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CORK Bibliography: Harm Reduction

49 citations. January 2009 to present

Prepared: September 2009

Anderson P. Global alcohol policy and the alcohol industry. Current Opinion in Psychiatry 22(3): 253-257, 2009. (38 refs.)

Purpose of review: The WHO is preparing its global strategy on alcohol, and, in so doing, has been asked to consult with the alcohol industry on ways it could contribute in reducing the harm done by alcohol. This review asks which is more effective in reducing harm: the regulatory approaches that the industry does not favour; or the educational approaches that it does favour. Recent findings: The current literature overwhelmingly finds that regulatory approaches (including those that manage the price, availability, and marketing of alcohol) reduce the risk of and the experience of alcohol-related harm, whereas educational approaches (including school-based education and public education campaigns) do not, with industry-funded education actually increasing the risk of harm. Summary: The alcohol industry should not be involved in making alcohol policy. Its involvement in implementing policy should be restricted to its role as a producer, distributor, and marketer of alcohol. In particular, the alcohol industry should not be involved in educational programmes, as such involvement could actually lead to an increase in harm.

Anderson P; Chisholm D; Fuhr DC. Alcohol and global health: Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. (review). Lancet 373(9682): 2234-2246, 2009. (110 refs.)

This paper reviews the evidence for the effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol, in the areas of education and information, the health sector, community action, driving while under the influence of alcohol (drink-driving), availability, marketing, pricing, harm reduction, and illegally and informally produced alcohol. Systematic reviews and meta-analyses show that policies regulating the environment in which alcohol is marketed (particularly its price and availability) are effective in reducing alcohol-related harm. Enforced legislative measures to reduce drink-driving and individually directed interventions to already at-risk drinkers are also effective. However, school-based education does not reduce alcohol-related harm, although public information and education-type programmes have a role in providing information and in increasing attention and acceptance of alcohol on political and public agendas. Making alcohol more expensive and less available, and banning alcohol advertising, are highly cost-effective strategies to reduce harm. In settings with high amounts of unrecorded production and consumption, increasing the proportion of alcohol that is taxed could be a more effective pricing policy than a simple increase in tax.

Bryant J; Hopwood M. Secondary exchange of sterile injecting equipment in a high distribution environment: A mixed method analysis in south east Sydney, Australia. International Journal of Drug Policy 20(4): 324-328, 2009. (16 refs.)

Background: In Australia, sterile needles are distributed to people who inject drugs through formal services for the purposes of limiting the transmission of blood borne viruses (BBV). Secondary exchange (SE) involves people acquiring needles from formal services and redistributing them to others. This paper describes the extent, patterns and contexts of SE in south east Sydney, Australia and examines whether SE is independently associated with BBV risk practices. Methods: Quantitative and qualitative data were collected through a cross-sectional study using surveys and in-depth interviews. Respondents were people using community-based pharmacies to obtain sterile needles and syringes. Results: Data were collected from 229 survey respondents, over half of whom (54%) reported SE in the previous month. Of these, 40% engaged in distribution only, 25% in receipt only and 36% in both. Respondents reported passing on 21.7% of their needles to others in the last month, most commonly to friends (51.6%) and partners (27.4%). Recipients of SE were four times more likely than non-secondary exchangers to report borrowing used syringes in the last month. Respondents reported supplying sterile equipment to others to prevent reuse and to reduce risks associated with unplanned drug use. Conclusion: SE is a common activity in south east Sydney but does not appear to be highly organised, usually taking place in small networks of friends and/or partners for altruistic reasons. Harm reduction programs could capitalise on the prevalence of SE to reach injecting drug users who do not use formal distribution services.

Burris S; Burrows D. Drug policing, harm reduction and health: Directions for advocacy. (editorial). International Journal of Drug Policy 20(4): 293-295, 2009. (20 refs.)

Dawson DA. Low-risk drinking limits: Absolumte versus relative risk. (commentary). Addiction 104(8): 1303-1304, 2009. (14 refs.)

Dube E; Masse R; Noel L. Acceptability of interventions in harm reduction: Contributions of the population to ethnic debates in public health. Canadian Journal of Public Health 100(1): 24-28, 2009. (22 refs.)

