Do crack smoking practices change with the introduction of safer crack kits?
Malchy, Leslie A. ; Bungay, Vicky ; Johnson, Joy L. 等
In Canada, crack smoking is a significant public health problem (1)
with well-known associated health-related harms. (2,3) Because many
people who smoke crack share their equipment, crack smoking has been
associated with infectious disease transmission including tuberculosis,
pneumonia, hepatitis C and HIV. (3-11) Crack use in Vancouver has been
on the rise over the past decade. (4) Pilot research with crack smokers
in Vancouver found that these individuals were engaging in unsafe crack
use practices such as sharing crack pipes. (12) Contributing to unsafe
practices in crack smokers are: a lack of available equipment for crack
use; specific stigma associated with crack smoking; (13,14) and the fact
that while harm reduction equipment is distributed through public health
agencies for IV drug users to reduce the harm of needle sharing
practices, similar harm reduction initiatives for people who smoke crack
are not as available. The objective of this research was to determine
the impact of distribution of safer crack use kits on crack smoking
practices; specifically, utilization of safer use items and equipment
sharing practices.
METHODS
Kit distribution and outreach
Two outreach approaches were used for distribution of the kits;
peer outreach and integrated outreach. Peer outreach involved teams of
two peers patrolling the neighbourhood on foot and providing outreach in
the alleys and main public areas. Integrated outreach combined
distribution with existing harm reduction services; some of this
outreach took place on foot and one team conducted mobile outreach from
a van. All teams distributed a limited number of kits per session
(25-100). The outreach process included a demonstration of how to
assemble kit contents (e.g., put brass screens into the pipe, attach the
mouthpiece), education regarding the rationale for using tobacco pipe
screens instead of Brillo[R], a discussion of the risks of sharing
equipment, and referrals to health and social service agencies when
required. The teams used a standard data collection form to record the
number of kits distributed as well as the recipient's gender.
Textbox 1 describes the rationale for items included in the kits.
Kit distribution evaluation
In order to examine utilization and effects of the distribution of
safer crack kits on crack use practices, cross-sectional surveys were
conducted prior to and post kit distribution.
Textbox 1. Safer crack use items included in kits
* Pyrex stems are stronger, less likely to explode, break or chip
and last longer than glass stems.
* Mouthpieces: 4 inch mouthpieces were cut from plastic food-grade
tubing; using a mouthpiece can prevent direct contact of the mouth
with broken or hot pipes. Providing individuals with their own
mouthpiece can prevent saliva exchange when a pipe is shared.
* Wooden push sticks are less likely to chip stems than metal ones
(e.g., coat hangers, car antenna).
* Condoms were included to promote safer sex. Crack use is
associated with high-risk sexual behaviours; many women who use
crack support themselves through sex work.
* Bandages were included to protect broken skin and sores/burns on
fingers.
* Alcohol swabs were included to promote cleaning of equipment
(e.g., pipes, mouthpieces) and to cleanse open wounds (e.g., sores
on the fingers).
* Brass screens designed for tobacco pipes are less likely to break
apart than steel wool or "Brillo[R]"and are not coated with
potentially toxic substances.
* Lighter: Each kit included one lighter. Smoking crack requires
consistent heat applied to the pipe. Using matches is more likely
to result in burns on fingers. Not having one's own "light" is
associated with unsafe circumstances (i.e., forced to share crack
or experience harassment from others).
* Information cards: Two cards were included in the kits: The tip
card covered harm reduction information for crack users, and the
resource card included local information with health and drug user
services
Total cost: $1.66
Instrument
The surveys were developed by team members and focused on items
related to crack use practices and crack kit utilization. The survey
items were drawn from previous empirical findings related to crack use
practices, (12,15) as well as the Short Form-36 Health Survey. (16) Kit
utilization was determined by questions such as "In the last year,
did you use each of the following items regularly (e.g., on a consistent
basis)?" with responses of "yes" or "no" as
answer choices. Smoking practice was determined by questions such as
"When you smoke crack, how often do you use a pipe that has already
been used by someone else?" with answer choices including
"never, almost never, sometimes, usually or always". An
additional sharing practices section included the question "Have
you ever shared a pipe with people you know?" and "people you
don't know?" with possible survey responses as "yes"
or "no". People who use crack provided critical feedback
regarding wording and relevance of survey items and the survey was pilot
tested prior to administration. One significant change was made to the
post-distribution survey regarding materials used as push sticks. Push
sticks are used to pack and position the filter or screen inside the
crack pipe. The push stick is used to move the screen back and forth to
recover the crack that has hardened on the inside of the pipe after it
cools. During the study, local agencies reported concerns that people
who smoked crack were using syringe plungers as push sticks; therefore a
question was added.
