Table 1 Summary table of included studies (N = 32)
Authors | Title | Location | Participant characteristics | Study design | Substance of focus | Key finding(s) | Theme(s) |
|---|---|---|---|---|---|---|---|
Bardwell et al. [39] | Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs | Canada | People who smoke drugs (n = 32) | Qualitative cross-sectional study: in-depth interviews | Any substance smoked | Smoking was most common method of drug use (n = 29), which was preferred due to negative views of other methods (i.e., injection), how long the high lasted when smoked, bad veins, and limited economic resources Smoking was thought of as harm reduction in and of itself; injection was perceived as having a higher risk of overdose, although some participants were concerned about the risk of overdosing from smoking Participants adapted to overdose risk by smoking smaller amounts more frequently Having a women-only consumption site was seen as beneficial Sharing drugs while smoking was common, and was seen as a method of social cohesion, although others were wary about sharing due to concerns of others stealing their drugs | Smoking as a form of harm reduction |
Bourque et al. [67] | Supervised inhalation is an important part of supervised consumption services | Canada | People who smoke drugs (n = 654) | Mixed methods: administrative data and cross-sectional study | Any substance smoked | Indoor drug smoking was found as a need for the population; thus, services have been heavily utilized People smoking drugs often do so in groups | Delivery and utilization of safer smoking services |
Boyd et al. [45] | Opportunities to learn to barriers to change: crack cocaine use in the Downtown Eastside of Vancouver | Canada | People who smoke drugs (n = 27) | Qualitative cross-sectional study: in-depth interviews | Crack | Many participants shared equipment as it was common practice to smoke in small groups in public, thus needing to be vigilant to avoid police harassment Mouthpieces were often used to mitigate sharing risk A lot of what participants knew about harm reduction and smoking was learned from watching others smoke crack Many participants said that there was a need for new paraphernalia to be in circulation Barriers to changing behavior included poor experiences with materials, lack of understanding of risks, and where crack fit in in their lives | Sharing of smoking materials Delivery and utilization of safer smoking services |
Bungay et al. [46] | Women’s health and use of crack cocaine in context: Structural and ‘everyday’ violence | Canada | People who use drugs (n = 126) | Mixed methods cross-sectional study: survey, participant observations, informal interviews, in-depth interviews | Crack | Participants reported frequently cutting themselves on broken pipes Mouthpieces were preferred as a method to prevent disease transmission, although women were often unable to find one when needed Supplies were expensive to purchase when they were unable to get them from HR agencies Women felt forced to share, especially with men due to fear of violence Police harassment and confiscation of pipes were common, forcing women to share | Sharing of smoking materials |
Cheng et al. [47] | Crack Pipe Sharing Among Street-Involved Youth in a Canadian Setting | Canada | People who use drugs (n = 567) | Quantitative prospective cohort study: secondary analysis of follow-up survey data | Crack | 88% reported sharing pipes during study follow-up period White ethnicity (aOR = 1.34), homelessness (aOR = 1.87), regular employment (aOR = 1.53), daily crack smoking (aOR = 1.37) or crystal methamphetamine use (aOR = 2.04), encounters with police (aOR = 1.42), difficulty accessing pipes (aOR = 1.58) and having unprotected sex (aOR = 1.95) all associated with crack pipe sharing | Sharing of smoking materials |
Collins et al. [48] | Potential uptake and correlates of willingness to use a supervised smoking facility for noninjection illicit drug use | Canada | People who inject drugs (n = 443) | Quantitative cross-sectional study: secondary analysis of baseline (demographics) and follow-up (drug use behavior) survey data from prospective cohort study | Any substance smoked | Factors associated with willingness to use safer smoking facility: Living in an HIV epicenter (aOR = 1.85), working in the sex trade (aOR = 2.24), and sharing crack pipes (aOR = 1.64) | Sharing of smoking materials Delivery and utilization of safer smoking services |
Cortina et al. [66] | Willingness to use an in-hospital supervised inhalation room among people who smoke crack cocaine in Vancouver, Canada | Canada | People who use drugs (n = 539) | Quantitative cross-sectional study: secondary analysis of follow-up survey data and serological HIV and HCV testing from two prospective cohort studies | Crack | 59.4% of participants said that they were willing to use an in-hospital safe inhalation site Factors associated with willingness: age (aOR = 0.98), daily noninjection crack use (aOR = 1.63)/binge noninjection crack use (aOR = 1.47), difficulty finding new pipes (aOR = 0.51), and ever using drugs in a hospital (aOR = 1.89) HIV positive serostatus = 48% (n = 261); HCV serostatus not reported | Delivery and utilization of safer smoking services |
