INTRODUCTION
Smoking of illicit drugs has been associated with the transmission of respiratory pathogens including bacterial pneumonia and tuberculosis.1-7 Although this association has multiple causes,8-17 the practice of “shotgunning” may contribute. “Shotgunning” or “doing a shotgun” refers to the practice of one individual forcibly exhaling (blowing) smoke into the mouth (or, rarely, nose) of another. The term may have originated from the practice of using an actual shotgun to smoke illicit drugs during the Vietnam War. Currently, this practice is more commonly performed by one individual drawing smoke into his or her mouth, holding it there temporarily and exhaling it directly into another individual’s mouth (either with the lips of the individuals touching directly or with one or both individuals using their fingers to form a “tube” around the blunt connecting their mouths) or by the placing of the cigarette, joint, blunt, or pipe directly into the individual’s mouth before exhaling.18-20
Shotgunning currently seems to be performed for a mixture of practical and other reasons including to increase the subjectively experienced “high” as the smoke is forced into the recipient’s lungs, to try to “conserve” smoke, to “share” with another individual in a controlled manner, to lessen the “harshness” of the smoke (when previously inhaled smoke is blown into another’s mouth), as an adjunct to intimate behavior, and as a novelty in social interactions.20
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Shotgunning has been associated with potential increased transmission of respiratory pathogens, including tuberculosis, as well as high-risk sex practices. Shotgunning of crack cocaine has also been associated with a retropharyngeal abscess which may result from increased intraoral pressure and a microperforation of the pharyngeal mucosa with subsequent introduction of air and oral bacteria into the retropharyngeal space.21 Several case reports have suggested a link between shotgunning (or sharing of a water pipe) and tuberculosis transmission.4,5,7 Perlman et al.19,20 interviewed 354 drug users who were participants at New York City syringe exchange or inpatient detoxification programs and found that 17% of the participants reported shotgunning in the prior 6 months. Shotgunning was associated with the use of crack cocaine and having engaged in high-risk sexual behaviors.19 In another study involving needle exchange participants in Baltimore, Riley et al. also found an association of shotgunning with positive purified protein derivative tuberculin skin test (PPD) results.22
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Individuals with serious mental illness (SMI) may be more likely to engage in high-risk sexual behaviors and have been shown to be at significantly increased risk for human immunodeficiency virus (HIV) and Hepatitis C virus (HCV) infection due in large part to co-occurring use of substances and elevated rates of high-risk drug related behaviors. Rosenberg et al.23 found an HIV prevalence of 3.1% (approximately 9 times the overall U.S. rate) and HCV prevalence of 19.6% (approximately 11 times the overall U.S. rate) in individuals with severe mental illness. Little is known about the rates of shotgunning in this population. The possible association of shotgunning with transmission of respiratory illness could incur a large risk to public health and also be especially devastating for individuals with SMI, 70-80% of whom also smoke cigarettes.24
We aimed to (1) describe the prevalence and practices of shotgunning among individuals having a current diagnosis of SMI and a current or lifetime diagnoses of a substance use disorder; (2) assess what clinical, demographic, and behavioral factors correlate with shotgunning; and (3) assess the risk of infectious disease among individuals who have a history of shotgunning.
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