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Social influences upon injection initiation among street-involved youth in Vancouver, Canada: a qualitative… Small, Will; Fast, Danya; Krusi, Andrea; Wood, Evan; Kerr, Thomas Apr 30, 2009

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ralSubstance Abuse Treatment, ssBioMed CentPrevention, and PolicyOpen AcceResearchSocial influences upon injection initiation among street-involved youth in Vancouver, Canada: a qualitative studyWill Small1, Danya Fast1, Andrea Krusi1, Evan Wood1,2 and Thomas Kerr*1,2Address: 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrarrd St, Vancouver, BC V6Z 1Y6, Canada and 2Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, CanadaEmail: Will Small - wsmall@cfenet.ubc.ca; Danya Fast - dfast@cfenet.ubc.ca; Andrea Krusi - akrusi@cfenet.ubc.ca; Evan Wood - uhri-ew@cfenet.ubc.ca; Thomas Kerr* - uhri-tk@cfenet.ubc.ca* Corresponding author    AbstractBackground: Street-involved youth are a population at risk of adopting injection as a route ofadministration, and preventing the transition to injection drug use among street youth representsa public health priority. In order to inform epidemiological research and prevention efforts, weconducted a qualitative study to investigate the initiation of injection drug use among street-involved youth in Vancouver, Canada.Methods: Qualitative interviews with street youth who inject drugs elicited descriptions of theadoption of injection as a route of administration. Interviewees were recruited from the At-RiskYouth Study (ARYS), a cohort of street-involved youth who use illicit drugs in Vancouver, Canada.Audio recorded interviews were transcribed verbatim and a thematic analysis was conducted.Results: 26 youth aged 16 to 26 participated in this study, including 12 females. Among studyparticipants the first injection episode frequently featured another drug user who facilitated theinitiation of injecting. Youth narratives indicate that the transition into injecting is influenced bysocial interactions with drug using peers and evolving perceptions of injecting, and rejectingidentification as an injector was important among youth who did not continue to inject. It appearsthat social conventions discouraging initiating young drug users into injection exist amongestablished injectors, although this ethic is often ignored.Conclusion: The importance of social relationships with other drug users within the adoption ofinjection drug use highlights the potential of social interventions to prevent injection initiation.Additionally, developing strategies to engage current injectors who are likely to initiate youth intoinjection could also benefit prevention efforts.BackgroundThe onset of drug injecting has been associated with ele-vated levels of health risks among young drug users [1].ated injecting [1,3,4]. Street youth are one sub-populationof drug users who are at heightened risk of adopting injec-tion drug use [5,6], and the prevalence of injection drugPublished: 30 April 2009Substance Abuse Treatment, Prevention, and Policy 2009, 4:8 doi:10.1186/1747-597X-4-8Received: 23 January 2009Accepted: 30 April 2009This article is available from: http://www.substanceabusepolicy.com/content/4/1/8© 2009 Small et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 8(page number not for citation purposes)New injectors often display high levels of syringe sharing[2], and HIV and hepatitis C (HCV) incidence is known tobe elevated among young drug users who recently initi-use is known to be high among street youth in manyurban settings [7-12]. Due to the pattern of injection-related harm evident among new injectors [13,14], theSubstance Abuse Treatment, Prevention, and Policy 2009, 4:8 http://www.substanceabusepolicy.com/content/4/1/8transition into injection drug use among non-injectiondrug users has become a focus for research and interven-tion efforts [15-17]. While further strategies to reduceinjection-related harm among active injectors are urgentlyrequired [4], some have argued that preventing the initialadoption of injecting behaviour should be a greater prior-ity for public health efforts [17,18].The transition towards injection among young drug usersis a complex process, influenced by an array of ecologicalfactors [17]. Epidemiological studies have highlighted therole of social influences upon injection initiation, docu-menting that the majority of drug users are introduced toinjection by an individual who is socially close to them[19-21], and in many instances new injectors are initiatedby an injection drug user (IDU) who is several years older[22]. Gender differences in injection initiation experi-ences have been identified, as some studies have foundthat female drug users are more often introduced to injec-tion by a male drug user [19,23,24], who is a boyfriend orsex partner. It appears