Objective: To explore convergence and divergence in ethical stances of public health and of members of the population regarding acceptability of harm reduction interventions, in particular needle exchange programs. Methods: Forty-nine semi-structured interviews were conducted with French-speaking residents of Quebec City. Content analysis was done to explore the views of the respondents with regard to injection drug users (IDUs) and interventions addressed to them, as well as Quebec policies on harm reduction. Results: Four main categories of social representations about IDUs have emerged from the discourses of the respondents. IDU were represented as: suffering from a disease (n=17); victim of a situation that they could not control (n=1 4); having chosen to use drugs (n=1 2); or delinquent people (n=6). Those social representations were associated with different ethical stances regarding acceptability of harm reduction interventions. Main divergences between respondents' ethical positions on harm reduction and public health discourses were related to the value of tolerance and its limits. Conclusions: The Quebec City population interviewed in this study had a high level of tolerance regarding needle distribution to drug addicts. Applied ethics could be a useful way to understand citizens' interpretation of public health interventions.

Faulkner N; McCambridge J; Slym RL; Rollnick S. It ain't what you do, it's the way that you do it: A qualitative study of advice for young cannabis users. Drug and Alcohol Review 28(2): 129-134, 2009. (16 refs.)

Introduction: Advice is a widely recommended and practised intervention with young drug users. Study of precisely how advice is given and received in any setting has, however, been limited. Design and Methods: We qualitatively analysed 106 audio-recordings of advice sessions on cannabis use for young people within a randomised trial. Inductive data analysis was guided by a focus on practitioner behaviour which served to engage the active participation of the young drug user in the session. Results: A cluster of 'Information Management' activities was identified together with an 'Interactive Orientation' evident in a series of specific behaviours. Participants were most successfully engaged when both were combined, understood here as 'Personalised Advice-giving'. Discussion and Conclusions: These components identified in this exploratory study might assist further research in rectifying the absence of a solid empirical basis for effective practice in advice giving with young drug users and more widely.

Gartner CE; Hall WD. Smokeless tobacco use in Australia. Drug and Alcohol Review 28(3): 284-291, 2009. (21 refs.)

Introduction and Aims. There has been little research published on the use of smokeless tobacco (SLT) in Australia. This study aimed to determine the prevalence of SLT use and the potential for harm reduction in current SLT users and smokers. Design and Methods. We undertook secondary analysis of data from a national household survey of drug use and surveyed 108 Australian SLT users about their patterns of SLT use and tobacco smoking. Results. The low prevalence of SLT use in the past year in Australia (0.57%; 95% confidence interval 0.48-0.66) might reflect the difficulty in importing these products. Prevalence of recent use was highest among males aged 18-29 who were current weekly smokers. US style oral snuffs were the most popular SLT products in Australia. Most of those surveyed were introduced to SLT by a personal contact and about half had used SLT to quit smoking. Australians who import SLT pay per can AU$21.30 on average and face substantial delays before receiving the product. Discussion and Conclusions. Cost and poor access present a substantial barrier to SLT use as a tobacco harm reduction measure for Australian smokers. Permitting low nitrosamine varieties of SLT to be sold in Australia might reduce harm in current SLT users and provide a viable alternative to cigarettes for some current smokers.

Gartner C; Hall W. The potentical role of snus in tobacco harm reduction. (editorial). Addiction 104(9): 1586-1587, 2009. (10 refs.)

Gilmore AB; Britton J; Arnott D; Ashcroft R; Jarvis MJ. The place for harm reduction and product regulation in UK tobacco control policy. Journal of Public Health 31(1): 3-10, 2009. (34 refs.)

Tobacco use remains the leading cause of preventable death in this country and more needs to be done to reduce smoking rates. Harm reduction is one policy option. Smokers smoke for the nicotine, but die from the other toxins in cigarette smoke. Harm reduction in tobacco control aims to reduce the harm arising from nicotine use by shifting smokers, who are unable to quit, to using far less hazardous sources of nicotine, notably medicinal nicotine, in place of cigarettes. This article argues that for harm reduction to work in the UK, a nicotine product regulation authority is first needed. This would regulate nicotine products in proportion to harm to ensure that, contrary to the current paradoxical arrangements, the most harmful source of nicotine, the cigarette, becomes the most highly regulated (and thus the least easily accessible, available and attractive). It goes onto explore how a harm reduction strategy might be further developed, exploring controversies and potential pitfalls. It argues that the public health community needs to own and drive this debate because failure to do so would let the tobacco industry gain the upper hand and see thousands of more unnecessary deaths from tobacco use.

Hall W; Gartner C. Supping with the Devil? The role of law in promoting tobacco harm reduction using low nitrosamine smokeless tobacco products. Public Health 123(3): 287-291, 2009. (52 refs.)

