How do children form beliefs about the infinity of space, time, and number? We asked whether children held similar beliefs about infinity across domains, and whether beliefs in infinity for domains like space and time might be scaffolded upon numerical knowledge . To test these questions, 112 U.S. children  completed an interview regarding their beliefs about infinite space, time, and number. We also measured their knowledge of counting, and other factors that might impact performance on linguistic assessments of infinity belief . We found that beliefs about infinity were very high across all three domains, suggesting that infinity beliefs may arise early in development for space, time, and number. Second, we found that—across all three domains—children were more likely to believe that it is always possible to add a unit than to believe that the domain is endless. Finally, we found that understanding the rules underlying counting predicted children’s belief that it is always possible to add 1 to any number, but did not predict any of the other elements of infinity belief. Who as a child did not lie in bed filled with a slowly mounting terror while sinking into the idea of a universe that goes on and on, for ever and ever?” – Rudy Rucker , what could possibly be beyond it? Alternatively, children may infer infinity by learning about iterative rules, like learning that it is always possible to add 1 to any number. Or, perhaps they learn about infinity via specific culturally-transmitted messaging. Beliefs about infinity may emerge one domain at a time , or all at once. In the present paper, we investigate the cognitive foundations of human reasoning about infinity by exploring how beliefs about infinity emerge across the domains of number, space, time. We ask whether these beliefs depend on domain-specific learning processes, or instead depend on a single insight that generalizes across domains. To our knowledge, the present study is the first to investigate young children’s intuitions about infinite time, and the first to ask how beliefs about infinite number, space, and time might be related.Considerable research has investigated how children reason about number, space, and time, focusing largely on the acquisition of beliefs about these domains that derive from observational learning and empirical induction  and then later learning about the relative magnitudes they represent , unless otherwise noted.All recruitment and exclusion choices were as preregistered . Our lab does not collect race or gender data from child participants, although participants were recruited from a predominately White and middle-class region of the U.S. Northeast. Participants were tested in a psychology lab on campus at Skidmore College or on-location in preschools, daycares, and elementary schools in the Capital Region of NY state. All provided verbal assent, and their parents provided written consent, in keeping with the approved IRB protocol at Skidmore College.We recruited 121 participants from the U.S. between the ages of 4 and 7 years old; all participants were tested in-person. One participant was excluded because we discovered that they had participated in a pilot version of a similar study conducted by our lab. As pre-registered, we terminated data collection for five participants because they failed to provide answers during the Warm-Up phase. Three participants were excluded for failing to complete at least 80% of the task. Our final sample included n = 5) who failed to answer at least 2/4 of these questions did not continue the study.The Infinity Interview began with a Warm-Up Phase, during which children were asked four questions: ‘What is the [fuzziest / spikiest / sweetest / loudest] thing you can think of?’ These questions familiarized participants with the question and answer format of the task, and ensured their ability to provide verbal answers. As noted above, children . Because our infinity interview required complex verbal processing and reasoning, we wanted to ensure that linguistic and cognitive factors weren’t limiting performance. To test this, we also included two blocks containing questions about hypothetical scenarios, also described below.that they conceived of one, if only provisionally, for the purposes of the game. So, for this reason, children who didn’t volunteer responses were provided with prompts: “Is 2 the biggest number you can think about? … What about 1000? … What about a million?” Once the child had agreed to a biggest number—any number, volunteered or accepted from the script—the researcher then said, “Okay, you said n is the biggest number you can think about. Can we add 1 to that number?” The researcher then asked, “Do numbers ever end, or do numbers go on forever?” Between-subjects, we varied the order of the alternatives presented to the child: half of the children heard e.g., “Do numbers ever end, or do numbers go on forever”, while the other half heard “Do numbers go on forever, or do numbers end?”The Infinity Interview was a simplified version of that described in Cheung et al. , which iQuestions about spatial and temporal infinity were asked in the same format. Children named the biggest space/time they could think of, and children who failed to volunteer answers were given prompts. Specifically, for space they were asked, “Is this room the biggest space you can think about? … what about this city? … what about all the way from here to the moon?” For time, they were asked, “Is this snap [researcher snaps fingers] the biggest time you can think about? … What about a day? … What about from when the Earth was first made until now?” They then were asked if the biggest time or space they could think of could be increased by one minute/inch, and if time/space end, or go on forever.not possible to add more , and to elicit both a response that something will stop/end  and that something will go on forever . The purpose of this task was to identify whether children’s performance on the infinity interview could be explained by domain-general task demands . Thus, participants’ responses were coded for whether they reflected comprehension. For example, for the question …would [the block] stay red forever, or would it stop being red?”, participants were credited with providing an acceptable response if they said it would stay red forever or if they gave plausible reasons why it wouldn’t stay red .In addition to questions about number, space, and time, there were two blocks of questions assessing children’s ability to respond to linguistically-presented hypothetical scenarios. For one question, participants saw a red block with a corner painted white. Participants were asked, “Could I add more red paint to this block?” and, “If nobody touched this block for a long time, would it stay red forever, or would it stop being red?” For the second question, participants were told that the researcher found a caterpillar outside. Participants were then asked, “Could I add more eyes to my caterpillar?” and “Will my caterpillar stay a caterpillar forever, or will it turn into a butterfly?” We designed the hypothetical scenarios to hopefully elicit both a response that it is possible to add more  and that it is Order of blocks was counterbalanced such that there were 12 possible orders: Infinity Block 1 , Hypothetical Block 1 , Infinity Block 2 , Hypothetical Block 2 , Infinity Block 3 . For example, a child might be presented with questions in the following order: Number-Caterpillar-Space-Red Block-Time.n bears, where n was 6, 9, 7, or 5 (in that order). After the child gave the researcher the bears, the researcher asked, “Is that n? Can you count and make sure?” The researcher recorded whether the child gave the correct number of bears, and whether or not they counted correctly. Children who failed one trial but succeeded on the other three were allowed to repeat the trial they failed on. Children who succeeded on at least three of four trials were considered to be competent counters.Children were given an abbreviated version of the Give-a-Number task Wynn, , 1992, a15; 13, 14, 15 … What comes next?” Children who responded correctly were allowed to continue counting. Children who were unable to identify the next number, or who made two sequential mistakes were stopped, and moved onto the next task. We recorded children’s Initial Highest Count—that is, the highest they reached without making an error—and their Final Highest Count .Children were asked to count as high as they could. The highest children were allowed to count was 140, at which point the game was ended. If a child made a mistake, the experimenter noted their error and provided a prompt. For example, if a child said, “14, 16”, the researcher noted the omission of 15, stopped the child, and prompted them: “Actually, the number that goes after 14 is This task probed children’s understanding of the successor function for familiar numbers. Children were given a number and asked to produce its successor: “In this game, I’m going to say a number, and you’re going to tell me the number that comes immediately after. So for example, if I say one, you say …?” The number “one” was used in the training trial. If the child correctly responded with the word “two”, there were 12 subsequent trials, ranging from 5–271 . If the child responded that they did not know, they were asked to “take their best guess”. If a child repeated the prompt number or said a number lower than the prompt number, the researcher reminded them that they were asked to say what number comes next.This task was structured similarly to the English Next Number task, except that participants were introduced to an unfamiliar counting system, and asked to produce the next number in that unfamiliar system. This allowed us to test whether children’s performance in the Next Number task was driven purely by memorized knowledge, or might also reflect an additive rule . Children were told, “In this game, I am going to say a number in Mobi language, and then I want you to say what comes next in Mobi language. Ready? OK!” The prompt novel numbers were Mobi-one, Mobi-five, Mobi-seven, Mobi-two, and Mobi-nine, in that order. Performance was coded as correct or incorrect on each trial .We employed an adapted version of the Corsi working memory task Corsi,  to measuM = 3.48/4 adult-like response), with 102/112 participants answering at least 3 of the 4 questions in an adult-like  manner. Critically, these children consistently provided answers in the format required by the infinity interview by indicating that it was possible to add more (red paint), that it was not possible to add more , that something would continue in its current state forever (the red block would stay red) and that something would not continue forever (the caterpillar would change to a butterfly). We report infinity classification for the 10 participants who failed the HSI in the SOM; notably, most of these participants were “Full Infinity Believers” , suggesting that poor performance on the HSI task does not explain some of the weak infinity knowledge described below.We first consider the HSI, in order to ensure that general limits on children’s ability to reason about or respond to linguistically-presented hypothetical situations were not responsible for children’s performance on the infinity interview. Participants performed well on this task , and 45/112 participants made no errors before reaching 100 . Mean Final Highest Count was 84 , with 62/112 participants successfully counted to 100 after receiving prompts. While counting ability was relatively strong, our data were bimodal: 31 participants had an Initial Highest count <20, and 24 of these participants could not count higher than 20, even with feedback.We conducted preliminary order effects analyses, as preregistered, in order to determine whether the order of questions in our infinity interview impacted performance; we did not find reliable order effects; full reporting is available in the SOM.As preregistered, we coded children’s responses to “What is the largest X you can think about” for whether their responses referenced space, time, number, and/or the explicit notion of infinity. Full data are reported in SOM.Endorsement of infinity-beliefs was high for both of our infinity interview questions. Within each domain, more than three quarters of participants indicated that it was possible to always add one . Similarly, a majority of participants indicated that each domain went on forever . Below, we analyze these data in greater detail.p >.10, see SOM and As preregistered, for each domain , we asked whether there was a relationship between each component of Infinity Knowledge  and age , using logistic regression. There were no effects of age . Interestingly, they were also the most frequent category for Space (55%) and Time (51.8%), resulting in nearly identical levels of