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Potential community and public health impacts of medically supervised safer smoking facilities for crack… Shannon, Kate; Ishida, Tomiye; Morgan, Robert; Bear, Arthur; Oleson, Megan; Kerr, Thomas; Tyndall, Mark W Jan 10, 2006

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ralssBioMed CentHarm Reduction JournalOpen AcceResearchPotential community and public health impacts of medically supervised safer smoking facilities for crack cocaine usersKate Shannon*1, Tomiye Ishida1, Robert Morgan2, Arthur Bear2, Megan Oleson1,2, Thomas Kerr1,3 and Mark W Tyndall1,3Address: 1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada, 2Rock User's Group (RUG) of Vancouver Area Network of Drug Users (VANDU), Vancouver, Canada and 3Faculty of Medicine, University of British Columbia, Vancouver, CanadaEmail: Kate Shannon* - kshannon@cfenet.ubc.ca; Tomiye Ishida - tishida@cfenet.ubc.ca; Robert Morgan - rob_morgan2@yahoo.com; Arthur Bear - abear@yahoo.ca; Megan Oleson - moleson@telus.net; Thomas Kerr - tkerr@cfenet.ubc.ca; Mark W Tyndall - mtyndall@cfenet.ubc.ca* Corresponding author    AbstractThere is growing evidence of the public health and community harms associated with crack cocainesmoking, particularly the risk of blood-borne transmission through non-parenteral routes. Inresponse, community advocates and policy makers in Vancouver, Canada are calling for anexemption from Health Canada to pilot a medically supervised safer smoking facility (SSF) for non-injection drug users (NIDU). Current reluctance on the part of health authorities is likely due tothe lack of existing evidence surrounding the extent of related harm and potential uptake of sucha facility among NIDUs in this setting. In November 2004, a feasibility study was conducted among437 crack cocaine smokers. Univariate analyses were conducted to determine associations withwillingness to use a SSF and logistic regression was used to adjust for potentially confoundingvariables (p < 0.05). Variables found to be independently associated with willingness to use a SSFincluded recent injection drug use (OR = 1.72, 95% CI: 1.09–2.70), having equipment confiscatedor broken by police (OR = 1.96, 95% CI: 1.24–2.85), crack bingeing (OR = 2.16, 95% CI: 1.39–3.12),smoking crack in public places (OR = 2.48, 95% CI: 1.65–3.27), borrowing crack pipes (OR = 2.50,95% CI: 1.86–3.40), and burns/ inhaled brillo due to rushing smoke in public places (OR = 4.37, 95%CI: 2.71–8.64). The results suggest a strong potential for a SSF to reduce the health related harmsand address concerns of public order and open drug use among crack cocaine smokers should afacility be implemented in this setting.IntroductionVancouver's Downtown Eastside (DTES) has been the siteof an explosive HIV and HCV epidemic associated with alarge open illicit drug use scene[1,2]. The health relatedconcerns of injection drug use, particularly blood bornelic order in this community, several harm reduction initi-atives have been implemented recently and in September2003 Vancouver received an exemption from Health Can-ada to pilot the first supervised injection facility in NorthAmerica [5].Published: 10 January 2006Harm Reduction Journal 2006, 3:1 doi:10.1186/1477-7517-3-1Received: 25 May 2005Accepted: 10 January 2006This article is available from: http://www.harmreductionjournal.com/content/3/1/1© 2006 Shannon 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)transmission, have been documented extensively [3,4]. Inresponse to these health related risks and concerns of pub-Harm Reduction Journal 2006, 3:1 http://www.harmreductionjournal.com/content/3/1/1To date, the scientific evaluation of the supervised injec-tion facility has documented several successes includinghigh uptake of the facility, improved public order [6], anda positive impact in reducing syringe sharing locally [7].However Vancouver is still contending with a open drugscene and issues of public order, particularly among non-injection drug using (NIDU) crack cocaine smokers andcrystal methamphetamine users [8]. Growing evidencehas highlighted the health related harms of crack cocaineuse, including the risk