IQALUIT — Iola Tikivik’s addiction began at 16 when friends offered him a cigarette after they’d hiked up one of the hills that frame this northern capital.

Two years later, Tikivik, now in Grade 12 at Inukshuk high school, smokes at least half a pack each day. He tried to quit earlier this year during a government-sponsored campaign designed to curb youth smoking by offering students who butt out the chance to win a computer.

Tikivik lasted four days. "It was too hard," he says, shaking his head.

Quitting was made more difficult by the fact that four of Tikivik’s five siblings and his father all smoke. "Someone always has a cigarette," he says.

His story is not unusual in the North. As a regular smoker, Tikivik is part of the majority in Nunavut. The 10-year-old territory has the highest rate of smoking in the country: 53 per cent of people over the age of 12 surveyed by Statistics Canada reported lighting up daily - even though cigarettes here can cost $16 a pack.

Nunavut’s smoking rate is more than double the national average (22 per cent) and is considerably higher than those in the Northwest Territories (36 per cent) and Yukon (30 per cent).

Among Nunavut’s Inuit, 85 per cent of the territory’s population, the rates are even worse. The 2006 Aboriginal Peoples Survey found that 64 per cent of the territory’s Inuit over the age of 15 light up daily; another eight per cent called themselves occasional smokers.

"The levels here are exceptionally high compared to the rest of the country," says Dr. Geraldine Osborne, Nunavut’s deputy chief medical officer of health, who has worked in the territory since 2001.

The tobacco problem is shared by Inuit across Canada and by many First Nations communities.

Today in Nunavut, young and old alike suffer from the territory’s extreme smoking:

— The leading causes of death in Nunavut are cancer, respiratory disease and heart disease; smoking is a major risk factor in all of them;

— Lung cancer rates among Canada’s Inuit are the highest in the world;

— Nunavut’s newborns and infants are the most unhealthy in the country, in part, because of the staggering number of pregnant women who smoke - four out of five expectant mothers, according to a Government of Nunavut study of babies born at Iqaluit’s Qikiqtani General Hospital between 2000 and 2005.

Osborne says the problem has so far defied public health and education campaigns.

"In fact," she says, "we know pregnant women are smoking more cigarettes per day than they were 10 years ago. It is about the same rate, 80 per cent, but they’re smoking more per day."

Nunavut’s mothers are the youngest in the country, with an average age of 24.7; the teen pregnancy rate is eight times the national average. It means many pregnancies are unplanned. And expectant mothers addicted to nicotine often find it difficult to give up cigarettes when a major new stress has just been added to their lives.

"It’s an addiction; it’s not like it’s something people can just decide to give up," explains Osborne.

The smoking epidemic among expectant mothers is one of the factors that puts Nunavut’s infants in peril.

Infant mortality in the territory is three times the Canadian average. The rates of prematurity and low birth weight are also high. (Low birth weight - less than 5.5 pounds - is an important indicator of a newborn’s overall health.)

Nunavut’s infants also suffer from the world’s highest reported rate of hospital admission for serious respiratory infections, according to a landmark study by University of Toronto researcher Dr. Anna Banerji.

"People don’t believe it, but almost half of all babies born in Nunavut end up in hospital early in their lives," says Banerji, an expert in pediatric infectious disease.

Her study found that about 12 per cent of infants admitted to hospital had to be flown to intensive care units in the South and placed on life-support. (Children who have suffered such a serious infection have a much greater risk of developing severe, chronic lung disease later in life.)

Exposure to cigarette smoke is a major problem. Banerji’s latest study, published in the August 2009 edition of the Pediatric Infectious Disease Journal, concluded that infants whose mothers smoked were at least four times more likely to be hospitalized for a serious lung infection during the first two years than infants whose mothers did not smoke.

Babies who were not breastfed and those who lived in overcrowded conditions (more than five people in a home) also faced a greater risk of hospitalization. A lack of proper maternal nutrition, along with deficiencies in vitamins A, D and iron, compounds the problem.

"This is a health crisis that wouldn’t be tolerated anywhere else in Canada," says Banerji, who began to study the problem in 1995 after confronting a raft of unexplained respiratory infections while training as a pediatrician in Iqaluit.

Infants are not the only ones whose health is put at risk by Nunavut’s smoking epidemic. Smoking has been tied to unusually high rates for everything from otitis media - a serious middle ear disease that can lead to early hearing loss - to lung cancer and colorectal cancer.

