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Elevated risk of incarceration among street-involved youth who initiate drug dealing Hoy, Carly; Barker, Brittany; Regan, Jackie; Dong, Huiru; Richardson, Lindsey; Kerr, Thomas; DeBeck, Kora Nov 22, 2016

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RESEARCH Open AccessElevated risk of incarceration among street-involved youth who initiate drug dealingCarly Hoy1, Brittany Barker1,2, Jackie Regan1, Huiru Dong1, Lindsey Richardson1,3, Thomas Kerr1,4and Kora DeBeck1,5*AbstractBackground: Street-involved youth are known to be an economically vulnerable population that commonly resortsto risky activities such as drug dealing to generate income. While incarceration is common among people who useillicit drugs and associated with increased economic vulnerability, interventions among this population remaininadequate. Although previous research has documented the role of incarceration in further entrenching youth inboth the criminal justice system and street life, less is known whether recent incarceration predicts initiating drugdealing among vulnerable youth. This study examines the relationship between incarceration and drug dealinginitiation among street-involved youth.Methods: Between September 2005 and November 2014, data were collected through the At-Risk Youth Study,a cohort of street-involved youth who use illicit drugs, in Vancouver, Canada. An extended Cox model withtime-dependent variables was used to examine the relationship between recent incarceration and initiation intodrug dealing, controlling for relevant confounders.Results: Among 1172 youth enrolled, only 194 (16.6%) were drug dealing naïve at baseline and completed atleast one additional study visit to facilitate the assessment of drug dealing initiation. Among this sample, 56(29%) subsequently initiated drug dealing. In final multivariable Cox regression analysis, recent incarceration wassignificantly associated with initiating drug dealing (adjusted hazard ratio = 2.31; 95% confidence interval (CI) 1.21–4.42), after adjusting for potential confounders. Measures of recent incarceration lagged to the prior study follow-upwere not found to predict initiation of drug dealing (hazard ratio = 1.50; 95% CI 0.66–3.42).Conclusions: These findings suggest that among this study sample, incarceration does not appear to significantlypropel youth to initiate drug dealing. However, the initiation of drug dealing among youth coincides with anincreased risk of incarceration and their consequent vulnerability to the significant harms associated therein. Giventhat existing services tailored to street-involved youth are inadequate, evidence-based interventions should beinvested and scaled up as a public health priority.Keywords: Drug dealing, Street-involved youth, Incarceration, EmploymentBackgroundPrior research of street-involved youth indicates thatthey are a population vulnerable to economic hardshipand poor health outcomes [1–5]. This group is highlysusceptible to various health-related harms due toproblematic substance use, high-risk sexual behaviour,poverty, neglect, and homelessness and housing instabil-ity [3, 6, 7]. High-risk behaviours in this population areoften compounded by mental health issues, incompleteeducation, and a lack of marketable job skills, all ofwhich lead to a dependency on the “street economy”[4, 8]. The street economy refers to informal orprohibited income-generating activities that street-involved youth may rely on to meet their basic needs;these activities include but are not limited to panhand-ling, recycling, acquisitive crime, sex work, and drugdealing [4, 8].* Correspondence: uhri-kd@cfenet.ubc.ca1Urban Health Research Initiative, British Columbia Centre for Excellence inHIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada5School of Public Policy, Simon Fraser University, Vancouver, BC, CanadaFull list of author information is available at the end of the article© The Author(s). 2016 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.Hoy et al. Harm Reduction Journal  (2016) 13:32 DOI 10.1186/s12954-016-0120-3Drug dealing, sex work, “binning” (salvaging recyclablematerials), and panhandling are frequently listed asincome sources among street-involved youth in urbancentres [4, 9, 10]. Drug dealing has been described asthe most prevalent prohibited income source amongstreet-involved youth [11], with prior research findingthat 58% of this population reported having been in-volved in the drug trade in the preceding 6 months [12].Prior research among adult drug-using populations hasdemonstrated that maintaining personal drug use is themost frequently cited factor underpinning an individual’sinitiation into drug dealing [13, 14]. Similar researchinvolving youth who engage in this prohibited income-generating activity suggests that youth are also fre-quently driven by personal