Do crack smoking practices change with the introduction of safer crack kits?

Leslie A. Malchy, Vicky Bungay, Joy L. Johnson & Jane Buxton
Canadian Journal of Public Health 102(3):188-92.
May-June 2011

Crack smoking has increased in Vancouver despite the harms associated with its use. Many people who smoke crack share their equipment, thereby increasing their risk for infectious disease. This project explored the effects of outreach distribution of "safer crack kits" on smoking practices. While kit distribution made safer use items more accessible, its impact on safer use practice was limited. Our findings highlight the need for targeted distribution of safer use items. Future research should explore the dynamics of unsafe crack smoking practices and ways to leverage safer use messaging.

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In Canada, crack smoking is a significant public health problem with well-known associated health-related harms. 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.

Pilot research with crack smokers in Vancouver found that these individuals were engaging in unsafe crack use practices such as sharing crack pipes. Contributing to unsafe practices in crack smokers are: a lack of available equipment for crack use; specific stigma associated with crack smoking; 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.

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. 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®, a discussion of the risks of sharing equipment, and referrals to health and social service agencies when required.

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.

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.

Explanation of this phenomenon cited social network variables (i.e., creation of user sharing networks). Difficulty with consistent access to safe equipment has also been a variable affecting harm reduction initiatives. Regulations regarding syringe availability affect unsafe needle practices, 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 significantly20 and positioning kit distribution in a continuum of services is necessary.

Despite research evidence to support the benefits of the distribution of safer use equipment, 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.

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.

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®”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