Domanico et al. [63] | Implementation of Harm Reduction Toward Crack Users in Brazil: Barriers and Achievements | Brazil | People who smoke drugs (n = 30) | Qualitative cross-sectional program evaluation, in-depth interviews | Crack | Funding, high staff turnover and police harassment/violence turnover were a barrier to implementation Engagement of peers was key to success Program participants felt that by having clean supplies distributed by peers, they were able to use more safely | Sharing of smoking materials Delivery and utilization of safer smoking services |
Elkhalifa et al. [49] | Combining respondent-driven sampling with a community-based participatory action study of people who smoke drugs in two cities in British Columbia, Canada | Canada | People who smoke drugs (n = 149) | Quantitative cross-sectional study: surveys and social network analysis | Any substance smoked | Rural participants more likely to get pipes from stores (29%), peers (24%) Urban participants more likely to get from outreach organizations (89%) More sharing in rural area reported (75% vs. 36% in urban) | Sharing of smoking materials |
Frankeberger et al. [50] | Safer Crack Kits and Smoking Practices: Effectiveness of a Harm Reduction Intervention among Active Crack Users in Mexico City | Mexico | People who smoke drugs: Baseline (n = 58) Follow-up (n = 35) | Quantitative pre-post, single-cohort evaluation of a pilot safer smoking intervention: surveys at baseline and 3-months post-intervention | Crack | At baseline, use of broken pipes/alternative materials were reported frequently (31% said they always used broken pipes) 20% of participants reported at baseline that they shared pipes Overall, respondents showed an increase in use of safer smoking materials Pyrex pipe always or almost always use went up significantly from 7.0 to 27.3% (p = .002) There was a significant increase in never/almost never alternate material use (67.2–90.9%, p = 0.008) Sharing pipes declined significantly (increase in never/almost never sharing 57.9–87.9%, p = .038), as well as sharing alternate materials (59.7–12.9%, p = 0.002) Those who received a crack kit were significantly likely to always/almost always use a Pyrex pipe (p = 0.040) | Sharing of smoking materials Delivery and utilization of safer smoking services Preliminary efficacy of safer smoking services |
Handlovsky et al. [51] | The process of safer crack use among women in Vancouver’s Downtown Eastside | Canada | People who smoke drugs (n = 27) | Qualitative cross-sectional study: in-depth interviews | Crack | Establishing safe place for women to smoke was crucial, as many had experienced violence Women were able to engage each other in safer use practices when smoking, e.g., not sharing Sharing pipes were associated with contracting infections and other negative experiences In order to cares for themselves and others, women emphasized the need for safe use equipment, the main barriers being lack of resources and limited hours programs were open | Sharing of smoking materials Delivery and utilization of safer smoking services |
Hunter et al. [52] | Reducing widespread pipe sharing and risky sex among crystal methamphetamine smokers in Toronto: do safer smoking kits have a potential role to play? | Canada | People who smoke drugs (n = 32) | Qualitative cross-sectional study: focus groups | Methamphetamine | Pipe sharing very common among people who smoke methamphetamine The group that most desired free pipes were homeless youth who did not have the ability to purchase them themselves Gay men and partiers would take free kits if they were conveniently offered; otherwise, they would buy their own pipes Participants doubted that dissemination of kits would reduce pipe sharing as the social aspect of smoking is important | Sharing of smoking materials |
Ivsins et al. [53] | Crack pipe sharing in context: How sociostructural factors shape risk practices among noninjection drug users | Canada | People who smoke drugs: Study 1 (n = 13), Study 2 (n = 31) | Qualitative cross-sectional study: secondary analysis of in-depth interviews data from two studies | Crack | Norms have developed wherein crack smokers share pipes between friends and intimate partners Stigma attached to sharing pipes with strangers Sharing seen as social bonding experience Economic motivations for sharing pipes: you loan someone your pipe; you get a hit off of their rock or build a push Social norms associated with pipe sharing | Sharing of smoking materials |
Ivsins et al. [64] | Uptake, benefits of and barriers to safer crack use kit (SCUK) distribution programmes in Victoria, Canada—a qualitative exploration | Canada | People who smoke drugs (n = 31) | Mixed methods cross-sectional study; survey and in-depth interviews | Crack | Health benefits from SCUK: preventing infectious disease diagnosis, reducing chances of cutting lips on broken pipes Economic benefits of SCUK: saving money by not having to buy from stores, don't have to take time away from work to go buy pipes Social benefits of SCUK: less crime/stealing pipes, less arguments/violence over pipes Barriers to SCUK: limited hours of distribution, fear of police harassment/violence/breaking pipes | Sharing of smoking materials Delivery and utilization of safer smoking services |
