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Developing harm reduction in the context of youth substance use: insights from a multi-site qualitative… Jenkins, Emily K; Slemon, Allie; Haines-Saah, Rebecca J Jul 31, 2017

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RESEARCH Open AccessDeveloping harm reduction in the contextof youth substance use: insights from amulti-site qualitative analysis of youngpeople’s harm minimization strategiesEmily K. Jenkins1*, Allie Slemon1 and Rebecca J. Haines-Saah2AbstractBackground: Youth substance use programming and educational strategies are frequently informed by preventionapproaches that emphasize abstinence goals, which often do not resonate with youth in their lack of acknowledgmentof young people’s social context and how young people perceive positive effects of substance use. Further,approaches to drug prevention have been critiqued as adopting a one-size-fits-all approach and thereforeinadequate in addressing substance use in the context of population variation and inequities. In response tothe limitations of current approaches to prevention, programming informed by harm reduction principles that aims tominimize harms without requiring abstinence is emergent in school settings. However, youth perspectives informingharm reduction are limited in both research and program development.Methods: This paper draws on data from the Researching Adolescent Distress and Resilience (RADAR) study, whichutilized an ethnographic approach to bring youth voice to the literature on mental health and substance use.Qualitative data collection included individual interviews (n = 86) with young people aged 13–18 across threecommunities—representing urban, suburban, and rural geographies—in British Columbia, Canada. A multi-sitequalitative analysis of interview data was conducted to identify themes across and within each research site.Results: Across all three sites, young people’s individual experiences of substance use were shaped by geographic,socio-cultural, and political contexts, with youth describing their use in relation to the nature of substance use in peergroups and in the broader community. To manage their own substance use and reduce related harms, youthemployed a variety of ad hoc harm minimization strategies that were reflective of their respective contexts.Conclusions: The findings from this study suggest the importance of harm reduction approaches that are contextuallyrelevant and responsive to the lived experiences of youth. Youth perspectives in the development of harm reductionprogramming are needed to ensure that approaches are relatable and meaningful to young people, and effective forpromoting the minimization of substance-related harms.Keywords: Youth, Substance use, Harm reduction, Harm minimization, Multi-site qualitative research, Social context,Drug prevention* Correspondence: emily.jenkins@ubc.ca1School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall,Vancouver, British Columbia V6T 2B5, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Jenkins et al. Harm Reduction Journal  (2017) 14:53 DOI 10.1186/s12954-017-0180-zBackgroundSubstance use, including both alcohol and drug use, isidentified internationally as a key issue affecting youthpopulations. The World Health Organization (WHO) re-ports that heavy episodic drinking is higher among youthages 15–19 than in the adult population (11.7 versus 7.5%)[1], and the United Nations [2] characterizes illicit druguse as a “youth phenomenon”, with rates of use increasingthrough teenage years to a peak in early adulthood. InCanada, prevalence of substance use echoes that of globalstudies: 40% of youth in grades 7 to 12 reported past-yearalcohol use, 17% cannabis use, and 1–4% used other il-legal drugs [3]. The potential health impacts of sub-stance use among youth include injury or death [4],over-consumption [5], and consumption of drugs withunknown potency or contents, a growing concern withinthe context of a “contaminated” illicit drug supply [6, 7].Early onset and frequency of substance use in adolescencehas also been linked to risk for mental health challengesand increased problematic substance use in adulthood[8, 9].The health risks and harms associated with youth sub-stance use have prompted a proliferation of universalprevention programs in schools, which predominantlyapproach substance use through an abstinence andavoidance lens [10, 11]. Drug and alcohol prevention hasalso been utilized to target populations identified as atrisk or marginalized (i.e., indicated prevention), includingyouth in the foster care system [12], LGBTQ youth [13],and youth in racialized communities [14, 15], for example.Some evidence has demonstrated that indicated preven-tion approaches applied to particular youth contexts mayreduce frequency or amount of use [16, 17]; however, pre-vention programs have been critiqued for their narrowfocus on preventing or avoiding use, as opposed to equip-ping youth with skills in identifying and mitigating harmsthat may occur within the context of choosing to use[18, 19]. Bok & Morales [20] argue that in social con-texts in which drug use is positively reinforced bypeers, and in which youth endorse positive effects ofdrug use, abstinence and prevention approaches to drugeducation are “a form of denial, by adults, about the actualbehaviors of teenagers and young adults” (p. 94). Further,prevention programming frequently presents alcohol anddrug information in a manner that may not resonate withthe intended youth audience, for example highlighting po-tential negative consequences as a deterrent strategy or“scare tactic”, rather than acknowledging and addressingsocial contexts of use [21, 22]. Prevention approaches alsofail to acknowledge that youth frequently use substancesfor pleasure and enjoyment of intoxication, insteadframing substance use as a sign of distress or lack ofcommon sense [23, 24]. Consequently, youth perspectiveson current substance use prevention programs demonstratea lack of trust in formal sources of alcohol and drug in-formation, with higher trust in information from peers[22, 25]. Drug education programs such as D.A.R.E.