ Current Ontario population meeting target BC target 



Key messages 

• Ontario lags considerably behind the British Columbia (BC) targets set for physical activity and diet. 

• Collectively, 77% of Ontarians would need to change at least one risk behaviour for Ontario to meet all three of BC's targets. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Findings 



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Public Health Ontario 



Discussion 

This study suggests that remarkable gains in life 
expectancy and health-adjusted life expectancy could 
be achieved in Ontario through healthier living. Overall, 
Ontarians would gain 7.5 years of life expectancy if 
everyone were in the healthiest category for all five 
behavioural risks examined. Smoking, physical inactivity 
and poor diet each contribute 2.0 to 2.5 years of lost 
life expectancy. If everyone modified only their most 
important health risk, life expectancy would increase by 
up to 3.7 years. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Discussion 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



ADDING LIFE TO YEARS AS WELL 
AS YEARS TO LIFE 

The potential gains in health-adjusted life 
expectancy (9.8 years) are even larger. This means 
that improving health behaviours would result in 
adding life to years as well as years to life. 13 People 
with healthy behaviours have consistently better 
health-related quality of life compared to people 
with poor health behaviours. 

If behavioural risks were reduced, Ontario could 
see a compression of morbidity, meaning people 
would spend fewer years in a state of poor health 
needing assistance for daily living. In turn, these 
improvements could be expected to reduce demands 
on both the formal health care system (doctors, 
hospitals, nursing homes, etc.) and informal family 
caregiving. That said, this study did not explicitly 
assess the impact of behavioural risks on health 
care needs. 

UNDERSTANDING INDIVIDUAL 
VERSUS POPULATION BURDEN 
OF RISKS 

Examining individual and population burdens 
provided different perspectives on the impact of 
behavioural risks. These differences explain what may 
seem like contradictory findings. For example, why 
is the gain in Ontario's overall life expectancy from 
improved health behaviour 7.5 years, even though we 
found a 20 -year difference in life expectancy between 
the healthiest and unhealthiest individuals? 



The reason is related to the number of people with 
the unhealthy behaviour. Individuals with a very 
hazardous behaviour, such as current smoking, have 
a high risk that affects their health and reduces their 
life expectancy. Furthermore, smoking will have 
an important population health impact unless it 
becomes very uncommon. However, a less hazardous 
risk, such as physical inactivity or poor diet, can 
have an equally important population health 
burden if the behaviour is common. We found that 
physical inactivity resulted in a smaller reduction 
in individual life expectancy (4.6 years) compared 
to smoking (11.5 years). But we also found lack of 
exercise was the leading risk for 43% of women, more 
than twice the proportion of women who smoked. 
As a consequence, the population health burdens 
from smoking and from physical inactivity were 
about the same. 

COMPARING THE IMPACT OF 
SOCIOECONOMIC POSITION 
AND OBESITY 

This study reconfirms findings from previous studies 
demonstrating large differences in life expectancy 
and health-adjusted life expectancy across different 
socioeconomic groups. 14 Furthermore, this study 
shows that life expectancy varied considerably across 
neighbourhoods — an effect observed after adjusting 
for individual or family income, education and health 
behaviours. At the same time, we found that half the 
differences in life expectancy and health-adjusted 
life expectancy across socioeconomic position could 
be attributed to higher levels of risk behaviour 
among people in low socioeconomic position. This 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Discussion 



suggests that reducing behavioural health risks in 
low socioeconomic groups could play a large role in 
reducing health inequities. 

The impact of BMI on life expectancy and health- 
adjusted life expectancy was much smaller than 
socioeconomic position, accounting for just one 
year of reduced life expectancy. Life expectancy 
differences for people with different BMI levels were 
also smaller than the differences associated with 
smoking (11.5 years), diet (7.2 years), and physical 
activity (4.6 years). 

We purposely focused this study on behavioural 
risks and so did not estimate the potential gains in 
Ontarians' health if obesity were reduced. Inactivity 
and excess calories are the main contributors to rising 
weights and, as expected, we found that physical 
inactivity and poor diet were the main behavioural 
risks contributing to reduced life expectancy for 
Ontarians who are obese. 

That said, our findings on BMI seem to be in 
opposition to predictions that the rise of obesity will 
reverse recent gains in life expectancy. 15 However, 
they are consistent with other studies demonstrating 
that, except for morbid obesity (BMI>35), the 
mortality risk of obesity is modest. 1617 Most recently, 
a study from the Manitoba Centre for Health Policy 
examined risk for a wide range of health and health 
care outcomes (hospitalization, physician services, 
disease outcomes and death) and found the same 
unchanging risks associated with BMI, with notable 
differences occurring only when people were 
morbidly obese. 18 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



35 



Conclusion 

HOW CAN ONTARIO BECOME THE HEALTHIEST 
PROVINCE IN CANADA? 

Ontario will see major improvements in health through 
improvements in healthy living. This province has been 
a leader in the development and implementation of 
comprehensive tobacco control, and now has among 
the lowest rates of smoking worldwide, although it still 
lags behind British Columbia. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Conclusion 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



Compared to Ontarians, people in British Columbia 
have more favourable health behaviours for all of the 
five risks examined in this study, particularly in being 
physically active and having healthy diets. In large 
measure, this is why British Columbia has had the 
leading life expectancy in Canada for almost 20 years. 
To achieve leading status, Ontario needs to build 
on its successes in smoking reduction and focus 
similar attention on increasing physical activity and 
healthy eating. 

Previous reports have examined how British 
Columbia and other leading jurisdictions have 
achieved healthier populations. Contributions 
include a clear vision, sustained attention and a high 
level of government funding directed at improving 
population health; healthy living goals with specific 
targets; a whole-of-government approach; and earlier 
adoption of healthy public policy 519 Compared 
to Ontario, British Columbia has a strong level of 
commitment to all of these attributes, including 
establishing the measureable healthy living goals we 
used in this study. 



Momentum for further action is building in Ontario, 
where 86% of members of the provincial legislature 
endorse a goal of supporting and promoting better 
health in Ontario. 20 Ontario's Chief Medical Officer 
of Health has called for a new initiative geared 
towards promoting good health and preventing 
chronic disease and injury. 21 Work on this initiative 
is underway, including the development of a 
blueprint for chronic disease prevention by Cancer 
Care Ontario and Public Health Ontario. 19 The 
blueprint will recommend coordinated strategies 
to improve Ontarians' health behaviour in four 
of the five areas studied in this report: smoking, 
alcohol, healthy eating and physical activity. 
Most recently, the Commission on the Reform of 
Ontario's Public Services recommended that Ontario 
adopt British Columbia's healthy living initiative: 
"Recommendation 5-82: Replicate British Columbia's 
Act Now initiative, which has been identified by the 
World Health Organization (WHO) as a best practice 
for health promotion and chronic disease prevention, 
in Ontario." 22 Our findings in this report could serve 
as benchmarks to inform future initiatives toward 
making Ontario Canada's healthiest province. 



Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Conclusion 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 



37 



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Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario 
Conclusion 



Institute for Clinical Evaluative Sciences 
Public Health Ontario 

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