consumption needs [12].Economic vulnerability is another contributing factorfor street-involved youths’ involvement in drug dealing.Previous studies have found that street-involved youthinitiate drug dealing for the purpose of fulfilling financialneeds that have not been met though legal means [8, 15,16]. Youth are especially vulnerable to becoming in-volved in the street economy when their basic survivalneeds, such as food, clothing, and shelter, are unmet [8].Further, street-involved youth are frequently unable torely on the financial support of their families due toestrangement and low socioeconomic status and, as aresult, live in situations characterized by extreme incomeand material insecurity [8, 10]. While a number of healthand social services exist with the mandate of addressingsome of these vulnerabilities, a recent analysis in ourstudy setting found that more than 60% of street-involved youth reported experiencing difficulty accessingone or more of these services in the last 6 months (e.g.housing, food bank, employment services) [17].A number of sociodemographic factors exacerbateentrance into street life and associated vulnerabilities.For example, previous research has found that sexualminority youth are overrepresented among street popu-lations, often stemming from stigma and rejection oftheir sexual orientation at home [8]. Similarly, particu-larly in Canada, indigenous individuals are dispropor-tionately represented among the homeless and unstablyhoused [18]. This overrepresentation is present in thecriminal justice system as well. A previous study inVancouver found indigenous street-involved youth weresignificantly more likely to be incarcerated, despiteadjusting for risk factors associated with incarceration,suggesting the possible presence of institutional discrim-ination within the criminal justice system [19].As street-involved youth commonly come from back-grounds of trauma and abuse, and incomplete educationand may lack strong social ties, these factors exacerbatetheir precarious economic situations [8, 10]. Previousresearch has found that vulnerable and street-involvedyouth with few social ties are more likely to be recruitedinto the street economy by predatory adults and peerswho may pose as mentors or protectors, but in realityare exploiting social and structural vulnerabilities [8].Lastly, the degree of familiarity and ease by which manystreet-involved youths can access the street economymakes it an attractive option to meet financial needs [8].Currently, there are limited efforts aimed at providingeconomic opportunities for street-involved youth andeven less that are sufficiently low barrier to be compat-ible with their transient lifestyles [1, 20]. A previousstudy among adult injection drug users in Vancouverfound that nearly half of the sample who used and solddrugs would be willing to forgo drug dealing in favour ofa low-threshold employment opportunity [1], suggestingthat barriers to formal work may be a driving factor.“Low-threshold” work refers to legitimate and low-barrier employment options that may not require adher-ence to regular schedules, abstinence from drug andalcohol use, and/or accommodate health and socialservice utilization [1, 11, 21].Transitions into drug dealing have been found to beassociated with other risky behaviours. For example, previ-ous research has found that initiating drug dealing amongpeople who use illicit drugs was associated with dangerousdrug use practices, including higher frequency of consist-ent use, drug “binges”, and the risk of overdose as supplyissues become less of a barrier [14, 22]. Both injection andhigh-intensity drug use have been shown to place individ-uals at an elevated risk for acquiring infectious diseasessuch as hepatitis C and human immunodeficiency virus[3, 7, 14]. Furthermore, drug dealing is commonly associ-ated with other risky practices including involvement inorganized crime, carrying weapons, violence, and evenhomicide [9, 23]. These risks have the potential to lead toincreased involvement with the criminal justice systemand incarceration [23].The conditions surrounding incarceration have beenassociated with high rates of depression, psychologicaldisorders, low self-esteem, suicidal ideation, self-harm,and an elevated risk of overdose upon release [24, 25].Further, evidence suggests that the incarceration perioditself has an immensely negative impact on mentalhealth generally and contributes to the onset of mentalillness or the worsening of existing pathology [26]. Inconjunction with these mental health concerns, transi-tioning out of prison frequently puts youth at-risk for avariety of economic, social, and physical health-relatedharms [24, 27–29]. The experience of incarceration hasbeen well documented as a contributing factor in recid-ivism and further entrenchment of individuals within thecriminal justice system [30–33]. However, less is knownabout whether recent incarceration predicts or is as-sociated with initiating drug dealing among vulnerableHoy et al. Harm Reduction Journal  (2016) 13:32 Page 2 of 8youth. Given the well-established harms of incarceration,this longitudinal analysis investigates the relationshipbetween recent incarceration and initiation into drug deal-ing among street-involved youth in Vancouver, Canada.MethodsData for this study were obtained from the At-Risk YouthStudy (ARYS), which is an open prospective cohort ofstreet-involved youth in Vancouver, Canada. To be eligiblefor the study, participants had to be between the ages of14–26 years at study enrolment; street-involved, definedas being homeless, unstably housed, or having used aservice specific to street-involved youth; to have used anillicit drug other than, or in addition to, marijuana in thepast 30 days; and provided written informed consent. Thisstudy has been described extensively elsewhere [34]. Inbrief, at the baseline study visit and biannually thereafter,participants complete an interviewer-administered ques-tionnaire, eliciting a range of information, including socio-demographic information, drug use patterns, sexual anddrug-related risk behaviours, engagement with health andsocial services, and involvement in the criminal justicesystem. After each visit, participants are remunerated$30 (CAD) for their time. The Providence HealthCare/University of British Columbia’s Research EthicsBoard has approved the study.The study period for this analysis extended fromSeptember 2005 to November 2014. Data from all par-ticipants who reported no history of drug dealing atenrolment and who returned for at least one subsequentstudy follow-up during the study period to assess fordrug dealing initiation were eligible for this analysis. Ourprimary outcome of interest was initiation into drugdealing, defined as exchanging illicit drugs for monetaryreward and including any middle-man activities formonetary reward. The primary explanatory variable ofinterest was incarceration, defined as responding af-firmatively to the question: “Have you been in detention,prison or jail in the last six months?” Participants whoreported being incarcerated were then asked to specifythe type of facility (e.g. juvenile detention, local jail,provincial, or federal prison) and the number of daysincarcerated. As we have done with other outcomes,such as injection initiation and HIV infection [35, 36],the date of when a participant initiated drug dealing wasestimated as the midpoint between the first study visitwith no reported drug dealing and the follow-up visitwhere the participant reported engaging in drug dealing.Participants who did not initiate drug dealing through-out the study period were right-censored at the date oftheir last follow-up visit.To better understand the potential relationship betweendrug dealing initiation and incarceration, we adopted a con-founding model building approach. Potential confounderswere chosen based on a known or hypothesized associationwith incarceration and drug dealing initiation [12, 14, 37,38]. These included the following: age (per year older);gender (female vs. male); ethnicity (Caucasian vs. others);homelessness [defined as having no fixed address, sleepingon the street, couch surfing, or staying in a shelter or hostel(yes vs. no)]; any injection and non-injection crystal meth-amphetamine use (yes vs. no); any crack-cocaine smoking(yes vs. no); any injection and non-injection heroin use (yesvs. no); any injection and non-injection cocaine use (yes vs.no); accessing services [defined as recently accessing anyhealth or social service (e.g. meal programme, supervisedinjection facility) (yes vs. no)]; being a recent victim ofviolence [defined as being attacked, assaulted, or sufferingviolence (yes vs. no)]; ever experiencing physical abuse (yesvs. no); and ever experiencing sexual abuse (yes vs. no).Physical and sexual abuse variables refer to lifetime circum-stances. All other drug use and behavioural variables referto circumstances over the previous 6 months and weretreated as time-updated covariates on the basis of semi-annual follow-up data.To examine the relationship between initiating drugdealing and incarceration, as a first step, we calculatedthe incidence rate ratio and 95% confidence interval fordrug dealing initiation among the sample using aPoisson model. We further examined the baseline char-acteristics, stratified by reports of initiating drug dealingover study follow-up, and then compared the resultsusing logistic regression. Then, using an extended Coxmodel with time-dependent variables, we estimated theunadjusted relative hazards and 95% confidence intervalsfor each explanatory variable that was hypothesized tobe associated with drug dealing [39]. The inclusion oftime-updated covariates in an extended Cox modelnegates the requirement