(Drug Abuse Resistance Education), which are led byadult authority figures such as police officers and centrefear-based messaging, are widespread yet are unrelata-ble to young people in their mode of delivery and inef-fective at minimizing substance use harms [26, 27].Contemporary harm reduction emerged in the early1990s, but is still a nascent, alternative orientation toyouth substance use programming. This approach holdspotential to address some of the shortfalls of existing pre-vention programs, although it remains contentious in thecontext of youth substance use and has not been widelystudied within this population [17, 19]. Harm reductionincludes abstinence goals, but is based on a philosophy of“starting where the user is at” and “offers a pragmatic yetcompassionate set of strategies designed to reduce theharmful consequences” [28] (p. 779) of substance use forboth the substance user and the broader community.Given this, it can be directed across the spectrum of sub-stance use and may be applied at the individual, commu-nity, or societal level [29]. In addressing minimization ofharms within the context of use, the philosophy of harmreduction differs from traditional approaches of preven-tion and abstinence, which have been largely oriented atreducing or preventing use altogether. Harm reductionapproaches to youth substance use, while still limited inpractice, have started to emerge in school settings in re-sponse to criticisms of prevention programs as ineffectivefor engaging youth in meaningful dialogues on substanceuse and for failing to acknowledge and tailor messagingand approaches to variations in youth contexts [26, 30].Examples of recent harm reduction approaches in schoolsinclude SHAHRP in the UK [31], DEVS in Victoria,Australia [32], and SCIDUA in Eastern Canada [33], all ofwhich aim to increase substance use knowledge and targetthe reduction of associated harms rather than frequencyor amount of use directly. Each program has resulted insafer attitudes toward substance use, and reduced inci-dents of harms associated with alcohol and drug use,providing an evidence base for shifting the framework ofschool-based substance use education from prevention toharm reduction.Outside of programming specifically directed to vulner-able youth and youth using injection drugs (e.g., [34]),youth perspectives on harm reduction are frequently ab-sent from the conversation informing these approaches[21, 30]. With limited research centering youth experiencesof and perspectives on drugs and alcohol, educational strat-egies for addressing the harms of youth substance use riskcontinuing with a top-down approach that is not informedby or relevant to youth context [22]. In this article, wetake an initial step at addressing these important gaps,Jenkins et al. Harm Reduction Journal  (2017) 14:53 Page 2 of 11presenting findings from the Researching AdolescentDistress and Resilience (RADAR) study, a qualitative studyinvolving youth across three communities in BritishColumbia (BC), Canada. By presenting a multi-sitequalitative analysis of youth reflections on the socialand community contexts for their experiences of sub-stance use and on their own harm minimization strat-egies, this study brings youth perspectives to the harmreduction literature and speaks to the importance ofcontextually relevant harm reduction programming.MethodsThe analysis reported in this paper draws on data from aqualitative study conducted in BC, Canada, from 2012 to2014. The RADAR study used ethnographic approachesincluding participant observation and field notes andindividual interviews to bring youth perspectives to themental health and substance use literature to informpolicies, practices, and programs targeting adolescents.Ethnographic approaches were selected because theysupport comprehensive understandings of participants’beliefs and behaviours as well as an understanding ofthe context within which these were established [35].Data analysed in this article were drawn from individualinterviews that were conducted with 83 young peopleages 13–18. Data collection occurred at three researchsites across the province, representing urban, suburban,and rural geographies. The sites were selected to repre-sent diversity in geography, community history, societaland cultural factors, and demographics. This paper pre-sents a multi-site qualitative analysis of all three studysites, which are described in detail below.Study sitesThe three research sites are identified by pseudonyms—TheCity, The Valley, and The North—to protect the confidenti-ality of study participants and members of their communi-ties. The City is a large urban centre with a population ofapproximately 604,000 within a metropolitan area of justunder 2.5 million [36]. The City is culturally and ethnicallydiverse: 48% of the population are first-generation immi-grants, and over half are a visible minority including 27%from Chinese descent [37]. The City’s leading industries aretourism, trade, and film. The per capita alcohol consump-tion in The City was 8.60 l in 2015, though varies widely byneighbourhood (3.31–16.79); the particular neighbourhoodfrom which the participant sample was drawn was close toThe City mean [38]. Rates of drug use by region are notavailable in BC, but drug-related hospitalizations provide ameasure of substance use-related harms and are reportedat 40.2 per 100,000 in 2015 in the study neighbourhood(40.2–427.38 in The City) [39].The Valley is a suburban city with a population ofapproximately 133,000, located proximally—within 75 km—toa large urban centre [36]. Seventy-three percent of TheValley’s population is religiously affiliated, with Christian-ity and Sikhism as the two most prominent religions—acontrast to The City, in which only 50% of the populationidentifies as religious [37]. The Valley’s ethnic compositionis predominantly of European descent (64%), with a largeSouth Asian community (22% of total population; 76% ofvisible minorities). Punjabi is spoken in one fifth of house-holds [37]. Over one quarter of the population are first-generation immigrants. The main industry in The Valley isfarming, with most of the municipality’s land zoned asagricultural. Per capita alcohol consumption in The Valleywas 6.57 l in 2015 [38], and drug-related hospitalizationswere 189.3 per 100,000 in this same year [39].The population of The North is approximately 4800,including individuals living in town, on surroundingFirst Nations reserve land, and more rural areas [40]. Inaddition to the individuals living on reserve land, 