Full Infinity Belief across domains see .not believe that it is always possible to add a unit were called Endless-Only Believers, and were rare across domains , as in previous studies on number . Participants who failed to answer enough questions within a domain to be categorized (n = 3–4 per domain) were classified as “Uncategorized”. Age was unrelated to infinity classification for any domain , Space (23.9%), and Time (27.8%). Children who endorsed the view that a domain is endless, but did within individual children. To explore this, we asked what percentage of children held consistent beliefs across multiple domains. For both of our measures , the most frequent outcome was that children held consistent beliefs across all three domains. As shown in Although the pattern described above suggests similar types of beliefs about infinity across the domains of Number, Space, and Time, these initial analyses leave open whether beliefs across domains are related Next, we asked whether classifications  were similar across all three domains. Out of 112 participants, 9 were unclassifiable (because they were missing data for at least one task), leaving 103 classifiable participants. Of these, 36 were classified identically all three domains, and 67 provided at least one diverging response for at least one domain. Of the 36 consistent children, 26 were “Full Infinity” believers in every domain. The remaining 10 consistent children were “Adding Only” believers across all three domains. No children were consistently Endless Only believers, and no children were consistently Non-Believers. The lack of consistent Non-Believers means that every classifiable child in our study reported at least one infinity-consistent belief. Indeed, 101/103 classifiable children provided at least 2 (out of 6 possible) infinity-consistent responses during our study.n = 26 were Full Infinity Believers in the third, n = 14 were Adding Only Believers for the third; n = 13 were Endless Only Believers for the third, and n = 2 participants were Full Infinity Believers in two domains, and non-believers in the third. These data show that more than half of all classifiable participants provided at least 5 (out of 6) infinity-consistent responses, and therefore that most participants who were Full Infinity Believers in two domains had partial infinity belief for the third domains.Because perfectly consistent responses make it difficult to test whether beliefs about one domain are contingent upon beliefs about another, we next consider children who performed inconsistently across domains. Of the 55 children who were Full Infinity Believers in at least 2 domains, n = 24 children who were Adding Only Believers across at least two domains. Of these, n = 10 were Adding Only Believers in the third, n = 10 were Full Infinity Believers for the third, n = 2 were Endless Only believers for the third, and n = 2 were Non-Believers for the third. In summary, 24 (23.3%) of the 103 classifiable participants were Adding Only Believers in at least two domains, meaning that they endorsed the belief that those domains could always be added to, but rejected the idea that those domains were endless. Only 9 children were Endless Only Believers in two domains , and 6 were Non-Believers in two domains . In other words, it was relatively rare to find children who fit into these categories. Finally, 11 children provided truly inconsistent responses: they were classified differently in each of the three domains, and 9 were unclassifiable because they had missing data.We next consider the n = 13), more than half of these children (7/13) held this belief only for number. These data are consistent with the idea that children are more likely to hold beliefs about the possibility of always adding 1 to a number than they are to hold those beliefs for other domains. However, evidence for the primacy of number is weak in the present dataset given the small sample size.Next, we focused more narrowly on children’s endorsement of the belief that it is always possible to add a unit to a quantity of space, time, and/or number, and asked whether these beliefs were more likely to be held in some domains, relative to others. Of the children who believed that it was always possible to add a unit for two domains, roughly equal numbers believed that it was possible to add to just space and time but not number, or to just number and space, or to just number and time see . A totaln = 11), just number and space were endless (n = 9), or just number and time were endless (n = 9). Another 20.8% of children believed that only one domain was endless. Like in the case of adding a unit, there was an asymmetry by domain, but unlike in that case, 14/22 (64%) of those who believed that a single domain was endless held this belief for the domain of Space. Smaller numbers of children believed that only Time (n = 4) or Number (n = 4) were endless. Thus, in this case, if any domain is primary, it is space, and not number.Like in the case of adding a unit, roughly equal numbers of children believed that just space and time (but not number) were endless  it is always possible to add 1 to the biggest number and (b) that space is endless.p > .05; see We next investigated predictors of children’s beliefs about infinity. If children’s beliefs were explained by learning about infinity as part of a prescribed curriculum in school, or because some cognitive capability that supports this reasoning matures at a particular age, then we might expect that age would be a strong predictor of performance. However, as noted above, age was not related to performance on any of the questions of our infinity interview  in separate logistic regressions from age, Initial Highest Count (as a proxy for familiarity with the count list), Final Highest Count (a proxy for the child’s generative knowledge of the count list), Novel Number performance, the English Next Number task (a measure of successor knowledge), and Corsi score.B = −.48, SE = .18, p = .007), as was age , when controlling for the above factors. There were no other significant predictors in any other analysis (full reporting in SOM).We found only 1 case in which any of our predictors predicted performance on the Infinity Interview. Specifically, English Next Number performance  was a significant predictor of whether participants endorsed the view that it was always possible to add 1 to the biggest number they could imagine , might be used to scaffold beliefs in another domain . We also measured children’s mastery of counting, on the premise that an understanding of the structure and rules of counting might lead to the intuition that numbers are infinite. Our main finding was that most children in our study believed that number, space, and time were infinite, and held generally consistent beliefs across all three domains. Also, while many children showed somewhat different levels of belief in infinity across our test items, beliefs about infinity did not systematically emerge earlier in any particular domain, leaving open whether knowledge of one domain might drive learning about another. Finally, although beliefs about infinity were related across domains, these beliefs were not consistently related to children’s knowledge of counting, and did not vary substantially according to age, raising questions about the learning mechanisms that support the development of these beliefs.The main finding of this study was that children expressed very high levels of belief in infinity across all three domains. We replicated previous findings that children as young as 4 to 5 years of age have emerging beliefs about infinite number  was nearly identical in each domain. Also, we found that about 60% of children believed that it was always possible to add a unit across all three domains, and just over 40% believed that number, space, and time were all endless.In addition to replicating previous findings that Full Infinity and Adding Only believers are frequent while Endless Only believers are rare within the domain of number  but had not yet learned it about another domain . On the other hand, children who expressed differing beliefs about infinity across domains may have an abstract understanding of infinity, but nevertheless believe that some domains are not infinite. For example, it is possible that children had arrived at an abstract understanding of infinity  but nevertheless decided not to endorse a belief about infinity in some domains because of their beliefs about those particular domains . Future research should consider methods that may be able to differentiate whether the types of inconsistencies in beliefs that we report in the present study are best explained by (a) differing beliefs about infinity or (b) differing beliefs about the domains.While we found substantial consistency in children’s beliefs about infinity across domains, a sizable minority of children held Critically, the trajectory of acquisition of beliefs about infinity is still uncertain based on our data. In order to demonstrate the trajectory for acquiring beliefs about infinity, it is important to demonstrate an initial state of non-belief. Unlike previous work that reports a sizeable group of Infinity Non-Believers for number , or perhaps because space more readily supports concrete visualizations like those described by Archytas . However, we also found that among the 13 children who believed it was possible to add a unit in only a single domain the majority held this belief only for number. These data are consistent with the possibility that children acquire beliefs about the possibility of unlimited addition for number before they do so for space or time. However, in both of these two cases just discussed, the number of children who believed in infinity for only one domain was small, limiting our ability to draw firm conclusions about causal interactions from this dataset. In addition, while there may be tentative evidence for primacy of some domains, there were many children who bucked this trend, demonstrating that there is no single entry point into beliefs about infinity.Contrary to our initial hypothesis that children’s beliefs about infinity might be based on knowledge of how to generate successors when counting, we did not find a significant relationship between counting productivity and infinity belief outside the domain of number. While the belief that it is always possible to add 1 to any number was predicted by children’s ability to produce successors on the Next Number task . One possible explanation for this is that, as noted above, our study may not have sampled enough young children to detect the transition from infinity-disbelief to belief. Another possibility, however, is that the trajectory from ‘lack of infinity belief’ to ‘full infinity belief’ is not linear, and not dependent only on chronological age. For example, it is possible that some individuals hold literally contradictory beliefs , but numbers are nevertheless finite , making it challenging to develop questions about infinity that don’t invoke multiple quantitative domains . Future research should examine new ways to minimize  the linguistic demands of tasks aimed at measuring infinity beliefs.To summarize, we explored the intuition of Archytas that beliefs about the infinity of space, time, and number might be deeply related to one another. Our most striking finding was that children had high levels of belief in infinity in each domain, and that these beliefs were often similar for number, space, and time. These data are consistent with the idea that children develop beliefs in infinity for space, time and number early in development, but leave open the possibility that asymmetries in these beliefs exist, and that knowledge in one domain may emerge earlier than in the others. Future research should focus on this question, while also exploring the individual differences in beliefs about infinity in adult participants, and how such beliefs might be impacted by cross-cultural differences in education, whether scientific, mathematical, or spiritual.Special thanks to students in J.S.’s “Psychology of Infinity” course for helpful comments on the manuscript, and to Sally Apolinsky, Ajna Kertesz, Michelle Mei, and Rose Schneider for assistance with early phases of stimulus design, testing, and recruitment.https://osf.io/694zg/. Alvarez, J., Sullivan, J., Schneider, R. M., & Barner, D. . Infinity Interview & Successors. Retrieved from osf.io/694zg.Preregistration, data, and materials are available on our OSF page: This work was supported by NSF#1749524 to J.S. and NSF #1749518 to D.B.1 Note that we failed to preregister the addition of the Corsi task into this model by accident; omitting the Corsi task from the models does not substantively alter the results. Descriptives for each task are available in SOM.Click here for additional data file.