of the proportional hazardassumption [39]. To fit our multivariable Cox models,we used a previously described backwards selectionprocess [40, 41], whereby all explanatory variables foundto be significantly associated with time to drug dealinginitiation in bivariable analyses (p value <0.10) wereincluded in the full model. Using a stepwise approach,we subsequently generated a series of reduced modelsby removing each secondary explanatory variable, one ata time. For each of these models, we assessed the relativechange in the coefficient for having been incarcerated inthe previous 6 months. The secondary explanatory vari-able of interest that resulted in the smallest absoluterelative change in the coefficient for having been incar-cerated was then removed. Secondary variables contin-ued to be removed through this process until thesmallest relative change in the coefficient for the effectof incarceration on initiation into drug dealing wasobserved to exceed 5%. Remaining variables wereconsidered confounders and were included in the finalHoy et al. Harm Reduction Journal  (2016) 13:32 Page 3 of 8multivariable model. Several authors have previouslyused this technique successfully [42, 43]. Lastly, to meas-ure if incarceration was a predictor of initiating drugdealing, we lagged accounts of recent incarceration tothe previous study visit before participants reportedinitiating drug dealing. All statistical analyses wereperformed using SAS software version 9.4 (SAS, Cary,NC, USA). All tests of significance were two-sided.ResultsBetween September 2005 and November 2014, 1175street-involved youth were recruited into the ARYScohort. Among 1172 youth enrolled, only 194 (16.6%)were drug dealing naïve at baseline and completed atleast one additional study visit to facilitate the assess-ment of drug dealing initiation. Among this group, dur-ing the study period, the average yearly loss to follow-uprate was 2.96%. There were no significant differenceswith respect to gender (p = 0.205), ethnicity (p = 0.695),or history of incarceration (p = 0.427) between the 194youth who represented the eligible study sample and the78 drug dealing naïve youth who were ineligible becausethey were not enrolled in the cohort long enough to bedue for a study follow-up or did not have a follow-upvisit at the time this analysis was conducted.Among the sample of 194 youth included in the study,91 (47%) were female, 127 (65%) were of Caucasian ethni-city, and the median age was 21 (interquartile range [IQR]19–23). These 194 youths contributed to 849 observationsover the study period. The median number of study visitswas 3 (IQR 2–5), the median time between study visitswas 5.9 months (IQR 4.9–7.2), and the median follow-uptime per participant was 19.7 (IQR 10.8–34.2) months.Over the course of study follow-up, 56 (29%) participantsinitiated dealing for an incidence density of 13.0 cases per100 person years (95% confidence interval [CI] 9.9–17.2).At some point during the study period, 55 (28%) youthreported being recently incarcerated. Among those whoreported being recently incarcerated, there were 2 (0.2%)reports of being held in a youth detention centre, 49(5.8%) reports of being held in a local jail, 29 (3.49%)reports of being held in a provincial jail, and 1 (0.1%)report of being held in a federal prison, and the medianlength of stay was 3 days (IQR 1–18) (it should be notedthat youth may have reported multiple incarcerations overthe study period and that the percentages reflect the pro-portion of total observations). Similarly, over the studyperiod, service uptake remained relatively consistent. Forexample, there were 467 (55.0%) reports of accessingdrop-in centres, 246 (29%) reports of accessing an out-reach worker, 299 (35.2%) reports of accessing a mealprogramme, and 111 (13.1%) reports of accessing thesupervised injection facility. Table 1 provides baselinecharacteristics stratified by initiation into drug dealing.Table 2 shows the unadjusted and adjusted relativehazard of explanatory variables associated with drugdealing initiation. In bivariable Cox regression analysis,incarceration was significantly associated with initiatingdrug dealing (hazard ratio [HR] = 3.85; 95% CI 2.19–6.76). In multivariable Cox regression analyses, incarcer-ation (adjusted hazard ratio [AHR] = 2.31; 95% CI 1.21–4.42) remained significantly and positively associatedwith initiating drug dealing after adjusting for thefollowing identified confounders: gender, crystal met-hamphetamine use, homelessness, and ever experiencingsexual abuse. In order to see if recent incarceration waspredictive of drug dealing, we checked for a reverserelationship by lagging incarceration to the previous 6-month study period. However, the bivariable associationwas not significant (HR = 1.50; 95% CI 0.66–3.42).DiscussionAmong street-involved youth in our sample, drugdealing was highly prevalent at