27% ofthe population in town identifies as “Indigenous” or“First Nations”, in comparison to 2–3% in The City andThe Valley [37]. The North’s main industries are forestry,mining, and agriculture. Per capita alcohol consumptionin the local health area in which The North is situatedwas 9.86 l in 2015 [38], and drug-related hospitalizationswere 175.6 per 100,000 [39].Data collectionEthics approval for the study was obtained through theUniversity of British Columbia, and permission wasgranted from the respective school districts in each com-munity. Each study site had one affiliated high schooland youth were recruited through flyers posted withinthe school and through the assistance of school andcommunity staff. Recruitment efforts were directed atensuring a diverse sample of participants with respect toage, gender, ethnicity, and experience with mental healthor substance use issues. To protect privacy and supportconfidentiality, youth provided their own consent to par-ticipate and did not require parent/guardian permission.Individual interviews were conducted by members of theresearch team on-site at each school in a private space.Interview questions aimed to elicit participant accountsof emotional distress and resilience as well as the con-textual factors shaping these experiences. Interviewsbegan with a grand tour question with probes used togain further depth and clarity as necessary. Interviewlength ranged from 30 to 120 min and participants weregiven $20 CAD honoraria to acknowledge their time andcontributions. Interviews were subsequently transcribed,with pseudonyms used to protect the confidentiality ofparticipants.The demographics of study participants were as follows:In The City, 29 youth participated in the study: 14 fe-males, 13 males, 1 “non-binary identifying”, and 1 whoJenkins et al. Harm Reduction Journal  (2017) 14:53 Page 3 of 11intentionally left the gender information blank; 16 partici-pants identified as “White”/European, 5 multi-racial, 3Asian, 1 Latin American, 1 West Asian, and 3 did notprovide details. In The Valley, 27 youth participated: 13females and 14 males; 12 participants identified as SouthAsian, 11 “White”/European, 1 “Black” (e.g., of African orCaribbean descent), 2 multi-racial, and 1 Asian. In theNorth, 27 youth participated: 14 females and 13 males; 16participants identified as Indigenous (encompassing youthwho self-identified as “Aboriginal”, “First Nations”, and“Indian”), 4 “White”/European, 4 multi-racial, 2 Métis,and 1 did not provide details.Data analysisAll interviews were transcribed and a thematic analysiswas carried out to identify emergent themes. RADARteam members collaboratively generated 15 broad codesthat captured youth experiences and reflections on men-tal health, substance use, and resilience. In this article,we primarily draw from the Substance Use code; ascodes were not mutually exclusive, the Substance Usecode also captures participants’ reflections on the inter-sections of substance use with the themes representedacross the other 14 codes such as Social Connectionsand Trauma and Stressors. Substance Use included allparticipant references to alcohol, tobacco, cannabis, andother drug use as related to participants’ own experiencesand those of friends and family. This code also capturedparticipants’ reflections on substance use in their schoolsand communities more broadly.The multi-site qualitative analysis undertaken for thispaper builds on Herriott and Firestone’s analytical ap-proach to case study data that spans more than one set-ting [41]. The authors argue that this approach canenhance the rigour of a study, while preserving depthand contextualization of research findings. In applica-tion of this approach to the qualitative data in thisstudy, we seek to extend the application of multi-sitequalitative analysis to ethnographic interview data fromthree geographical sites. Following thematic coding ofall study data, analysis for this paper began with awithin-site thematic coding and analysis of the SubstanceUse code for each of the three research sites [42]. Distinctanalysis of data from each study community allowed forthe preservation of the shared participant experiences andnarratives within each site and ensured in-depth de-scription of the ways in which substance use wasuniquely situated [41]. Subsequently, a between-siteanalysis was conducted in which emergent themes werecompared to uncover patterns across sites; through thisanalysis, the research team identified two broad themesat the level of the entire study population: youth contextand experiences of use, and substance use management.To avoid “context-stripping”, in which research findingsare removed from their local contexts, a second within-site analysis was conducted following the identificationof themes to ensure that findings remained locally andcontextually grounded [43].ResultsFindings from our multi-site qualitative analysis illus-trate the ways in which youth in each of the threesites took up informal harm minimization strategiesbased on the context of substance use in their peergroups and communities. The findings are reportedseparately for each of the three research sites in orderto highlight location-specific themes. For each site,we provide contextual descriptions of the communityand social settings in which youth substance use wassituated, as well as participants’ experiences of sub-stance use. We then present the strategies that youthemployed to manage and minimize the harms of theirown substance use.The CityContext and experiences of use: parties and popularityYouth participants in The City described a peer andschool context in which substance use was not thenorm. Many participants stated that they did not drinkalcohol or use drugs and those who did engage in personaluse described occasional or infrequent use of alcohol orcannabis. For example, one participant describing canna-bis use stated: “it’s like drinking, you do it once every threemonths, not at the same time of course.” When partici-pants did consume alcohol, it was almost exclusively inthe context of parties. In describing a typical party, manyparticipants characterized the event solely through sub-stance use: “a lot of drinking”, “get piss assed drunk anddo stupid things”. For many youth, partying was synonym-ous with substance use; for example, one participant refer-enced friends