that males often facilitate the injec-tion initiation of female drug users; however, this is hasnot consistently been documented in all studies examin-ing this topic [25]. Individual drug users also experiencediverse trajectories in the transition surrounding injectioninitiation, including movements away from newlyadopted modes of consumption which may be viewed asreverse transitions [26]. Although only a small number ofqualitative studies have explored the transition towardsinjecting, these investigations have highlighted the impor-tance of social circumstances and networks in facilitatingthe adoption of injection as a route of administration [27-29]. Both epidemiological research and interventionefforts could benefit from further qualitative accountsdocumenting the social processes surrounding the initia-tion of injection drug use [17], and contextualized under-standings of the onset of injecting may help facilitate thedevelopment of appropriate interventions to preventinjection among street youth.Vancouver, Canada, is a city with a large street youth pop-ulation, characterized by high levels of drug use andhomelessness [30,31]. Recent reports of high rates of crys-tal methamphetamine use [32] and overdose [33], result-ing from both opiate and methamphetamineconsumption, among local street youth indicate increas-ing public health problems within this population. Addi-tionally, injection drug use is prevalent among local streetyouth, with 30% reporting recent injection drug use [7].Alarmingly, high rates of syringe sharing are also evidentwith 29% of local street youth engaged in injection druguse reporting syringe sharing in the past six months [7].qualitative study to explore the initiation of injection druguse among street youth in Vancouver. Our study isinformed by the risk environment framework [34,35],which emphasizes the importance of ecological influ-ences, including social and structural factors, in shapingpatterns of drug-related risk and harm in a specific locale.More specifically, situated cultural norms, includingbeliefs regarding specific drug use practices (includingroutes of administration) and "folk" harm reduction strat-egies, may significantly shape the character of drug usebehaviors among particular social groups of drug users[17,35]. Therefore, we focused this analysis upon socialinfluences which shape the adoption of injection drug useamong street youth in Vancouver.MethodsWe conducted a series of 26 in-depth qualitative inter-views to elicit accounts of the transition into injection,first injection experiences and uptake of injecting amongyoung drug users. Interviews were conducted from Sep-tember 2007 to January 2009, and interviewees wererecruited from the At-Risk Youth Study (ARYS), a prospec-tive cohort study composed of over 500 young street-involved drug users aged 16–26 in Vancouver [30]. First,in order to gather accounts from individuals who recentlyhad initiated injection drug use, we identified and con-ducted interviews with 8 youth who had begun injectingover the previous 24 months. Secondly, in order toincrease the overall number of qualitative study partici-pants and permit consideration of a larger collection ofaccounts regarding injection initiation, we recruited anadditional 18 study participants who had injected drugsprior to enrolling in the ARYS study. The second wave ofindividuals were selected from persons visiting theresearch office for cohort interviews, and during thisround of recruitment, quotas were employed to ensureadequate representation of female and Aboriginal partici-pants. These recruiting efforts created a sample of individ-uals who had experience injecting drugs, and which alsoreflected the socio-demographic profile of the largercohort study. Interviews were undertaken by three trainedinterviewers (one male and two female) and facilitatedthrough the use of an interview guide. Topics discussedincluded the transition towards injection, first injectionexperiences, ongoing injection drug use, and perceptionsof injecting as a route of administration. Audio-recordedinterviews lasted between 40 and 80 minutes and weretranscribed verbatim.The research team discussed the content of the interviewsthroughout the data collection process, thus informingthe focus of subsequent interviews as well as the develop-ment of a coding scheme for partitioning the data categor-Page 2 of 8(page number not for citation purposes)In light of the emerging problem of injection drug useamong street-involved youth locally, we undertook aically. The content of transcribed interviews was reviewed,and all text segments related to the adoption of injectionSubstance Abuse Treatment, Prevention, and Policy 2009, 4:8 http://www.substanceabusepolicy.com/content/4/1/8drug use were catalogued. The catalogued data were sub-jected to a thematic analysis which focused upon theonset