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International Journal of Drug Policy 14 (2003) 431–435

Public opinion about syringe exchange programmes in


the USA: an analysis of national surveys
Jon S. Vernick a,b,∗ , Scott Burris b,c , Steffanie A. Strathdee a
a Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205, USA
b Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities, 624 North Broadway, Baltimore, MD 21205, USA
c Temple University Beasley School of Law, 1719 North Broad Street, Philadelphia, PA 19122, USA

Received 1 December 2002; received in revised form 2 July 2003; accepted 4 July 2003

Abstract

Background: Despite scientific evidence demonstrating their effectiveness, syringe exchange programs (SEPs) have not been as widely
embraced by policy-makers in the USA as in some other nations. One reason for this disjunction between science and policy may be the effect
of public opinion.
Methods: To better understand the role of public opinion in shaping SEP policies, we undertook a systematic search for all reported U.S.
national surveys asking about support or opposition to SEPs. Relevant polls were identified through a national database of public opinion
questions, and a similar search of a newspaper database. We present the survey findings. The wording of poll questions and the agenda of
organisations sponsoring the polls are also examined.
Results: Twenty-one questions from 14 different polls conducted from 1987 to 2000 were identified. Support for SEPs ranged from 29 to
66%. Surveys conducted by organisations with a public health agenda were more likely to suggest support for SEPs than those sponsored
by organisations with a “family values” perspective. Question wording appeared to strongly influence support for SEPs. Poll questions that
referred to “drug addicts” were less likely to indicate majority support for SEPs than those that avoided loaded terms or that provided public
health information to respondents.
Discussion: Public opinion regarding SEPs is very malleable, strongly affected by question wording or other biases of organisations
sponsoring the polls. Therefore, there may be no clear national consensus on the desirability of SEPs. Our findings are particularly relevant
for national policy, such as federal funding for SEPs.
© 2003 Elsevier B.V. All rights reserved.

Keywords: Syringe; Needle exchange; Survey; HIV/AIDS; Injection drug users

Introduction laws, and other pharmacy regulations make it difficult or


impossible for SEPs to legally operate in some jurisdictions
The scientific evidence, generated by the public health (Burris, Strathdee, & Vernick, in press; Gostin, Lazzarini,
and medical communities, indicates that syringe exchange Jones, & Flaherty, 1997).
programmes (SEPs) reduce the transmission of HIV with- Of course, many other factors besides scientific evidence
out increasing drug use (Vlahov et al., 2001). But law and are likely to influence the political debate in any given area.
policy in the USA has not always reflected this consen- Importantly, public policy is at least potentially influenced
sus. At the national level, this disjunction between science by public opinion. But as with scientific evidence, a con-
and policy is best exemplified by the ban on federal fund- sensus regarding public support or opposition for a partic-
ing for SEPs or even for research regarding their effective- ular policy does not always translate into a corresponding
ness (Heimer, Bluthenthal, Singer, & Khoshnood, 1996). At response from policy-makers. This disconnection between
the state level, drug paraphernalia laws, syringe prescription public opinion and public policy may be more likely to occur
where public opinion is relatively malleable and easily influ-
enced by rhetoric. Also, opponents of a given public health
∗Corresponding author. Tel.: +1-410-955-7982. policy sometimes feel more strongly about the issue than do
E-mail address: jvernick@jhsph.edu (J.S. Vernick). supporters. There are many examples of this phenomenon.

0955-3959/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S0955-3959(03)00144-0
432 J.S. Vernick et al. / International Journal of Drug Policy 14 (2003) 431–435