who “party a lot…by party I mean like, theydrink.” The connection between parties and drinking wasunderstood as not only a school norm, but also a culturalnorm: as one participant reflected, “it seems like a typicalhigh school experience.”Of all the substances discussed by participants, what theparticipants referred to as “hard drugs”—including drugssuch as cocaine and methamphetamine—were used theleast in their school and peer group. Many interviewssuggested this form of substance use was outside of sharedsocial expectations in the youth community. As one par-ticipant stated:There’s always a rumour that someone snorted a lineof cocaine or something and you’re just like “someonedid that?” Like, “sorry this isn’t like the Bronx orsomething. We usually don’t do that here.” That kindof stuff, that’s really a shock…Jenkins et al. Harm Reduction Journal  (2017) 14:53 Page 4 of 11Participants often described individuals who did use harddrugs as “popular” or “cool”—one participant speculatedthat a friend who frequently talked about drug use wassimply “trying to be all cool and everything”, though didnot believe that this friend actually used substances. Yetdespite the social cachet of substance use, individuals whodid use drugs were frequently described by participants innegative terms. Substance use was viewed as an indicatorof low intelligence—“the people who do that generallyaren’t the smartest”—or connected with adverse outcomesin adulthood such as homelessness and mental illness—“crazypeople” or “hobos”. One participant described an incident inwhich a classmate was bullied online regarding her “drug ad-dictions”, demonstrating that despite associations of drugswith a popular crowd, the use of hard drugs was not sociallyendorsed.In contrast, cannabis use was reported by many, andfrequently described in positive terms: “quite nice”, “justmakes you happy”. Participants regularly invoked theneighbourhood, city, and provincial context as explana-tory for its ubiquity: “weed is everywhere, this is [nameof neighbourhood]”, “this is [The City], lots of kidssmoke weed”, “it’s BC, it’s peaceful, everyone smokesweed.” Many participants explained that peers wereoften relatively open about their use—the prevalence ofcannabis use was known throughout the school, andpeers were described as smoking across the street fromthe school (in order to be technically off of schoolgrounds) in plain view. In the context of commonplacecannabis use, many youth characterized substance useeducation as equating the harms of different drugs includ-ing cannabis, which was not reflective of youth perspec-tives. This lack of clarity in messaging led one young manto reflect:They make weed sound so bad, and then when peoplefind out that weed’s not that bad, they think all drugsare not that bad, so then they go into the drug thing,and they think that all drugs won’t change them, butthose other drugs change you.For youth, exaggerating the effects of some substancesresulted in the minimizing of harms of others, and par-ticipants in The City called for honesty in describing therelative harms of substance use.Substance use management: staying away and limiting useYouth in The City predominantly maintained their ownsubstance use limits through the strategy of staying awayfrom contexts in which these limits may be exceeded bythose around them. This involved both physical and socialpositioning to avoid particular events or peer groups. Par-ticipants described choosing to attend certain parties,while avoiding other “more intense ones” at which drugsmay be present or alcohol use may be increased. One par-ticipant stated that young people in her peer group whoshe termed “the average people”will have their own couple parties, but there’ll bealcohol but there won’t be any drugs. So that one’sfine, I’ll go to that one—but the other ones, you’ve gotthe popular people from different schools all going,and then you get a lot of those sort of people togetherand just generally isn’t a good idea.Many participants who drank alcohol in moderation de-scribed attending and enjoying parties in which alcoholwas present, but stayed away from contexts in whichpeers may “drink a lot and go overboard.” In addition toavoiding spaces of alcohol and drug use perceived as ex-cessive may occur, participants also described stayingaway from individuals and social groups who used cer-tain substances or had a particular pattern of use. Oneparticipant described that after a former best friend“turned to cocaine”, she felt that she “was not part ofthat crowd whatsoever, so [she] just left them all.” Stay-ing away was articulated as a strategy for avoiding par-ticular substances or patterns of substance use, but alsofor forming an identity as an individual who uses withinthe socially acceptable limits—as one participant stated,“I’ve noticed the people that do that, and the people thatdon’t do that…and who do I wanna be?” Staying awaywas viewed by youth as a form of self-protection fromperceived harms, including getting “caught” by parentsor caregiver, or experiencing negative effects, which wereoften described in non-specific terms: “like a zombie”,“you get messed”, “changes your brain”. Additionally,staying away also served to reinforce belonging in groupsthat share use patterns and perspectives on substanceuse—very few participants described having friends or so-cial groups who used differently from themselves, andthose who did described the isolating impact of this differ-ence. One participant whose friends used but did not usehimself stated “there’s so many things I don’t know aboutthem”; conversely, one participant who smoked cannabisand described coming to school “baked” stated “peoplelook—they treat you different of course.” For youth in TheCity, a predominant strategy for managing substance usewas staying away from particular contexts—both partiesand peer groups—that young people perceived as havingpotential for substance-related harms.When participants in The City chose to use sub-stances, most utilized the strategy of limiting their ownuse: using in moderation (in frequency or amount) andintentionally selecting the types of substance used. Manyparticipants described the approach of moderation todrinking or smoking cannabis, for example limiting alco-hol consumption to “once every like three months orJenkins et al. Harm Reduction Journal  (2017) 14:53 Page 5 of 11once every six months, which amounts to pretty muchnever.” Another participant described himself as “notreally that much of a drinker” and stated that at partieshe “might have a beer or something.” Youth also avoidedparticular substances while continuing to use others—frequently, this involved using alcohol and cannabiswhile avoiding “hard drugs”. One participant shared:I personally smoke weed sometimes on the weekends,I’m not going to lie, I’ve never done other drugs…Then there’s also like the kids doing coke and all thisstuff but I’m not into that, my friends are not reallyinto that. I know some people that do this stuff butit’s not my thing, it’s not my life, I don’t really care.There’s this drug that people do, I don’t really knowthese people, but it’s like meth, and it’s like in fiveyears you’re gone, I mean it’s messed up.As in this example, many participants cited concernsabout potential harms as a primary reason for not usingparticular substances. Participants did not explicitly drawon formalized sources of drug education, such as at schoolor in the community, in informing these choices. Rather,knowledge of these harms was often drawn from witnes-sing individuals in the community who the participantsinterpreted as being negatively impacted by drug use. Forexample, one participant who smoked “a lot of weed” butchose not to use other drugs described seeing individualsin a particular neighbourhood in The City:…whenever I see those people…like one girl’s juststanding there and she’s hitting herself in the head orsomething, like saying “get out of my head, get out ofmy head” smashing—it’s like “oh my God! Don’t dodrugs.” It’s like a warning: “Don’t do drugs. You endup messed up.”The ValleyContext and experiences of use: social divisions and peerinfluenceYouth in The Valley described their social context asstratified on the basis of substance use. Despite manyparticipants reporting substance use as widespread inthe school, many others stated that they “don’t reallyknow anybody who uses” or described themselves as“sheltered”. Interaction between those who used sub-stances and those who did not was limited: “It’s mostlythose guys dating those girls that are into that kind ofstuff I guess.” Participants described “rivalries” and “ten-sions” between the two groups, and one youth stated,“most of us just kinda wanna get through high schooland never wanna see some of these kids again… ‘causewe’re going to be going on to university while they’restill here doing drugs.” As in this example, participantswho did not use substances tended to hold strong nega-tive views of peers who did use, characterizing substanceuse as a “stupid decision”, and individuals who use as“bad” or “dangerous”. One participant in describing thetwo “completely separate” groups of the school’s socialscene differentiated between those who are “all clean,they’re all good, they don’t do drugs” and “the ‘bad’people…the bad part of school”. Participants who formerlyused substances but had since stopped drew on similar de-scriptors in discussing their own previous use. One par-ticipant explained, “I was going down a really rough road”before becoming “all clean”; another participant commen-ted “I did a lot of stupid things, and boy…I’m glad that I’mout of it.” Many participants associated substance use withviolence, describing individuals who use substances as “al-ways starting fights” and carrying weapons. Youth whopreviously used substances also endorsed this associationof alcohol and drug use with other behaviours such asbullying or stealing cars, however contextualized their his-tory of use as a coping strategy for managing “extremestress” and other difficult emotions. Some individuals whodid not use substances suggested that drug use may be a“bad way to cope” but many struggled to make sense oftheir peers’ substance use: “…other kids are blatantly badlike drugs and alcohol and that kind of thing, right? Fightsfor no reason.”Though participants described distinct social groupsand limited interaction between youth who used sub-stances and those who did not, the danger of being in-fluenced into using was viewed as a present and realconcern. Individuals who used substances were frequentlydescribed as “bad influences” by those who did and didnot use alike. However, substance use, described almostexclusively in negative terms, was not itself viewed as ap-pealing or tempting. Rather, participants suggested thatproximity to individuals who used substances was a riskfactor for being influenced to use:There are some students out there, probably aren’tthe best of friends they could be…So we just feel safebeing in that group away from friendships that could bedangerous…Like it could lead to things in a friendship,that maybe you wouldn’t’ve gotten yourself into?Things like, I guess, like smoking and drugs and thingslike that…There could be some people that could causeyou to go down a road like that.While one participant suggested that individuals who usedrugs “recruit”—“they might meet the little kid at thegym…and slowly get them to smoke marijuana”—mostparticipants described this potential for negative influencein non-specific terms. One young man described his ownintroduction to substances use as “I guess I just met morepeople and started smoking weed with these people”,Jenkins et al. Harm Reduction Journal  (2017) 14:53 Page 6 of 11while another participant who did not use speculated thatothers are influences: “maybe someone, a relative or somefriend, who is just like ‘oh yeah, he’s doing that, should Ido that now?’” Many youth expressed concern regardingthe potential for being influenced to use substances, andfear of this influence reinforced social divisions betweensocial groups.Substance use management: social avoidance and positiveinfluenceIn accordance with the common perception of substanceuse as harmful and “dangerous”, many participants inThe Valley made efforts to minimize potential harms byavoiding individuals and social groups who used. Manyparticipants described evading friendships with peoplewho used substances, and one individual stated that hekept his distance from “these kids” in the hallways.Avoiding individuals who used substances and fosteringrelationships with peers who did not use gave many par-ticipants a sense of belonging: “we have similar values…so that’s really what’s drawn us together as friends.” Oneparticipant described breaking up with a partner due tohis substance use, while another participant shared thatshe would avoid entering into romantic relationshipswith someone who might “pull me down to a lowerlevel.” Participants consistently viewed friendships withpeers who did not use as protective from the perceivedharms involving substance use, and avoided interactionwith individuals characterized as “bad influences”.When youth did engage with peers or friends whoused substances, they often attempted to exert what theyviewed as positive influence. Among participants whoboth used and did not use themselves, they describedencouraging friends to stop or reduce their use. Oneparticipant shared: “In grade 10, my friend was going tostart dealing, and me and my friend just took him into acorner and beat the crap out of him. We’re like ‘whatare you doing?’ So he didn’t deal.” Another participantstated that even in the context of his own substance use,“I try to be the best influence I can…I try to be a bigbrother sort of person to other people, making surethey’re making the right choices.” These “right choices”included not using at school, and using only certaindrugs. Attempts to influence friends or partners’ sub-stance use were not always successful: participants whoused substances described lying to partners about theiruse or experiencing relationship difficulties. One individ-ual who smoked cannabis stated that her boyfriend“wants me to respect the fact that he doesn’t like it, so Ishouldn’t do it either” but had not stopped her use. Inaddition to youth reflections on the influences of peers,some participants viewed teachers as having the abilityto positively influence youth. One participant stated “ifthey’re just comfortable talking about it normally withstudents, they’ll feel that they can actually ask questionsabout it, right?” However, youth described teachers asnot consistently confident in discussing substance usewith students.The NorthContext and experiences of use: boredom and availabilitySubstance use in The North was described by partici-pants as commonplace among their peers, and most par-ticipants in the study used alcohol or drugs. Youthdescribed the predominant influence for substance useas boredom. The North was described as having few ser-vices, activities, or spaces for young people, and mostparticipants repeated the refrain of “there’s nothingreally to do”. In the context of this boredom and lack ofopportunities, participants regarded substance use as anactivity itself—one participant stated, of cannabis, “it justgives me something to do”. Many participants echoedthis notion, listing alcohol and cannabis use as the pri-mary activities for “kids our age”. For example, one par-ticipant stated, “All there really is to do in this town isdrink, smoke pot, and get into trouble.” Some partici-pants were able to identify alternate activities, such assports, as providing a relief from boredom and “help[ing]keep away the alcohol”, however, explained that theseopportunities remain limited, and only beneficial “if youare athletic”. Youth described engaging in substance useas an activity to do on one’s own, with small groups offriends, and at parties. One young woman described atypical Friday night as “hanging out with friends, smokingup, and drinking…we find ways to entertain ourselves”,while a young man described his primary activities aswatching TV or “once in a while I just go walk around,whenever I drink”.The participants also described the environment ofThe North, as well as its lack of available activities, as afactor in the context of youth substance use. Youth de-scribed substance use as visible and prevalent in theircommunity: “You go into town on Main Street, and yousee people sitting there, bottles and bottles of alcoholand drugs.” While some participants described finding iteasier to avoid substance use on the First Nations re-serve, as the area’s only liquor store was located in town,others noted “a lot of drug selling and drinking that goeson on Rez”. Participants described relatively easy accessto alcohol in both locations from “whoever’s willing toboot [provide alcohol to minors]”. One participant’snarrative addressed the inter-generational impacts ofalcohol availability, as adults who “have already wentdownhill” in turn sold to young people: “The alcoholicsin town, they don’t care—like, ‘if you’re going to sup-port for my next bottle, then hey, I’ll get you yours’”. Inthe context of inter-generational use, many participantsgrappled with the narrative of substance use asJenkins et al. Harm Reduction Journal  (2017) 14:53 Page 7 of 11inevitable in The North. While some participants ac-tively rejected this narrative for themselves, othersspoke to the distress of identifying their own use asconsistent with this societal narrative. As one 17-year-old First Nations participant stated: “I wish I didn’tskip—flunk out on school and, and just become one ofthose reserve Indians that just party around, smokeweed and whatnot.”Substance use management: using selectively and reducinguseIn The North, harm minimization strategies predomin-antly arose from witnessing and/or experiencing negativeeffects of substance use. Some participants describedpersonal experiences of substance use that contributedto their desire to use differently. For example, one par-ticipant shared: “I went on a complete binge, never go-ing to do that again. I can see why a lot of people aremessed up from drinking so hard core, really harsh onyour body.” For other participants, witnessing negativeeffects of substance use in their families and communi-ties shaped their perspectives on their own use. Oneparticipant described negative experiences of a familymember’s drug use: “it ended up making her hit mymom and steal money and all that from us…And it’sjust like, I don’t want to do that…What’s the point if it’sgoing to mess you up that bad?” Stemming from witnes-sing harmful aspects of substance use, many participantsmanaged their use through using selectively—choosing touse particular substances and avoiding others. A commonsubstance of choice was cannabis, which was described asa “natural herb” and “the main thing that wouldn’t makeyou crazy”, while other drugs were frequently avoided.One young man gave his rationale for not using drugs as“my