In Sweden, male cigarette smoking has declined as snus, a smokeless tobacco product which is low ill Carcinogenic nitrosamines, has gained popularity among male tobacco users. Epidemiological modelling based on the Swedish experience indicates that there would be major public health gains if a substantial number of current smokers in other countries could also be persuaded to switch to this product. This form of 'tobacco harm reduction' is very controversial in the public health community for many reasons. These include: Objections in principle to the use of less harmful but still addictive nicotine products: uncertainties about the long-term effects of these products on health; doubts about the likely interest in and uptake of these products among existing smokers: concerns that increasing the availability of these products will increase the number of new tobacco users and eventually the number of smokers in the population; and anxiety about how the tobacco industry may use these products to undermine current tobacco control policies. This paper concludes with suggestions for a graduated series of policies that may allow exploration of the public health costs and benefits of encouraging smokers to switch to snus.

Hall WD. Challenges in reducing cannabis-related harm in Australia. Drug and Alcohol Review 28(2): 110-116, 2009. (85 refs.)

This paper outlines the major policy challenges in reducing cannabis-related harm in Australia. The first is uncertainty about the health effects of cannabis, especially in young people. The second is uncertainty about the extent and severity of harms attributed to cannabis prohibition by its critics. The paper summarises and briefly states the extent of these putative harms to the degree that the data allow. The third challenge is a consequence of the first two, and the very different weightings that proponents of more liberal or restrictive policies give to harms arising from cannabis use and those arising from prohibition, namely, strong disagreements within the community about how we should respond to cannabis use by young people. In the face of such disagreement the formulation of cannabis policy necessitates a political compromise. The compromise that has emerged is a continued prohibition of cannabis production, sale and use, combined with either civil penalties for use in some states and reduced penalties or diversion in others. It concludes with suggestions about what needs to be learned about the health effects of cannabis use and the costs and benefits of cannabis prohibition if we are to develop policies that are more effective in reducing harms caused by cannabis use.

Hathaway AD; Callaghan RC; Macdonald S; Erickson PG. Cannabis dependence as a primary drug use-related problem: The case for harm reduction-oriented treatment options. Substance Use & Misuse 44(7): 990-1008, 2009. (70 refs.)

Few studies have focused on cannabis dependence as compared to other drugs more commonly acknowledged as presenting a substantial need for treatment. This paper presents findings front a 2004-2005 study of drug user treatment clients in Southern Ontario, Canada. Clients with cannabis (n = 128) or cocaine (n = 300) as their primary drug problem were compared on psychosocial and demographic characteristics, drug effects, and clinical impairment. There are more similarities than differences between groups, with DAST and DSM scores showing high rates of "dependence" and reported symptoms of "abuse." However cannabis consistently scored lower on these items, supporting the idea of a continuum of risk on which its rank compared with other potentially misused drugs holds across a wide range of symptoms of impairment. The less disruptive nature of cannabis use-related problems poses greater challenges for drug user treatment providers guided by strict abstinence agendas. The authors call for the expansion of harm reduction treatment options and educational initiatives beyond primary prevention that acknowledge benefits of moderate controlled use when addressing cannabis misuse.

Hawkins N; Sanson-Fisher R; Shakeshaft A; Webb G. Differences in licensee, police and public opinions regarding interventions to reduce alcohol-related harm associated with licensed premises. Australian and New Zealand Journal of Public Health 33(2): 160-166, 2009. (28 refs.)

Objectives: To determine the level of support by licensees, police and the general public for interventions to reduce alcohol-related harm associated with licensed premises and to identify differences between the three groups. Methods: Participants were 108 licensees of premises licensed to sell alcohol; 132 police officers; 200 members of the public. Questionnaires were administered either through work settings or by mail. Respondents' levels of agreement with interventions to reduce alcohol-related harm associated with licensed premises: responsible service of alcohol; security and crowd control; policing; patron transport; and linking of alcohol-related harm to licensed premises and communication. Results: Police and members of the public were significantly more likely than licensees to agree with strategies under licensee control, such as subsidising patron transport and training staff to deal with intoxicated patrons. Police were more likely than licensees and members of the public to agree with strategies requiring community action and changes to liquor licensing laws. Licensees had significantly lower levels of agreement than the other groups about licensees' responsibility to reduce alcohol-related harm as a consequence of drinking at their premises. Conclusions: While there was good agreement between police officers and members of the public about strategies for reducing alcohol-related harm at licensed premises, licensees held divergent views about strategies within their control. Licensees were less likely than police and members of the public to agree they were responsible for reducing alcohol-related harm resulting from drinking at their premises.