Data collection
The surveys were administered by a team of researchers in local
service agencies over 3-5 months. The survey participants were men and
women living or "hanging out" in the target neighbourhood who
self-reported smoking crack in the previous 30 days and who could speak
and understand English. Women were oversampled due to the specific
interests of research team members; results on women's experience
are published elsewhere. (17) Participants for both surveys were
recruited from locations known to be frequented by people who use crack
(i.e., drop-in centres, transition housing, shelters and "on the
street"). Recruitment also occurred by word-of-mouth and via flyers
noting survey date, time and locations. Surveying took place in a closed
room separated from the general services area of the agency, with
research team members screening participants for duplicate
participation. While this study was not longitudinal, several
respondents participated in both pre- and post-test surveys. Surveys
took approximately 20 minutes to complete and participants received a
$10 stipend. Ethical approval for this research was obtained from the
University of British Columbia Behavioural Research Ethics Board.
Textbox 2. Reported use of items in the safer crack use kits
(n=106)
Pyrex stem 99%
Lighter 98%
Mouthpiece 79%
Push stick 58%
Condoms 59% (Males 61%, Females 57%)
Bandages 53%
Alcohol swabs 58%
Screens 42%
74% indicated the safer crack kit harm reduction tip card was useful;
66% indicated that the services/resource list cards were useful.
Data analysis
All outreach record forms and participant surveys were entered into
SPSS[R] version 17. A sample of 177 per group enabled us to detect a 20%
difference in changes in kit item use (+/-10%) with 95% level of
confidence. The database was checked for accuracy by team members.
Descriptive statistics were obtained for demographic data including
gender, age, amount and source of income, ethnicity, crack use and other
drug use. Chi-square analysis was used to examine differences in crack
smoking and equipment sharing practices at each time point for the pre-
and post-distribution questionnaires.
RESULTS
The pre-distribution survey was completed by 206 persons, 58% were
female and the median age was 40 years. During the study period, 12,499
kits were distributed; 6,386 kits were received by men, 6,007 by women
and 106 by transgendered individuals; 6,092 kit recipients reported
receiving more than one kit. The post-distribution survey was completed
by 150 persons, of whom 106 (71%) had received a study kit. Injection
drug use was reported by approximately 40% of participants. Demographic
characteristics of the two samples are shown in Table 1. We analyzed the
data for differences in characteristics in the two different survey
samples. There were significantly more persons of Aboriginal heritage
and more persons receiving public assistance in the post-distribution
group.
Textbox 2 shows the post-distribution survey results of the
frequency with which kit recipients used each of the safer crack kit
items. Pyrex stems and lighters were used by more than 98% of
respondents, mouthpieces were used by 79% and condoms by 59%. There was
no significant difference in condom use between male and female
recipients. Three quarters of the recipients found the harm reduction
tip card useful.
Table 2 outlines smoking practices pre and post kit distribution.
Respondents reported an increase in usually or always finding and using
Pyrex pipes and mouthpieces. There was also an increase in use of items
that had been previously used by someone else. Most post-distribution
survey respondents (87%) reported using metal push sticks, 42% used
wooden push sticks, 32% used plastic push sticks and 41% used syringe
plungers.
DISCUSSION
The distribution of safer use kits promoted access and utilization
of these tools; we found the use of "safer" items such as
Pyrex pipes had increased at the one-year time point, highlighting the
need for and acceptability of less harmful non-injection drug using
equipment for crack users in Vancouver.
Sharing crack-use paraphernalia is very prevalent; Fischer et al.
reported that 79% of study participants had shared equipment in the
previous 30 days, with almost half doing so on more than 20 occasions.