To learn about the experiences of people who use drugs, specifically opioids, in the Halifax Regional Municipality (HRM), in Nova Scotia, Canada during the COVID-19 pandemic through qualitative interviews with people who use drugs and healthcare providers (HCP). This study took place within the HRM, a municipality of 448,500 people [We conducted a qualitative study using semi-structured interviews with 13 people who use drugs and 6 HCPs, including physicians who work in addiction medicine (3), a pharmacist, a nurse, and a community-based opioid agonist therapy (OAT) program staff member. Participants were recruited within HRM. Interviews were held via phone or videoconference due to social distancing directives. Interviews focused on the challenges people who use drugs and HCPs faced during the pandemic as well as elicited perspectives on a safe supply of drugs and the associated barriers and facilitators to the provision of a safe supply.Of the 13 people who use drugs who participated in this study, ages ranged from 21–55 years (mean 40). Individuals had spent on average 17 years in HRM. Most people who use drugs  utilized income assistance, the Canadian Emergency Response Benefit, or disability support. Many had experienced homelessness  and almost half  were currently precariously housed in the shelter system. The main themes among interviews (people who use drugs and HCPs) were housing, accessing healthcare and community services, shifts in the drug supply, and perspectives on safe supply.We identified several challenges that people who use drugs face in general, but especially during the COVID-19 pandemic. Access to services, housing support, and interventions to use safely at home were limited. As many challenges faced by people who use drugs exist outside of COVID-19, we concluded that the formal and informal interventions and changes in practice that were made to support people who use drugs should be sustained well past the end of the pandemic. The need for enhanced community supports and a safe supply of drugs, despite its complicated nature, is essential for the health and safety of people who use drugs in HRM, especially during COVID-19. The overdose death epidemic has been impacting the lives of Canadians long before the global COVID-19 pandemic. Between January 2016 and June 2021 there were over 32, 632 opioid toxicity deaths in Canada alone, averaging over 20 a day . ArguablControlled Drugs and Substances Act (CDSA), allowing people who use drugs to stay home to self-isolate ?”–HCP, addiction medicine physician.Another HCP expressed hesitation and discomfort with the idea of prescribing a safe supply of drugs without an evidence base to support its use or a dire enough environment to necessitate its use:“[Safe supply] spread very rapidly without a lot of rigorous evidence behind its safety… I’m leery about myself being a safe supply provider without having rigorous clinical trials backing the practice. I think what’s kind of caught fire with regards to safe supply is because it’s a necessity, like in the inner city of Vancouver, where it’s the only intervention that will save some lives. But I don’t think that’s the truth for the entirety of the rest of the country.” -HCP, addiction medicine physician.Another HCP argued that much evidence exists out of British Columbia and Ontario supporting safe supply, and to say that we need more evidence in our local context is a “stall tactic”. They likened it to not using a cardiac medication in Nova Scotia if the clinical trial was done in another country. They added, “there is a place for evidence-based medicine and a place for clinical judgement”. Among HCPs who offer safe supply, none reported an adverse event (overdose events or death) among the patients for whom they had prescribed safe supply during COVID-19 .There was a common consensus among HCPs that neither option (safe supply provision or not) feels “good”, but felt the impact of doing nothing (not offering safe supply) is often worse. Multiple HCPs shared concerns around prescribers providing a safe supply without formal training in addiction medicine and/or a trusting relationship with the patient. A few HCPs felt that an authentic safe supply should consist of a legalized and regulated supply of drugs, and all agreed that layering other health and social services such as increased housing, income, and rehabilitation supports is essential. One HCP described safe supply as a trusting relationship and a human connection that “meets people where they are”, another described a success in safe supply provision as “keeping someone alive one more day, so the next day they can chose the same or something better”. Overall, the majority of HCPs in our study were planning to start or were already prescribing a safe supply of drugs to individuals on a case-by-case basis.Most HCPs agreed that OAT is a separate discussion and was not considered safe supply by many participants. It was recognized that OAT alone does not help everyone remain safe, such as those who continue to use other drugs while on OAT, and this population in particular needs a safe supply of drugs:“That’s what safe supply is really about. Recognizing that some people cannot give up the needle and will not be able to and it’s not acceptable to ask them to, so what can we do to make that as safe as possible?”–HCP, pharmacist.Conceptions of safe supply among people who use drugs often turned into discussions around OAT. Some felt that medications like methadone and buprenorphine were a poor solution to addiction, and referred to it as “liquid hand cuffs” as OAT medications are also addictive and often require daily dispensing and/or witnessed ingestion . When as“I think [safe supply] is amazing. Because people like me and other women like me who are selling our bodies for drugs wouldn’t have to sell much. You know what I mean?”–Person who use drugs, 38-year-old.Some barriers to safe supply from the HCP perspective included fear of potential college repercussions, going “against the grain” of an opioid de-prescribing culture, poor education in professional programs on safe supply, burnout and limited time to spend learning about safe supply, political and moral issues tied to substance use, and fear of causing harm via overprescribing leading to overdose and/or diversion. One HCP felt that safe supply is out of reach as currently “we can’t even get healthcare providers to recognize addiction as a medical problem, let alone provide a safe supply”.Another barrier to prescribing safe supply relates to the criminalization of drugs in Canada. One participant (HCP) felt the recent regulation and decriminalization of cannabis should be swiftly followed by regulation and decriminalization of opioids as well:“Don’t put [safe supply] on the shoulders of doctors and say now you must make this a medical thing. We’ve used drugs since the beginning of time and we will always use drugs, and what drugs are used will look different but can we just decriminalize this already, and try not to medicalize it? [Drug use] is real life, but it’s also this taboo thing that’s always been with us and we just need to accept it and have some understanding.”–HCP, addiction medicine physician.One HCP described how previous, less accepted methods of practice, such as extending carries (take home doses of medication), or offering carries in the first place, were occurring more often during COVID-19 as a necessary response to social distancing directives. However, it is worth noting that this arose out of necessity among select physicians, not as a result of the federal exemptions put in place . One participant proposed bringing together a community of practice specifically for prescribers of safe supply:“We have to be housed somewhere because right now there’s a bunch of clinicians practicing addiction medicine and serving people who use drugs and we don’t have a united place where we can all speak.”–HCP, addiction medicine physician.Among people who use drugs, some shared concern about the risk of misuse, such as diversion, as a potential barrier to safe supply. Almost all people who use drugs described stigma and discrimination as an additional barrier to accessing safe supply while only some mentioned the current criminalization of drugs as another barrier. Some felt it unlikely that safe supply could be a legitimate option due to criminalization of substances and mistrust between people who use drugs and HCPs. For example, one participant who lives with anxiety received a recommendation to start on pregabalin by a pharmacist. When the patient brought this up with their family doctor they were met with hostility:“You could tell he was not a fan of anybody asking for anything. He said stuff like “do you really want a pill for every ill” … he was belittling me … I said could you please just talk to the pharmacist before you go off on me. He called the pharmacist, and he made sure to say with extra emphasis that I was seeking extra meds.”–Person who uses drugs, 29-year-old.Another participant described being met with similar antagonism:“I was severely depressed, and [my doctor] had me on every anti-anxiety/depression medication and after doing the amount of time they suggested for them to work, I would keep telling her ‘these aren’t working, could we try something else?’ And she eventually said ‘listen I know you’re just trying to get drugs from me and it’s not going to happen, just cut the bullshit.’”–Person who uses drugs, 21-year-old.The benefits (facilitators) of safe supply, as described by people who use drugs, included the prospect of saving the lives of people who could otherwise fatally overdose from a tainted supply:“I’m sure a lot of my friends would still be here if we had a safe supply. I’ve lost so many friends due to this stuff it’s just insane.”–Person who uses drugs, 29-year-old.In March 2020, the federal government used its powers to exempt prescribers and pharmacists from certain restrictions relating to “controlled substances” under the CDSA, making prescribing and dispensing certain substances more flexible under a certain set of conditions. This allowed physicians to provide prescriptions over the phone and allowed pharmacists to extend and renew prescriptions for controlled substances such as opioids. People who use drugs were also able to have prescriptions delivered to them. Speaking with people who use drugs, however, revealed that many were unaware of these exemptions. One HCP, an addiction medicine physician, explained how the exemptions themselves did not facilitate safe supply as per CAPUD’s definition:“[The exemptions] simplify my life a billion times from an administrative and logistical standpoint, but how we can use a triplicate [prescription pad] versus a telephone to do a prescription now… that is not the barrier to safe supply at all.”