Dr. Bill Williams, a cardiologist at the University of Ottawa Heart Institute, has been travelling to Nunavut for 10 years as part of a medical outreach program.

Heart disease, once virtually unknown among Inuit, is now widespread, said Williams, who blames junk food and smoking for its advance.

"Coronary disease is striking these people more aggressively and at a more premature age - at least a decade sooner than in the southern population," he says.

Lung cancer rates have also risen sharply among Inuit across the circumpolar region during the past two decades, according to Prof. Kue Young, who holds the TransCanada Pipelines Chair in Aboriginal Health and Wellbeing at the University of Toronto.

Circumpolar Inuit are twice as likely to contract lung cancer as a white person living in the United States, according to a 2008 study led by Young.

The same study found that Canada’s Inuit have a decidedly higher incidence of lung cancer than those living in Greenland and Alaska. Inuit men in Canada are 1.5 times more likely to have lung cancer, while the incidence among this country’s Inuit women is two to three times higher.

Young says policymakers need no more scientific evidence to justify an aggressive anti-smoking campaign in the North. "With lung cancer," he says, "there’s no point in looking for any additional risk factors when there’s one staring you in the face: Smoking."

Nunavut’s Osborne agrees: "There’s huge potential there to drastically reduce our cancer mortality rates if we can just get our smoking rates down."

Lung cancer is now responsible for half of all cancer deaths in Nunavut.

Breaking Nunavut’s smoking habit will not be easy.

The territory already has a tough set of anti-smoking laws. In 2004, Nunavut’s Tobacco Control Act made the territory one of the first jurisdictions to ban smoking in public places, including bars. The law made it illegal to sell cigarettes to anyone under 19; banned cigarette vending machines; and eliminated most tobacco retail displays.

Since 2000, the government has also run a series of public education campaigns that have warned parents to smoke outdoors, away from their children. The latest tobacco control strategy targets youth and pregnant women.

Despite the efforts, Nunavut’s smoking rate is going down "very slowly," says Osborne.

"I’m realistic. Things aren’t going to change overnight," she says. "Particularly in public health."

A pack-a-day habit in the North can cost $6,000 a year, a price magnified in families with three or four smokers. "It’s taking money out of their food budgets," says Dr. Ron Aspinall, a family physician who works in the Nunavut hamlet of Rankin Inlet.

The territorial government spends almost one-quarter of its $1.2 billion annual budget on health care. (About $1 billion of the budget comes from federal transfers.)

The government has not assigned a dollar figure to smoking-related costs, but statistics show respiratory problems are the most common health complaint. Respiratory diseases accounted for 29,978 health centre visits in 2006 - more than twice the number of visits attributable to any other single category of disease.

What’s more, the territory spends about $40 million each year to fly patients to southern hospitals. More than 1,300 Nunavut residents, one-third of them children, flew to Ottawa last year for treatments unavailable on Baffin Island.

Nunavut Health Minister Tagak Curley says he’s frustrated by the hold tobacco maintains on Inuit.

"These are preventable health issues."

Curley argues better education is critical since new legal restrictions are unlikely to succeed. "People see it as an individual freedom, smoking," Curley says. "But I, for one, know we just simply have to find a way to communicate better."

The federal government’s renewed interest in the North - fuelled by a desire to secure Canada’s claim to the Arctic and its resources - has brought the region’s health and social problems into sharper focus. Canada also has an Inuk - former Nunavut MLA Leona Aglukkaq - serving as the federal health minister. She understands the problem, Curley says, and earlier this year she announced $734,000 will be spent over two years to encourage aboriginal youth to quit smoking.

One program will train young people in Nunavut to educate their peers about the dangers of smoking; another offers prizes to young aboriginals who take part in a smoking-cessation challenge.

Like so many other endeavours in the North, smoking requires a certain fortitude - particularly since the ban on smoking in public places.

Those like Iola Tikivik huddle in doorways and porches to light up. Even on the coldest days - temperatures routinely reach minus 40 C in Iqaluit’s winter - Tikivik can be found outside the space-station shaped Inukshuk high school with his shoulders hunched against the wind, drawing on a cigarette.

"I wanted to quit ever since I read about what smoking can do," he says. "But it’s too addictive."

- Ottawa Citizen reporter Andrew Duffy received a grant from the Canadian Institutes of Health Research to conduct research for this two-part series. © Copyright (c) Canwest News Service