For example, reasonably stable majorities of the American to SEPs we looked for differences in: how SEP participants
public have long supported making it more difficult to ob- are described, how the risks and benefits of SEPs are pre-
tain and carry handguns (Teret, Webster, & Vernick, 1998). sented, and the self-reported missions of some of the spon-
Yet progress in enacting gun violence prevention laws has soring organisations. Without the raw data for each poll and
been relatively slow (Vernick & Teret, 2000). question, we were not able to conduct any secondary or meta
The first step in assessing the role of public opinion in analyses of the polls, or of support among subgroups of the
SEP policy is to understand just what the public thinks. Lev- population.
els of public support for SEPs have been reported in the lit-
erature since at least the early 1990s. In 1993, Lurie et al.
concluded that “approximately half of the general public has Results
supported harm reduction efforts, including . . . needle ex-
change . . . ” (Lurie, Reingold, & Bowser, 1993). Normand After eliminating poll questions that did not meet our in-
et al. report an increase in support for SEPs among respon- clusion criteria, a total of 21 different questions from 14
dents to 13 different polls from 1985 to 1991 (Normand, separate polls remained. The polls were conducted between
Vlahov, & Moses, 1995). However, just two of those polls 1987 and 2000 by 10 different organisations. These are sum-
were national in scope. The other polls they discussed pri- marised in Table 1. To allow the reader to better assess how
marily included respondents from a single state or city, mak- question wording can influence poll results, we have in-
ing comparisons of the results over time difficult. In the con- cluded the full text of each question in Table 1. Where survey
text of public opinion and illicit drugs, Blendon and Young results do not total to 100%, the remainder of respondents
described polling results from three national surveys con- were categorised as “Don’t Know/Refused” or otherwise did
ducted from 1995 to 1997. In those polls, support for SEPs not indicate support or opposition. Although survey sample
ranged from 44 to 66% (Blendon & Young, 1998). sizes varied, each included 1000 or more respondents.
To better understand the possible role of public opinion As Table 1 demonstrates, there is considerable variation
in shaping present and future syringe access policies we in levels of support for SEPs in national polls. Over time,
sought to identify all national public opinion polls in the initial levels of support ranged from 29% in a 1999 poll to
USA that included questions about support or opposition to 66% in a 1995 poll. At the national level, this suggests that
SEPs. Focusing exclusively on national polls allows for eas- a clear, stable consensus may not have yet emerged. There
ier comparison of results. Because the prior literature sug- was no evidence of a notable increase or decrease in support
gests that public opinion regarding SEPs may be particularly from 1987 to 2000.
malleable, we also consider issues of question wording and As is often the case with public opinion polls, however,
potential biases of poll sponsors. precise question wording can strongly affect observed public
support or opposition. For example, in both 1998 and 1999,
the Family Research Council asked questions about support
Methods for SEPs. In the 1998 question, users of SEPs were referred
to as “those addicted to illegal drugs”. In 1999, the question
We undertook a systematic search for all reported na- was identical, except that users of SEPs were now described
tional surveys in the USA. Several different methods were as “drug addicts”. Support in 1998 was 43%; in 1999, it
employed. The Roper Center for Public Opinion Research had fallen to 34%. In an earlier 1997 poll sponsored by
at the University of Connecticut acts as a repository for the Kaiser Family Foundation, the phrase “IV (intravenous)
public opinion polls on all topics (Roper Center for Public drug users” is employed, and 64% of respondents favoured
Opinion Research, 2001). We performed a search of its SEPs.
database for any survey question with the words “needle”, Other differences in question design can also be important.
“syringe” or “drug paraphernalia”. Next we reviewed each For example, in the same 1997 Kaiser poll (above), a sepa-
question and eliminated those that were: (a) unrelated to rate question using what are called “permissive statements”
SEPs; (b) from polls that were not national in scope; or (c) was asked of a different subset of respondents. Respon-
tangential to basic support or opposition to these polices. To dents were told that “some people favour offering clean
supplement the Roper Center’s dataset, we also performed needles . . . to reduce the spread of HIV; others oppose
a search of US newspapers for stories that might identify exchange programmes because they . . . send the message
additional national polls. That search was conducted using that it’s OK to use illegal drugs.” One goal of this type of
the Nexis database and included all “major newspapers” as question design is to reduce the impact of any social de-
defined by Nexis (Lexis/Nexis, 2001). It employed the same sirability bias that may be perceived by respondents. With
search terms as above, and also included the words “poll” or these permissive statements, support was substantially lower,
“survey”. just 48%.
After identifying relevant poll questions, we present the Also suggesting the malleability of survey results are polls
results. In considering how question wording and the per- that included follow-up questions providing additional in-
spective of the poll sponsor influence support or opposition formation about SEPs. In these polls, respondents are first
J.S. Vernick et al. / International Journal of Drug Policy 14 (2003) 431–435 433

Table 1
Public support for syringe exchange programs in US national surveysa
Year Sponsor Question wording Results

