CAM in UME Project
http://www.caminume.ca
CAM Use in Canada: Extent and User Characteristics
CAMpod Section: Foundations for CAM
Author: Rebecca Brundin-Mather, MASc
Institution: University of Calgary
Creation Date: February, 2007
Revision Date: May, 2008
Synonyms and Related Terms: CAM prevalence
Descriptors: use / utilization; methods / methodology
This CAMpod provides a general summary of recent surveys on the use of complementary and
alternative medicine as well as ideas for student discussion around the points contained within.
It was developed as a teaching aid for undergraduate medical education instructors who can
use the points and references to generate their own course-relevant curriculum materials. At
the same time, the POD may also aid individual student learning and the development of
courses for all levels of medical education as well as for education of other health professionals.
Other related teaching/learning resources or CAMpods that are available in the CAM in UME
Digital Resource Repository are hyperlinked to the document.
1. Purpose
This CAMpod provides a snapshot of the extent of CAM use. As the POD is not intended to provide a
comprehensive summary, we have produced a Citation List of Surveys on CAM Use in Canada that will
help direct instructors to specific surveys. This CAMpod primary focuses on Canadian data; however, key
American studies are also cited. The National Center for Complementary and Alternative Medicine’s
(NCCAM) site provides a succinct summary of most recent U.S. data. This is available at
http://nccam.nih.gov/news/camsurvey_fs1.htm.
1.1
Rationale for including this topic in UME
Surveys over the past decade indicate that many Canadians are using CAM for illness prevention and/or
for treatment of acute or chronic conditions. Unfortunately, not all patients disclose their CAM use to
their physician,1 a situation that raises concern about the potential consequences to the patient’s health.
In order to understand why it is important to ask patients about CAM, physicians need to be aware of
how many individuals are using CAM as well as the reasons they are choosing to do so. The CAMpods,
Reasons for CAM Use: Patient Choices and Reasons for CAM Use: Social Forces provide information on
the later topic.
1.2
Key CAM Competencies
The information in this CAMpod will contribute to enhancing CanMEDS competencies in the roles of
Professional and Scholar. It will also contribute to meeting CAM-focused educational objectives from
the list of core CAM competencies for undergraduate medical education available at
http://www.caminume.ca/documents/competencies.pdf.
2. Overview
Eisenberg et al.’s 1993 publication2 on the use of ‘unconventional’ medicine in the United States was a
ground breaking article because it demonstrated what had been largely unacknowledged—the majority of
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Americans were using complementary therapies and many were not telling their doctors about their use.
Since then there have been numerous surveys on CAM use in different populations—by country, disease,
age, gender, and by various permutations of these as well as other inclusion criteria.
2.1
Limitations of Surveys
Surveys can be an important and useful tool for collecting data on public attitudes and behaviours
regarding CAM. However, varied design criteria can make cross-study comparisons of surveys difficult, if
not inappropriate. Examples of sources of variation include:

Sample selection criteria and/or participant characteristics such as sex, age, and disease or health
condition.

Data collection methods such as question format (structured, semi-structured, or open-ended
questions) and survey delivery (on-line, paper, telephone interview).

Definition of CAM: what is included as “CAM” treatment (e.g., in some studies exercise, prayer,
and/or vitamins are included under the umbrella of CAM; other categorize these as conventional
medicine).* Similarly, some studies define CAM as therapies only delivered by a practitioner, thus
excluding self-care therapies (e.g., Over the counter Natural Health Products, † Meditation).

Definition of a CAM user: studies can define a CAM user as someone who has ‘ever tried’ CAM,
‘used CAM in the last year’, ‘last month’, ‘on a regular basis’, etc. In addition, as noted above, a
CAM user could be limited to someone who visits a CAM practitioner, excluding individuals who self
treat with CAM.
Differences in study samples and design can generate vast differences in reported prevalence statistics.
Therefore, it is always important to read and apply data on CAM use cautiously. Ernst outlines
additional reasons why prevalence data should be “taken with a pinch of salt.”3
2.2 How many people use CAM
2.2.1 Canadian Data
National data on the extent of CAM use by Canadians is scarce and beginning to be outdated.
Government Surveys:
Statistics Canada’s surveys, the National Population Health Survey (NPHS) and the Canadian
Community Health Survey (CCHS) include one question‡ that limits the definition of CAM to therapies
via a practitioner (i.e., excludes self care).