of injecting with attention to similarities and diver-gences in experiences. We present representative excerptsfrom the interview data to illustrate themes related to theuptake of injecting.All participants provided informed consent to participate,and the study received ethical approval from the Univer-sity of British Columbia Research Ethics Board. There wereno refusals of the offer to participate in the interview andno drop-outs during interviews. All interviewees receivedCAD$20 for their participation.ResultsThe sample of 26 qualitative interview participants con-sisted of 12 females, 13 males, and one trans-genderedindividual. The age of participants ranged from 16 to 26years, and the median age of participants was 23. Table 1depicts the demographics of the qualitative study samplecompared to the larger group of young drug users partici-pating in the ARYS study. Among the qualitative studysample the median age at first injection was 19, andamong the entire ARYS cohort the median age at firstinjection in the entire cohort is 17 (IQR: 15–19).The role of social influences in facilitating first injection experiencesAccording to participants, other drug users often played asignificant role in instances when drugs were first injected.The majority of first injection experiences reported by par-ticipants involved an established injection drug user, whowas known to the individual, introducing the initiate toinjection drug use and facilitating initiation by providingguidance with the injection process. As indicated in thecase of "G", a young man who was a heavy crack user andhad previously smoked heroin, his closest friend was theperson who introduced him to injecting:And it was raining, and then my best buddy...he comesalong and he's like, you okay man? I'm like so, reallychoked, depressed. And he had a bunch of heroin on him.And he used to give me something to smoke too, right? Butall this heroin was in one rig. He had a rig full... you knowlike it was a clean rig [...]So I guess it was just meant to be.And I was like, man I need some kind of a drug [...]"but,it's all liquid man." He had a shit load, he had all the sup-plies and everything like that. He did a little shot for me,and, as he was about to poke me right, and he looks at mehe says, "God, strike me with lightening if you don't wantme to do it.", but I was like " just do it, fuckin' hurry up."But I couldn't look, holy fuck- needles! – Male Participantage 24, Interview #9Similar to this description, several accounts of first injec-tion experiences described a hesitancy to initiate injectionamong both the initiate and the individual initiatingthem.Being injected by another individual was a common fea-ture of first injection experiences among both male andfemale participants. Approximately half of the partici-pants reported that their first injection was physicallyadministered by the person who introduced them toinjection as a mode of consumption. In some cases theinitiator was the initiate's sex partner or boyfriend/girl-friend, and equal numbers of male and female partici-pants reported that this dynamic characterized their firstinjection. In the instance of "D", a nineteen year oldfemale drug user, her boyfriend was the person who facil-itated her injection initiation:My ex-boyfriend, P, he... just happened to be a heroinaddict. I mean I'd sit there watching him shoot up andstuff...he'd just do heroin in front of me and he'd just likekeep hooking me up with jib [methamphetamine], andthen I'd smoke some crack, and I was SO so out of my mindhigh by the third day. I hadn't slept... I told him, "I'm waytoo high ...can I do some heroin?" He was like, "No, no,no". And I was like, "Please. I need to like, settle down."...that's the excuse, cause I'm not going to say, "Can I dosome heroin? I've always wanted to do it." So then he's like,"Fine". And he was going to give me some tinfoil, to smokeit in. And I was like, "no, no, no, if I'm gonna do it, I wantTable 1: Characteristics of qualitative study sample compared to the composition of the At-Risk Youth Study (ARYS)Qualitative Interview Participants ARYS CohortTotal Number 26 529Median Age (range) 23 (16–26) 21.9 (14.3–30.2)GenderFemale, n (%) 12 (46.2) 156(29)Male, n (%) 13 (50.0) 371(70)Trans-gendered, n (%) 1 (3.8) 2 (< 1)Aboriginal EthnicityYes, n (%) 8(30.8) 127 (24)Page 3 of 8(page number not for citation purposes)No, n (%) 18(69.2) 879(81)Substance Abuse Treatment, Prevention, and Policy 2009, 4:8 http://www.substanceabusepolicy.com/content/4/1/8to shoot it". Like, that's the only way that I think heroinshould be done. [...] And then he looked at my arm, "Fuck,you have awesome veins. I could hit them in the dark."yeah, and then he shot me up. – Female Participant age19, Interview #8Although this participant was injected by her boyfriend,the account emphasizes that rather than being passive