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Needle and Syringe Programmes (NSP) play an important role in providing targeted services for people who inject drugs to prevent the harms associated with drug use. This commentary considers whether the role of NSP could be expanded to include prevention of initiation to injecting. In an Australian case study, consultations were undertaken with 13 stakeholders working with at-risk youth and/or in the drug field. Ongoing formal and informal discussion in other forums expanded on the points raised during the stakeholder interviews. Incorporating strategies to prevent initiation to injecting within the existing NSP framework is complex and requires attention to the following: the current focus and success of NSP, the target group that access NSP, concerns about perceived moralism, workforce development concerns and the culture and setting of NSP. Without careful consideration of these important issues, a strategy to prevent initiation to injecting could undermine the core business of NSPs – of preventing harms associated with injecting drug use – and could alienate injecting drug users who are their primary target group.