–HCP, addiction medicine physician.She also described how physicians were prescribing more take home doses of OAT medications, filling larger prescriptions, having fewer scheduled appointments, and requesting fewer urinary drug screens during COVID-19 independent of these exemptions. She described that, for the most part, the changes that arose in healthcare out of necessity during COVID-19 reinforced what she and other addiction medicine physicians were already advocating for and doing in their practices. One HCP shared hope that the pandemic may accelerate positive changes for people who use drugs and improve access to safe supply. But it was clear that the CDSA exemptions introduced during COVID-19 were, by themselves, insufficient to securing safe supply for many people who use drugs.While tele-medicine may be more accessible for a certain population, not everyone has access to internet or other required technology. Some participants (not restricted to those without technology) commented that their doctors were inaccessible during the switch to tele-medicine. One participant described a feeling that was shared by others in this study:“It’s almost impossible to get a hold of a doctor, or get an intake, or get in to see anybody. So, you’re dealing with being over the phone, all that fun stuff. I find it extremely frustrating, even now with my surgery, to talk to my own doctor has been a nightmare. I find basically we’ve just been ignored.”–Person who uses drugs, 35-year-old.Later, the same participant shared that they were not able to get in contact with their doctor when they had a leg abscess due to an infected injection site:“I went without antibiotics for over a week until my leg was to the point of seeping, abscessing… I could have died of a blood infection.”–Person who uses drugs, 35-year-old.She was finally seen by the Mobile Outreach Street Health (MOSH) service a week later and was treated with an aggressive antibiotic, highlighting how injection-related infections  are justSimilarly, HCPs mostly felt that care was not ideal via the telephone during the early stages of the pandemic. One HCP explained:“The greatest challenge has been the disconnect … Because that’s the crux of harm reduction, of the work, is that connection. Meeting people wherever they’re at in their lives. That contact. That engagement. That dialogue. That respect. That care, compassion, respect and dignity that is so integral. So that has been very challenging for people. And for us, doing our work. We miss the people. We miss that. So [switching to telemedicine] has been a challenge.”–HCP, program lead.The HRM has multiple OAT clinics around the city, only one OPS, one needle and syringe program, and one withdrawal management center. As these services were not deemed essential, many were closed, albeit some only for a short (1–4 weeks) period during the pandemic. This impacted street-involved clients, who collectively are at higher risk of contracting not just COVID-19 but other drug use-related infections or illnesses .“We did feel really worried about that (spreading COVID-19). So, we tried to minimize a lot our contacts with people, but we still found it was a really delicate balance because we thought in some ways the risk was worth it to be out and about because COVID isn’t the only cause of death.”–HCP, mobile health service.Services reported as most helpful during COVID-19 included MOSH, Barry House, CAPUD, Direction 180, Open Door, local foodbanks, Stepping Stone as well as Mainline Needle Exchange (see Appendix 1 for description of these services). The latter organization is a needle and syringe program with a user-directed and grounded approach. During interviews, participants described positive experiences with Mainline Needle Exchange more frequently than any other service, with examples such as: learning how to inject safely, being connected with helpful resources, and receiving safe injection supplies, among other forms of support such as daily dispensing of cigarettes:“Mainline for example, they are handing out harm reduction things. And during the pandemic they started giving a lot of pharmacies essentially little gift bags of drug use equipment that you would need…which has been really helpful.”–Person who uses drugs, 26-year-old.Their closure, although brief, made using drugs more dangerous for people who use drugs in the community and in the hospital as well. Mainline’s services include dropping off kits with injection supplies to hospital in-patients at the request of medical staff. In Nova Scotia, there is no formal inpatient addiction support service. While an informal hospital Addiction Medicine Consultation Service has formed to try to address this gap in care ,36, partOne interviewee, a HCP who is part of the Addiction Medicine Consultation Service, shared that they received an increase in consults during COVID-19. They commented:“My dream is that eventually we’ll have a fully resourced, professional consultation service at the [local hospital] and be able to provide that [care] around the clock.”–HCP, resident physician.One particularly important service that shut down indefinitely and unexpectedly during the pandemic (June 2020) was the only OPS in Atlantic Canada . It did not re-open (under the name of “ReFIX”) until August 2020, leaving many people who use drugs without a safe space to use for months . Some pa“A lot of these women are escaping abusive relationships and drug addicts and for them to have to go down there and face that, I didn’t think it was an ideal spot [the new location]… This is coming from a woman that was involved in prostitution and abusive relationships.”–Person who uses drugs, 35-year-old.Participants cited housing instability as a major area of concern. During the initial stages of the pandemic, sweeping efforts were made to house those who were homeless and many Nova Scotians were housed in hotels. One HCP criticized this move, suggesting that there are more efficient ways to spend public funds than housing people in “expensive hotels”. Additionally, some HCPs shared concerns that if people who use drugs were using alone in a hotel room it could increase the risk of overdose deaths .One participant in this study, who was living in a hotel at the time of the interview said they had been moved around many times, and this was made more difficult with their physical disabilities and being far away from their OAT clinic. They were worried about what would happen once the government stopped paying for their hotel room as some shelters do not accept people who are actively using drugs and many shelters were at capacity to begin with. A different participant shared:“Homelessness is real here in Halifax and especially for women. There’s not a lot of opportunities for us. Especially when we’re drug addicted. As soon as they find out you have an addiction problem, you’re a monster.”–Person who uses drugs, 38-year-old.With a relatively recent boom in real estate prices in HRM, trying to find affordable housing has become increasingly difficult . This pr“When you can’t pay more than $600 per month in rent, you’re going to have thousands of roommates in the form of rodents and insects and bedbugs and all that. And that’s just the way it is. You have to learn to live with those rodents and insects”.–HCP, nurse.Participants reported an increase in the price of opioids during the pandemic. We hypothesized that this was because the supply was restricted by border closures, limiting access to a secure supply of drug ingredients (precursors) and increasing chances of being caught either carrying or trafficking drugs. However, as one HCP explained, a further factor we had not considered was that the opioids purchased on the streets in pre-pandemic Halifax were diverted prescription drugs:“The street supply of drugs, or prescription supply of drugs really dried up. Halifax has historically been a prescription opioid town. If somebody has opioid use disorder in NS, they are historically addicted to prescription drugs. What’s happening is because the doctors weren’t able to provide care or prescribers were providing really acute emergency care, the street supply of prescription drugs really dried up. That was our way of having a safe supply.”–HCP, Pharmacist.For some, diverted prescription opioid prices increased so much that people who use drugs ended up using fentanyl instead, as it had become cheaper than the remaining street supply of prescription drugs. According to interviews, the cost of stimulants also increased. On top of this, with the release of the CERB cheques, many people who use drugs noted a concurrent increase in panic buying , which further deteriorated the supply of drugs, changing our local market:“[People are] straight up pulling out $2000 and buying everything that they can because they can at the time. Not that I’ve done that specifically but there’s been a lot of panic buying for people and their supply. People that usually have sold their prescriptions no longer do because they’re so afraid of running out. So, it’s just leading to this panic.”–Person who uses drugs, 21-year-old.With higher prices and an elusive supply, some people who use drugs reported difficulty accessing drugs. One HCP pointed out that drug dealers were facing difficulty being discreet about selling drugs as the streets were mostly free of pedestrians or traffic. Almost all people who use drugs expressed a fear of fentanyl contamination within their supply of drugs, a concern exacerbated by the fact that there are no drug testing facilities or safe supply clinics in Nova Scotia:“People are being forced into a situation so desperate that they’re going to that purple fentanyl of unknown purity and source. It could even not be fentanyl it could be carfentanil and that really sucks about this pandemic, everybody’s got money and everybody’s looking, everybody’s getting money around the same time and it’s just a free for all. I have both witnessed and heard of overdoses that have occurred because of it.”–Person who uses drugs, 21-year-old.These pandemic-related changes led to people who use drugs using more dangerously—in isolation, with an increasingly precarious supply and a lack of social support services and safe using supplies . Inevita“I do know that heroin is a lot more dangerous, there’s the fentanyl involved with it, and I experienced, for the second time, I overdosed. And I had a friend who overdosed. So that’s something that’s changed during the pandemic because I wasn’t used to people overdosing… you don’t know what’s in it [street drugs], it’s so easy for people to overdose.”