orcoerced into experimenting with injection, female initi-ates may play an active role in their first injection experi-ence. The account of a young woman who soughtguidance with the injection process from an establishedinjection drug user, who she knew through her social net-work, also illustrates how initiates may be active in bring-ing about their injection initiation:Well I knew that my boyfriend's mom had been doing it, foryears and years. She's like 37 and, she's been using drugsfor 20 years or something like that. I knew she knew how toinject it. And I didn't know anything about it, but...I hadbought heroin, and I knew I wanted to try it for some rea-son. So, I asked her to do it for me. And, she did do it forme. [...] I wasn't really watching that closely but, I justremember she prepared it, 'cause she knew I didn't knowhow to do it. – Female Participant age 22, Interview #1Although a small number of participants' initiation didnot involve another drug user who facilitated the firstinjection, these individuals had greater depth of previousexposure to injecting, with many reporting that membersof their family were injectors who transmitted knowledgeof injection techniques.Evolving perceptions of injection drug use and participation in injecting behaviourNegative perceptions of injecting appear to be prevalentamong street youth, and avoiding identification with"junkie" behaviour was a motivation for rejecting injec-tion prior to initiation. Many participants reported thatthey did not anticipate they would ever adopt injection asa route of administration, and perceptions of injectingprior to initiation indicate that injection drug use repre-sented a "risk boundary" [36]. An aversion to injectingbehaviour and the use of syringes, as described in the fol-lowing quote, was featured in many accounts detailing thetransition towards injection:I didn't think I would ever do it. I was telling myself that Iwould never do it. Because I [...] [didn't]like needlesbefore. And then I tried it...-Male Participant age 20,Interview #18While injecting was initially constructed as a "high-risk"the transition toward injecting indicate that negative per-ceptions were often replaced with the view that injectionwas an acceptable and expedient route of administration:I: What were your thoughts about injecting before that[first injection]?R: I thought about trying it, and I thought that was a verybad idea, and it was disgusting... and then my thoughtsturn to "hey, it's actually the cleanest and the fastest way todo it, so why not?" – Female Participant age 22, Inter-view #11The observation that injecting was more efficient thanother routes of administration, which may enable a reduc-tion in the amount of drugs used per dose, was a keydimension of the positive attributes ascribed to adminis-tration via injection:I got really high really fast, and you only need a smallamount in order for you to get... super high. – Female Par-ticipant age 16, Interview #13Other participants also emphasized the importance of amore intense high as a key facet of the attraction of admin-istration through injection.The accounts of youth regarding initiation and subse-quent patterns of injection emphasize the diversity ofexperiences, including the discontinuation of injectiondrug use after the first occasion and the existence ofreverse transitions away from injecting. While positiveperceptions of injecting were influential in the transitiontowards injecting, once the initial injection episode hadoccurred negative attributes of injection became moresalient for some youth. A common belief among youthwho continued injecting was that injection was a more"addictive" route of administration and was inherentlymore difficult to quit. The perception that continuedinjecting leads to increased dependency was also evidentamong youth who did not continue to inject, and was cru-cial in the motivation to avoid further injection drug use:I: So why'd you never inject again?R: Because I noticed right away that I could become ajunkie if I kept doing it. Cause morphine's pretty good. Ifyou're having a hard day, you have a morphine pill. – MaleParticipant age 22, Interview #10Youth who did not establish a regular injection pattern,emphasized their rejection of "junkie" identity and thesalience of negative perceptions of injecting within theirPage 4 of 8(page number not for citation purposes)and unacceptable behaviour among youth, accounts of social network:Substance Abuse Treatment, Prevention, and Policy 2009, 4:8 http://www.substanceabusepolicy.com/content/4/1/8R: Heroin, no I'm going to stay away from that. Crack, Icould fight that, I don't need it. I don't want to turn out likethe people on Hastings. Man, I'm way better than that.I: Thinking back to that time when you just tried that injec-tion just once, what stopped you from injecting again?R: Um, seeing junkies. And plus hearing about junkies, peo-ple disliking junkies and, like man, I don't want to bethem.