Jozaghi et al. [54] | Peer-engagement and its role in reducing the risky behavior among crack and methamphetamine smokers of the Downtown Eastside community of Vancouver, Canada | Canada | People who smoke drugs (n = 20) | Qualitative cross-sectional study: in-depth interviews | Any substance smoked | There was a scarcity of high-quality materials until recently High prices of pipes was a major barrier, leading participants to share materials Having a safe use site was vital to mitigate risk of violence Peer work was crucial to engaging participants | Sharing of smoking materials Delivery and utilization of safer smoking services |
Leonard et al. [55] | The Urgent Need to Respond to HIV- and HCV-Related Risk Practices among Youth in Ottawa Who Smoke Crack | Canada | People who use drugs (n = 97) | Quantitative cross-sectional study: surveys and blood test for HIV and HCV | Crack | 61% of women and 49% of men had experienced a nonfatal OD; crack was involved in these OD's 21% of times for women and 1% for men Crack smoking injuries had occurred for 42% of women and 26% of men 57% of women and 56% of men had smoked crack in public 76% of women and 59% of men used glass stems to smoke Other recent materials used to smoke were soda cans (11% of women; 19% of men), inhalers (11% of women; 4% of men) and a metal pipe (4% of men) The majority of participants had never used a mouthpiece (54% of women; 62% of men), the main reasons being the material had a poor taste or feel and that it was challenging to put the mouthpiece on the pipe Use of brass screens was more prevalent than mouthpieces Using a previously smoked out of pipe was common (61% of women; 55% of men recently) Reasons for sharing included lack of resources and fear of police harassment 60% of women and 63% of men actually took safe smoking supplies from a health agency in the last 6 months, however 70% of women and 52% of men reported that they had had challenges accessing these programs at least once Sixty-two finger-prick blood samples were tested for HIV; none was positive Seventy-three finger-prick blood samples were tested for HCV; 15% of women providing samples tested positive for HCV (95%CI: 4.0, 36.0) as did 15% of men (95%CI: 7.3, 26.7) | Sharing of smoking materials Delivery and utilization of safer smoking services |
Leonard et al. [56] | "I inject less as I have easier access to pipes": injecting, and sharing of crack smoking materials, decline as safer crack smoking resources are distributed | Canada | People who smoke drugs (n = 550): Pre-intervention (n = 112), 1-month post-intervention (n = 114), 6-month post-intervention (n = 157), 12-month post-intervention (n = 167) | Quantitative pre-post, evaluation of a pilot safer crack smoking intervention: repeated cross-sectional surveys at 6-moths pre-intervention and 1-, 6- and 12-months post-intervention | Crack | After 1 month, 80% of participants had accessed safer smoking initiative Injecting prior to interview decreased over course of study Majority of participants reported rates of injecting had not changed, but a large proportion of participants reported that they had decreased injecting Majority reported level of engagement with smoking crack had not changed Quarter of participants said that they were smoking more since there was sterile equipment available "Modest downward trend" in sharing across all phases, but significant decrease in frequency of sharing, including post-implementation | Sharing of smoking materials Delivery and utilization of safer smoking services Preliminary efficacy of safer smoking services |
Malchy et al. [65] | Do Crack Smoking Practices Change With the Introduction of Safer Crack Kits? | Canada | People who smoke drugs: Pre-intervention (n = 206), 1-year post-intervention (n = 150) | Quantitative pre-post, evaluation of a pilot safer crack smoking intervention: repeated cross-sectional surveys at pre-intervention and 1-year post-intervention | Crack | Stems and pipes used by almost all participants who received a kit (> 98%) | Delivery and utilization of safer smoking services |
Malchy et al. [57] | Documenting practices and perceptions of 'safer' crack use: a Canadian pilot study | Canada | People who smoke drugs (n = 97) | Quantitative cross-sectional study: survey | Crack | Most people said they could find crack pipes if they needed them (64%) 80% of participants shared their mouthpieces or pipes People who shared were more likely than those who did not share to sell drugs for sex (56%), experiencing burns (79%), lesions (61%), have a pipe explode (66%), and use broken pipes (87%) | Sharing of smoking materials |
McNeil et al. [44] | "We need somewhere to smoke crack": An ethnographic study of an unsanctioned safer smoking room in Vancouver, Canada | Canada | People who smoke drugs (n = 23) | Qualitative cross- sectional study: ethnographic observations and in-depth interviews | Crack | Poverty/homelessness restricted access to places where people could smoke crack, especially because preference was to smoke at home Frustrated that safe smoking not incorporated into consumption spaces PWSC highly stigmatized Smoking in public exposed PWSC to violence Pipe sharing was common All participants said that their desire to use SSR was motivated out of wanting to minimize exposure to social violence SSR promoted adoption of risk reduction practices | Smoking as a form of harm reduction Sharing of smoking materials Delivery and utilization of safer smoking services |