baseline (77%) and sub-sequent initiation into drug dealing over study follow-upwas also high (29%). The overwhelmingly high preva-lence of participants with a history of drug dealing attheir baseline study visit should be emphasized andunderscores the importance of the illicit drug trade tomeet this population’s needs. In multivariable analysiswith time-updated measures, we found that recent incar-ceration was positively and significantly associated withinitiating drug dealing. While previous research has foundsimilarly significant associations between drug dealing andincarceration [20], our study sought to determine whetherdealing predicted incarceration. However, when incarcer-ation was lagged to the study interview prior to the reportof initiating drug dealing, the association between incar-ceration and drug dealing initiation was no longer signifi-cant. Therefore, these findings indicate that incarcerationdoes not clearly predict future drug dealing among thissample. Rather, study findings appear to suggest the initi-ation of drug dealing coincides with an increased risk forincarceration among our study sample.This interpretation is aligned with previous researchindicating that novice, low-level drug dealers are morevulnerable to detection and incarceration [20]. Given theknown harms of incarceration, it is evident that furthermeasures should be in established to reduce youthinvolvement with criminal justice system. Conversely, in2007, Canada’s federal government implemented theNational Anti-Drug Strategy that included ManditoryMinimum Sentancing (MMS) legislation [44]. Previousreports have found MMS to be ineffective in reducingpopulation rates of drug dealing, as it targets low-level,street drug dealers who are primarily involved in dealingto support personal drug use [45]. As many youthsare early in their drug dealing careers and dealing toHoy et al. Harm Reduction Journal  (2016) 13:32 Page 4 of 8mitigate their economic insecurity, an unintended conse-quence of MMS is that youth may be more susceptible tobeing arrested and incarcerated.Our finding of a significant association between recentdrug dealing initiation and incarceration suggests a needfor evidence-based interventions to improve the eco-nomic security of youth and prevent them from re-sorting to drug dealing. A study based in Los Angelesfound that low-threshold social enterprise employmentinterventions were effective in utilizing street-involvedyouths’ existing entrepreneurial skills that may have beendeveloped through their experience with the street-basedeconomy, such as management and budgeting [46]. Theprogramme taught and strengthened complementary skillsnecessary to obtain legitimate means of employment as analternative to the street-based economy, and many of theTable 1 Baseline sociodemographic characteristics and substanceuse behaviours associated with initiating drug dealing amongstreet-involved youth in Vancouver, Canada (n = 194)Characteristic Drug dealing initiation p valueYes56 (29%)No138 (71%)Odds ratio(95% CI)IncarcerationaYes 4 (7) 10 (7) 0.99 (0.30–3.30) 0.985No 51 (91) 126 (91)Age (median, IQRb) 21 (19–22) 21 (19–23) 0.94 (0.84–1.05) 0.278Female genderYes 19 (34) 72 (52) 0.47 (0.25–0.90) 0.022No 37 (66) 66 (48)Caucasian ethnicityYes 36 (64) 91 (66) 0.93 (0.49–1.78) 0.826No 20 (36) 47 (34)HomelessaYes 33 (59) 91 (66) 0.76 (0.40–1.45) 0.401No 22 (39) 46 (33)Heroin useaYes 13 (23) 45 (33) 0.63 (0.31–1.30) 0.211No 42 (75) 92 (67)Crack-cocaine useaYes 24 (43) 66 48) 0.83 (0.44–1.56) 0.569No 31 (55) 71 (51)Crystal methamphetamine usedYes 23 (41) 69 (50) 0.71 (0.38–1.33) 0.285No 32 (57) 68 (49)Cocaine useaYes 17 (30) 51 (37) 0.76 (0.39–1.49) 0.428No 38 (68) 87 (63)Victim of violencebYes 19 (34) 52 (38) 0.90 (0.47–1.75) 0.761No 34 (61) 84 (61)Physical abuseYes 46 (82) 111 (80) 1.19 (0.50–2.86) 0.695No 8 (14) 23 (17)Sexual abuseYes 44 (79) 86 (62) 2.40 (1.11–5.21) 0.026No 10 (18) 47 (34)Accessed servicesYes 45 (80) 116 (84) 0.78 (0.35–1.73) 0.535No 11 (20) 22 (16)All column percentages may not sum to 100% due to missing data orrounding errorCI confidence intervalaDenotes activities in the last 6 monthsbIQR interquartile rangeTable 2 Bivariable and multivariable Cox regression analyses ofdrug dealing initiation among street-involved youth in Vancouver,Canada (n = 194)Characteristic Unadjusted hazard ratio Adjusted hazard ratioHR (95% CI) p value AOR (95% CI) p valueIncarcerationYes vs. no 3.85 (2.19–6.76) <0.001 2.31 (1.21–4.42) 0.011AgePer year older 0.95 (0.86–1.04) 0.252GenderFemale vs. male 0.53 (0.30–0.93) 0.025 0.54 (0.27–1.08) 0.082Caucasian ethnicityYes vs. no 0.95 (0.56–1.62) 0.857HomelessaYes vs. no 2.35 (1.33–4.16) 0.003 1.83 (1.01–3.32) 0.047Heroin useaYes vs. no 2.19 (1.26–3.79) 0.006Crack cocaine useaYes vs. no 2.87 (1.67–4.93) <0.001Crystal methamphetamine useaYes vs. no 2.78 (1.63–4.76) <0.001 2.60 (1.46–4.62) 0.001Cocaine