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Public crack cocaine smoking and willingness to use a supervised inhalation facility: implications for… DeBeck, Kora; Buxton, Jane; Kerr, Thomas; Qi, Jiezhi; Montaner, Julio; Wood, Evan Feb 23, 2011

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RESEARCH Open AccessPublic crack cocaine smoking and willingness touse a supervised inhalation facility: implicationsfor street disorderKora DeBeck1, Jane Buxton2, Thomas Kerr1,3, Jiezhi Qi1, Julio Montaner1,3, Evan Wood1,3*AbstractBackground: The health risks of crack cocaine smoking in public settings have not been well described. Wesought to identify factors associated with public crack smoking, and assess the potential for a supervised inhalationfacility to reduce engagement in this behavior, in a setting planning to evaluate a medically supervised crackcocaine smoking facility.Methods: Data for this study were derived from a Canadian prospective cohort of injection drug users. Usingmultivariate logistic regression we identified factors associated with smoking crack cocaine in public areas. Amongpublic crack smokers we then identified factors associated with willingness to use a supervised inhalation facility.Results: Among our sample of 623 people who reported crack smoking, 61% reported recently using in publiclocations. In multivariate analysis, factors independently associated with public crack smoking included: daily crackcocaine smoking; daily heroin injection; having encounters with police; and engaging in drug dealing. In subanalysis, 71% of public crack smokers reported willingness to use a supervised inhalation facility. Factorsindependently associated with willingness include: female gender, engaging in risky pipe sharing; and havingencounters with police.Conclusion: We found a high prevalence of public crack smoking locally, and this behavior was independentlyassociated with encounters with police. However, a majority of public crack smokers reported being willing to usea supervised inhalation facility, and individuals who had recent encounters with police were more likely to reportwillingness. These findings suggest that supervised inhalation facilities offer potential to reduce street-disorder andreduce encounters with police.BackgroundThe use of illicit drugs in public settings, includingstreet, alleys and parks is both a public health and pub-lic order concern in many urban areas [1-3]. To date,the use of injection drugs in public settings has receivedthe most attention from policy-makers and public healthresearchers [2,4,5]. Public injecting is known to presentproblems for citizens who reside in or around areaswhere public drug use is prevalent, and scientific studieshave documented that using injection drugs in publicsettings can discourage safer injecting practices resultingin many public health problems, including increased riskfor drug overdose events and HIV and other blood-borne infections [6-8]. As a result, some cities haveimplemented supervised injection facilities which aim toprovide an alternative injecting environment thatreduces both the health risks associated with injectiondrug use and the street disorder it can generate [9-13].While supervised injection facilities have been noted tohave measurable success in achieving these public healthand public order objectives, the use of inhalable drugs,particularly crack cocaine smoking, has been growing inpopularity in many street-based drug scenes [14-16].In Vancouver, Canada the popularity of crack cocaineand ease of administration through smoking has madepublic crack cocaine use a common feature of thestreets in the city’s drug use epicentre, known as theDowntown Eastside [17]. Public crack cocaine smoking* Correspondence: uhri-ew@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, CanadaFull list of author information is available at the end of the articleDeBeck et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:4http://www.substanceabusepolicy.com/content/6/1/4© 2011 DeBeck et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.is posing a growing burden for law enforcement agen-cies responsible for maintaining public order [18]. Inaddition, the health