family members are into hard drugs and stuff, so I’veseen that they fuck shit up.” Other participants describedcertain drugs as “more harsh” or “gross”, and some dis-cussed the concern of substance use challenges: “It is funfor the first time or two, then you get addicted or some-thing and then you just need it, need, need, need. I don’twant to be addicted.” Participants who used cannabisoften spoke adamantly about not using other drugs norwanting to use them: “never touched it [cocaine]”, “reallydon’t wanna do it [other drugs]”, “do not wanna try any-thing else”, “absolutely not”.In addition to using selectively to avoid perceivedharms of particular substances, many participants alsosought to minimize harms by reducing use. For many ofthe participants, the desire to reduce their use followednegative experiences: some described a single incident,such as blacking out when drinking and subsequentlylosing items or incurring injuries. Others described anaccumulation of negative effects—one participant ex-plains reducing her alcohol intake because “I don’t thinkmy liver could really take the hard stuff anymore…Thedoctors are saying that I’ve been drinking too much hardstuff…there could be something wrong with my stom-ach.” As well as managing negative effects of substanceuse, many participants reduced their use in order tofocus on other goals including attending school. Mul-tiple participants had received school suspensions fordrinking or smoking at school or attending school intox-icated, and articulated clear goals to “keep in school thisyear”. One participant described smoking cannabis “lotslast year, but…I actually didn’t go to school lots last year,so this year I just [need] to buckle down, actually to goto school.” Another participant reported cutting downon cannabis and alcohol consumption during the schoolyear, “but during the summer, drink a little too much.” Afew individuals viewed reducing or abstaining from useas a strategy for achieving the level of success requiredto attend university or get a good job, and limited theirown use with these goals in mind.Though many participants reflected on the harms ofsubstance use and demonstrated their use of individualstrategies to minimize these harms, youth also acknowl-edged their perceptions of positive effects of substanceuse. Some of the youth described using drugs as “a goodtrip” or having the effect of “mak[ing] me excel at stuff”.Others described using substances to manage difficultemotions, including to control anger, “keep me calm”, orsimply to “get through the day”. In this context in whichyouth articulated perceived benefits from substance use,and in which use was commonplace, abstinence-basedmessaging was described as unrealistic and unhelpful.One young woman commented “they have a lot ofschool awareness things but it seems like a lot of thepeople like know that already, and they still just do it, soI think maybe, instead of telling kids not to do it at all,they should tell them how to do it safer at least.”DiscussionOur findings illustrate that youth experiences, perspec-tives, and strategies related to substance use are deeplysituated within geographical, social, and cultural contexts.In The City, cannabis is openly discussed and frequentlyused by youth, alcohol is a foundational element of a“typical” party, and “hard drugs” are viewed as danger-ous. In The Valley, type and frequency of use dividessocial groups, with youth who avoid alcohol and drugscharacterizing substance use as harmful and againstcommon sense. In The North, alcohol and cannabis useis commonplace, yet many of the youth discuss redu-cing use and avoiding particular substances due to wit-nessing the potential for harmful effects within theirfamilies and community. Youth, regardless of their ownpattern of use, describe their substance use experiencesJenkins et al. Harm Reduction Journal  (2017) 14:53 Page 8 of 11and decisions in relation to the broader social contextof their friends, peer groups, and community; youthvariously describe their use as congruent with, or expli-citly in contrast to, the dominant contextual experiencein their communities.The emergence of a shared narrative of substance useacross youth interviews within each research site is con-sistent with the concept of “differentiated normalization”,which emerged from a critical analysis of Measham, New-combe, and Parker’s [44] theory of normalization. Whilenormalization suggests that drug use has shifted withinyouth culture from the fringe to the mainstream, differen-tiated normalization posits that individual substances andmodalities of use become variously normalized within dif-ferent geographic and social contexts [45]. Differentiatednormalization has been utilized within the youth sub-stance use literature to frame the geographic differenti-ation of youth urban/rural substance use trends [46] andto understand the impact of socio-political contexts withinwhich particular substances, such as cannabis, becomenormalized within youth populations [47]. In our study,youth descriptions of the context for substance use revealboth the differentiated normalization of substance use be-haviours and perspectives within each community context,and demonstrate youth’s awareness of the ways in whichtheir individual experiences of substance use are shapedby particular geographic, socio-cultural, and political fac-tors—for example, ways in which governmental policy andlegislation is taken up in youth attitudes toward cannabisuse in The City, or the ways in which a small town identityin The North informs youth characterization of substanceuse as an activity to counter boredom.In addition to local contexts shaping the normalizationof particular substance use trends, youth substance useperspectives and experiences in this study were also in-formed by the neoliberal conceptualization of individualresponsibility for substance use and associated harms[23]. In The City and The Valley, substance use wasframed as a poor decision by both users and non-users,mirroring the “individual deficit” perspective frequentlytaken up in substance use education and public healthmessaging [19]. While peer influence was identified as acontextual factor for use in The Valley, youth-centred in-dividual responsibility and decision-making, framing useand abstinence as personal choices as opposed to situ-ationally