useaYes vs. no 2.06 (1.18–3.58) 0.011Victim of violenceaYes vs. no 2.00 (1.15–3.47) 0.014Physical abuseYes vs. no 1.21 (0.62–2.34) 0.579Sexual abuseYes vs. no 2.26 (1.17–4.36) 0.015 2.48 (1.20–5.14) 0.014Accessed servicesaYes vs. no 1.93 (0.92–4.03) 0.080CI confidence intervalaRefers to activities in the previous 6 monthsHoy et al. Harm Reduction Journal  (2016) 13:32 Page 5 of 8youth involved in the programme have transitioned intolong-term employment in a variety of industries [46].Low-threshold employment programmes aimed at ad-dressing underlying barriers to employment such as lowself-esteem, incomplete education, substance use, andhomelessness have also been shown to be effective amongstreet-involved youth [47]. For example, a youth employ-ment programme in northern British Columbia offeredpart-time employment opportunities to vulnerable youthwith the intention of moving youth into full-time em-ployment if they were able to work with staff to addresstheir individual barriers to employment [47]. Eighty-eightpercent of youth who completed the programme wereable to find either formal employment or enrol in schoolat follow-up a year later [47]. Another example, located inthe present study’s setting, offers a low-threshold employ-ment programme, where street-involved youth can workcasual shifts to assist with “street beautification” and arecompensated with a financial honorarium on the sameday [48]. The extent to which low-threshold interventionsof this nature successfully address the economic vulner-abilities experienced by street-involved youth and maysubsequently reduce engagement in drug dealing and riskof incarceration warrants rigorous evaluation as thepotential for public health benefits are significant.For youth who do become involved with the criminaljustice system, ensuring there are viable economic op-portunities post-release has the potential to addressvulnerabilities previously mentioned. For example, ameta-analysis conducted in 2009 found that engagementwith counselling, multiple coordinated services (e.g. casemanagement, residential services), skill building, andrestorative interventions (e.g. restitution and mediationbetween offenders and victims) had a moderate impacton reducing youth recidivism (between 10 and 13%) [49].Additionally, a study conducted in 2004 among adult of-fenders with a history of drug use found that post-releaseemployment programmes had a high programme comple-tion rate (78%), and more than half secured competitiveemployment, often including benefits [50].This study has limitations. First, as with all community-recruited research cohorts, the ARYS cohort is not arandom sample and therefore may not be generalizable toother populations of street-involved youth. Second, datacollected was based on self-report and thus could be sub-ject to response bias, including socially desirable respond-ing, which may have resulted in the under-reporting ofillicit substance use, engagement in drug dealing, andother stigmatized activities. However, self-reported riskbehaviour has been shown to be largely accurate amongadult substance-using populations [51], as well as amongvarious youth populations [52]. Furthermore, the non-randomized nature of this study results in the conclusionsbeing potentially influenced by confounders that are notaccounted for. Given the extremely high prevalence ofdrug dealing at baseline, future research should investigatethe relationship between incarceration and initiating drugdealing using larger samples. Further, our broad definitionof incarceration in the current study (e.g. detained,charged, prosecuted) may result in the estimates beingunder- or overestimated. Future studies that differentiatebetween distinct types of criminal convictions and lengthsof incarceration events would be beneficial. Additionally,our study instrument did not measure the reason youthwere incarcerated. As a result, we are unable to assess ifincarceration events were related to drug dealing vs.violent crime, acquisitive crime, or other types of offences.Therefore, it should be noted that income-generatingcrimes may not be the only activity related to incarcer-ation in this population. Future research in this area wouldbe helpful to better inform the relationship between theinitiation of drug dealing and incarceration.ConclusionsIn summary, among our study sample of street-involvedyouth, we found that the experience of recent incarcerationdoes not appear to significantly drive youth to initiate drugdealing. However, the initiation of drug dealing was foundto coincide with an elevated risk for incarceration. Thisfinding suggests that efforts to improve the economicsecurity of street-involved youth may have the potential toreduce engagement in drug dealing and subsequent harmsincluding incarceration. Given the inadequacy of existingservices among this population, governments shouldinvest and scale