(18) Individuals in our study reported the use of less safe strategies
(i.e., sharing pipes) despite kit distribution, putting them at risk for
infectious disease. Some parallels may be drawn to early days of harm
reduction initiatives. Early Canadian reports found high rates of
equipment sharing between intravenous drug users despite participation
in needle exchange programs. (19,20) Explanation of this phenomenon
cited social network variables (i.e., creation of user sharing networks)
which may have informed our findings. Difficulty with consistent access
to safe equipment (21,22) has also been a variable affecting harm
reduction initiatives. Regulations regarding syringe availability affect
unsafe needle practices; (23) in BC, changes from one-to-one needle
exchange to distribution of needles to enable persons to have a new
needle for every injection as well as deregulation of syringe sales in
pharmacies impacted the way in which needle practices occurred. In our
project, recipients received one kit per person and outreach supplies
quickly ran out. As pipes for the sole use of smoking crack are
currently illegal in BC, a scarcity mentality among user networks may
have created urgent "supply and demand" dynamics in our study;
an increased but inadequate supply of items may contribute to an
increase in sharing behaviours. When distribution of harm reduction
equipment is part of a comprehensive program within a spectrum of other
health services, risk behaviours decline significantly (20) and
positioning kit distribution in a continuum of services is necessary.
People who use Brillo[R] when smoking crack report small fragments
of steel wool breaking off and being inhaled. (24) Although brass
screens were included in the kits, only 42% of kit recipients reported
using them and 91% reported usually or always using Brillo[R]. Brass
screens are harder to manipulate to pack into the pipe. Despite
providing demonstrations of equipment use during kit distribution, our
findings emphasize the need to further explore effective harm reduction
messaging accompanying street distribution.
Although condoms are available from harm reduction distribution
sites and outreach, the majority of kit recipients used those provided
in the kit. In a study of crack users in BC, more than one third of
respondents had engaged in unprotected sex in the 30 days prior to
assessment; (18) therefore we believe that provision of condoms within a
targeted distribution program is useful.
While this project documented trends in crack use practices, it is
important to note that it is not possible to attribute changed practices
in crack smoking behaviour as this evaluation involved two independent
sample cross-sectional surveys; although the recruitment methods and
interview sites were similar, there were differences in the samples. Our
gender sampling indicated that women were over-represented in our study
compared to other studies which report more male participants who use
crack. (7,18) Age demographics in our sample as well as the
over-representation of Aboriginal individuals in our study are
reflective of Vancouver's inner city. (25)
Over 40% of respondents reported using syringe plungers to scrape
crack resin from the inside of the pipe. Using syringe plungers may
result in melting plastic onto the pipe and also discarding the rest of
the unused syringe and needle. As a result of this study, interviews
conducted with harm reduction supply distribution sites in BC, (26)
combined with the evidence that crack smoking is associated with
infectious disease transmission, led to the decision to make crack pipe
mouthpieces and wooden push sticks available through the BC provincial
harm reduction supplies. Pyrex crack pipes are not currently distributed
provincially.
This work took place in Vancouver's inner city, however
similar issues are present across many major Canadian cities. (27)
Despite research evidence to support the benefits of the distribution of
safer use equipment, (7) there is a lack of harm reduction programming
available for those who smoke crack. The finding that over half of the
study sample did not inject drugs suggests that access to more
traditional harm reduction initiatives geared towards injection drug
users, such as needle distribution, may miss this population. This
highlights the need for targeted services to engage individuals who
smoke crack and calls for a more comprehensive understanding of their
risk environment. (28)
CONCLUSION
Our findings highlight the need for targeted distribution of safer
use items. While kit distribution made safer items more accessible, its
impact on safer use practice was limited. Further research should
explore dynamics regarding the sharing of equipment as well as
strategies to leverage messaging about specific harmful practices.
Efforts should promote a generous supply of harm reduction tools, and
kit distribution must be positioned in a continuum of health services.
Acknowledgement of Sources of Support: This research was made
possible by funds from Health Canada.
Conflict of Interest: None to declare.