and structurally mediated states [48]. Further, inThe North in particular, historical and ongoing colonial-ism impacted youth perspectives on their own use and thecontext of use in their community. O’Gorman [49] arguesthat normalization of substance use not only occurswithin geographic and socio-cultural contexts but also re-sults from the intersectional context of class, race, andgender. It is through these complexities that substance usecan be simultaneously normalized and positioned asdeviant [50]. In The North, one participant’s expressionof distress at “becom[ing] one of those reserve Indians”highlights the ways in which pervasive colonial narra-tives of substance use in First Nations communitieshave positioned contextually normalized patterns andtypes of substance use as deviant. In each of the threecommunities, youth experiences of substance use werecontextualized within particular social and communitynorms, but were also informed by neoliberal and colo-nial framing of responsibility and blame for particularcontexts of use.Viewing youth substance use through a critical lens ofdifferentiated normalization is crucial not only for framingthe context of use for youth within the three communitiesin this study but also for understanding youth’s strategiesfor minimizing harms. Youth in The City speak to select-ing social events that were likely to involve use that wasconsistent with their own use patterns and preferences,and discussed limiting their frequency and type of sub-stance use in accordance with their personal beliefs sur-rounding moderation. In The Valley, many participantsdescribed forming friendships that were perceived asprotective from substance use harms; youth who diduse frequently attempted to influence the substance usebehaviours of others in what they viewed as a positivedirection. Youth in The North also described selectivelyusing particular substances as a harm minimizationstrategy for their own use; additionally, substance usereduction and moderation were frequently cited, withyouth maintaining and shifting their personal limitsbased on their experiences and aspirations. In each ofthese settings, youth developed and maintained harmminimization approaches to their own substance usethat allowed for the navigation of the contexts of sub-stance use in accordance with their own beliefs andpreferences. Many of the youth we interviewed describedthe perceived positive effects of substance use, includ-ing pleasure and enjoyment, and managing difficultemotions—yet also described the ways in which theyengaged in “bounded consumption” supported by harmminimization strategies that limited their pleasure-seekingand balanced their use with other responsibilities anddesires [24, 51].ConclusionsThis study suggests that youth are actively engaging instrategies to minimize the harms of substance use withintheir local contexts—yet are doing so on an informal orad hoc basis. The development and implementation ofsubstance use programming that is informed by evidencefrom harm reduction approaches is needed in order toresonate with young people. Further, for harm reductionprograming to be effective, it must also be informed byyouth experiences [21] and, as youth called for in thisJenkins et al. Harm Reduction Journal  (2017) 14:53 Page 9 of 11study, honesty. Multi-site analysis of findings across re-search sites in this study has illustrated the differencesin the ways in which substance use is taken up by youthbased on a range of individual and community factors.While some youth substance use approaches havesought cultural relevancy in programming, for example,for First Nations communities [52], content must alsohold specific relevancy to young people’s “actual attitudinaland behavioural norms”, including types of substancesused, patterns of use, and informal harm minimizationstrategies utilized by youth [53]. Harm reduction within aframework of culturally, socially, and geographically differ-entiated normalization, as supported by the findings fromthis study, holds the potential to speak directly to the waysin which youth use and manage their use and therebysupport youth resilience and may reduce the possibilityof harms associated with substance use.AcknowledgementsA special thank you to the youth who took the time to participate in thisstudy and share their important insights. The research team also wishes tothank members of the three communities who generously provided timeand resources to support the success of this project.FundingThis study and article were made possible by the Canadian Institutes ofHealth Research (CIHR) (Grant MOP-120776). Trainee support was providedto AS through a SSHRC Master’s Award.Availability of data and materialsThe data analysed in this current study is not publicly available due to itcontaining information that could compromise research participant privacyand consent, but are available from the corresponding author on reasonablerequest.Authors’ contributionsEKJ led the conceptualization, design, and project coordination for thisanalysis and contributed to the writing of this manuscript. AS contributed tothe analysis and interpretation of data, and drafted the initial manuscript.RHS contributed to the analysis of data and writing of the manuscript. Allauthors read and approved the final manuscript.Ethics approval and consent to participateEthics approval for this study was obtained from the University of BritishColumbia Behavioural Research Ethics Board, Reference #H12–00963. Toprotect privacy and support confidentiality, youth provided their ownconsent to participate, and did not require parent/guardian permission.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall,Vancouver, British Columbia V6T 2B5, Canada. 2Community Health Sciences,University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4,Canada.Received: 8 June 2017 Accepted: 25 July 2017References1. World Health Organization. Global status report on alcohol and health 2014.2014. http://apps.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf. Accessed 7 June 2017.2. United Nations Office on Drugs and Crime. 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JAlcohol Drug Educ. 2013;57:27–46.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Jenkins et al. Harm Reduction Journal  (2017) 14:53 Page 11 of 11

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