up evidence-based interventions tohelp reduce the economic vulnerabilities experiencedby street-involved youth.AbbreviationsARYS: At-Risk Youth Study; MMS: Mandatory Minimum SentencingAcknowledgementsThe authors thank the study participants for their contribution to theresearch, as well as current and past researchers and staff. The authorswould specifically like to thank Evan Wood, Cody Callon, Jennifer Matthews,Deborah Graham, Peter Vann, Steve Kain, Tricia Collingham, Kristie Starr, andCarmen Rock for their research and administrative assistance.FundingThe study was supported by the US National Institutes of Health(R01DA028532, U01DA038886) and the Canadian Institutes of HealthResearch (MOP–102742). Dr. Kora DeBeck is supported by a Michael SmithFoundation for Health Research/St. Paul’s Hospital-Providence Health CareCareer Scholar Award. Lindsey Richardson is supported by a New InvestigatorAward from the Canadian Institutes of Health Research and a Scholar Awardfrom the Michael Smith Foundation for Health Research. Brittany Barker issupported by a Canadian Institutes of Health Research Doctoral Award.Availability of data and materialsThe data from this study are not available in a public repository dueto ethical concerns. Participants were assured during the informedconsent process and throughout each study visit that their responseswere confidential.Hoy et al. Harm Reduction Journal  (2016) 13:32 Page 6 of 8Authors’ contributionsCH, JR, BB, and KD conceptualized the study design and drafted the initialmanuscript. HD performed the statistical analyses, and CH, BB, and KDinterpreted the results. TK, LR, and KD provided substantial revisions of themanuscript and guidance throughout the writing. All authors have read andapproved the final manuscript.Authors’ informationNot applicable.Competing interestsThe authors declare that they have no competing interests.Consent for publicationThis study does not include any details, images, or videos relating toindividual participants; however, Dr. Kora DeBeck (senior author andPI of ARYS) has access to all of the study data and consent to publishthe findings.Ethics approval and consent to participateThe At-Risk Youth Study has been approved by the Providence Health Care/University of British Columbia’s Research Ethics Board. All participants haveprovided written informed consent to participate in the study.Author details1Urban Health Research Initiative, British Columbia Centre for Excellence inHIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada. 2Interdisciplinary Studies Graduate Program, University of BritishColumbia, Vancouver, BC, Canada. 3Department of Sociology, University ofBritish Columbia, Vancouver, BC, Canada. 4Division of AIDS, Department ofMedicine, University of British Columbia, Vancouver, BC, Canada. 5School ofPublic Policy, Simon Fraser University, Vancouver, BC, Canada.Received: 3 August 2016 Accepted: 10 November 2016References1. DeBeck K, Wood E, Qi J, Fu E, McArthur D, Montaner J, Kerr T. Interest inlow-threshold employment among people who inject illicit drugs:implications for street disorder. Int J Drug Policy. 2011;22:376–84.2. Boivin J-F, Roy É, Haley N, du Fort GG. The health of street youth: aCanadian perspective. 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Inner city youth and drug dealing: a review of theproblem. J Youth Adolesc. 1998;27:395–411.10. Gaetz S, O’Grady B. Making money exploring the economy of younghomeless workers. Work Employ Soc. 2002;16:433–56.11. DeBeck K, Shannon K, Wood E, Li K, Montaner J, Kerr T. Income generatingactivities of people who inject drugs. Drug Alcohol Depend. 2007;91:50–6.12. Werb D, Kerr T, Li K, Montaner J, Wood E. Risks surrounding drug tradeinvolvement among street-involved youth. Am J Drug Alcohol Abuse.2008;34:810–20.13. Small W, Maher L, Lawlor J, Wood E, Shannon K, Kerr T. Injection drug users’involvement in drug dealing in the downtown eastside of Vancouver: socialorganization and systemic violence. Int J Drug Policy. 2013;24:479–87.14. Kerr T, Small W, Johnston C, Li K, Montaner JS, Wood E. Characteristics ofinjection drug users who participate in drug dealing: implications for drugpolicy. J Psychoactive Drugs. 2008;40:147–52.15. Baron SW. Street youth, strain theory, and crime. J Crim Just. 2006;34:209–23.16. Baron SW. Street youth, unemployment, and crime: is it that simple? Usinggeneral strain theory to untangle the relationship. Can J Criminol CrimJustice. 2008;50:399–434.17. Barker B, Kerr T, Nguyen P, Wood E, DeBeck K. Barriers to health and socialservices for streetinvolved youth in a Canadian setting. J Public HealthPolicy. 2015;3:350–63.18. Oelke ND, Thurston WE, Turner D, University of British Columbia O, First PeoplesGroup A, Univerity of C. Aboriginal homelessness: a framework for best practicein the context of structural violence. Int Indigenous Policy J. 2016;7:5.19. Barker B, Alfred GT, Fleming K, Nguyen P, Wood E, Kerr T, DeBeck K.Aboriginal street-involved youth experience elevated risk of incarceration.Public Health. 