We found that the majority of crack cocaine smokers in our study reported having used drugs in public areas at some point in the last six months. This group was more likely to be higher-intensity drug users with respect to heroin injection and crack cocaine smoking, have encounters with the police and be involved in drug dealing. Of these public crack cocaine smokers, 71% reported being willing to use a supervised inhalation room if one was available. Individuals who reported being willing were more likely to be female, engage in risky pipe sharing and have encounters with the police.
The profile of public crack cocaine smokers as higher-intensity drug users who have interactions with the criminal justice system is reflective of previous findings describing public injection drug user populations [1
]. The association between drug dealing and public crack use may reflect the increased amount of time individuals spend on the street when engaged in street-level drug dealing. It may also be a function of the accessibility of drugs and additional resources gained through drug dealing which may lead to greater drug consumption and hence a greater likelihood for consuming in public areas [23
Our finding that 71% of public crack cocaine smokers are willing to use an inhalation facility also supports previous willingness estimates conducted among the general population of Vancouver-based illicit drug users and suggests that an intervention of this nature will likely reach the target population [36
]. The high degree of willingness that this study found among public crack cocaine smokers to use an inhalation facility suggests that, like supervised injection facilities, these interventions are likely to successfully encourage public drug users to relocate to indoor venues.
The increased likelihood of being willing to use an inhalation facility among female participants may reflect heightened vulnerability of women involved in street drug use and it is noteworthy that Vancouver's supervised injection facility has had success in attracting vulnerable female drug users and providing them with safer alternatives to street-based drug using venues. In previous research female IDU have described the unique role that Vancouver's supervised injection facility has played in promoting their physical security and health safety [42
Interestingly, one of the common features among both public crack cocaine smokers and those who are willing to use a supervised inhalation facility is their elevated likelihood of recently having encounters with law enforcement. This suggests that public crack cocaine smokers who are the subject of law enforcement attention are very willing to relocate to alternative off-street and health-focussed environments if they were made available. Indeed, our data indicate that 81% of public crack cocaine smokers who have had a recent encounter with police are willing to use a supervised inhalation facility.
A key implication of these findings is that there is a large demand for supervised inhalation rooms among individuals that are potentially key contributors to drug-related street disorder. The association between public crack smoking and encounters with police suggests that interventions of this nature are likely to target a critical sub-population of drug users and could be a valuable tool for police in the management of street disorder. Previous studies have found that Vancouver police regularly refer public injection drug users to the local supervised injection facility [43
]. Since our analysis indicates that local police are already frequently interacting with public crack smokers the establishment of a supervised inhalation facility could provide a unique opportunity for police to direct this vulnerable group to a low-threshold service where they will have opportunities to be linked with appropriate health and social services.
It is critical to note that although this study suggests that supervised inhalation facilities could aid in the reduction of public disorder, drug consumption facilities do not address the route causes of street disorder and are not appropriate substitutes for other essential health and social interventions such as supportive housing and addiction treatment. To be effective supervised inhalation facilities should be integrated into broader comprehensive approaches to addressing the problems associated with illicit drug addiction.
This study has a number of limitations. Firstly, VIDUS is a community recruited non-randomized sample and therefore our findings may not be generalizable to other settings. If supervised inhalation facilities are being considered in other settings, willingness studies should be conducted among the local target population and should not rely on the findings emerging from our setting. The generalizability of our findings is also limited by our study sample which was restricted to individuals with a history of injection drug use. Crack cocaine smokers who did not have a history of injection drug use were not eligible for our study. Given the harms associated with injection drug use we anticipate that if a selection effect were present it would likely bias our sample towards high risk drug users, suggesting that this group would be an appropriate target population for public health intervention. We should also note that among our study sample daily crack cocaine smoking was significantly more common than daily injecting, suggesting that despite the requirement of a history of injecting, our sample represents a primarily crack cocaine smoking population. Secondly, some of our measures relied on self-report and could be vulnerable to socially desirable reporting. This would have likely been of most relevant to our measure of willingness, since respondents might perceive a pressure to report being willing to engage with low-threshold services of this nature given the widespread activism among local drug users in our study setting to implement supervised drug consumption facilities [32
]. While it is possible that some respondents may over-report willingness, a previous study comparing measures of willingness to use a supervised injection facility before it was established with later reports of actual attendance after an injection facility was established suggests that willingness measures are good predictors of later behaviour among this population [44
]. Lastly, socially desirable reporting could have influenced reports of stigmatized behaviour, such as public drug use leading to an underestimation of public crack smoking. If social desirability was an issue in our study we suspect our finding would be a conservative indication of the prevalence of and harms associated with public drug use among crack cocaine smokers.
In summary, our study found that locally public crack smoking is a common practice that is also associated with recent encounters with police. We found that the majority of public crack smokers were willing to use an inhalation facility if one were available. Furthermore, public crack smokers who had recent encounters with police were even more likely to be willing to use an inhalation room, suggesting that supervised inhalation facilities may offer unique opportunities to decrease one component of drug-related street disorder and reduce the burden on local law enforcement agencies.