The current study identified discernible patterns of health-related behaviours in the Canadian adult population. Findings indicated that about 21% of Canadian adults report at least three adverse health-behaviours, which is consistent with other research in the general Canadian adult population . Overall, a higher proportion of Canadian men reported all adverse health-related behaviours compared to women, with the exception of inadequate sleep. This is in contrast to previously published work, which suggests that women are at an increased risk of sleep disorders, including insomnia and lower quality sleep, and that sleep dysregulation may have more severe health consequences for women . Sex-based patterns in groupings of health-related behaviours were present such that adverse behaviours co-occurred more strongly with current smoking among men and with high-risk alcohol use among women.
Fruit and vegetable intake, inadequate sleep, smoking, and inadequate physical activity all demonstrated an income and education gradient, consistent with other Canadian studies [5, 27]. The pathways between socioeconomic status and the various health-related behaviours are multiple and complex . Low-income neighbourhoods may be less likely to have facilities or locations such as parks, gyms or community centres that facilitate physical activity. Families may also shift towards cheaper, more energy-dense foods when incomes drop, often-forgoing high quality proteins, fruits, and vegetables . Although it is not clear whether lower income leads to shorter, lower quality sleep or vice versa, research suggests the correlation between poverty and sleep does exist [30, 31].
The consistent and significant association between socioeconomic status and several health-related behaviours, and how they occur together, underscores the necessity of addressing social determinants of health. Consideration of these associations could potentially maximize effective, targeted interventions in low socioeconomic groups, subsequently reducing the adverse health effects of these behaviours. The need to address social determinants is further supported by growing evidence of the limited tractability of many health-related behaviours [32,33,34].
Alcohol use has shown a two-way relationship with socioeconomic status; risky or heavy alcohol use has been shown to predict unemployment, and unemployment increases the odds of problem alcohol use among young men in the UK . Furthermore, lower lifetime income trajectories were associated with higher odds of both adult alcohol abstinence and heavy drinking in US adults . The lack of socioeconomic gradient for high-risk alcohol use in the present study may be specific to the Canadian context and time period, or it may reflect the criteria used to dichotomize high- and low-risk alcohol use. Notably, high-risk alcohol use in Canada has increased over time .
Results from our study also reveal sex differences in the co-occurrence of health-related behaviours. High-risk alcohol use in women demonstrated increased odds of all other adverse health-related behaviours examined in this study. This pattern did not hold true for men. To interpret these differences and conduct a SGBA  it is important to discuss sex and gender, and their respective influences on health-related behaviours. The sex differences observed may be related to the rise in binge drinking among young Canadian women , which may be driven by a number of social factors. For example, relatively recently women have experienced increased participation in the workforce and subsequently increased income , and cultural norms related to alcohol use for women have changed such that it is more acceptable for women to binge-drink . Importantly, women are more likely to consume alcohol in response to negative emotions and stress as compared to men , but women also view alcohol as an important and pleasurable aspect of their social life .
The increasing rates of alcohol-related hospitalization of Canadian women  and recently published recommendations that deem no amount of alcohol is safe , suggest that further research examining drinking among Canadian women is needed. We have previously reported that Canadian women who report high-risk alcohol use also report better self-rated health , suggesting future avenues of research should focus on the sociological aspects to explain why women drink alcohol. A particular focus on Canadian women in the workforce may be warranted given the lack of socioeconomic gradient in high-risk alcohol use and the potential role of stress in driving these relationships between health-related behaviours.
For men, smoking was a significant predictor of all other health-related behaviours, which was not the case for women. Similar to the relationships observed with high-risk alcohol use among women, it is important to consider both sex and gender  in the interpretation of relationships of health-related behaviours and smoking among men. The Surgeon General’s Report concluded that women who smoke are more susceptible to depression and anxiety disorders than non-smokers, and that women trying to quit smoking relapse for different reasons than men . Women are more likely to use smoking as a coping mechanism for stress, weight control and negative emotions, while men who smoke do so more for stimulation and in pleasurable settings . Smoking is strongly associated with alcohol use among men , which is, at least partially, due to increased pleasure from smoking cigarettes when consuming alcohol . Neuroimaging studies also suggest that smoking activates men’s reward pathways more than women’s, consistent with the idea that men smoke for the reinforcing effects of nicotine . Taken together, these results suggest both sex and gender differences, i.e. social differences, may be affecting different relationships between smoking and other health-related behaviours among men and women.
The different patterns of relationships between health-related behaviours, particularly concerning smoking or high-risk alcohol use, suggest pleasure and behaviors associated with sociability remain strong influencers of behavior, regardless of public health recommendations. Public health, when urging behavior modification or abstinence, must grapple with the legitimate value of pleasure in individuals’ lives, particularly when considering issues of health equities [49, 50].
The study is subject to limitations. The pooling of samples from two time periods has limitations, namely if a large change has occurred in the sample populations, for example age structure. Given the close time period of data collection between the two surveys though, any change is likely to be fairly minimal. Importantly, the survey questions that were used in the present study did not change between the two surveys. Research that is dependent upon voluntary subject participation is particularly vulnerable to sampling bias. Notably, the CHMS has a low response rate, which may have impacted the analysis reported here, specifically in terms of underestimating adverse health-related behaviours. Response bias of self-assessed behaviour has been observed in the literature, potentially resulting in underestimation in prevalence of health-related behaviours . Unfortunately, we are unable to test for differences among respondents and those who did not participate, which limits our ability to speculate as to how non-response may have influenced relationships between health-related behaviours. The lower response rate for the questions related to alcohol use is also a limitation and may have influenced the results. Finally, all health-related behaviours have been dichotomized. Each health-related behaviour has demonstrated a dose response relationship or J-shaped relationship with a variety of health outcomes. Regardless of threshold effects, some information may have been lost through dichotomizing, such as grouping former smokers with never smokers in the non-smoker group.