and social harms associated withcrack cocaine smoking are extensive. Compared to otherdrug user populations, crack users are more likely toengage in risky behaviors [19-21] and illegal activities[22,23] and to experience homelessness [14] and healthproblems [14,24-27], yet are less likely to access healthand social services [28]. It has also been recently docu-mented that daily crack cocaine smokers are at a four-fold greater risk of contracting HIV compared to theirdrug using peers who smoke crack cocaine less often ornot at all [16].Given the dramatic rise in crack cocaine smoking andthe public order and public health concerns associatedwith it, the need for targeted interventions for peoplewho smoke crack cocaine is unambiguous. One poten-tial intervention that is receiving increasing attentionfrom public health officials, health researchers and localcommunity groups is supervised drug consumptionfacilities analogous to supervised injection sites but thataccommodate crack smoking and distribute drug con-sumption materials specific to safer inhalation (such assterile crack pipes, mouthpieces, and screens) [16,29-33].The Canadian Institutes of Health Research recentlyapproved funding to conduct a randomized control trialto evaluate the impact of a supervised inhalation facilityon access to medical and social services, particularlyaddiction treatment, among Vancouver-based crackcocaine smokers [34].Previous studies have assessed general willingnessamong local drug users to use a supervised inhalationfacility [35,36]; however, these studies were not primar-ily concerned with street disorder and therefore did notconsider the specific risks associated with smoking crackcocaine in public areas nor did they assess willingnessto use an inhalation facility among public crack cocainesmokers exclusively. Therefore we conducted a studyfocused on public crack smokers to identify factors asso-ciated with this practice. We also sought to assess will-ingness to use an inhalation facility among individualswho smoke crack cocaine in public areas to determinethe potential impact a supervised inhalation facilitymight have on street disorder in Vancouver, Canada.MethodsData for this study was obtained from the VancouverInjection Drug Users Study, which is an open prospec-tive cohort that began enrolling people who inject drugs(IDU) through street outreach as self-referral in May1996. This study has been described in detail previously[37,38]. In brief, to be eligible participants at recruit-ment must reside in the Greater Vancouver RegionalDistrict, have injected illicit drugs in the previousmonth, and provide written informed consent. Atenrollment and on bi-annual basis participants completean interviewer-administered questionnaire, and after anexamination with a study nurse provide a blood samplefor serologic testing. At each study visit participants areprovided with a stipend ($20 CDN) for their time. Thestudy has received ethics approval from St. Paul’s Hospi-tal and the University of British Columbia’s ResearchEthics Board. The present analyses are restricted tothose participants who reported smoking crack cocainein the last six months, and were seen for study follow-up during the period of November 2008 and June 2009as measures for one of our outcomes of interest areavailable only for this sample period.In our first analysis among crack cocaine smokers, theoutcome of interest was using drugs (non-injection) inpublic areas in the last six months. As in previous ana-lyses, public areas included city streets, parks, publicwashrooms, parking lots, clubs or bars and abandonedbuildings. To characterize our outcome of interest wea priori selected a range of socio-demographic andbehavioural variables we hypothesized might be relevantto smoking crack cocaine in public areas. This selectionwas informed by the ‘risk environment framework’ andprevious analyses among street-involved drug usershighlighting connections between social, structural andenvironmental level factors and risky drug consumptionpractices [14,31,39-41]. Variables included: age (per yearolder); gender (female vs. male); Aboriginal Ancestry(yes vs. no); limited access to private space, defined asanswering “no” to the question: “Do you have a privateindoor space for socializing with friends and acquain-tances?” or reporting that the number of guests theywere allowed to have in their residence at one time wasrestricted to less than three (yes vs. no); daily cocaineinjection (yes vs. no); daily heroin injection (yes vs. no);daily crack cocaine smoking (yes vs. no); non-fatal over-dose, self identified by participants (yes vs. no); encoun-ters with police in the last month, defined as beingquestioned, searched or stopped by police (yes vs. no);being a victim of violence defined as being physicallyassaulted (yes vs. no); sex trade involvement, defined asexchanging sex for money, shelter, drugs or other com-modities (yes vs. no), and participation in drug dealing(yes vs. no). Unless otherwise stated, all drug use andbehavioural variables refer to the previous six monthperiod.In a second analysis, we sought to assess and identifypredictors of willingness to use a supervised inhalationroom. Because we were particularly concerned withpublic drug use we restricted our sample to crackcocaine smokers that reported recently using non-injection drugs in public areas. To measure willingnesswe asked participants “If there was a safe place toDeBeck et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:4http://www.substanceabusepolicy.com/content/6/1/4Page 2 of 8smoke your drugs (ventilated inhalation room), close towhere you buy or use, would you use it?”Variables of interest for our second analysis were alsoselected a priori based on factors we hypothesizedmight be associated with willingness to use an inhalationroom. These included age (per year older); gender(female vs. male); Aboriginal Ancestry (yes vs. no); lim-ited access to private space, as defined above (yes vs.no); drug scene exposure, defined as spending an aver-age of seven or more hours on the street each day inVancouver’s drug use epicentre in the previous sixmonths (yes vs. no); most drug use in public areas,defined based on reports that public locations werewhere they most frequently used drugs (yes vs. no);daily crack cocaine smoking (yes vs. no); risky pipe shar-ing, defined as reporting sharing a crack pipe or mouth-piece in the same six month period as having burns orsores on their mouth (yes vs. no); encounters withpolice in the last month (yes vs. no); and being a victimof violence (yes vs. no). As above, unless otherwise sta-ted, all drug use and behavioural variables refer to theprevious six month period.For both of our first and second analyses, we usedunivariate and multivariate statistics to determine fac-tors associated with our outcomes of interest. In uni-variate analysis categorical explanatory variables wereanalyzed using Pearson’s chi-square test and continuousvariables were analyzed using the Wilcoxon rank sumtest. Fisher’s exact test was used when one or more ofthe cell counts was less than or equal to five. To evalu-ate factors independently associated with our outcomesof interest, all variables that were p < 0.05 in univariateanalyses were entered into the respective multivariateregression models. All statistical analyses were per-formed using SAS software version 9.1 (SAS, Cary, NC).All p-values are two sided.ResultsDuring the study period 623 participants were seen forstudy follow-up visits and reported smoking crackcocaine in the last six months. These included 249(40%) women and 231 (37%) persons who identified asAboriginal. The median number of times that partici-pants reported smoking crack cocaine in an average daywas 4 (interquartile range = 2-10). Among our sampleof 623 crack smokers, a total of 382 (61%) reportedusing in public areas in the last six months. The charac-teristics of the study sample stratified by public drug useare presented in Table 1, and the univariate analyses ofbehavioral and socio-demographic variables associatedwith public drug use among crack cocaine smokers arepresented in Table 2. The results of the multivariatelogistic regression for factors associated with publicdrug use among crack cocaine smokers are also shownin Table 2. Factors that remained independently asso-ciated with our outcome of interest included: dailyheroin injection, daily