Received: August 25, 2010
Accepted: December 20, 2010
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Leslie A. Malchy, MSc, [1] Vicky Bungay, PhD, [2] Joy L. Johnson,
PhD, [2] Jane Buxton, MD [3]
[1.] Nursing and Health Behaviour Research Unit, School of Nursing,
University of British Columbia, Vancouver, BC
[2.] School of Nursing, University of British Columbia, Vancouver,
BC
[3.] School of Population and Public Health, University of British
Columbia, Vancouver, BC
Correspondence: Leslie A. Malchy, Nursing and Health Behaviour
Research Unit, School of Nursing, 302-6190 Agronomy Rd., University of
British Columbia, Vancouver, BC V6T 1Z3, Tel: 604-240-9611, Fax:
604-822-7869, E-mail:
[email protected]
Table 1. Characteristics of the Samples
Pre- Post-
distribution distribution p-value
Survey Survey
(N=206) (N=150)
n (%) n (%)
Gender 0.125
Men 80 (39.0) 74 (49.7)
Women 120 (58.5) 71 (47.7)
Transgendered/Other identity 5 (2.4) 4 (2.7)
Age (yrs) [Mean (SD)] 39.8 (8.9) 40.6 (8.3) 0.397
Aboriginal heritage 73 (35.4) 75 (50) 0.006
Low income (less than
$1450/month) 174 (86.6) 129 (90.2) 0.304
Currently receiving public 139 (68.8) 116 (78.9) 0.036
assistance (welfare,
disability pension) as main
source of income
Crack smoking
Male 0.314
Less than once/week 4 (5.0) 2 (2.7)
Weekly 23 (28.8) 29 (39.7)
Daily 53 (66.3) 42 (57.5)
Female 0.182
Less than once/week 12 (10.0) 2 (2.8)
Weekly 34 (28.3) 21 (29.6)
Daily 74 (61.7) 48 (67.6)
Other methods of use
IV use (heroin, cocaine,
crack or other drugs) 83 (40.5) 58 (38.7) 0.729
Snorting 56 (27.3) 47 (31.3) 0.410
Table 2. Changes in Frequency of Crack Smoking Practices from Pre- and
Post-distribution Time Points
Survey Smoking Practices
Never/ Sometimes Usually/
Almost n (%) Always
Never n (%)
n (%)
Use Brillo[R] Pre 4 (1.9) 15 (7.3) 187 (90.8)
Post 5 (3.3) 9 (6.0) 136 (90.7)
Use Pyrex pipes Pre 17 (8.3) 67 (32.5) 122 (59.2)
Post 8 (5.4) 19 (12.8) 122 (81.9)
Use pipes with Pre 108 (52.4) 62 (30.1) 36 (17.5)
splits/cracks Post 66 (44.6) 55 (37.2) 27 (18.2)
Use a mouthpiece Pre 51 (24.8) 46 (22.3) 109 (52.9)
Post 23 (15.3) 23 (15.3) 104 (69.3)
Use a used mouthpiece Pre 130 (63.4) 58 (28.3) 17 (8.3)
Post 82 (55.4) 36 (24.3) 30 (20.3)
Use a used pipe Pre 93 (45.1) 86 (41.7) 27 (13.1)
Post 62 (41.6) 43 (28.9) 44 (29.5)
Pipe explodes or Pre 121 (59.0) 59 (28.8) 25 (12.2)
breaks apart Post 78 (52.0) 40 (26.7) 32 (21.3)
Obtain own crack Pre 8 (3.9) 14 (6.8) 183 (89.3)
Post 8 (5.3) 5 (3.3) 137 (91.3)
Find pipe when needed Pre 17 (8.3) 32 (15.6) 156 (76.1)
Post 5 (3.3) 12 (8.0) 133 (88.7)
Find mouthpiece when Pre 51 (25.4) 49 (24.4) 101 (50.2)
needed Post 15 (10.3) 12 (8.2) 119 (81.5)
Smoke with others Pre 36 (17.6) 70 (34.1) 99 (48.3)
Post 16 (10.7) 32 (21.3) 102 (68.0)
p-value *
Use Brillo[R] 0.645
Use Pyrex pipes <0.001#
Use pipes with 0.301
splits/cracks
Use a mouthpiece 0.007#
Use a used mouthpiece 0.005#
Use a used pipe <0.001#
Pipe explodes or 0.067
breaks apart
Obtain own crack 0.299
Find pipe when needed 0.010#
Find mouthpiece when <0.001#
needed
Smoke with others 0.001#
* Bolding in p-values indicates statistically significant findings.
Note: Statistically significant findings indicated with #.
