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The objective of this study was to examine the association between adolescent exposure to and understanding of needle exchange programs (NEPs) and their perceptions of the impact of NEP on the decision to use illicit drugs. From November 1998 to February 1999, 9th and 10th grade students from 4 Baltimore City high schools completed surveys reporting perceptions of the effect of NEP and other factors on adolescents' decisions regarding illicit drug use. The perceived effect of NEP was compared to that of other factors, using the Wilcoxon signed rank test. The impact of seeing drug users attend NEPs on adolescents' decisions to use drugs was modeled using multiple linear regression. Among 1,110 students, 88% were African American, 58% were female, and the mean age was 15 years. The percentage of students who thought the specified factors promoted drug use follows: peer drug use, 49.9%; parents drug use, 43.5%; seeing drug users attend NEP, 11.1%; school drug education, 6.6%; and anti-drug TV advertisements, 6.1%. The percentage viewing these factors as having no influence on illicit drug use was 21.7, 19.1, 42.4, 36.9, and 29.8% respectively. Students of African American race, female gender, and those with medium/high knowledge about NEP were significantly less likely to consider NEP a promoter of drug use. These data suggest that the influence of NEPs on promoting illicit drug use among adolescents appears to be neutral compared to other factors known to be influential to this population group.