crack cocaine smoking, encoun-ters with police and drug dealing (see Table 2).For our second analysis, the demographic and beha-vioural characteristics of public crack cocaine smokersstratified by willingness to use a supervised inhalationroom are presented in Table 3, and the univariateresults of factors associated with willingness to use aTable 1 Characteristics of crack cocaine smokersstratified by public drug use (n = 623)Public drug useaCharacteristic Yes n= 382,n (%)No n= 241,n (%)Age pre year older(Median, IQR)c 43 (37-49) 46 (40-50)Female GenderYes 145 (38) 104 (43)No 237 (62) 137 (57)Aboriginal AncestryYes 137 (36) 94 (39)No 245 (64) 147 (61)Limited Access to PrivateSpacedYes 316 (83) 169 (70)No 66 (17) 72 (30)Daily Cocaine Injection dYes 39 (10) 9 (4)No 343 (90) 232 (96)Daily Heroin Injection dYes 107(28) 25 (10)No 275 (72) 216 (90)Daily Crack Smoking dYes 220 (58) 72 (30)No 162 (42) 169 (70)Overdose (non-fatal)dYes 18 (5) 3 (1)No 364 (95) 238 (99)Encounters with police eYes 114 (30) 35 (15)No 268 (70) 206 (85)Victim of Violence dYes 77 (20) 30 (12)No 305 (80) 211 (88)Sex Trade dYes 60 (16) 19 (8)No 322 (84) 222 (92)Drug Dealing dYes 150 (39) 46 (19)No 232 (61) 195 (81)Note: a Public locations include: city streets, parks, public washrooms, parkinglots, clubs or bars, and abandon buildings; c IQR = Inter Quartile Range; dDenotes activities or situations referring to previous 6 months; e Denotesactivities or situations referring to previous month.DeBeck et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:4http://www.substanceabusepolicy.com/content/6/1/4Page 3 of 8supervised inhalation room are presented in Table 4.The results of the multivariate logistic regression forfactors associated with willingness to use a supervisedinhalation room are also shown in Table 4. Factors thatremained independently associated with willingnessincluded: female gender, risky pipe sharing and recentencounters with police (see Table 4.).DiscussionWe found that the majority of crack cocaine smokersin our study reported having used drugs in publicareas at some point in the last six months. This groupwas more likely to be higher-intensity drug users withrespect to heroin injection and crack cocaine smoking,have encounters with the police and be involved indrug dealing. Of these public crack cocaine smokers,71% reported being willing to use a supervised inhala-tion room if one was available. Individuals whoreported being willing were more likely to be female,engage in risky pipe sharing and have encounters withthe police.The profile of public crack cocaine smokers as higher-intensity drug users who have interactions with thecriminal justice system is reflective of previous findingsdescribing public injection drug user populations [1,5].The association between drug dealing and public crackuse may reflect the increased amount of time individualsspend on the street when engaged in street-level drugdealing. It may also be a function of the accessibility ofdrugs and additional resources gained through drugdealing which may lead to greater drug consumptionand hence a greater likelihood for consuming in publicareas [23].Our finding that 71% of public crack cocaine smokersare willing to use an inhalation facility also supports pre-vious willingness estimates conducted among the generalpopulation of Vancouver-based illicit drug users and sug-gests that an intervention of this nature will likely reachthe target population [36]. The high degree of willingnessthat this study found among public crack cocaine smo-kers to use an inhalation facility suggests that, like super-vised injection facilities, these interventions are likely toTable 2 Univariate and multivariate analyses of factors associated with public drug use among crack cocaine smokersa(n = 623)Univariate MultivariateCharacteristic ORb (95% CI) p-valuec AOR (95% CI) p-valueOlder AgePer year older 0.96 (0.94 - 0.98) <0.001 0.98 (0.96 - 1.00) 0.065GenderFemale vs. Male 0.81 (0.58 - 1.12) 0.197Aboriginal AncestryYes vs. No 0.87 (0.63 - 1.22) 0.429Limited Access to Private Space dYes vs. No 2.04 (1.39 - 2.99) <0.001 1.49 (0.99 - 2.26) 0.058Daily Cocaine Injection dYes vs. No 2.93 (1.39 - 6.17) 0.003 1.70 (0.77 - 3.75) 0.190Daily Heroin Injection dYes vs. No 3.36 (2.10 - 5.38) <0.001 1.95 (1.17 - 3.27) 0.011Daily Crack Cocaine Smoking dYes vs. No 3.19 (2.26 - 4.49) <0.001 2.17 (1.49 - 3.14) <.001Overdose (non-fatal)* dYes vs. No 3.92 (1.13 - 20.98) 0.020 2.04 (0.55 - 7.61) 0.288Encounters with Police eYes vs. No 2.50 (1.64 - 3.81) <0.001 1.69 (1.07 - 2.68) 0.025Victim of Violence dYes vs. No 1.78 (1.12 - 2.80) 0.013 1.52 (0.92 - 2.51) 0.100Sex Trade dYes vs. No 2.18 (1.26 - 3.75) 0.004 1.30 (0.72 - 2.38) 0.386Drug Dealing dYes vs. No 2.74 (1.87 - 4.01) <0.001 1.61 (1.06 - 2.47) 0.027Note: a Public areas included: city streets, parks, public washrooms, parking lots, clubs or bars, and abandon buildings; bOR = Odds Ratio, CI = ConfidenceInterval; AOR = Adjusted Odds Ratio; cUnless otherwise stated, values are based on Pearson’s chi-square test for categorical variables and Wilcoxon rank sum testfor continuous variables with 1 degree of freedom; d Denotes activities or situations referring to previous 6 months; e Denotes activities or situations referring toprevious month. *p-value and 95% CI reported from Fisher’s Exact Test as 25% of cells had expected counts less than 5.DeBeck et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:4http://www.substanceabusepolicy.com/content/6/1/4Page 4 of 8successfully encourage public drug users to relocate toindoor venues.The increased likelihood of being willing to use aninhalation facility among female participants may reflectheightened vulnerability of women involved in streetdrug use and it is noteworthy that Vancouver’s super-vised injection facility has had success in attracting vul-nerable female drug users and providing them with saferalternatives to street-based drug using venues. In pre-vious research female IDU have described the uniquerole that Vancouver’s supervised injection facility hasplayed in promoting their physical security and healthsafety [42].Interestingly, one of the common features among bothpublic crack cocaine smokers and those who are willingto use a supervised inhalation facility is their elevatedlikelihood of recently having encounters with law enfor-cement. This suggests that public crack cocaine smokerswho are the subject of law enforcement attention arevery willing to relocate to alternative off-street andhealth-focussed environments if they were made avail-able. Indeed, our data indicate that 81% of public crackcocaine smokers who have had a recent encounter withpolice are willing to use a supervised inhalation facility.A key implication of these findings is that there is alarge demand for supervised inhalation rooms amongindividuals that are potentially key contributors to drug-related street disorder. The association between publiccrack smoking and encounters with police suggests thatinterventions of this nature are likely to target a criticalsub-population of drug users and could be a valuabletool for police in the management of street disorder.Previous studies have found that Vancouver police regu-larly refer public injection drug users to the local super-vised injection facility [43]. Since our analysis indicatesthat local police are already frequently interacting withpublic crack smokers the establishment of a supervisedinhalation facility could provide a unique opportunityfor police to direct this vulnerable group to a low-threshold service where they will have opportunities tobe linked with appropriate health and social services.It is critical to note that although this study suggeststhat supervised inhalation facilities could aid in thereduction of public disorder, drug consumption facilitiesdo not address the route causes of street disorder andare not appropriate substitutes for other essential healthand social interventions such as supportive housing andaddiction treatment. To be effective supervised inhala-tion facilities should be integrated into broader compre-hensive approaches to addressing the problemsassociated with illicit drug addiction.This study has a number of limitations. Firstly, VIDUSis a community recruited non-randomized sample andtherefore our findings may not be generalizable to othersettings. If supervised inhalation facilities are being con-sidered