–Person who uses drugs, 26-year-old.People who use drugs face several social and health challenges which only worsened during the COVID-19 pandemic. We found that access to services, housing support, and interventions to use safely were lacking during COVID-19 in HRM. As many challenges faced by people who use drugs exist outside of COVID-19, we argue that it would be unethical to retract the community interventions and changes in practice that were made to support people who use drugs during the pandemic, such as prescribing a safe supply of drugs.This study had two main limitations. First, we did not collect or analyze any quantitative demographic data on gender, ethnicity, or sexual orientation. Second, our findings are context specific and drawn from a small sample of interviews, such that they may therefore be difficult to extrapolate from, but this is the first qualitative study related to safe supply in our local context. The main strength of our study is that it centers the voices of people who use drugs, whose expertise is consistently absent from research, service design and delivery, and policy-making—locally, provincially, and nationally . This hiOur research participants, particularly those who identified as people who use drugs, were united in the view that communities know best how to solve their own problems, and that political will and financial support are the most significant obstacles to designing and implementing community-led responses to the most pressing issues affecting people who use drugs.This is especially true with respect to the design and implementation of safe supply. In places like Vancouver or Toronto, safe supply was being prescribed by physicians prior to the pandemic and by prescribers in the HRM, but to a much lesser extent ,41. Yet Our findings nevertheless underscore several areas of ambiguity surrounding the meaning of safe supply, which is consistent with previous research ,47,48.The first concerns the scope of substances understood to constitute safe supply. While CAPUD’s definition of safe supply encompasses a broad range of drugs, it expressly excludes those that aim to reduce drug use and/or treat drug related dependence, such as OAT. Yet, one of the prescribers and two participants in our study disagreed with this conceptualization and regard OAT as an essential part of safe supply.Secondly, the mechanism or mechanisms by which safe supply is provided is not settled. The consensus among HCP in our study was that safe supply should be provided on a case-by-case basis by skilled addiction medicine physicians. In our study, two of three healthcare providers with prescribing privileges were prescribing a version of safe supply in their practices prior to the pandemic. Most HCPs we interviewed had difficulty envisioning, or outright opposed, the provision of safe supply outside of a prescriber-patient relationship. People who use drugs, in contrast, generally expressed enthusiasm for the idea of safe supply but, in many cases, unfamiliarity with the concept and its scope. This disconnects between the level of understanding and related consolidation of opinion among HCPs on the one hand, and people who use drugs on the other, indicates first the exclusive or near-exclusive space occupied by medical professionals in shaping safe supply in line with their comfort zones and preferences, and second, the absence of people who use drugs in informing policies and processes relating to service design and delivery, including those oriented to safe supply. This suggests a missed opportunity to draw upon a wide range of experiences and opinions, inclusive of those whose fundamental interests are most affected, in determining whether or how to expand the meaning of safe supply to include access to a broad range of drugs, possibly with minimal prescriber supervision, under conditions that diverse people who use drugs experience as safe.Therein lies the third, and final, area of ambiguity: the conditions under which safe supply is accessed. Similar to a syndemic, our participants’ experiences and insights show how safe supply must be understood in intersectional terms. For example, where safe supply is accessed matters depending on the people involved: for women who use drugs, the relocation of the OPS to a site neighboring a men’s shelter rendered it unsafe given the abuse some women in our sample had previously endured from some of the men living there. For people who use drugs with HCP relationships that are characterized by stigma, rooting safe supply in the same relationship is, too, going to make the experience of accessing safe supply feel less safe. Also, for people who use drugs that are experiencing homelessness, accessing healthcare in general is a challenge requiring creative models of delivering a safe supply of unadulterated drugs that is accessible to those who may benefit most.The question moving forward is how will these areas of ambiguity come to be resolved. In our view, meaningful integration of people who use drugs is essential to shaping the scope, model, and conditions of safe supply in Nova Scotia.With the perspectives of people who use drugs at the forefront of our study, we learned of the many threats to safety and wellbeing that were worsened by the pandemic. The rapid switch to telemedicine was met with mixed reviews in our study with an overall consensus that it was challenging to both HCPs and people who use drugs. Much of the criticism stemmed from the growing pains of implementing a new system on short notice as well as the reported unavailability of virtual appointments during early stages of the pandemic. This intervention has the potential to greatly improve access to healthcare, but if used without discretion, may lend toward subpar care–a concern from some HCPs in our study.The stigma and discrimination faced by people who use drugs when accessing healthcare, as reported in our study as well as in the literature ,8, is inA major concern among the people who use drugs in our study was homelessness or insecure housing, despite many individuals being rapidly but temporarily housed in hotels during the pandemic. People living on the streets were underrepresented in our study, as this population is much more difficult to connect with, especially with the social distancing requirements imposed at the time our study took place. Nonetheless, we highlight the need for further housing supports as we know many people who use drugs are forced to live on the streets, and this is exacerbated by “zero tolerance” policies for substance use in most local shelters. Homelessness can preclude individuals from receiving a safe supply of drugs or carries (take home doses) with OAT, as they have no safe space to store their medications. On top of this, people who are injecting drugs in the streets are in less safe environments and at higher risk of acquiring injecting-related infections such as infective endocarditis, sepsis, and skin abscesses .Eventually, a group of HCPs, including doctors, nurses, pharmacists, and community workers in HRM provided 77 precariously housed individuals required to isolate in a hotel due to community related COVID-19 exposure with a wide ranging medicalized safe supply of drugs, such as pharmaceutical alternatives to opioids, benzodiazepines, and stimulants as well as alcohol and cigarettes. This intervention lasted 25 days and the results showed low rates of adverse events  and high rates of successful completion of the mandatory 14-day isolation, suggesting this intervention was safe and effective ,51. ThisThe federal drug exemptions did not obviously improve care for people who use drugs in our study. HCPs commented that it did not assist people who use drugs in HRM during COVID, other than by simplifying administrative burden on HCPs that may indirectly free up prescriber time to see more patients. Within our cohort, however, some HCPs were making exceptions and prescribing substances (safe supply) out of “sheer necessity” within a trusting prescriber-patient relationship, with or without back up from the college.People who use drugs who were not able to access a safe supply of drugs, which was the vast majority in our study, reported major changes in the drug supply. This is in line with the findings of Ali and colleagues (2021) who describe major disruption in supply during COVID-19 and an increased risk of overdose as a result . In addiCommunity service availability may have lacked emergency preparedness. Many services were forced to shut down or closed briefly during certain stages of COVID-19 lockdowns and the people who use drugs in our study suffered the consequences of not being able to access safe injection supplies, community supports, housing, or access to food via food banks. This was recently corroborated in a national study . It is wIn conclusion, people who use drugs in HRM are in the same crisis as the rest of Canada, including a wide variety of health and social issues contributing to the syndemic of high rates of overdose, COVID-19, homelessness, HIV, and HCV. As the COVID-19 pandemic remains, the drug supply continues to become more potent with deadly toxins. People who use drugs continue to lack access to the basic supports required to meet their most fundamental human needs, a problem that pre-existed the COVID-19 pandemic yet has been exacerbated by it. In 2022, Nova Scotia reported 62 overdose deaths, implying that our interventions have not been sufficient . The voiS1 Appendix(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