2015;129:1662–8.20. Omura JD, Wood E, Nguyen P, Kerr T, DeBeck K. Incarceration among street-involved youth in a Canadian study: implications for health and policyinterventions. Int J Drug Policy. 2014;25:291–6.21. Richardson L, Sherman SG, Kerr T. Employment amongst people who use drugs:a new arena for research and intervention? Int J Drug Policy. 2012;23:3–5.22. Sherman SG, Latkin CA. Drug users’ involvement in the drug economy:implications for harm reduction and HIV prevention programs. J UrbanHealth. 2002;79:266–77.23. Gabor T, Crutcher N. Mandatory minimum penalties: their effects oncrime, sentencing disparities and justice system expenditures. OttawaDept. of Justice Canada, Research & Statistics Division. 2002. http://www.justice.gc.ca/eng/rp-pr/csj-sjc/ccs-ajc/rr02_1/rr02_1.pdf. Accessed 13July 2016.24. Mace D, Rohde P, Gnau V. Psychological patterns of depression and suicidalbehavior of adolescents in a juvenile detention facility. J Juvenile JusticeDetention Serv. 1997;12:18–23.25. Beletsky L, LaSalle L, Newman M, Paré JM, Tam JS, Tochka AB. Fatalre-entry: legal and programmatic opportunities to curb opioid overdoseamong individuals newly released from incarceration. Northeast UnivLaw J. 2015;7:155–215.26. Forrest CB, Tambor E, Riley AW, Ensminger ME, Starfield B. The health profileof incarcerated male youths. Pediatrics. 2000;105:286–91.27. Freudenberg N, Daniels J, Crum M, Perkins T, Richie BE. Coming home fromjail: the social and health consequences of community reentry for women,male adolescents, and their families and communities. Am J Public Health.2008;98:S191–202.28. Apel R, Sweeten G. The impact of incarceration on employment during thetransition to adulthood. Soc Probl. 2010;57:448–79.29. Holzer HJ. Collateral costs: the effects of incarceration on the employmentand earnings of young workers. Bonn: Urban Institute and IZA; 2007.Available from: repec.iza.org/dp3118.pdf.30. Cottle CC, Lee RJ, Heilbrun K. The prediction of criminal recidivism injuveniles a meta-analysis. Crim Justice Behav. 2001;28:367–94.31. Dunnet A. The Cedar Project: vulnerability to recidivism among Aboriginalyoung people who use drugs [graduate thesis]. 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Correlates of drug dealing infemale methamphetamine users. J Urban Health. 2013;90:529–41.38. Ludwick MD, Murphy S, Sales P. Savvy sellers: dealing drugs, doing gender,and doing difference. Subst Use Misuse. 2015;50:708–20.39. Kleinbaum DGKM. Survival analysis. New York: Springer; 1996.Hoy et al. Harm Reduction Journal  (2016) 13:32 Page 7 of 840. Maldonado G, Greenland S. Simulation study of confounder-selectionstrategies. Am J Epidemiol. 1993;138:923–36.41. Rothman KJ, Greenland S, Lash TL. Modern epidemiology. Phillidelphia:Lippincott Williams & Wilkins; 2008.42. Lima VD, Geller J, Bangsberg DR, Patterson TL, Daniel M, Kerr T, MontanerJS, Hogg RS. The effect of adherence on the association betweendepressive symptoms and mortality among HIV-infected individuals firstinitiating HAART. AIDS. 2007;21:1175–83.43. Lima VD, Kopec JA. Quantifying the effect of health status on healthcare utilization using a preference-based health measure. Soc Sci Med.2005;60:515–24.44. Department of Justice Canada. National anti-drug strategy evaluation: finalreport. Ottawa: Government of Canada; 2012.45. Symington A. Legislation imposing mandatory minimum sentences for drugoffences passes second reading. HIV/AIDS Policy Law Rev. 2008;13:25–27.46. Ferguson KM. Implementing a social enterprise intervention with homeless,street-living youths in Los Angeles. Soc Work. 2007;52:103–12.47. Matsuba MK, Elder GJ, Petrucci F, Marleau T. Employment training forat-risk youth: a program evaluation focusing on changes inpsychological well-being. Child Youth Care Forum. 2008;37:15–26.48. Directions Youth Services. Street youth job action. http://directionsyouthservices.ca/services-centre/street-youth-job-action/.49. Lipsey MW. The primary factors that characterize effective interventions withjuvenile offenders: a meta-analytic overview. Vict Offenders. 2009;4:124–47.50. Kemp K, Savitz B, Thompson W, Zanis DA. Developing employment servicesfor criminal justice clients enrolled in drug user treatment programs. SubstUse Misuse. 2004;39:2491–511.51. Darke S. Self-report among injecting drug users: a review. Drug AlcoholDepend. 1998;51:253–63.52. Brener ND, Billy JO, Grady WR. Assessment of factors affecting the validity ofself-reported health-risk behavior among adolescents: evidence from thescientific literature. J Adolesc Health. 2003;33:436–57.•  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:Hoy et al. Harm Reduction Journal  (2016) 13:32 Page 8 of 8


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