in other settings, willingness studies should beconducted among the local target population and shouldnot rely on the findings emerging from our setting. Thegeneralizability of our findings is also limited by ourstudy sample which was restricted to individuals with ahistory of injection drug use. Crack cocaine smokerswho did not have a history of injection drug use werenot eligible for our study. Given the harms associatedwith injection drug use we anticipate that if a selectionTable 3 Characteristics of crack cocaine smokers who usedrugs in public stratified by willingness to use asupervised inhalation room (n = 382)Willing to use SIR aCharacteristic Yes n= 271,n (%)No n= 111,n (%)Age pre year older(Median, IQR)c 43 (37-49) 44 (37-48)Female GenderYes 117 (43) 28 (25)No 154 (57) 83 (75)Aboriginal AncestryYes 108 (40) 29 (26)No 163 (60) 82 (74)Limited Access to PrivateSpace eYes 230 (85) 86 (77)No 41 (15) 25 (23)Drug Scene Exposure e, fYes 157 (58) 49 (44)No 114 (42) 62 (56)Most Drug Use in Public AreaseYes 140 (52) 43 (39)No 131 (48) 68 (61)Daily Crack Cocaine Smoking eYes 164 (61) 56 (50)No 107 (39) 55 (50)Risky Pipe Sharing eYes 38 (14) 3 (3)No 233 (86) 108 (97)Encounters with Police dYes 92 (34) 22 (20)No 179 (66) 89 (80)Victim of Violence eYes 53 (20) 24 (22)No 218 (80) 87 (78)Note: c IQR = Inter Quartile Range; d Denotes activities or situations referringto previous 6 months; e Denotes activities or situations referring to previousmonth; f Drug scene exposure was defined as spending an average of 7 ormore hours on the street each day in Vancouver’s drug use epicenter in theprevious six months.DeBeck et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:4http://www.substanceabusepolicy.com/content/6/1/4Page 5 of 8effect were present it would likely bias our sampletowards high risk drug users, suggesting that this groupwould be an appropriate target population for publichealth intervention. We should also note that amongour study sample daily crack cocaine smoking was sig-nificantly more common than daily injecting, suggestingthat despite the requirement of a history of injecting,our sample represents a primarily crack cocaine smok-ing population. Secondly, some of our measures reliedon self-report and could be vulnerable to socially desir-able reporting. This would have likely been of most rele-vant to our measure of willingness, since respondentsmight perceive a pressure to report being willing toengage with low-threshold services of this nature giventhe widespread activism among local drug users in ourstudy setting to implement supervised drug consump-tion facilities [32]. While it is possible that some respon-dents may over-report willingness, a previous studycomparing measures of willingness to use a supervisedinjection facility before it was established with laterreports of actual attendance after an injection facilitywas established suggests that willingness measures aregood predictors of later behaviour among thispopulation [44]. Lastly, socially desirable reporting couldhave influenced reports of stigmatized behaviour, suchas public drug use leading to an underestimation ofpublic crack smoking. If social desirability was an issuein our study we suspect our finding would be a conser-vative indication of the prevalence of and harms asso-ciated with public drug use among crack cocainesmokers.In summary, our study found that locally public cracksmoking is a common practice that is also associatedwith recent encounters with police. We found that themajority of public crack smokers were willing to use aninhalation facility if one were available. Furthermore,public crack smokers who had recent encounters withpolice were even more likely to be willing to use aninhalation room, suggesting that supervised inhalationfacilities may offer unique opportunities to decrease onecomponent of drug-related street disorder and reducethe burden on local law enforcement agencies.FundingThe study was supported by the US National Institutesof Health (R01DA011591) and (R01DA021525) and theTable 4 Univariate and multivariate analyses of factors associated with willingness to use a supervised inhalationroom among participants that smoke crack cocaine and