*
†
‡
The most recent collection of NPHS data was in 2004/2005 (cycle 6); however, the data set
is not due for release until July 2008. Because the NPHS is a longitudinal survey there is no
public file available. The most recent publication using NPHS data unfortunately dates back
to 1998/99 (cycle 3).4 At that time, approximately 17% of Canadians reported consulting
with an alternative medicine provider, the most frequent being a chiropractor. This figure is
an increase of 2% from 1994/95.
Refer to the CAMpod, What is CAM? for additional information about how CAM can be defined.
Under Health Canada’s Natural Health Products Regulations which cam into effect on January 1st 2004, natural health products
(NHPs) are defined as: vitamins and minerals, herbal remedies, homeopathic medicines, traditional medicines such as traditional
Chinese medicines, probiotics, and other products like amino acids and essential fatty acids. [Definition extracted from
http://www.hc-sc.gc.ca/dhp-mps/prodnatur/index_e.html].
The question is: In the past 12 months, have you seen or talked to an alternative health care provider….about your physical,
emotional or mental health? Who did you talk to (practitioner list provided). http://www.statcan.gc.ca/concepts/nphs-ensp/q04eng.pdf.
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
The CCHS is collected biennially, though the 2005 collection did not include the CAM-oriented
questions. From the 2003 CCHS, Park5 published that 20% of Canadians aged 12 and older
(approximately 5.4 million Canadians) reported consulting with an alternative care provider in
the past year.
Health Canada’s Baseline Natural Health Products (NHP) Survey Among Consumers (March 2005)
reported that 71% of Canadians have used a Natural Health Product. Of this group, 38% use a NHP
on a daily basis, 37% "only during certain seasons," and 11% weekly.
Researchers estimate that the extent of CAM use among individuals with chronic medical conditions is
higher than the reported national average. For example, from the 2003 CCHS data, 25% of
individuals who reported having at least one chronic condition used CAM compared with 16% who
did not report having a chronic condition.5
Appendix A provides more information about these surveys as well as their website links.
Individual Surveys
Six years after Ramsay, Walker and Alexander’s6 1997 national survey,§ The Fraser Institute again
commissioned a survey of CAM use in Canada. Esmail reports7 that in 2006, 74% of Canadians had
used at least one alternative therapy in their lives (alternative therapy included non-practitioner
based therapies or self-care therapies such as taking Natural Health Products); 54% reported using
at least one alternative therapy in the previous 12 months. These figures are slightly elevated from
1997.**
There are many Canadian studies which provide prevalence rates for specific populations with specific
conditions. These studies tend to be provincially sampled or further localized (e.g., hospital
sampled). Unfortunately, it is not known what percentage of investigators has, in fact, published
their survey data. To obtain a list of specific Canadian surveys on CAM use, please refer to the
CAMpod supplement, Citation List of Surveys on CAM Use in Canada.
2.2.2 Data from outside Canada

Although now somewhat dated, Ernst8 published a systematic review of the prevalence of CAM use
among random or representatives samples of the general population; rates ranged from 9% to
65% internationally.
o

Through the CAM-Cancer website, Ernst provides prevalence data of CAM use by cancer
patients in Europe (http://www.cam-cancer.org/index.asp?o=2618).
The most recent survey on Americans’ use of CAM was released in May 2004.9 It indicates that 36%
of American adults are using some form of CAM. When megavitamin therapy and prayer specifically
for health reasons are included in the definition of CAM the number rises to 62%.
o
In a recent study of adults 50 years and older, the American Association of Retired Persons
(AARP) and NCCAM reported that 2/3rds of respondents reported using CAM, yet only 1/3rd of
those discussed their use with their physician. Full details of this study can be found on the
NCCAM website at: http://nccam.nih.gov/timetotalk/.
§
Although this survey has been criticized because of low response rate (26%) and geographic response bias (primarily BC), it is
far more comprehensive in its content than any other national survey.
****
Note that data collected from 1997 and 2006 would be from different samples of the Canadian population.
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2.3
Commonly Used CAM

In the 2003 CCHS survey, Park5 found that consultations with chiropractors were most common
(11%), followed by massage therapists (8%) and acupuncturists (2%). ††

Esmail7 found that chiropractic was the most common form CAM used (40%), followed by massage
(35%), and relaxation techniques (20%). While the number of individuals who had tried chiropractic
went up from 1997, those trying massage and relaxation went down.
o Esmail reported that most people using CAM in the 12 months preceding the survey did so
for “wellness”—to prevent future illness from occurring or to maintain health and vitality.
The most common therapy used in this context was Yoga.

The Baseline NHP Survey found that the most commonly used NHPs were: Vitamins (57%),
Echinacea (15%), herbal remedies and algal and fungal products (11%).

In the U.S., prayer specifically for health reasons was the most commonly used CAM therapy,
followed by Natural Health Products (19%). The most commonly used NHPs were Echinacea (40%),
Ginseng (24%), and Ginkgo biloba (21%).
o Most people who use CAM use it to treat themselves; only about 12% of the survey
respondents sought care from a licensed CAM practitioner.