Heather N. The importance of keeping regular: Accurate guidance to the public on low-risk drinking levels. Alcohol and Alcoholism 44(3): 226-228, 2009. (11 refs.)

Aim: The aim of this study was to argue that recommendations to the general public on daily amounts for low-risk alcohol consumption must retain the word 'regular' in order to avoid being rejected. Method: Narrative review of the evidence-base for daily limits to alcohol consumption, the guidance the public actually receives in the UK and media reactions to this guidance. Results: Evidence for daily limits (not more than 3-4 units for men and 2-3 units for women) rests on epidemiological surveys that enquire about 'average' or 'usual' amounts of consumption and this is reflected by the use of 'regular' or 'consistent' in the UK Government's Sensible Drinking report in 1995 and in guidance currently issued by the English Department of Health. In contrast, guidance the public actually receives often omits the word 'regular' and implies that the limits in question are maximum daily amounts. Media reactions to this inaccurate information suggest that the general public is likely to find these recommendations incredible and to reject them. Conclusion: If guidance to the public on daily drinking amounts is to stand any chance of being credible and effective, it must be accurate and must therefore retain the word 'regular'.

Higgs P; Dwyer R; Duong D; Thach ML; Hellard M; Power R et al. Heroin-gel capsule cocktails and groin injecting practices among ethnic Vietnamese in Melbourne, Australia. International Journal of Drug Policy 20(4): 340-346, 2009. (38 refs.)

Background: Evidence of harms associated with temazepam gel capsule injecting among injecting drug users in Australia led to its withdrawal from manufacture in Australia. Subsequently, diphenhydramine gel capsule injecting was identified among a subset of ethnic Vietnamese injecting drug users. Methods: Observational fieldwork around an active street-based illicit drug marketplace together with targeted purposive sampling enabled 66 ethnic Vietnamese injecting drug users to be recruited for in-depth interview. Results: Data revealed that the injection of gel capsules increases exposure to non-viral infections. Analysis of participant interviews show how participants have established their own ways of reducing these harms including thinning the drug solution by jacking regularly during injection. Controversially, femoral vein administration of diphenhydramine-heroin cocktails was also seen as a harm reduction strategy by participants. Discussion: Health education campaigns to address the potentially negative consequences of gel capsule groin injection will not be successful unless health workers and policy makers work with drug users and incorporate local understandings and meanings of risk in health promotion activities.

Holm LE; Fisker J; Larsen BI; Puska P; Halldorsson M. Snus does not save lives: Quitting smoking does! (editorial). Tobacco Control 18(4): 250-251, 2009. (14 refs.)

Jamrozik K. Where now for tobacco control: No place yet for harm reduction in tobacco control. Journal of Public Health 31(1): 11-12, 2009. (3 refs.)

Jarlais DC; McKnight C; Goldblatt C; Purchase D. Doing harm reduction better: Syringe exchange in the United States. Addiction 104(9): 1441-1446, 2009. (13 refs.)

Objective: To trace the growth of syringe exchange programs (SEPs) in the United States since 1994-95 and assess the current state of SEPs. Methods: Annual surveys of US SEPs known to North American Syringe Exchange Network (NASEN). Surveys mailed to executive directors with follow-up interviews by telephone and/or e-mail. Response rates have varied between 70% and 88% since surveys were initiated in 1996. Results: The numbers of programs known to NASEN have increased from 68 in 1994-95 to 186 in 2007. Among programs participating in the survey, numbers of syringes exchanged have increased from 8.0 million per year to 29.5 million per year, total annual budgets have increased from $6.3 to $19.6 million and public funding (from state and local governments) has increased from $3.9 to $14.4 million. In 2007, 89% of programs permitted secondary exchange and 76% encouraged it. Condoms, referrals to substance abuse treatment, human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) counseling and testing and naloxone for overdose were among the most commonly provided services in addition to basic syringe exchange. Each of these services was provided by 40% or more of SEPs in 2007. Conclusions: While syringe exchange has remained controversial in the United States, there has been very substantial growth in numbers of programs, syringes exchange and program budgets. Utilizing secondary exchange to reach large numbers of injecting drug users and utilizing SEPs as a new platform for providing health and social services beyond basic syringe exchange have been the two major organizational strategies in the growth of SEPs in the United States.