of non parental transmission ofHCV, through the sharing of non-injection drug use para-phernalia [9-11], and risky sexual behaviours[12,13].Crack smokers are known to have a high prevalence oforal lesions, including burns, blisters, and sores, on lipsand mouth that may facilitate the oral transmission ofblood-borne infections [14]. In addition, crack cocainesmokers have been shown to be at increased likelihood ofengaging in high risk sexual and drug related behavioursassociated with both HCV and HIV infections [12].In Europe, several safer smoking facilities (SSF) for non-injection drug users have been opened in addition tosupervised injection facilities [15], and yet in North Amer-ica, the extent and potential uptake of such a facilityamong NIDUs have not been characterized. Currentlysupervised drug consumption facilities are operating in 36cities across four European countries [15]. The existing lit-erature indicates that the ideal drug consumption room ismade up of three sections: a clinical area for injecting, awell-ventilated area for free-basing or chasing, and anadjacent common room where no drug use is allowed[16]. Of the 22 drug consumption facilities in the Nether-lands, all 22 facilities include spaces for injectors andinhalation areas for crack and heroin smokers [15]. Theprimary mode of drug consumption in Dutch consump-tion rooms is smoking or chasing[16], and increasinglypresent in both German and Swiss facilities [17]. Of the12 drug consumption facilities in Switzerland, 8 providespaces for both injection and inhalation. The objectives ofa safer smoking facilities are similar to those of injectionfacilities including a safe environment that enables low-risk, more hygienic drug consumption, reducing thehealth related risks of drug use and sharing of smokingparaphernalia, minimising the open drug use scene andassociated public nuisance, and establishing contact withhard-to-reach drug user populations [18-21]. Throughengaging high-risk populations that would otherwiseremain outside of conventional medical care, SSF aim toincrease potential uptake of health services, drug treat-ment and addiction services, referral to housing and socialsupports, and ultimately stabilize and promote clienthealth [15]. Similar to safe injection facilities, SSF providesterile drug use equipment, a clean and safe environmentnity exists at a SSF to delay or prevent the transition frominhaling to injecting drugs [22]. Previous studies haveshown that 85% of IDUs engage in illicit non-injectiondrug use prior to initiating injection drug use [23], andevidence suggests that interventions need to target cracksmokers to prevent transition to injecting [24].Currently advocates and policy makers in Vancouver,Canada are calling for a medically supervised safer smok-ing facility to smoke pre-obtained non-injection drugs,particularly crack cocaine, and consideration is beinggiven to applying for a federally-administered exemptionfrom Health Canada (under exemption 56) to pilot a safeinhalation room [25,26]. Although evidence of the extentof the health related risks of crack cocaine smoking isgrowing, the reluctance on the part of health authorities islikely due to the lack of existing evidence of crack useharms and potential uptake of a SSF by crack cocainesmokers in this setting. As such, a partnership between theRock Users' Group of VANDU and CHASE, a community-based research project, undertook an assessment of thewillingness to use a safer smoking facility should one bemade available.MethodsVancouver Area Network of Drug Users (VANDU)The Vancouver Area Network of Drug Users (VANDU) is adrug user organization that formed in 1997 in response toa growing HIV epidemic and health emergency in theDowntown Eastside of Vancouver associated with illicitdrug use, and perceived government inaction. The mis-sion of VANDU is "to improve the lives of people who useillicit drugs through user-based peer support and educa-tion"[27]. Today, the organization has grown to includeapproximately 1500 members and is well known interna-tionally as one of the most organized drug user associa-tions in the world. In addition to ongoing politicalactivism and advocacy, VANDU