-Male Participant age 23, Interview #4Other participants who reduced their participation ininjecting reported that strained social relationships andintervention on the part of their peers was an importantfactor in their trajectory away from injection:I: How did you stop injecting?R: Um, my friends, really. My friends, 'cause they noticed,and I noticed, that I was going through some significantweight loss. I was starting to [have]borderline sociopaththoughts. I started thinking really insanely and violentlyand that kind of weirded people out. Yeah, [friends]they'relike the slap in the head everybody kind of needs. – MaleParticipant age 24, Interview #2I didn't want to get hooked on heroin, to the point wheresome people get really sick, so I stopped doing that. Andthen I stopped doing it with needles as well because otherpeople that are close to me are shaking their heads at mebecause I use needles right? So then I was like, "whoa, Iactually use needles". One thing that I said I'd never do, soI actually stopped. – Female Participant age 22, Inter-view #17Similar to the initiation of injection, the influence of othermembers of youth social networks and perceptions ofinjection drug use were central in transitions away frominjecting. Notably, narratives describing transitions awayfrom injecting were less evident in the accounts of femaleparticipants, and fewer female participants reported thatthey had ceased injecting.Social norms and sanctions regarding initiating others into injectionReluctance on the part of the person initiating youth intoinjection was evident in many participants' first injectionexperiences, including the accounts presented above.Interview data revealed the existence of a "code" amonglocal IDU which stipulates that young drug users shouldnot be initiated into "hardcore" drug use, particularlyinjecting behaviour. The first injection experience of D,which was described above, illustrates how her boy-And now if anyone asks him, he says that I forced him to...[inject me] I, you know, bribed him and fucking threat-ened him to do it. But really, as I remember it... he was con-vinced quite easily. And I don't hold it against him, right?But he used to get so defensive about it, 'cause ...he kindahad a little reputation for getting young girls that are newto downtown wired to heroin. He had nothing to do withme getting wired. I wasn't wired for a long time after I didthat first one. But, it's funny 'cause, he totally didn't needany convincing, you know. I said, "I wanna' shoot", andhe's like, "Ok, I'll doctor you". – Female Participant age19, Interview #8This account highlights that boyfriends and girlfriends aresometimes pressured to facilitate their partner's first injec-tion, which may prevail over social norms discouraginginitiating young users into injection. This interview alsorevealed that the boyfriend involved had a reputation assomeone who had initiated multiple young females intoinjection drug use, and the significance of this codeamong local drug users is indicated by the fact that thisperception precipitated difficulties for him within thestreet scene.Participants who were established injectors describedmany situations where youth sought to inject andappealed to them to act as an injection guide. Some par-ticipants indicated that they attempt to discourage youngusers from adopting injection as a route of administra-tion:'Cause even though I know how to do it and stuff, I don'tlike other people knowing- 'cause knowing how do to it isthe main spark, right there. – Male Participant age 24,Interview #2These participants were adamant that they would avoidendorsing injection and refrain from initiating youth intoinjecting. Interview data suggests that the code discourag-ing initiating youth into injection is more prevalentamong established injectors and those who have beeninjecting for a longer period of time, who likely havegreater experience of negative consequences of injecting.However, while many local drug users subscribe, at leastsuperficially, to a code which discourages injection druguse among young drug users, our analysis indicates thatthis convention is routinely ignored. One participant whohad sought help injecting from an older IDU, who wasnot well-known to her, provided an account which par-tially explains the motivations which may lead estab-lished injectors to deviate from this convention:Page 5 of 8(page number not for citation purposes)friend's initial reluctance to deliver an injection wasrelated to the social convention which discourages initiat-ing youth into injecting:When that girl injected me, I was fine and everything, I justdidn't like the way it all happened. You know, she's the typeof person that will go around saying, "Anyone who givesSubstance Abuse Treatment, Prevention, and Policy 2009, 4:8 http://www.substanceabusepolicy.com/content/4/1/8drugs to anybody under 19... fuck man, I'm gonna' punchthem out." But then, because I had the money... She askedme how many times have I done it [injecting], and I said,"honestly, I've only done it once before, two days ago." Andshe's like, "Oh fuck, oh well." So, obviously because I'mpaying for the drugs, who cares? She'll fucking inject me.