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Background  Health promotion strategies ultimately rely on people perceiving the consequences of their behaviour as negative. If someone is indifferent towards death, it would logically follow that health promotion messages such as safe using messages would have little resonance. This study aimed to investigate attitudes towards death in a group of injecting drug users (IDUs) and how such attitudes may impact upon the efficacy/relevance of 'safe using' (health promotion) messages.    Methods  Qualitative, semi-structured interviews in Geelong, Australia with 60 regular heroin users recruited primarily from needle and syringe programs.    Results  Over half of the interviewees reported having previously overdosed and 35% reported not engaging in any overdose prevention practices. 13% had never been tested for either HIV or hepatitis C. Just under half reported needle sharing of some description and almost all (97%) reported previously sharing other injecting equipment. Many interviewees reported being indifferent towards death. Common themes included; indifference towards life, death as an occupational hazard of drug use and death as a welcome relief.    Conclusion  Most of the interviewees in this study were indifferent towards heroin-related death. Whilst interviewees were well aware of the possible consequences of their actions, these consequences were not seen as important as achieving their desired state of mind. Safe using messages are an important part of reducing drug-related harm, but people working with IDUs must consider the context in which risk behaviours occur and efforts to reduce said behaviours must include attempts to reduce environmental risk factors at the same time.

Safe using messages may not be enough to promote behaviour change amongst injecting drug users who are ambivalent or indifferent towards death