2.4
Most studies find regional differences in CAM use.
CAM use varies by health conditions

The 2003 CCHS survey5 indicated that 37% of individuals with fibromyalgia reported alternative
health care consultations in the past year, followed by 36% of individuals with back problems, and
33% of individuals with multiple chemical sensitivities.

Of the 10 most common medical conditions reported by the respondents in the Fraser Institute study 7
massage therapy, prayer, and relaxation techniques were the most common CAM used. Of the top 3
medical conditions, namely allergies (29%), back or neck problems (28%), and arthritis or
rheumatism (21%), suffers of back/neck problems and arthritis or rheumatism used chiropractic care
along with massage and relaxation.

According to Barnes et al.9 Americans are most likely to use CAM for back, neck, head, or joint aches,
as well as other painful conditions. CAM is also used for colds, anxiety or depression, gastrointestinal
disorders, and sleeping problems.
2.5
Who uses CAM
CAM use spans people of all backgrounds. But, the general trend indicates greater CAM use by:

Women

People who are younger (18-34 years)

People with higher educational levels

People with higher incomes

People who have been hospitalized in the past year

Former smokers, compared with current smokers or those who have never smoked.

People who live in Western Canada.
†† Remember that the CCHS (and NHPS) surveys do not include self-care practices (e.g., natural health products and meditation).
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2.6
Spending on CAM

Variation of CAM use reflects differences in coverage by provincial medical plans and extended health
plans as well as regulatory policies.

CAM use, particularly uninsured CAM, tends to rise with income. The 2003 CCHS5 found that 26% of
individuals in the highest household income group had used CAM in 2003 compared with 13% of
those in the lowest income group.

Esmail7 estimated that in the later half of 2005 and early half of 2006, Canadians spent more than
$7.84 billion on complementary and alternative medicines and therapies; an increase over the
$5.37 billion estimated to have been spent in the 12 months prior to the 1997 survey. Approximately
72% of the 7.84 billion was spent on providers (acupuncture, chiropractic, etc), 13% on books,
classes, equipment, etc, 12% on herbs and vitamins, and 3% on special diet programs.
2.7
Disclosure of CAM Use to Physician
Most people who use CAM use it in conjunction with conventional medicine.
Survey rates of disclosure of CAM use to physicians range widely from 23% to 90%.1
Reasons for not disclosing CAM use include:
o Patient’s perception that the physician did not need to know about CAM use (either not
important for physician to know or none of physician’s business).
o Physician did not ask or did not appear interested.
o Concern about a negative response from the medical practitioners.



3. Discussion
3.1
Questions for Discussion and/or Reflection

Ask students to search and summarize the literature on CAM use in a specific health condition or
population.

Discuss the limitations of survey data and with the comparison of data across surveys. Are these
shortcomings limited to CAM research?

Do you think the profile of CAM users is changing? Do you think CAM use is changing over time for
suffers of chronic conditions, for example?