The Norwegian actor Toralv Maurstad died on November 4th 2022, at the age of 95. To many Norwegians, he represented an incarnation of Peer Gynt, the character in Henrik Ibsen’s famous play. Maurstad, a major cultural figure in Norway, played Peer Gynt in numerous productions throughout a period of almost 70 years, most recently at the age of 92.The Norwegian playwright and poet Henrik Ibsen 1828–1906) is the second most performed playwright worldwide, after Shakespeare. His international breakthrough “A doll’s house”, published in 1879, is considered the start of modern, realistic drama and still contributes to social debate. “Peer Gynt”, a five-act play in verse, was written in 1867, during the romantic period. The original music for the play was written by the contemporaneous composer Edvard Grieg. Grieg was another famous representative of romanticism, a great period for many art disciplines in Norway. The music remains part of standard repertoire, and includes some of today’s most recognised classical pieces worldwide [828–1906 “Go roundabout, Peer! [” becomes a motto to Peer. Confronted with the fear of responsibility and upcoming trouble, he leaves Solveig, the innocent, pure, Christian girl who loves him. “Be patient, my girl; be my way long or short – you must wait.”“Peer Gynt” is a chronological story following Peer’s life from youth to old age. Peer is an unprincipled and irresponsible character, only true to his own wishes and needs. From village gossip, we know Peer’s father drank too much and died early, and that his mother drowned the shame in lies and fairy tales. Confronted with difficulties, Peer shies away from reality and makes up stories. On his adventurous way, he faces trolls and monsters, such as “the Bøyg”: in Norwegian folklore this represents something impossible to overcome. The Bøyg’s saying t, Peer! ” becomesIn Maurstad’s last performance as Peer Gynt, in a production performed at ‘Det Norske Teater’ in Oslo in 2018–19, five different actors play the character of Peer as he increases in age . MeanwhiDespite Maurstad’s remarkable endurance as an actor, we recognise signs of ageing and frailty. His posture and voice reveals lived life, and he moves with the pace of an elderly man, trying to be nothing but a nonagenarian. Wearing a benevolent grey suite, as if to emphasise that a costume is redundant in this matter. He adds outstanding credibility to the character and leaves us with the question if it could be his own, or anyone’s life and ego he so critically observes Fig. .Fig. 1ThThe director Erik Ulfsby has not attempted to cover any weakness or frailty. Instead, he has embraced the age and constitution of the actor as a powerful means of action. Maurstad has a bottle of water within reach and sips from it during the long play. He might have a dry mouth, a common complaint at his age. At times, he seems to make a side step, suggesting his balance is not what it used to be. The rich text in verses is challenging to anyone, requiring cognitive capacities such as attention and deferred recall, but Maurstad controls it as his own. Any hesitation or slowness provides us with the moment we need to have glimpses of insight, to feel the insecurity, loss and sorrow of Peer. The director’s way of dealing with any necessary adaptations relating to the actor’s age, is practical as well as a piece of art itself. In Ibsen's original manuscript, the end of the play has the Button-moulder confronting Peer. In this production instead, the Button-moulder is played by a younger actor, and he accompanies Peer to the stage throughout, functioning as a prompter and support. This constant physical proximity and interaction between the two leave us with time for reflection upon the mysterious character of the Button-moulder. Who is he? Peer’s alter ego? A walking self-criticism sent by God?“Your grave is dug ready, your coffin bespoke.The worms in your body will live at their ease; but I have orders, without delay, on Master's behalf to fetch in your soul.”After having travelled the world, Peer returns to Norway as an old, betrayed and disappointed man. Confronted with the Button-moulder’s order, Peer is finally forced to confront his (mis)deeds and account for his life and actions:“(…) in the small circle where he saw his calling,There he was great because he was himself.His inborn note rang true unto the end. (…)Yet dare I freely, firmly, speak my hope:He scarce stands crippled now before his God!”Engaged and gripped as never before, and whilst attending a funeral from a distance, Peer listens to the priest speaking at the graveside, strongly wishing that the sermon could have been said about him.“meet at the next cross-roads”.“So unspeakably poor, then, a soul can goBack to nothingness, into the grey of the mist.Thou beautiful earth, be not angry with meThat I trampled thy grasses to no avail.(…)The spirit is niggard and nature lavish;And dearly one pays for one’s birth with one’s life.”Peer suddenly faces all the hints he did not take, his unsung songs, his unmade works, his unwept tears, and the questions that were never asked. Faced with the universal fear; that he has been nothing, meant nothing to anyone, Peer struggles to prove that he has not been a troll, but has been himself with a soul. The Button-moulder provides him with some more time, but just until they “Tell me, then where was my real self, Complete and true the Peer who bore The stamp of God upon his brow?”[Finally, marked by age, and facing death, even Peer shows signs of self-awareness, contrition and some insight into the wisdom that may accompany ageing and maturity. He asks Solveig, who has loved him and waited her whole life; is brow?”. “In my faith, in my hope, and in my love”.And she answers;Has she saved Peer in the last minute? Ibsen left the question open.While future productions will continue to suggest new answers, Toralv Maurstad has reached his last crossroads. Controversial at times, but foremost admired and respected. He refused to go roundabout. His soul may last and not be forgotten. However, this was how he commented on his last role: “I don’t see Peer as a liar. He has an all too lush and untamed imagination. He brags and rhymes, with charm and wit. The mistake is that he abuses his imagination to impress and to get attention—also from the ladies. It will be interesting to come to terms with such a life. I think he has to adjust to being melted down, to join the crowd among other people. As we are all perhaps expected to do ”.


Participants liked the term indulgence, as they could apply it to their normal dietary intake and make small changes. They found self-monitoring what they said no to helpful and reported that emotional eating and habits affected consumption. They had difficulty overcoming these. As most people are consuming too many foods that are EDNP, this simple intervention of “Say No” seven times/week has the potential to be developed as a public health campaign. There is a growing interest in the effects of ultra-processed/energy-dense nutrient-poor foods on health outcomes, and few interventions to reduce their consumption have been tested. We tested a simple intervention to help people reduce the indulgences they consume (energy-dense nutrient-poor (EDNP) foods). Herein, we report the qualitative findings to understand how participants reduced their consumption by exploring intervention fidelity and the factors affecting consumption. We conducted a qualitative descriptive study of 23 adults who had taken part in a feasibility randomised controlled trial that asked participants to say no to seven indulgences/week and record what they said no to. Data were collected using face-to-face semi-structured interviews and analysed thematically. A total of 23 adults with an average BMI of 30.8 kg/m In developed countries, the environment is one in which food is readily available and relatively inexpensive and there are frequent instances of food temptations and opportunities to eat . This prThere is little consensus about the characterisation of these types of foods. In Australia, they are described as discretionary foods, with the definition being “foods and drinks not necessary to provide the nutrients the body needs, but that may add variety” . HoweverThere is a range of environmental drivers associated with an unhealthy diet. These include proximity to convenience shops and fast-food restaurants . FrequenAppelhans and colleagues (2016) have proposed a neurobehavioural model for managing temptations in obesity treatment . They suQualitative research may provide more in-depth contextual information about the factors affecting consumption. Such research has found that individuals use exercise, manipulation of the availability of tempting foods, and strategic formation of meals to manage their consumption of indulgences . HoweverTo build on the evidence, we conducted a feasibility randomised controlled trial to examine the effectiveness of an intervention based on self-regulation theory to reduce indulgences over eight weeks ,26. The The method of inquiry used was qualitative description , thereby2, and participants that were motivated to reduce the number of indulgent foods and beverages they consumed. Informed consent was obtained at the beginning of the trial, and participants were informed that they may be asked to take part in an interview about the study in their follow-up appointment at the end of the intervention (eight weeks).Details relating to the recruitment of participants into the ‘Say No’ trial have been reported elsewhere . To summParticipants were recruited using convenience sampling from those participating in the trial. This meant that participants were invited to interview if they attended the follow-up. In some cases, there may have not been time to conduct an interview (due to participant or researcher availability), and, therefore, not all participants took part in an interview. We also decided to interview members of the control group to understand their experiences, and these members were invited on a first-come basis. This study was approved by the Royal Prince Alfred Hospital Sydney Local Health District Human Research Ethics Committee  and the clinical trial registration is ACTRN12616001239459. A semi-structured interview schedule was developed and used as a guide when conducting the interviews to ensure that the interviews included similar content. At the beginning of the interviews, information on the researcher’s role with respect to the interviews, the aim of the interviews, the anticipated duration, and anonymity and confidentiality were provided, and the importance of the participants’ own opinions, experiences, and ideas was emphasised.We explored the participants’ views on what an indulgence was and their experiences of saying no to indulgences. The questions examined why participants thought they were successful or not, if they struggled with trying to say no, and if they used other strategies that helped them to manage their weight. In addition, participants were asked about the process measures of the trials  and what improvements could be made. Probes and follow-up questions were used to provide examples and elaborate on ideas and opinions. All interviews took place in a quiet and private room at the Charles Perkins Centre Royal Prince Alfred Hospital Clinic (CPC-RPA), Sydney, where the ‘Say No’ trial was being conducted. All interviews were conducted by two female members of the research team (C.M. and C.H.) involved in the delivery of the trial and who had expertise in public health and clinical trials. There were no prior relationships with participants before the start of the trial. Before the interviews, participants may have previously met with the interviewer only once, depending on which researcher completed the baseline assessments for the trial. The study methods and reporting were completed in accordance with the Standards for Reporting Qualitative Research Checklist .All interviews were audio recorded and transcribed verbatim into Microsoft Word , wherein the data were deidentified and referred to by an identification code before the transcripts were checked against the recordings for accuracy. The data analysis