has expanded over theyears to include public education, and peer support andcare programs for methadone users and Hepatitis C posi-tive individuals. As well the organisation provides asyringe exchange and recovery program, alley patrol, andstreet and hotel-based programs.The Rock Users' Group (RUG) was formed throughVANDU in response to a growing need to address thehealth needs of crack cocaine smokers. The RUG groupmeets weekly to educate members on the related concernsof crack cocaine use and discuss ways to expand harmreduction initiatives to include crack smokers. Throughprivate donations, RUG has recently begun distributingsafer smoking kits to users in the community at a cost ofCan$1, including a mouthpiece, durex pipe, brass screens,Page 2 of 8(page number not for citation purposes)to use drugs, and education describing the risks of cracksmoking and safer ways to smoke. As well, a key opportu-lubricant, and condoms.Harm Reduction Journal 2006, 3:1 http://www.harmreductionjournal.com/content/3/1/1The Community Health and Safety Evaluation (CHASE) projectThe Community Health and Safety Evaluation (CHASE)Project is a prospective open cohort that was establishedto evaluate the impacts of recently implemented healthinitiatives on residents of the DTES; to identify priorityhealth issues; shortfalls; and populations at greatest risk.All community residents are eligible to participate, andare enrolled through various recruitment strategiesincluding community-based organizations, several store-front locations and door-to-door initiatives in a singleroom occupancy hotel (SRO) and subsidised housingbuildings. The goal is to enrol a large representative sam-ple of people residing in and having access to services inthe DTES community. A short baseline questionnaire isadministered by a trained peer interviewer, and elicitsquestions related to sociodemographic characteristics,health status, service utilization, barriers to healthcareaccess, and patterns of illicit drug use. In addition, permis-sion is requested to link personal identifiers with anumber of health related databases in the province. Par-ticipants are followed prospectively through these datalinkages on a bi-annual bases. Upon completion of thesurvey, study participants receive an honorarium of $10 ascompensation for their time. University of British Colum-bia / Providence Health Care Research Ethics Board pro-vided ethical approval for this study.Assessment of the health related harms of crack smokingThrough a community-based partnership between theRock Users' Group (RUG) of Vancouver Area Network ofDrug Users (VANDU) and the Community Health andSafety Evaluation (CHASE) Project of the BC Centre forExcellence in HIV/AIDS, the following assessment ofhealth related harms of crack cocaine use was conductedin November of 2004. A total of 437 crack cocaine smok-ers participated in peer-administered interviews. To be eli-gible, individuals had to be current crack cocaine smokers(i.e., defined as having smoked crack cocaine in the previ-ous month at the time of interview). Participants wererecruited through targeted recruitment strategy thatincluded allocation of referral cards at staggered times andlocations over a three-week period. Referral cards werehanded-out by CHASE peers through street recruitmentand VANDU members on alley patrol and outreach withactive crack smokers, as well as through community-basedorganisations and service providers. Questionnaires wereconducted at various storefront locations, and includedwomen's only days to ensure inclusion of multi-riskwomen. Although participants were asked about formerand current injection drug use practices, a history of injec-tion drug use was not considered an eligibility criteria andthus both IDU and NIDU crack smokers were eligible toSocio-demographic variables that were considered in thisanalysis included gender, age, ethnicity, housing status,education level, health status, health and addiction serv-ice uptake, recent incarceration, and drug use patterns. Forthe purpose of this analysis, unstable housing was definedas living arrangements that included SRO hotels, transi-tional housing, and no fixed address/ homelessness. Druguse behaviours included: frequency of cocaine injection,heroin injection, crystal methamphetamine injection, andcrack cocaine smoking. As previously [28], "any drug use"was defined as any illicit drug use in the last six months atthe time of interview and "frequent drug use" was definedas daily, or most days. Risky drug behaviours includedcrack bingeing, borrowing crack pipes, smoking in agroup of unknown people (such as crack houses, oralleys), and buying used pipes off the street. Public druguse variables included frequency of smoking crack in pub-lic places (such as streets, alleys, and parks), having felt indanger when smoking in public places, rushing smokedue to police presence, inhaling brillo / burns due to rush-ing, and having equipment confiscated or broken bypolice (without being arrested). Sex work variablesincluded ever having exchanged sex for money or drugs,and having exchanged sex for money or drugs while usingcrack in the last six months.Descriptive and univariate analysis were used to deter-mine bivariate associations between willingness to use aSSF and sociodemographic characteristics, selected druguse patterns, crack use behaviours and related risks. Meanaverages were used to describe normally distributed varia-bles, and median averages were used to describe skewedvariables. Categorical and explanatory variables were ana-lyzed using Pearson X2, normally distributed continuousvariables were analyzed using t-tests for independent var-iables, and skewed continuous variables were analyzedusing Mann-Whitney U tests. In order to identify factorsindependently associated with willingness to use a SSF, alogistic regression was performed. Variables found to beassociated with willingness to use a SSF at the univariatelevel (p < 0.05) were entered into the logistic model. Allreported p-values are two-sided.ResultsA total of 437 participants were recruited over a three-week period in November 2004, and thus were eligible forthe present analysis. Of the total, 289 (66%) were maleand 145 (33%) were female. The median age was 41 years(interquartile range [IQR] = 35 – 45). One-hundred andeighty-four (42%) individuals self identified as Aborigi-nal, and 335 (77%) were living in unstable housing. Two-hundred and forty-six (56%) reported a history of injec-tion drug use (either former of current IDUs), while 191Page 3 of 8(page number not for citation purposes)participate. (44%) were NIDU crack smokers with no history of injec-tion drug use.Harm Reduction Journal 2006, 3:1 http://www.harmreductionjournal.com/content/3/1/1Of the 437 participants, 303 (69%) expressed a willing-ness to use a medically supervised safer smoking facility(SSF) if one was made available. The univariate analysesof associations between willingness to use a safer smokingfacility and sociodemographic characteristics and selecteddrug use patterns are shown in Table 1. As indicated, will-ing to use a SSF was positively associated with homeless-ness (OR = 2.61, 95% CI: 1.19–5.71), having sleptoutdoors in the last six months (OR = 1.91, 95% CI: 1.22–2.98), exchanging sex for money or drugs while usingcrack (OR = 1.76, 95% CI: 1.00–3.24), recent IDU (OR =1.71, 95% CI = 1.27–2.31), injecting with others (OR =2.15, 95% CI: 1.39–3.32), and injection binge drug use(OR = 2.10, 95% CI: 1.30–3.38).The univariate analyses of associations between willing-ness to use a SSF and crack use behaviours and relatedrisks are shown in Table 2. As indicated, willingness to usea SSF was positively associated with daily crack cocaineuse (OR = 1.31, 95% CI: 1.00–1.73), crack bingeing (OR= 2.25, 95% CI: 1.46–3.46), smoking crack in public(such as crack houses, or alleys) (OR = 2.20, 95% CI =1.73–5.36), borrowing crack pipes (OR = 2.78, 95% CI:2.17–3.71), buying used pipes off the street (OR = 2.34,95% CI: 1.14–4.77), feeling in danger when smokingcrack in public places (OR = 2.37, 95% CI: 1.53–3.75),rushed smoking due to police presence (OR = 3.89, 95%CI: 2.44–6.22), inhaling brillo/ burns due to rushingsmoke (OR = 4.45, 95% CI:2.55–7.76), and having equip-ment confiscated or broken by police (without beingarrested) (OR = 2.26, 95% CI: 1.48–3.46).Results of