As a physician, how can you foster openness with your patients to discuss CAM? It may be helpful
to read the CAMpod, Patient-Physician Communication about CAM to help prepare.
3.2
Readings
3.2.1 Annotated Readings
Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among
adults: United States, 2002. Advance Data May, 2004;343:1-20. Available at: URL:
http://nccam.nih.gov/news/report.pdf.
This report provides the most recent national estimates on CAM use in the United States. The
data presented was collected from the 2002 National Health Interview Survey (NHIS) conducted
from the Centers for Disease Control and Prevention’s National Center for Health Statistics. The
2002 NHIS is an improvement over the previous 1999 collection as it asks respondents about
their use of 27 different complementary therapies. It also presents the frequencies and adjusted
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percentages of adults who have ever used CAM and used CAM in the past 12 months. Summary
data and graphs are also available.
de Bruyn T. A summary of national data on complementary and alternative health care – current status and
future development: a discussion paper. 2002. Available at: http://www.hc-sc.gc.ca/dhpmps/pubs/complement/cahc-acps-summary-synthese/cahc-acps-summary-synthese_1_e.html
This paper provides a useful and more comprehensive summary of the information contained in
this CAMpod. This includes results from national population surveys as well as other individual
surveys. It also includes suggestions on how surveys could be refined to collect more useful data
on CAM. However, the article is becoming somewhat dated, particularly with regard to the
national population surveys presented.
Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: a review of qualitative and
quantitative studies. Comp Ther in Med. 2004;12:90-98. PMID: 15561518
This article provides a nice review of 12 studies published in the past decade that examined what
percentage of consumers did not to disclosure their CAM use to their physician and why. To
simplify comparisons across studies, the authors list (a) study design, (2) CAM usage, (3)
disclosure rate, and (4) reasons for non-disclosure in two tables. This is an American publication.
3.2.2 Reference List
1. Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: a review of qualitative and
quantitative studies. Comp Ther in Med. 2004;12:90-98.
2. Eisenberg DM, et al. Unconventional Medicine in the United States: prevalence, costs, and patterns of
use. NEJM. 1993:328:246-252.
3. Ernst E. Prevalence surveys: to be taken with a pinch of salt. Comp Ther in Clin Prac. 2006;12: 272-75.
4. Millar W. Pattern of alternative medicine use in Canada Health reports. 2001;13(1): Available at:
http://www.statcan.ca/english/studies/82-003/feature/hrab2001013001s0a01.htm.
5. Park J. Use of alternative health care. Statistics Canada: Health Reports. 2005;16(2):38-42. Available
from: www.statcan.ca/english/ads/82-003-XPE/pdf/16-2-04.pdf.
6. Ramsay C, Walker M, and Alexander J. Alternative Medicine in Canada: Use and Public Attitudes. Public
Policy Sources. 1999;21:3-31. Available from:
http://www.fraserinstitute.ca/admin/books/files/Altmed(v8).pdf.
7. Esmail N. Complementary and alternative medicine in Canada: trends in use and public attitudes, 19972006. Public Policy Sources. 2007;87:1-53. Available from:
http://www.fraserinstitute.org/Commerce.Web/product_files/Altmedicine.pdf.
8. Ernst E. Prevalence of use of complementary/alternative medicine: a systematic review. Bulletin of the
World Health Organization. 2000;78(2):252-256.
9. Barnes PM, Powell-Griner E, McFann K, Nahin RL. (2004). Complementary and alternative medicine use
among adults: United States, 2002. Advance Data May, 2004;343:1-20. Available at: URL:
http://nccam.nih.gov/news/report.pdf.
A citation list of surveys on CAM use in Canada is supplements this CAMpod. You can download it from
the CAM in UME Digital Resource Repository at: http://www.caminume.ca/drr/resources/pod_008a.doc.
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Appendix A
Statistics Canada and Health Canada Surveys
For a list of Canadian population surveys, go to: http://www.statcan.ca/english/rdc/whatdata.htm.

National Population Health Survey
The National Population Health Survey (NPHS) collects information related to the health of the
Canadian population and related socio-demographic information. It is composed of three
components: the Household, the Health Institutions, and the North components.
Conducted by Statistics Canada every two years, the NPHS Household component started in 19941995. The first three cycles (1994-1995, 1996-1997 and 1998-1999) were both cross-sectional and
longitudinal. Beginning in Cycle 4 (2000-2001), the survey became strictly longitudinal (i.e. collecting
health information from the same individuals each cycle for up to 20 years). The cross-sectional
component is now part of the Canadian Community Health Survey. The cross-sectional and
longitudinal documentation for the Household component is presented separately as well as the
documentation for the Health Institutions and North components.
In addition to a common set of questions asked in cycles 1, 2 and 3, the questionnaire included focus
content and supplements that changed from cycle to cycle. General health questions were asked
about each member of the selected household and specific health questions were asked to the
selected member of the household. For the complete list of topics covered by the NPHS over time,
please consult the NPHS Content, Household Component, Cycles 1 to 5.
http://www.statcan.ca/english/rdc/whatdata.htm

Canadian Community Health Survey
The Canadian Community Health Survey (CCHS) initiative began in 2000 with its main goals being the
provision of population-level information on health determinants, health status and health system
utilization. This series of surveys is a joint effort of Health Canada, Statistics Canada and the
Canadian Institute for Health Information (CIHI). The CCHS operates on a two-year data collection
cycle that comprises two types of surveys:

A general health survey takes place in the first year of the cycle (cycles 1.1, 2.1, and so on). It
samples approximately 130,000 Canadians and is designed to provide reliable estimates at the
provincial health region level.

A focused topic survey takes place in the second year of the cycle (cycles 1.2, 2.2, and so on)
and samples approximately 35,000 Canadians and is designed to provide provincial level results
on specific focused health topics.
In Canada, the primary use of the data is for health surveillance, such as in prevalence of disease
and other forms of health research. The data are used extensively by the research community and
other health professionals. The uniqueness of the CCHS arises from the regional nature of both
content and survey implementation. These aspects allow for analysis of health data at a regional
level, across Canada.
http://www.statcan.ca/english/rdc/whatdata.htm

Baseline Natural Health Products (NHP) Survey Among Consumers (March 2005)
http://www.hc-sc.gc.ca/dhp-mps/pubs/natur/eng_cons_survey_e.html
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