was led by the first author. The data were imported into NVivo . Inductive thematic analysis was used to provide a nuanced and descriptive account of participants’ views on indulgences. In thematic analysis, the application of themes across data sets facilitates a systematic overview of the scope of the data, which allows the combination of the analysis of their meanings with their particular contexts .Following Braun and Clarke’s  six phasThe trustworthiness of the findings was facilitated using two methods. First, one of the co-authors (A.C.) independently checked the initial coding strategies and the coding framework generated by the first author to establish procedural reliability and conceptual credibility. Secondly, interpretations were openly discussed and appropriately challenged to achieve a final consensus by reviewing the framework and critically probing for explanations of certain decisions made by the first author.2. Participants reported consuming 29 (SD 14) indulgences per week on average, and this reduced to 18 (SD 12) at follow-up. The weight change was −0.9 kg (SD 2.0) at follow-up. Most participants were employed or retired, and one participant was a PhD candidate. The majority were of White ethnicity, with one participant being Asian. There were five participants in the control group, eight in Group 1, and nine in Group 2. We conducted 23 interviews; the mean duration was 16.8 min (ranging from 12 to 36 min).A total of 23 participants were recruited, and the mean age of the participants was 52 years (SD 10), and 16 (70%) of them were female. The average BMI at baseline was 30.8 (SD 3.6) kg/mFive higher-order themes were identified as being important to the participants’ consumption of indulgences: the definition of an indulgence, factors affecting consumption, self-regulation, strategies individuals used to overcome consumption, and negative effects of trying to reduce consumption. I think it’s, it’s really important to allow people to determine what their own indulgence are” . Participants frequently described indulgences as specific foods or food groups. Typically, these were energy-dense and nutrient-poor. They included savoury as well as starchy foods , sweet foods, and alcohol. As one participant commented:“Cakes, chocolate. Chocolate, I didn’t go through as much. Yes, I’ve actually cut back on chocolate. But things like the pastries and the muffins and the large coffees, so. And ice creams have been on the radar a bit as well.” Male, 50 years.The participants had specific ideas of what an indulgence was and being able to define these was important due to their individualised nature. As one participant reflected: ““So, but then I was wondering about things like, so after I’ve played some tennis on the weekend, we went to somebody’s place afterwards for a kind of afternoon tea. And so having that extra slice of fruit bread with nice soft cheese on it. And really, you’re not hungry. So, I suppose that’s a good, an easy part of the definition. If you’re really not hungry and you’re just having something for the taste of it, all that.” Female, 61 years. Participants also referred to indulgences as an excess of food, for example, portions that were perceived to be too big or eating when not hungry. As one participant expressed:“Usually anything processed that I know isn’t necessarily positive calories. So, anything empty calories or sugary or overly processed, I would consider an indulgence, particularly if it’s not even disguising itself as healthy food, so chocolate bars, soft drinks, things like that.” Male, 41 years.Participants mentioned indulgences in reference to their nutritional value, be it empty calories  or what they defined as “bad foods” in relation to health:This theme was developed to capture things participants described as influencing the consumption of indulgences. Participants commented on the access to and widespread availability of food and drinks. Examples included having many items available in the supermarket, access to takeaway services, and the bombardment of food advertising, which made it difficult to resist consumption.“Well, when I go to a lot of cafes, you know, like even in the window, it’s just a carb window; I just look at it and go, “Carb, carb, carb, sugar, carb, carb, carb, sugar”. That’s it, that is the window.” Female, 55 years.“I’ve got an Aldi on the corner from work and that’s been really helpful because Aldi is very limited in what they keep, but they tend to keep seasonal things … and that’s where I go, and I can buy two salmon pieces at Aldi, which are the right size for us to eat, whereas at Woolworths I’ve got to buy one and a half times what we can eat, and then it goes in the fridge and then I’ll pick at it after tea and the next morning. And I really find it hard to throw anything in the bin.” Female, 60 years. Participants also spoke about the availability of foods at supermarkets and how it affected the choices they made and the subsequent consumption of indulgences:“We’re lucky enough to get food offered a few times a week and sometimes it’s pastries, sometimes it’s left-over sandwiches or salads and you know, I really know that I’ve already had my lunch; there’s no reason to want it but because it’s there and because somebody else has prepared it and of course it’s free, it’s really hard to resist.” Female, 54 years.Workplaces were frequently mentioned as a place where indulgences were available and affected consumption:“Yeah, so I find, you know, I go to bed and I’m trying not to be stressed but as soon as I start thinking about planning for the rest of the week, I think that’s when it gets stressful which is when I’m more likely to eat the packet of Twisties or the ice cream and the stuff before I go to sleep.” Female, 54 years. Another participant spoke about stressing over their weight encouraging more eating: “It’s just, I want to go down to 70 kilo at least, because now it’s over the top. And the more I stress the more I eat, and now I’m thinking, what’s going on?” Female, 61 years.Indulgences were more likely to be consumed when feeling emotional, and this was observed as the most difficult time to try and say no. Specific examples given included when participants felt tired, sad, depressed, or stressed. During these times, the ability to resist eating indulgences often waned and participants “gave in” and consumed indulgences. This was explained by one participant who saidParticipants reported that social influences from friends, family, and others had both a positive and negative influence on their ability to reduce indulgences. Participants reflected that others were supportive of their attempts to change their behaviour and held them to account if they were perceived to be consuming too much. “And it was like, normally once or twice a week, on the weekends I treat myself. I like cheese, but my daughter keeps telling me, “Mum, you’re only allowed two slices”. [laughs] “Now go away”. Or [pause], and I find it hard, and I love blue cheese.” Female, 60 years. “I actually got my flatmate onto it as well. I just said well we’re going to go, and this is what we’re going to do for the next eight weeks. And they lost 10.5 kilos.” Male, 33 years. There were also examples shared of the positive impacts of participants influencing others to change their behaviour and engage with the intervention. As one participant explained:“Really, the house is very healthy because of the young kids; they don’t get chocolate, they don’t get McDonald’s, so as long as I’m home I’m like, “Yeah, okay,” I won’t drink any beer, so I haven’t been drinking beer, so I haven’t been socialising. It’s pretty healthy. A bit boring.” Male, 42 years.One positive influence mentioned was having young children within the house. Parents exert a level of control and responsibility over their children’s consumption, which meant that they tried to keep these foods unavailable in the home. Additionally, as the children were not consuming any indulgences, this made the adults reflect on their own behaviour:“And it’s interesting, like, you have, kind of find yourself in certain situations where it’s expected. Like, it’ll be, I was at work the other day and there was someone’s birthday, so we’re having cakes and stuff. And I just got handed a plateful of cake. And it would have, kind of one of those situations where it would have been rude not to have, to have said, oh, actually I don’t want it, and passed it along. Whereas the, one of my colleagues had already snuck out of the room at that point. And I thought, oh, I should have just snuck out of the room and that way I wouldn’t have had to coped with it all. But yeah. So I ate it.” Female, 43 years. As noted above, accessibility reportedly affected consumption; however, this also interacted with social pressures or expectations to consume indulgences. One example included the challenges of social expectations:Participants spoke about eating behaviours being habitual in that there was a pattern of, or association with, their eating, which meant that they continued consuming indulgences. They also found it hard to change their eating behaviour. “… What I realised it’s not so much the food, it’s just a pattern of eating, and a pattern of indulgence and pattern of, you know that you just …. It’s old habits, yeah. And it’s just choosing to ignore this, because you know, once you know that you shouldn’t be eating something, or you should be eating less of something, you can’t un-know it. You just choose to ignore it.” Female, 59 years. Interruptions to normal routines were reported as both positively and negatively influencing consumption. Some participants reported that while travelling, there was healthy food available and fewer indulgences, so, therefore, they changed their behaviour. This was not always the case. In other situations, there was a perception that because participants were on holiday, they could indulge more often. Some participants reported that if they had guests staying with them or special occasions, their usual eating habits changed, and this often increased their consumption of indulgences. Participants reported that there were specific times of days when they were likely to consume indulgences, particularly in the afternoon or evening. A few participants struggled with reducing indulgences, and we have described this as a lapse, such that participants had changed their behaviour but then started to consume the indulgences again. Some participants reported feeling that if they gave in to indulgences once during a day, they would continue to give in, seeing it as an all-or-nothing experience. A positive observation, but one that was less frequently mentioned, was resilience. This was the perceived ability to continue making changes to their consumption beyond the initial trial.