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unanswered questions and limitations the prevalence of chronic diseases among crack-cocaine users may be underestimated because they are not captured in mortality statistics. confounding and bias cannot be excluded, although these are unlikely to be differential because of the greater prevalence of crack-cocaine use in men, young adults and the poorer ses groups. the quality of most studies was low or poor; most were cross-sectional and failed to adequately adjust for confounding, and few had sufficient sample size to account for the necessary stratification or population sub-group analyses needed to isolate the effects of crack-cocaine use alone. many studies relied on self-reported data, which are known to underestimate the prevalence of crack-cocaine use. moreover, crack-cocaine use was commonly assessed as a secondary covariate, making it difficult to distinguish between the direct effects of crack-cocaine use and other co-existing issues (e.g., sex, ses, etc.). the impact of crack-cocaine use may be underestimated by the lack of assessment of its impact on the quality of life, and by the failure to fully account for the use of other drugs.

the high prevalence of crack-cocaine use in young people suggests a need for preventive interventions to reduce the incidence of crack-cocaine use and subsequent harms. evidence about the impact of crack-cocaine use on birth outcomes, neonatal health, and suicide is mixed, and the impact on other health outcomes is largely unknown. risk-reduction strategies to reduce crack-cocaine use should consider not only the potential for harms, but also the potential of crack-cocaine use to reduce the prevalence of sexual and other risky behaviours in vulnerable populations. because crack-cocaine use is associated with a range of adverse health outcomes, prevention strategies may need to address the multiple factors associated with crack-cocaine use, including crack-cocaine use itself, and polysubstance use.

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