2000 Kaiser Family “To help stop the spread of AIDS, do you favor or oppose needle exchange programs Favour: 58%; oppose:
Foundation which offer clean needles to IV drug users in exchange for used needles?” 35%
1999 Family Research “I am now going to read to you the opinions of two voters. Please tell me which comes Voter A, agree or
Council closest to your own. Voter A says that needle exchange programs reduce the spread of the somewhat agree: 34%;
HIV virus and do not contribute to more drug use. Federal funds should be used to give voter B, agree or
syringes to drug addicts. Voter B says that the science supporting needle exchange somewhat agree: 59%
programs is uncertain and that giving needles to addicts would increase drug use as well
as send pro-drug messages to vulnerable teens. With whom do you agree most?”
1999 Family Research “Would you support or oppose giving clean needles to drug addicts to slow the spread of the Strongly or somewhat
Council AIDS virus if you knew that this might increase illicit drug use among America’s youth?” support: 29%; strongly or
somewhat oppose: 65%
1999 Family Research “The latest studies of needle exchange programs have found that people who are not Strongly or somewhat
Council enrolled in needle exchange programs were less likely to become HIV infected than those support: 28%; strongly or
who were enrolled in needle exchange programs. Knowing this, do you support or oppose somewhat oppose: 63%
federal funding of needle exchange programs?”
1998 Family Research “I am now going to read to you the opinions of two voters. Please tell me which comes Voter A, agree or
Council closest to your own. Voter A says that needle exchange programs reduce the spread of the somewhat agree: 43%;
HIV virus and do not contribute to more drug use. Federal funds should be used to give voter B, agree or
syringes to those addicted to illegal drugs. Voter B says that the science supporting needle somewhat agree: 53%
exchange programs is uncertain and giving needles to addicts sends pro-drug messages to
drug-use vulnerable teens. With whom do you agree most? Voter A or Voter B?”
1998 Family Research “Would you support or oppose the creation of a needle exchange program in your Strongly or somewhat
Council neighborhood?” support: 36%; strongly or
somewhat oppose: 59%
1997 Kaiser Family “Do you favor or oppose needle exchange programs, which offer clean needles to IV Favour: 64%; oppose:
Foundation (intravenous) drug users in exchange for used needles, to help stop the spread of HIV?” 30%
1997 Kaiser Family Asked of those opposed above: “Several different government agencies and independent Favour initially: 64%;
Foundation scientific organisations, including the National Academy of Sciences, have concluded that switched to favour: 9%;
needle exchange programs are effective at reducing HIV infections among IV still oppose: 20%
(intravenous) drug users without increasing their drug use. Knowing this, would you now
favor or oppose needle exchange programs?”
1997 Kaiser Family “Some people favor offering clean needles to IV (intravenous) drug users in exchange for Favour: 48%; oppose:
Foundation used needles because it helps to reduce the spread of HIV. Others oppose needle exchange 46%
programs because they feel these programs send the message that it’s OK to use illegal
drugs. Which one comes closer to your view?”
1997 Kaiser Family Asked of those opposed above: “Several different government agencies and independent Favour initially: 48%;
Foundation scientific organisations, including the National Academy of Sciences, have concluded that switched to favour: 12%;
needle exchange programs are effective at reducing HIV infections among IV still oppose: 32%
(intravenous) drug users without increasing their drug use. Knowing this, would you now
favor or oppose needle exchange programs?”
1997 Kaiser Family “Do you favor or oppose needle exchange programs, which offer clean needles to IV Favour: 58%; oppose:
Foundation (intravenous) drug users in exchange for used needles, to help stop the spread of HIV?” 38%
1997 Kaiser Family “Some people favor offering clean needles to IV (intravenous) drug users in exchange for Favour: 43%; oppose:
Foundation used needles because it helps to reduce the spread of HIV. Others oppose needle exchange 53%
programs because they feel these programs send the message that it’s OK to use illegal
drugs. Which one comes closer to your view?”
1997 Harvard School “Do you think drug addicts should be given free, clean needles to prevent the spread of Should give needles:
of Public Health AIDS, or not?” 44%; should NOT give
needles: 53%
1997 The Human “Some local communities have adopted ‘needle exchange’ programs as a way to curb the Strongly or somewhat
Rights Campaign spread of AIDS and HIV. ‘Needle exchange’ programs allow drug users to trade in used favour: 55%; strongly or
needles for clean needles. Generally, speaking, do you favor or oppose these kinds of somewhat oppose: 38%
‘needle exchange’ programs?”
1995 Institute for a “I’m going to read some statements. For each statement, please tell me how much you Strongly agree or agree:
Drug-Free agree or disagree with the statement . . . The government should dispense clean needles 27%; Strongly disagree
Workplace for drug addicts.” or disagree: 56%
1995 Kaiser Family “Do you favor or oppose having clinics make clean needles available to IV (intravenous) Favour: 66%; oppose:
Foundation drug users to help stop the spread of AIDS?” 30%
1994 Drug Strategies “I am going to read you several proposals that have been suggested as ways of controlling Favour: 55%; oppose:
the damage that is done to society’s health and that of drug users themselves, because of 40%
illegal drugs. For each one that I read, please tell me if you would favor or oppose the
proposal . . . Implementing needle exchange programs to reduce the spread of diseases
such as AIDS.”
434 J.S. Vernick et al. / International Journal of Drug Policy 14 (2003) 431–435