the multivariate logistic regression analysis offactors independently associated with willingness to use aSSF are presented in Table 3. Variables found to be inde-pendently associated with willingness to use a SSFincluded recent injection drug use (OR = 1.72, 95% CI:1.09–2.70), having equipment confiscated or broken bypolice (OR = 1.96, 95% CI: 1.24–2.85), crack bingeing(OR = 2.16, 95% CI: 1.39–3.12), smoking crack in publicplaces (OR = 2.48, 95% CI: 1.65–3.27), borrowing crackpipes (OR = 2.50, 95% CI: 1.86–3.40), and inhaled brillo/Table 1: Univariate associations between sociodemographic characteristics, selected drug use behaviours and willingness to use a safer smoking facility (SSF)Willingness to Use a Safer Smoking FacilityCharacteristic Yes No OR p-valuen(%) n(%) (95% CI)AgeMedian [IQ range] 40 (35–46) 41 (34–45) 0.729GenderMale 199 (67) 90 (68) 0.90 (0.58–1.39) 0.642Female 103 (34) 42 (32)EthnicityAboriginal 136 (45) 48 (36) 1.46 (1.00–2.22) 0.077Non-Aboriginal 167 (55) 86 (64)HomelessYes vs. No 43 (14) 8 (6) 2.61 (1.19–5.71) 0.014Slept outdoorsYes vs. No 122 (40) 35 (26) 1.91 (1.22–2.98) 0.004HIV positiveYes vs. No 81 (27) 30 (22) 1.18 (0.84–1.67) 0.336HCV positiveYes vs. No 210 (69) 86 (64) 1.17 (0.90–1.57) 0.290Exchanged sex for drugs or moneyYes vs. No 107 (35) 38 (28) 1.26 (0.91–1.73) 0.154Exchanged sex for drugs or money while using crack (last 6 months)Yes vs. No 55 (18) 15 (11) 1.76 (1.00–3.24) 0.047Current IDUYes vs. No 163 (54) 47 (35) 1.71 (1.27–2.31) <0.001Inject with othersYes vs. No 142 (47) 39 (29) 2.15 (1.39–3.32) 0.001Injection bingeingYes vs. No 108 (36) 28 (21) 2.10 (1.30–3.38) 0.002Page 4 of 8(page number not for citation purposes)places (such as, streets, alleys, parks) (OR = 2.59, 95% CI:1.79–3.12), smoking crack in a group of unknown peopleburns due to rushing smoke in public places (OR = 4.37,95% CI: 2.71–8.64).Harm Reduction Journal 2006, 3:1 http://www.harmreductionjournal.com/content/3/1/1InterpretationOf a total of 437 crack cocaine smokers, 303 (69%)reported a willingness to use a safer smoking site (SSS)should one be made available. A willingness to use a SSFwas associated with recent injection drug use, havingequipment confiscated or broken by police, crack bingeuse, smoking crack in public places, borrowing crackpipes, and burns/ inhaled brillo due to rushed smoking.The association between crack bingeing and willingness touse a SSF shows a potential for such a facility to intervenein risky drug use behaviours through increased contactand referral with primary care, education and addictionservices [29]. Drug bingeing has been previously identi-fied as a high-risk behaviour associated with an elevatedrisk of HIV seroconversion [30,31]. Intensive crack use hasalso been associated with increased sexual risk taking,including exchanging sex for drugs or money, multiple sexpartners and unprotected sexual encounters[12,13].In this context, the observed association between borrow-ing crack pipes and willingness to use a SSF is particularlynoteworthy given the increasing evidence of blood bornehigh-risk group. Oral sores, cuts, and burns are commonamong crack cocaine smokers and have been shown tofacilitate HCV transmission, as well as increased potentialrisk for HIV transmission, through the sharing of contam-inated equipment, such as crack pipes [9,10,32]. Giventhe ability of Hepatitis C virus to maintain its infectivity inthe environment, the risk of sharing of drug use equip-ment is particularly concerning [11]. Increasing evidencehighlights a higher rate of HCV infection among crackcocaine and heroin smokers reporting no history of injec-tion drug use when compared to the general popula-tion[10]. A previous study among female drug users withno history of injection use, found that the sharing of bothoral and intranasal non-injection drug use implementswas a significant and independent predictor of HCV infec-tion after accounting for other known transmission routes[9]. Given the high prevalence (51%) of individuals hav-ing smoked in a group of unknown people (such as crackhouses or alleys) in the last six months, as well as the highnumber of injection drug using crack smokers in thisstudy, the