use drugs in public locations (n = 382)Univariate MultivariateCharacteristic ORa (95% CI) p-valueb AORc (95% CI) p-valueOlder AgePer year older 1.01 (0.98 - 1.04) 0.446GenderFemale vs. Male 2.25 (1.38 - 3.68) 0.001 2.11 (1.26 - 3.55) 0.005Aboriginal AncestryYes vs. No 1.87 (1.15 - 3.05) 0.011 1.61 (0.96 - 2.72) 0.072Limited Access to Private Space dYes vs. No 1.63 (0.94 - 2.84) 0.083Drug Scene Exposure dYes vs. No 1.74 (1.12 - 2.72) 0.014 1.40 (0.86 - 2.28) 0.181Most Drug Use in Public Areas dYes vs. No 1.69 (1.08 - 2.65) 0.022 1.39 (0.85 - 2.28) 0.187Daily Crack Cocaine Smoking dYes vs. No 1.51 (0.96 - 2.35) 0.071Binge Drug Use dYesRisky Pipe Sharing* dYes vs. No 5.87 (1.79 - 30.29) <0.001 5.50 (1.63 - 18.56) 0.006Encounters with Police eYes vs. No 2.08 (1.22 - 3.53) 0.006 2.09 (1.20 - 3.65) 0.010Victim of Violence dYes vs. No 0.88 (0.51 - 1.52) 0.648Note: aOR = Odds Ratio, CI = Confidence Interval; bUnless otherwise stated, values are based on Pearson’s chi-square test for categorical variables and Wilcoxon ranksum test for continuous variables with 1 degree of freedom; cAOR = Adjusted Odds Ratio; dDenotes activities or situations referring to previous 6 months; e Denotesactivities or situations referring to previous month. *p-value and 95% CI reported from Fisher’s Exact Test as 25% of cells had expected counts less than 5.DeBeck et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:4http://www.substanceabusepolicy.com/content/6/1/4Page 6 of 8Canadian Institutes of Health Research (MOP-79297,RAA-79918). Thomas Kerr is supported by the MichaelSmith Foundation for Health Research and the CanadianInstitutes of Health Research. Kora DeBeck is supportedby a Michael Smith Foundation for Health ResearchSenior Graduate Trainee Award and a Canadian Insti-tutes of Health Research Doctoral Research Award. JulioMontaner has received an Avant-Garde award(DP1DA026182) from the National Institute of DrugAbuse, US National Institutes of Health.AcknowledgementsThe authors thank the study participants for their contribution to theresearch, as well as current and past researchers and staff. We wouldspecifically like to thank Deborah Graham, Tricia Collingham, Carmen Rock,Peter Vann, Caitlin Johnston, Steve Kain, and Calvin Lai for their research andadministrative assistance.Author details1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada.2School of Population and Public Health, University of British Columbia,Vancouver, Canada. 3Division of AIDS, Department of Medicine, University ofBritish Columbia, Vancouver, Canada.Authors’ contributionsThe specific contributions of each author are as follows: KD, TK, and EWwere responsible for study design; JQ conducted the statistical analyses; KDprepared the first draft of the analysis; TK, JB, JM and EW contributed to themain content and provided critical comments on the final draft. All authorsapproved the final manuscript.Competing interestsJM has received grants from, served as an ad hoc advisor to, or spoke atvarious events sponsored by; Abbott, Argos Therapeutics, Bioject Inc,Boehringer Ingelheim, BMS, Gilead Sciences, GlaxoSmithKline, Hoffmann-LaRoche, Janssen-Ortho, Merck Frosst, Pfizer, Schering, Serono Inc,TheraTechnologies, Tibotec, Trimeris.Authors declare no other competing interests.Received: 4 November 2010 Accepted: 23 February 2011Published: 23 February 2011References1. Navarro C, Leonard L: Prevalence and factors related to public injectingin Ottawa, Canada: implications for the development of a trial saferinjecting facility. International Journal of Drug Policy 2004, 15(4):275-284.2. Cusick L, Kimber J: Public perceptions of public drug use in four UKurban sites. International Journal of Drug Policy 2007, 18(1):10-17.3. Weisburd D, Mazerolle LG: Crime and Disorder in Drug Hot Spots:Implications for Theory and Practice in Policing. 