Health issues associated with increasing use of "crack" cocaine among female sex workers in London

Objectives: To document changes in "crack" cocaine use in the sex industry in London, and to assess health risks associated with the drug. Design: Two serial cross sectional surveys. Subjects: Sex workers interviewed in 1989-9 and 1995-6. Main outcome measures: Self reported use of crack cocaine; clinical history of sexually transmitted infection and pregnancy, clinical outcomes. Results: The proportion of women reporting crack use increased significantly from 22/193 (11%) in 1989-91 to 48/143 (34%) in 1995-6. Women in all the main prostitution sectors reported crack use. Crack users had been working in prostitution for longer, were more likely to have worked on the streets, to inject drugs, and to have a partner who injected. Crack use was associated with termination of pregnancy and with hepatitis C infection. The association with hepatitis C was partially explained by confounding with injecting drug use. Conclusions: Crack use is more common and less problematic than clinical presentation suggests. Use has increased over the past decade, and is associated with hepatitis C infection and termination of pregnancy. It is possible that crack use facilitates hepatitis C transmission due to oral lesions from smoking. Crack use can be difficult to identify because of the stigma of being labelled a "crack whore," therefore information on crack might usefully be integrated into general health promotion material on drugs and safer sex.