potential for sharing of crack pipes betweenIDU and NIDU smokers highlights an increased likeli-hood for infectious disease transmission. In light of theseTable 2: Univariate associations between crack use behaviours and related risks, and willingness to use a safe smoking facility (SSF)Willingness to Use a Safer Smoking FacilityCharacteristic Yes No OR p-valuen(%) n(%) (95% CI)Crack use history≥ 5 years 174 (57) 70 (56) 0.94 (0.62–1.44) 0.786≥ 10 years 84 (28) 31 (25) 1.11 (0.90–1.57) 0.535Daily crack cocaine useYes vs. No 183 (60) 68 (51) 1.31 (1.00–1.73) 0.060Crack bingeingYes vs. No 228 (75) 77 (58) 2.25 (1.46–3.46) <0.001Smoke crack in public places (ie, streets, alleys, parks)Yes vs. No 170 (56) 53 (40) 2.59 (1.79–3.12) 0.001Smoke in a group of unknown people (ie, crack houses, alleys)Yes vs. No 157 (52) 44 (33) 2.20 (1.44–3.36) <0.001Borrowed crack pipesYes vs. No 212 (70) 76 (57) 2.78 (2.17–3.71) 0.007Buy used pipes off the streetYes vs. No 48 (16) 10 (8) 2.34 (1.14–4.77) 0.017Cocaine-induced psychosis/paranoiaYes vs. No 116 (38) 45 (33) 1.15 (0.85–1.56) 0.347Felt in danger when smoking in publicYes vs. No 139 (46) 35 (26) 2.40 (1.53–3.75) <0.001Rushed smoking due to police presenceYes vs. No 157 (52) 29 (22) 3.89 (2.44–6.22) <0.001Inhaled brillo/burns due to rushing smokeYes vs. No 121 (40) 12 (9) 4.45 (2.55–7.76) <0.001Equipment confiscated or broken by police (without being arrested)Yes vs. No 159 (53) 44 (33) 2.26 (1.48–3.46) <0.001Page 5 of 8(page number not for citation purposes)transmission through the sharing of non-injection druguse implements and the potential of a SSF to reach thisfindings, and the previously observed impacts of drugconsumption facilities on sharing of drug use equipmentHarm Reduction Journal 2006, 3:1 http://www.harmreductionjournal.com/content/3/1/1[7], SSFs may have the potential to reduce harms associ-ated with crack pipe sharing in this setting.The observed association between willingness to use a SSFand recent injection use is also particularly relevant, giventhat this feasibility study was conducted a year followingthe implementation of the SIF in this community. Asmentioned above, the SIF has had positive impacts byimproving public order[6], minimising the number ofdiscarded needles in public places, and reducing localsyringe sharing [7]. However, the open drug use scene inalleys, doorways and parks persists[8], and is likely reflec-tive of the high rates of NIDU, particularly crack smokers,in this community. As well, given the high percentage ofdual users in this study, the implementation of a SSF mayhelp to engage IDU crack smokers who continue to con-sume drugs in public places. In addition, SSFs also havethe opportunity to delay or prevent the transition frominhaling to injecting drugs though prevention-transitionprograms [22]. Recent studies have suggested that theinfection risk hierarchy should be updated to include thepublic health importance of preventing transition toinjection drug use[29], and approximately 85% of IDUsreport non-injection drug use prior to initiation into injec-tion use[23].Given the objective of drug consumption rooms to reducepublic nuisance and a visible drug scene, the observedassociation between public crack use and increased will-ingness to use a SSF is also noteworthy. Although there iscurrently limited information available exclusively onSSFs, preliminary findings in Switzerland show anincrease in public order and increased contact betweenNIDUs and health and social services[17]. As well, severalstudies of drug consumption rooms in Europe have high-lighted the benefits of both injection and inhalation areasto increase public order, engage high-risk groups, andreduce visible drug scenes [18-21].Within the context of public drug use, the associationsbetween willingness to use a SSF, and burns or/ inhaledbrillo due to rushing smoke and having equipment con-concerns of public order. Common modes of crackcocaine smoking such as metal pipes are known to causefrequent burns and blisters through excessive heat, whileglass and durex pipes frequently splinter causing asmoker's lips to cut [14,33]. In addition, brillo or brassscreens commonly used as