Parent et al. [38] | Examining prevalence and correlates of smoking opioids in British Columbia: opioids are more often smoked than injected | Canada | People who use drugs (n = 369) | Quantitative cross-sectional study: secondary analysis of one-time survey data from a repeated measures monitoring survey | Opioids | Associated odds of smoking opioids include living in a small urban/rural area (aOR 2.41), being a woman (aOR 1.84), under 30 (aOR 5.41), between 30 and 39 years of age (aOR 2.77), using drugs alone (aOR 2.98), and having naloxone (aOR 2.01) | Smoking as a form of harm reduction |
Persaud et al. [40] | Controlling Chaos: The Perceptions of Long-Term Crack Cocaine Users in Vancouver, British Columbia, Canada | Canada | People who smoke drugs (n = 31) | Qualitative cross-sectional study: focus groups | Crack | Smoking crack allowed participants to exert control over their lives Majority of participants smoked crack in addition to or as a replacement for injecting crack Smoking allowed users to not constantly think about using, compared with injection Participants felt that smoking was safer than injecting Participants felt there was a lack of safe spaces for them to smoke, often necessitating sharing of materials; most preferred to smoke inside for fear of being assaulted Participants felt supervised inhalation site as most helpful to HR | Smoking as a form of harm reduction Sharing of smoking materials Delivery and utilization of safer smoking services |
Pizzey et al. [42] | Distributing foil from needle and syringe programs (NSPs) to promote transitions from heroin injecting to chasing: An evaluation | England | People who use drugs (n = 320) | Quantitative cross-sectional evaluation of safer consumption intervention: post-implementation survey and administrative data | Heroin | -Women were more likely to take foils when offered as compared to men (62.3% vs. 44.6%) -Visits to the service programs increased on average by 32.5% after foils were introduced -Several new non injectors started visiting the programs -All participants at the pilot site agreed that having the foils provided was beneficial -Some people who initially refused foil went to use at later date -Providing foils was beneficial to social networks, e.g., participants brought home and encouraged partners to use it/avoid injecting | Smoking as a form of harm reduction Sharing of smoking materials Delivery and utilization of safer smoking services Preliminary efficacy of safer smoking services |
Poliquin et al. [41] | Understanding experiences of and rationales for sharing crack smoking equipment: A qualitative study with persons who smoke crack in Montréal | Canada | People who use drugs (n = 26) | Qualitative cross-sectional study: focus groups | Crack | Many injectors had transitioned to smoking for health reasons/being tired of injecting All participants were aware of agencies or businesses they could get or buy smoking equipment from; however, some participants thought there was not enough availability in hotspots Materials were still seen as easy to get Pipes were shared for a variety of reason: not wanting to appear as a "drug addict" and have materials on hand, to maintain social bonds, feeling pressured to share, to build a push/save money, or when intoxicated Perceived risk varied; some participants kept their pipes to themselves out of germaphobia, while others were skeptical about the risk for infection from sharing Using mouthpieces was common among participants, as well as only sharing with people the participants knew, as well as keeping extra pipes to give out to others (prevention strategies) | Smoking as a form of harm reduction Sharing of smoking materials Delivery and utilization of safer smoking services |
Prangnell et al. [68] | Declining rates of health problems associated with crack smoking during the expansion of crack pipe distribution in Vancouver, Canada | Canada | People who inject drugs (n = 1718) | Quantitative prospective cohort study: secondary analysis of survey data and HIV and HCV blood test data from two prospective cohort studies; collected at enrollment and every 6 months thereafter | Crack | Proportion of study participants reporting health issues related to smoking crack declined by 18.5% over the study period Participants accessing crack pipes only through a health service (as compared to friends, bodegas) increased significantly (7.2–62.3%) Obtaining pipes through health service associated with decreased health issues 41% (n = 698) of the same were HIV positive; HCV results were not reported | Delivery and utilization of safer smoking services Preliminary efficacy of safer smoking services |