“I found the first part of it where we filled out the diary for a week really helpful because it made me aware exactly what I was eating. Sometimes it’s a bit hard to just keep tabs of all the snacks and you know, over at the …. School, we have our morning tea, lunch, afternoon tea but there’ll be lots of food left over from functions and stuff and so you think if you have a small square of a pastry or a cake that, you know, if you’re not writing it down, it’s easy to forget that you’ve actually had a small piece.” Female, 54 years.This theme was developed to describe participants’ abilities to understand and manage their own eating behaviour. Participants reported that having to record indulgences made them more conscious about what they were eating. This was described as particularly beneficial:As well as recording consumption, participants reported that being part of this study and having a goal helped them reduce their consumption of indulgences and, in some cases, improved their overall eating patterns. This was because it created an intention to change behaviour. Some participants also started monitoring the quantity of food and beverages they consumed, such as measuring their wine rather than freely pouring it. Participants described that recording their consumption and reflecting on their eating behaviour provided a sense of accountability for themselves and an awareness of how many indulgences they were consuming. “Well, I’ve obviously been reasonably good, because I’ve lost nearly four kilos. It’s made me more mindful. It made me a little bit more accountable and more mindful.” Female, 54 years.“I was, the first weeks I was better. I was thinking more. But then I think after, as the week goes, and because I don’t have anything to report, I guess I should be feeling that, okay, accountable. Like, in a way, it’s what I need to. Like, maybe get weighed, like every week. Or once a week.” Female, 58 years.This sense of accountability extended to the researchers within the trial as participants were weighed at the end of the intervention. Many perceived this to be helpful for reducing consumption. By contrast, others spoke about needing more accountability and wanting to be weighed weekly or to have more contact with the researchers to help them reduce their food consumption:“We don’t have the snacks in our rooms; we just have trays. The other rooms have a lot of snacks, so I don’t go to the other rooms.” Female, 42 years.This theme was developed to describe methods and techniques participants employed to reduce their consumption of indulgences. Participants explained how they reduced or could reduce the number of indulgences they consumed. The most frequently reported strategies were avoidance, accessibility, portion control, substitution, and cost/benefit analysis. Others less frequently mentioned included distraction and elimination. Participants reported avoiding indulgences by not visiting an environment where the temptation for an indulgence was more likely. For example:“Like, even, like, I don’t buy Magnums by the box and keep them in the fridge. And so, then I have to go to the service station, where they’re three times the price. And so you think about how much it’s going to cost you.” Female, 68 years.As noted above, the accessibility of indulgences affected consumption, but to overcome this, participants tried to make them unavailable or more difficult to access (particularly at home):“But it’s like you don’t need three big pieces of toast. Just try and have one or one and a half and just try and cut back.” Female, 55 years.Most participants reported reducing the portions they consumed by making small changes so that they consumed an indulgence, but less of it:Another commonly used strategy was the substitution of indulgences for foods perceived to be healthier or ‘less bad’ items. “I’ve had a banana, like I would have a banana instead of a chocolate, or I had a cup of this fantastic tea I just discovered, instead of the sweet biscuits and a cup of tea at night, with my mum, I’ve even got my mum onto this different tea. And it’s just a herbal tea, so no milk, … but because you’ve had this herbal tea it doesn’t set up the attachment to the biscuits …” Female, 58 years.“I sometimes compare that I drive my bike from my home to here; it is 25 k, it is one hour of pedalling. I just spend 700 calories, and one Tim Tam has 100 calories.” Male, 44 years.Participants reported examples where they would weigh up the pros and cons of consuming an indulgence. That is, participants would make their decisions based on objective information regarding the costs and disadvantages of consuming the indulgence in relation to the merits, possibilities, and advantages of consuming the indulgence. This was conducted in relation to physical activity by examining how much physical activity was required in comparison with the energy equivalent of the indulgence:“Twofold things occurred, this study and also the fact that I’m now saving frantically for a deposit on a house. So, basically, any time I’ve felt like something, in the last week particularly, I’ve just gone, “No, instead of spending that and eating it, oh great I’ve said ‘No’, at the same time I’m moving the money into my savings account. So, I would literally stand in 7-Eleven, holding the bag of chips, or holding whatever I was saying “No” to, putting them back on the shelf and transferring the money straight away. So, I’ve spent the money but it’s just gone somewhere else and not in my mouth.” Female, 58 years. Interestingly, one participant went further to explain how they used this strategy in combination with a reward system to help achieve another personal goal:A few participants reported that they decided to eliminate certain foods/drinks from their diet entirely, which meant they reduced their consumption . Another strategy was to keep busy by focusing on a specific task and avoiding thinking about the consumption of indulgences. “Yes, the word “denial” is not very nice! If I deny myself something it turns up somewhere else and worse.” Female, 58 years. This theme was used to describe unfavourable effects associated with participants’ attempts to reduce indulgences. There were a few participants who reported experiencing negative consequences of reducing indulgences, and these mainly related to the uncomfortable emotion and distress of saying no to an indulgence:Nevertheless, this participant managed to work through their belief about denial and was able to reduce their indulgences. “And towards the end, so that was the first six weeks it was quite a battle, and then, in the last two weeks, I’ve had, something’s shifted, and I’ve actually made better choices. Even after I’ve said “No” to something really bad, I’ve then immediately chosen something good.” Female, 58 years.“Yeah, so I thought I should probably, “I’m doing this study, I shouldn’t be having that. Really, I should not be having that. The purpose of the study is not having the indulgences”, so then I was getting a bit, “No, I’m not going to be a good student for them.” Female, 58 years.Participants also felt guilty that they were not saying no to all indulgences, as one participant explained:Considering that 35% of diets consist of energy-dense nutrient-poor foods/beverages (indulgences), we need to find effective interventions to help people reduce consumption . Herein,Participants reported that they tried to manage environmental influences on consumption by making small changes via portion control, the substitution of foods/beverages, and weighing up the pros and cons of consumption. Self-monitoring and -reflecting on the goal of trying to reduce indulgences by seven per week was reported as helpful. The results suggest it might be helpful to include strategies to break habits and reduce emotional eating in future interventions. This simple intervention of Saying No has the potential to be developed as a public health campaign. There are many different terms used by the public and health promotion community to define foods and beverages that individuals should have occasionally, including EDNP foods, junk food, discretionary foods, and ultra-processed foods . We usedThere were several factors reported that increased the consumption of indulgences, including emotional eating, the influence of others, the availability of foods and beverages, and habitual eating behaviour. Our findings support the neurobehavioural model of temptations, such that if individuals are exposed to cues and are in a “hot state”, they are unlikely to be able to resist indulgences . Thus, aParticipants often reported that eating indulgences was habitual and that it was quite hard to break the cycle of consumption. Potential strategies included the avoidance of places where indulgences were more likely to be available and/or restricting availability in the home. These strategies are similar to those found in a previous qualitative study of participants with healthy weights . ParticiIt was evident in participants’ responses that the “Say No” intervention worked primarily by promoting self-regulation. All participants reported that recording what they were consuming helped them reflect on their intake and adjust their behaviour. Self-monitoring is arguably one of the most effective techniques for changing behaviour and some participants reported that they would continue to write down what they were consuming after the intervention ended ,38. PartParticipants reported five additional strategies to help reduce indulgences: avoidance, accessibility, portion control, substitution, and weighing up the pros and cons. These have all been reported previously as helpful methods to change overall eating behaviour ,32. In oSmall changes reported by participants included reducing portion sizes. In a secondary analysis of an RCT that aimed to reduce problem foods, women who reported more frequently limiting portions of problem foods had greater weight loss at 12 months . AlthougAt the time of design, there were only two intervention studies that aimed to reduce indulgences, and no process evaluation had been completed to better understand trial effects ,24. HereGiven the importance of reducing the consumption of indulgences, which are independently associated with a range of health outcomes, interventions are needed to help people. Our findings suggest a simple behavioural intervention to reduce the consumption of indulgences, which worked as planned and supports the findings of the feasibility trial. Emotional and habitual eating were two areas that participants reported affecting consumption, but it was unclear how participants would manage these influences. Future research should focus on refining this intervention and testing the effectiveness of these strategies as a public health campaign.