Table 1 (Continued )
Year Sponsor Question wording Results

1992 Gallup “I will read a list of things some people say the government should do to prevent the Approve: 41%;
Organisation spread of AIDS. Please tell me whether you approve or disapprove of each . . . Dispense disapprove: 55%
free needles and syringes to IV (intravenous) drug users to cut down on shared needles.”
1989 Associated Press “The AIDS virus can be transmitted when people who use drugs share needles. If giving Favour: 50%; oppose:
intravenous drug users free needles would slow down the spread of AIDS (Acquired 43%
Immune Deficiency Syndrome), would you favor or oppose giving addicts sterilised
needles for free?”
1988 CBS News/New “Would you favor or oppose giving injection drug users sterilised needles for free if it Favour: 40%; oppose:
York Times would slow down the spread of AIDS?” 53%
1987 Metropolitan Life “Do you think drug addicts should be given free, clean needles to prevent the spread of Yes, should: 52%; no,
AIDS (Acquired Immune Deficiency Syndrome) or not?” should not: 46%
a All survey data, except the 2000 Kaiser Family Foundation poll, are from a search of the online database of poll questions, POLL, maintained by

the Roper Center for Public Opinion Research, Storrs, Connecticut, searched 1 June 2001.

asked about initial levels of support for SEPs. Those who buy clean needles without prescriptions from pharmacies”;
were opposed were then asked whether their view would 40% favoured “removing criminal penalties for the simple
change if they knew that “several different government agen- possession of needles and syringes.” By comparison, in the
cies and independent scientific organisations, including the 2000 poll sponsored by the Kaiser Family Foundation a
National Academy of Sciences, have concluded needle ex- majority of respondents supported: changing federal law to
change programmes are effective at reducing HIV infections permit “state and local governments [to] decide for them-
among IV (intravenous) drug users without increasing their selves whether to use their federal funds for needle exchange
drug use.” The proportion switching their response to now programmes”(60%); “allowing IV drug users to purchase
favour SEPs ranged from 9 to 12% (See Table 1). clean needles from a licensed pharmacist” (61%); and “al-
Despite our efforts to eliminate questions that did not lowing doctors and physicians to provide IV drug users with
focus on support or opposition to SEPs, the descriptions a prescription for clean needles” (60%) (Henry J. Kaiser
of the programmes themselves also vary from question to Family Foundation, 2001).
question. For example, some questions refer to the exchange
of clean needles for used needles, while others ask about
providing clean needles to IDUs without explicit reference Discussion
to an exchange. How these variations may have affected
levels of support is difficult to predict. It can be very difficult to interpret the policy impact of
The biases of the organisations sponsoring the polls may survey research findings on topics that most respondents
also affect the outcomes of interest. For example, the Family have probably not carefully considered. Weak levels of sup-
Research Council describes itself as “champion[ing] mar- port may simply mean that many respondents do not fully
riage and family as the foundation of civilisation, the seedbed understand an issue (or its scientific basis)—especially one
of virtue, and the wellspring of society” (Family Research that cannot be explained effectively in a brief telephone in-
Council, 2001). By comparison, the Kaiser Family Founda- terview. In fact, in one 1997 poll, 55% of respondents in-
tion is an “independent philanthropy focusing on the major dicated a lack of familiarity with SEPs or similar policies
health care issues facing the nation” (Henry J. Kaiser Family (Blendon & Young, 1998).
Foundation, 2001). The Family Research Council, therefore, Even if national polls do not suggest consistently strong
is likely to view syringe access interventions through the lens and stable support for SEPs, this is less relevant for some
of its “family values” mission, while Kaiser will pose the aspects of syringe access policy than for others. Most SEPs
question as one primarily of health policy. Although these are locally designed and implemented. In that sense, local
descriptions of the sponsoring organisations were not pro- levels of support are probably far more important than na-
vided to survey respondents, the organisations’ views may tional levels. In addition, since many of these programs are
nevertheless be perceived (perhaps subtly) by the partici- privately funded, governmental or public support may sim-
pants. They are also likely to affect the context in which ply not be needed in some places. However, national public
questions about syringe access policies are asked within the opinion may influence some policy-makers willingness to
larger survey instrument. support SEPs, and might be most directly relevant to efforts
Though not the focus of this study, we were able to iden- to overturn the federal funding ban.
tify relatively few national polls with questions querying Our results also suggest possible ways to increase pub-
public support for other syringe access policies. In a 1994 lic support for syringe access interventions. It appears that
poll sponsored by an organisation called Drug Strategies, linking syringe access with broader drug policy is associated
just 37% of respondents favoured “allowing drug users to with lower levels of support. To the extent that the “war on
J.S. Vernick et al. / International Journal of Drug Policy 14 (2003) 431–435 435

drugs” is seen as a moral crusade by some, and a misguided References


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