filters in the pipe stem maybreak up and be inhaled by the user when the process isrushed. The epidemic of crack cocaine has been associatedwith heightened violence and crime, as well as exploita-tion of users, particularly women [12]. In Vancouver,speculations suggest widespread human rights violationson public drug users as part of the police crack down onopen drug use scene and concerns of public order [34].Given that a key objective of drug consumption rooms isto provide a safe place to use pre-obtained illicit drugs andhygienic drug use equipment, these findings highlight apotential to move crack smokers out of alleys and streets,minimize risky crack use, and related harms of rushing inpublic places should a SSF be implemented in this setting.Similar to safe injection facilities[35], SSF would also pro-vide a key opportunity to couple enforcement and publichealth efforts as police officers could direct NIDUs on thestreet to a SSF [22].Several limitations should be considered. First, this studyrelied on self-reported information and thus is subject tosocially desirable reporting. However previous studieshave reported the validity of self-reported informationamong drug user populations[36]. Second, this study askparticipants about the willingness to use a safer smokingfacility that does not currently exist and thus participantsmay have been unsure about the potential use of such afacility. However given that a supervised injection facilityhas recently been implemented in this setting, and thehigh rates of injection use among crack cocaine smokers,it is likely that individuals would have been familiar withthe concept of a drug consumption site. In addition, sim-ilar feasibility studies were conducted prior to the openingof the SIF and were highly predictive of the uptakeobserved following the opening of the SIF[37,38].The high reported rate of willingness to use a safer smok-Table 3: Logistic Regression Model of Factors Associated with Willingness to Use a Safer Smoking FacilityCharacteristic AOR 95% CI p-value(95% CI)Current IDU 1.72 1.09–2.70 0.019Equipment confiscated or broken by police 1.96 1.24–2.85 0.003Crack bingeing 2.16 1.39–3.12 0.014Smoking crack in public places 2.48 1.65–3.27 0.002Borrowing crack pipes 2.50 1.86–3.40 0.006Inhaled brillo/burns due to rushing smoke 4.37 2.71–8.64 <0.001Page 6 of 8(page number not for citation purposes)fiscated or broken by police, highlight a strong potentialto reduce the community harms of public crack use anding facility (SSF) in this study highlights an importantopportunity to connect with a known high-risk drug userHarm Reduction Journal 2006, 3:1 http://www.harmreductionjournal.com/content/3/1/1population. Given the observed associations betweenwillingness to use a SSF and public drug use and relatedharms, borrowing of crack pipes, and other risky drug usebehaviours, this study identifies a strong potential toreduce community health risks, including infectious dis-ease transmission, and address issues of open drug useand concerns of public order, if a facility was imple-mented in this setting.AcknowledgementsThis work was supported by grants from Vancouver Coastal Health and we thank all participants, peer researchers, and community organizations for their ongoing contribution.References1. Strathdee SA, Patrick DM, Archibald CP, Ofner M, Cornelisse PG,Rekart M, Schechter MT, O'Shaughnessy MV: Social determinantspredict needle-sharing behaviour among injection drugusers in Vancouver, Canada.  Addiction 1997, 92:1339-1347.2. 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European AddictionResearch 2003, 9:94-100.19. Jong W, Weber U: The professional acceptance of drug use: acloser look at drug consumption rooms in the Netherlands,Germany, and Switzerland.  International J Drug Policy 1999,10:99-108.20. Stoever H: Consumption rooms- a middle ground betweenhealth and public order concerns.  Journal of Drug Issues2002:597-606.21. Zurhold H, Degkhitz P, Verthein U, Haasen C: Drug conumptionrooms in Hamburg, Germany: Evaluation of the effects onharm reduction and the reduction of public nuisance.  