Rigoni et al. [58] | From opiates to methamphetamine: building new harm reduction responses in Jakarta, Indonesia | Indonesia | Staff and people who use drugs: Survey of management (n not reported), Staff interviews (n = 8), Service user interviews (n = 2), Service user focus group (n = 10) | Mixed methods cross-sectional study: review of contextual and program documents, survey of management, field observations, in-depth interviews with service providers and service users, a focus group with service users | Any substance | Involving peers was a vital step to reaching stimulant users Most people said that they shared materials, thus program staff adapted distributed materials to include silicone mouth pieces to reduce risk | Sharing of smoking materials Delivery and utilization of safer smoking services Preliminary efficacy of safer smoking services |
Shannon et al. [35] | Potential community and public health impacts of medically supervised safer smoking facilities for crack cocaine users | Canada | People who smoke drugs (n = 437) | Quantitative cross-sectional study: survey | Crack | Factors associated with willingness to use safer smoking facility: current IDU (aOR 1.72), equipment confiscated/broken by police (aOR 1.96), crack bingeing (aOR 2.16), smoking crack in public (aOR 2.48), borrowing crack pipes (aOR 2.5), inhaling Brillo/getting burned due to rushed crack use (aOR 4.37) | Sharing of smoking materials Delivery and utilization of safer smoking services |
Stöver et al. [43] | SMOKE IT! Promoting a change of opiate consumption pattern-from injecting to inhaling | Germany | People who use drugs: T1 (n = 165) T2 (n = 141) T3 (n = 89) | Quantitative single-cohort pre-post evaluation of a safer smoking intervention: survey at baseline (T1), post-intervention (T2), and 30-days after T2 (T3) | Any substance smoked | 65.3% of the participants used the foils rather than injecting 58.9% of participants said that they preferred smoking with the foils over injecting because it was healthier, 35.7% because of the reduced risk of HIV/HCV, 33.9% to avoid OD 87.6% of participants continued to use the foils in the third study period | Smoking as a form of harm reduction Delivery and utilization of safer smoking services Preliminary efficacy of safer smoking services |
Strike et al. [59] | Education and equipment for people who smoke crack cocaine in Canada: progress and limits | Canada | Staff (n = 80) | Quantitative cross-sectional study: survey data and secondary analysis of a prior survey | Crack | Majority of programs reported that they did provide education sharing risk reduction for smoking (76%), including on risks from improvised equipment (75%), and how to use safer smoking equipment (72%) 64% of program managers reported that they distributed safer smoking materials, including pipes (96%), mouthpieces (94%), screens (94%), and push sticks (92%) For those that were not able to distribute these materials, the most common reasons were funding (32%) and lack of demand (25%) | Sharing of smoking materials Delivery and utilization of safer smoking services Preliminary efficacy of safer smoking services |
Ti et al. [60] | Difficulty accessing crack pipes and crack pipe sharing among people who use drugs in Vancouver, Canada | Canada | People who use drugs (n = 503) | Quantitative cross-sectional study: secondary analysis of follow-up survey data and serological HIV testing from two prospective cohort studies | Crack | 47.3% of participants shared a pipe during the past 6 months Factors associated with sharing a pipe were: having acquired a mouthpiece (aOR 1.91), challenges accessing pipes (aOR 2.19) and binging noninjection drugs (aOR 1.39) | Sharing of smoking materials |
Ti et al. [61] | Factors associated with difficulty accessing crack cocaine pipes in a Canadian setting | Canada | People who use drugs (n = 914) | Quantitative prospective study: secondary analysis of follow-up survey data and serological HIV and HCV testing from two prospective cohort studies | Any substance | Characteristics of people who had difficulty accessing pipes included doing sex work (aOR 1.57), having shared a crack pipe (aOR 1.69), having police be present where drugs are bought or used (aOR 1.47), difficulty accessing services (aOR 1.74) and reporting health problems (aOR 1.37) HIV positivity = 54% (n = 498); HCV positivity not reported | Sharing of smoking materials Delivery and utilization of safer smoking services |
Voon et al. [62] | Risky and rushed public crack cocaine smoking: The potential for supervised inhalation facilities | Canada | People who use drugs (n = 1085) | Quantitative prospective cohort study: secondary analysis of follow-up survey data and serological HIV and HCV testing from two prospective cohort studies | Any substance | Factors associated with public crack use: younger age (aOR 1.03), homelessness (aOR 3.48), dealing drugs (aOR 1.59), daily or more crack smoking (aOR 2.69), sharing a crack pipe (aOR 1.98), public injection use (aOR 5.42), noticing police presence (aOR 1.3), and a history of incarceration (aOR1.47) Factors associated with rushed public crack use: younger age (aOR 1.02), homelessness (aOR 1.23), dealing drugs (aOR 1.39), smoking crack daily or more (aOR 1.48), and sharing crack pipes (aOR 1.44) At baseline, 46% (n = 496) of the sample had an HIV positive serostatus; HCV serostatus was not reported | Sharing of smoking materials |