-Female Participant age 19, Interview #8As indicated in this account, the ability to obtain drugs inexchange for assistance with the injection process may, forsome established IDU, overwhelm concerns regarding ini-tiating young people into injecting.DiscussionOur study is among the few qualitative studies examiningthe adoption of injection as a route of administrationamong street youth who use drugs, and our analysisunderscores the importance of social influences upon theinitiation of injecting. While initiates did play an activerole in the initiation of injecting, the majority of firstinjection episodes involved another drug user facilitatingthe process, and this individual often physically adminis-tered the injection. We found that both the transitiontowards and movement away from injecting among newinjectors is heavily influenced by the perceptions of peersand interactions with fellow drug users. These social inter-actions and perceptions of injecting serve to emphasizeeither the benefits or drawbacks of injection in compari-son to other modes of consumption, and encourage ordiscourage injection drug use. It also appears that socialconventions discouraging initiating young drug users intoinjection exist among many local IDU, although this codeis often ignored.Within our study, first injection episodes typicallyinvolved close friends, sex partners and older IDU knownthrough social networks. These actors often facilitated theuptake of injecting, by creating a situation which pre-sented an opportunity to inject within a familiar socialcontext, and by providing injection expertise. Within ourqualitative study sample, equal numbers of males andfemales reported being initiated by their sex partner ortheir boyfriend/girlfriend. However, epidemiologicalanalysis of initiation patterns across the larger ARYScohort indicate that females were more likely than malesto report that their sex partner was involved in their injec-tion initiation [37]. While romantic and sexual partner-ships play an important role in structuring initiationexperiences among women, this should not be interpretedto mean that women are inevitably coerced or persuadedinto injection [38]. Our qualitative data indicates thatfemale drug users often played an "active" role in bringingabout their first injection experience, a dynamic which hasedge and skills are acquired from fellow drug users [29],within our study approximately half of the first injectionepisodes involved another drug user physically adminis-tering the injection. This is consistent with epidemiologi-cal studies documenting that first injection episodes ofteninvolve assisted injection [22,39]. It appears that this prac-tice is particularly prevalent in our setting, as among asample of 861 adult IDU in Vancouver, over 75% of firstinjections experiences involved assisted injections [40].Some individuals in our study did not continue injectingafter initiation, highlighting that the first injection experi-ence does not immediately establish identification as aninjector and that there is significant potential for transi-tions away from injecting among newly initiated youth[26,41]. Consistent with previous research, individualswho described these reverse transitions emphasized hownegative perceptions of injection discourage injectingbehaviour and peer intercession served to promote cessa-tion [27], suggesting directions for future research andintervention efforts. Notably within our qualitative sam-ple fewer female participants described reverse transitionsaway from injecting, and epidemiological examinationacross the entire ARYS cohort indicates that females weremore likely to become regular injectors (injecting at leastonce a week) subsequent to their first injection, in com-parison to males [37].As young drug users are socialized into injecting [27,29],learning the behaviour and its meanings from other drugusers, prevention efforts should adopt a social approachand develop peer interventions to complement conven-tional educational messages [1]. Participation in injectingis heavily influenced by socially constructed perceptionsof injection [28], developed through social relationshipsand interactions with other drug users, rather than arational calculation of the risks attached to injecting as aroute of administration [36,42]. The perception thatinjecting resulted in a more intense high was one of thepositive perceptions attributed to injecting within