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Shannon K, Rusch M, Morgan R, Oleson M, Kerr T, Tyndall MW: HIV andHCV prevalence and gender-specific risk profiles of crack cocainesmokers and dual users of injection drugs. Subst Use Misuse 2008, 43(3-4):521-534.25. McCoy CB, Lai S, Metsch LR, Messiah SE, Zhao W: Injection drug use andcrack cocaine smoking: independent and dual risk behaviors for HIVinfection. Ann Epidemiol 2004, 14(8):535-542.26. Kral AH, Bluthenthal RN, Booth RE, Watters JK: HIV seroprevalence amongstreet-recruited injection drug and crack cocaine users in 16 USmunicipalities. Am J Public Health 1998, 88(1):108-113.27. Cook JA, Burke-Miller JK, Cohen MH, Cook RL, Vlahov D, Wilson TE,Golub ET, Schwartz RM, Howard AA, Ponath C, Plankey MW, Levine AM,Grey DD: Crack cocaine, disease progression, and mortality in amulticenter cohort of HIV-1 positive women. AIDS 2008, 22(11):1355-1363.28. Booth RE, Kwiatkowski CF, Weissman G: Health-related service utilizationand HIV risk behaviors among HIV infected injection drug users andcrack smokers. Drug Alcohol Depend 1999, 55(1-2):69-78.29. Blackwell T: ’Safe crack’ houses urged. National Post 2009 [http://www.nationalpost.com/Safe+crack+houses+urged/2121292/story.html].30. Stueck W: BC health officer calls for crack-inhaling rooms. Globe and Mail2009, A:1-5.31. Fischer B, Rudzinski K, Ivsins A, Gallupe O, Patra J, Krajden M: Social, healthand drug use characteristics of primary crack users in three mid-sizedcommunities in British Columbia, Canada. Drugs: education, preventionand policy 2010, 17(4):333-353.DeBeck et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:4http://www.substanceabusepolicy.com/content/6/1/4Page 7 of 832. Guillemette D: Vancouver to open illegal smoking site for crack cocaine.The Thunderbird 2009 [http://thethunderbird.ca/2009/10/30/vancouver-to-open-illegal-smoking-site-for-crack-cocaine/].33. Canadian National Specialty Society for Community Medicine: NSSCMPosition Statement: Supervised Drug Consumption Sites and InSiteprogram. 2009 [http://www.nsscm.ca/files/POSITION_ON_SUPERVISED_CONSUMPTION_SITES.pdf].34. Canadian Institutes of Health Research: Funding decisions. 2010 [http://www.cihr-irsc.gc.ca/e/193.html].35. Collins CL, Kerr T, Kuyper LM, Li K, Tyndall MW, Marsh DC, Montaner JS,Wood E: Potential uptake and correlates of willingness to use asupervised smoking facility for noninjection illicit drug use. J UrbanHealth 2005, 82(2):276-284.36. Shannon K, Ishida T, Morgan R, Bear A, Oleson M, Kerr T, Tyndall MW:Potential community and public health impacts of medically supervisedsafer smoking facilities for crack cocaine users. Harm Reduct J 2006, 3:1.37. Kerr T, Stoltz J, Tyndall M, Li K, Zhang R, Montaner J, Wood E: Impact of amedically supervised safer injection facility on community drug usepatterns: a before and after study. BMJ 2006, 332(7535):220.38. Wood E, Lloyd-Smith E, Li K, Strathdee SA, Small W, Tyndall MW,Montaner JS, Kerr T: Frequent needle exchange use and HIV incidence inVancouver, Canada. Am J Med 2007, 120(2):172-179.39. Rhodes T: The ‘risk environment’: a framework for understanding andreducing drug-related harm. International J Drug Policy 2002, 13(2):85-94.40. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA: The socialstructural production of HIV risk among injecting drug users. Soc Sci Med2005, 61(5):1026-44.41. Rhodes T: Risk environments and drug harms: A social science for harmreduction approach. Int J Drug Policy 2009, 20(3):193-201.42. Fairbairn N, Small W, Shannon K, Wood E, Kerr T: Seeking refuge fromviolence in street-based drug scenes: women’s experiences in NorthAmerica’s first supervised injection facility. Soc Sci Med 2008,67(5):817-823.43. DeBeck K, Wood E, Zhang R, Tyndall M, Montaner J, Kerr T: Police andpublic health partnerships: evidence from the evaluation of Vancouver’ssupervised injection facility. Subst Abuse Treat Prev Policy 2008, 3:11.44. DeBeck K: Drug-related street disorder: Evidence for public policyresponses. Published PhD Dissertation University of British Columbia,Vancouver, Canada; 2010.doi:10.1186/1747-597X-6-4Cite this article as: DeBeck et al.: Public crack cocaine smoking andwillingness to use a supervised inhalation facility: implications for streetdisorder. Substance Abuse Treatment, Prevention, and Policy 2011 6:4.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitDeBeck et al. Substance Abuse Treatment, Prevention, and Policy 2011, 6:4http://www.substanceabusepolicy.com/content/6/1/4Page 8 of 8


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