Journalof Drug Issues 2003:663-688.22. Collins CLC, Kerr T, Tyndall MW, Marsh D, Kretz DC, Montaner JS,Wood E: Rationale to evaluate medically supervised safersmoking facilities for non-injection illicit drug users.  CanadianJournal of Public Health 2005, 96:344-347.23. Fuller CM, Vlahov D, Latkin CA, Ompad DC, Celentano DD, Strath-dee SA: Social circumstances of initiation of injection drug useand early shooting gallery attendance: implications for HIVintervention among adolescent and young adult injectiondrug users.  J Acquir Immune Defic Syndr 2003, 32:86-93.24. Irwin KL, Edlin BR, Faruque S, McCoy HV, Word C., Serrano Y.,Inciardi J, Bowser B, Holmberg SD: Crack cocaine smokers whoturn to drug injection: characteristics, factors associatedwith injection, and implications for HIV transmission. TheMulticenter Crack Cocaine and HIV Infection Study Team.Drug Alcohol Depend 1996, 42:85-92.25. City of Vancouver: The latest on inhalation rooms.  The Four Pil-lars Coalition 2004 [http://www.city.vancouver.bc.ca/fourpillars/newsletter/Sept04/latestoninhalationrooms.htm].26. Howell M: Vancouver mayor says legal crack smoking room isno pipe dream.  Vancouver Courier 2004 [http://www.vancourier.com/issues04/085104/news/085104nn2.html.].27. Kerr T, Small W, Peeace W, Douglas D, Pierre A, Wood E: Harmreduction by a "user-run" organization: A case study of theVancouver Area Network of Drug Users (VANDU).  Interna-tional J Drug Policy 2005, In Press:.28. Wood E, Tyndall MW, Spittal PM, Li K, Hogg RS, Montaner JS,O'Shaughnessy MV, Schechter MT: Factors associated with per-sistent high-risk syringe sharing in the presence of an estab-lished needle exchange programme.  AIDS 2002, 16:941-943.29. Vlahov D, Fuller CM, Ompad DC, Galea S, Des Jarlais DC: Updatingthe Infection Risk Reduction Hierarchy: Preventing Transi-tion into Injection.  J Urban Health 2004, 81:14-19.30. Craib KJ, Spittal PM, Wood E, Laliberte N, Hogg RS, Li K, Heath K,Tyndall MW, O'Shaughnessy MV, Schechter MT: Risk factors forelevated HIV incidence among Aboriginal injection drugusers in Vancouver.  CMAJ 2003, 168:19-24.31. Miller CL, Spittal P, Kerr T: Binge drug use independently pre-dicts HIV seroconversion among injection drug users: Impli-cations for public health strategies.  Subst Use Misuse 2006,41:199-210.32. Conry-Cantilena C, VanRaden M, Gibble J, Melpolder J, Shakil AO,Viladomiu L, Cheung L, DiBisceglie A, Hoofnagle J, Shih JW: Routesof infection, viremia, and liver disease in blood donors foundto have hepatitis C virus infection.  N Engl J Med 1996,334:1691-1696.33. Faruque S, Edlin BR, McCoy CB, Word CO, Larsen SA, Schmid DS,Von Bargen JC, Serrano Y: Crack cocaine smoking and oralsores in three inner-city neighborhoods.  J Acquir Immune DeficSyndr Hum Retrovirol 1996, 13:87-92.34. Csete J, Cohen J: Abusing the user: police misconduct, harmreduction and HIV/AIDS in Vancouver.  Human Rights Watch2003, August 2005:15 (2B). 1-28. www.hrw.org/reports/2003/can-ada/canada0503.pdf.35. Wood E, Kerr T, Spittal PM, Tyndall MW, O'Shaughnessy MV,Schechter MT: The healthcare and fiscal costs of the illicit druguse epidemic: The impact of conventional drug control strat-egies and the impact of a comprehensive approach.  BCMJ2003, 45:130-136.36. De Irala J, Bigelow C, McCusker J, Hindin R, Zheng L: Reliability ofself-reported human immunodeficiency virus risk behaviorsPage 7 of 8(page number not for citation purposes)reduction include safe smoking rooms: ; Melbourne, Aus-tralia.  ; 2004. in a residential drug treatment population.  Am J Epidemiol1996, 143:725-732.Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2006, 3:1 http://www.harmreductionjournal.com/content/3/1/137. Kerr T, Wood E, Small D, Palepu A, Tyndall MW: Potential use ofsafer injecting facilities among injection drug users in Van-couver's Downtown Eastside.  CMAJ 2003, 169:759-763.38. Wood E, Kerr T, Spittal PM, Li K, Small W, Tyndall MW, Hogg RS,O'Shaughnessy MV, Schechter MT: The potential public healthand community impacts of safer injecting facilities: Evidencefrom a cohort of injection drug users.  JAIDS 2003, 32:2-8.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 8 of 8(page number not for citation purposes)

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