ourstudy. In light of the fact that other studies have identifiedthe "rush" associated with injecting to be an attractive fea-ture of this route of administration [43,44], the role ofpleasure in the adoption of injecting should receivegreater consideration within prevention efforts. Our find-ings suggest prevention efforts targeting youth at-risk ofinjecting should deliver prevention messages throughdrug user networks in terms meaningful to youth [27,45].Our qualitative study indicates that specific individualsmay be involved in the initiation of multiple new injec-tors, and while this has been documented by epidemio-logical studies [46], future research should pay greaterPage 6 of 8(page number not for citation purposes)been documented in other studies [25]. While previousqualitative research has emphasized that injection knowl-attention to the characteristics and motivations of IDUwho initiate young drug users into injection, in order toSubstance Abuse Treatment, Prevention, and Policy 2009, 4:8 http://www.substanceabusepolicy.com/content/4/1/8develop intervention strategies which involve currentinjectors in prevention efforts [29]. This study is amongthe first to document a "code" among IDU in the Cana-dian context that discourages the initiation of young drugusers into injection drug use. Although interview datarevealed the existence of this social convention, it appearsthat many IDU are unable to adhere to this "moral code"due to the pressures of drug dependency and contextualfactors which limit individual agency [47]. While currentIDU do often initiate young drug users into injection, anethic discouraging IDU from participating in the initia-tion of youth suggests the existence of "folk" harm reduc-tion strategies, which could be incorporated intointerventional efforts [48,49]. However, it may be thatwithin injection-discordant couples, it is even more diffi-cult for established injectors to refuse requests to initiatepartners who currently use through non-injection routes,and these challenges should be prioritized within preven-tion efforts targeting current injectors. While preventionefforts targeting current IDU appear to be effective inreducing their involvement in the injection initiation ofother users [16], interventions that reinforce negative per-ceptions of injecting may potentially exacerbate existingstigma and discrimination against established IDU[15,50,51].The present study has a number of limitations. Althoughmany interviewees had only very recently begun injecting,some participants may not have been able to recall detailsrelated to their injection initiation. However, previousresearch indicates that drug users possess adequate recallof early drug use experiences [52]. Additionally, as all par-ticipants offered retrospective narratives of early injectionexperiences, these may be subject to social desirabilitybias. While this analysis has concentrated upon socialinfluences related to injection initiation, social processesand meanings among youth are also shaped by structuralconstraints and other contextual factors including povertyand homelessness. Lastly, our findings are based uponinterviews with a relatively small sample of young IDU inVancouver, and may not be representative of youth expe-riences with injection initiation in other urban settings.In summary, our findings highlight the role social actorsand processes play in the initiation of injection drug use,and further serve to underscore the potential of socialinterventions seeking to prevent initiation. Additionally,the reverse transitions away from injecting documented inthis study suggest that interventions seeking to reduce theincidence of injection drug use among youth should alsotarget new injectors.Competing interestsAuthors' contributionsWS and TK designed the study. WS, DF and AK conductedall the qualitative interviews for this study, and performedthe analysis of the interview data. WS prepared the firstdraft of the article. All authors commented on the originaldraft and contributed to the revision of the manuscript.All authors have approved the final manuscript.AcknowledgementsFunding for this qualitative study was provided by the Canadian Institutes of Health Research (CIHR), operating grant MOP-81171. CIHR had no fur-ther role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. Support for the ARYS cohort study was provided by CIHR grant HHP-67262 and National Institutes of Health grant R01 DA011591. Additional support was provided by CIHR grant RAA-79918.Mr. Small is supported a Michael Smith Foundation for Health Research (MSFHR) Senior Graduate Studentship and a CIHR Doctoral Research Award. Dr Kerr is supported by a MSFHR Scholar Award and a CIHR New Investigator Award.The authors wish to thank the study participants for their time and partic-ipation. 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