Jarvinen M; Andersen D. The making of the chronic addict. Substance Use & Misuse 44(6): 865-885, 2009

Inspired by social problems theory, this article analyzes the formula story of harm reduction in a Danish addiction-treatment context. In Denmark, very few opiate addicts are in drug-free therapeutic treatment. Instead, they are offered methadone (often on a permanent basis) accompanied by practical help in tackling the negative social, economic, and health-related consequences of their drug use. The aim of this article is to show how the formula story of harm reductionand first and foremost the idea that opiate addiction is an incurable condition tends to work as a self-fulfilling prophesy. Opiate addicts entering the treatment system risk being made up as chronic addicts regardless of how they themselves look upon their own addiction problem and notwithstanding that many of them have not given up their hope of becoming drug-free. The article is based on two types of data: (1) file records (gathered in 2007) describing the addiction problems and treatment careers of clients enrolled at outpatient treatment centers in Copenhagen, and (2) qualitative interviews (conducted in 2006) with 30 methadone-program participants at the centers. The analysis is qualitative and the empirical results cannot necessarily be generalized to other methadone-maintenance programs. Yet the theoretical message of the article is applicable to all treatment institutions and social problems work in general. Definitions and categorizations of clients are not innocent, and naming people and their problems is the same as changing them.

Kelly BC. Mediating MDMA-related harm: Preloading and post-loading among ecstasy-using youth. Journal of Psychoactive Drugs 41(1): 19-26, 2009. (48 refs.)

Ecstasy use remains a key concern for professionals working in fields related to youth and drug use. At the forefront of these concerns are issues related to neurological dysfunction and depression -- both acute and long-term -- associated with MDMA use. Ecstasy users have been shown to assess Ecstasy related harms and to engage in a variety of practices to manage these risks. To contend with risk related to neurological dysfunction and depression, some youth have turned to "preloading" and "post-loading": the practice of consuming other substances to mitigate the negative effects of Ecstasy. Drawing upon data from an ethnographic study of club drug use among youth, the author provides a descriptive profile of the practices of preloading and post-loading as well as the motivations underlying these behaviors among New York City area youth. Youth utilize a range of preloading and post-loading practices, yet do not universally share similar practices, attitudes, and knowledge. It is critical to link clinical and behavioral sciences research to further study both the efficacy and safety of these practices.

Kim D; Irwin KS; Khoshnood K. Expanded access to naloxone: Options for critical response to the epidemic of opioid overdose mortality. American Journal of Public Health 99(3): 402-407, 2009. (48 refs.)

The United States is in the midst of a prolonged and growing epidemic of accidental and preventable deaths associated with overdoses of licit and illicit opioids. For more than 3 decades, naloxone has been used by emergency medical personnel to pharmacologically reverse overdoses. The peers or family members of overdose victims, however, are most often the actual first responders and are best positioned to intervene within an hour of the onset of overdose symptoms. Data from recent pilot programs demonstrate that lay persons are consistently successful in safely administering naloxone and reversing opioid overdose. Current evidence supports the extensive scaleup of access to naloxone. We present advantages and limitations associated with a range of possible policy and program responses.

LaBrie JW; Feres N; Kenney SR; Lac A. Family history of alcohol abuse moderates effectiveness of a group motivational enhancement intervention in college women. Addictive Behaviors 34(5): 415-420, 2009. (49 refs.)

This study examined whether a self-reported family history of alcohol abuse (FH+) moderated the effects of a female-specific group motivational enhancement intervention with first-year college women. First-year college women (N = 287) completed an initial questionnaire and attended an intervention (n = 161) or control (n = 126) group session, of which 118 reported FH+. Repeated measures ANCOVA models were estimated to investigate whether the effectiveness of the intervention varied as a function of one's reported family history of alcohol abuse. Results revealed that family history of alcohol abuse moderated intervention efficacy. Although the intervention was effective in producing less risky drinking relative to controls, among those participants who received the intervention, FH+ women drank less across five weeks of follow-up than FH- women. The current findings provide preliminary support for the differential effectiveness of motivational enhancement interventions with FH+ women.

Larimer ME; Malone DK; Garner MD; Atkins DC; Burlingham B; Lonczak HS et al. Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons With Severe Alcohol Problems. Journal of the American Medical Association 301(13): 1349-1357, 2009. (38 refs.)

Context Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates. Objective To evaluate association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs. Design, Setting, and Participants Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington. Main Outcome Measures Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls. Results Housing First participants had total costs of $8 175 922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs. Conclusions In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.

Maccoun RJ. Harm reduction is a good label for a criterion all drug programs should meet. (editorial). Addiction 104(3): 341-342, 2009. (4 refs.)

Meise M; Wang X; Sauter ML; Bao YP; Shi J; Liu ZM et al. Harm reduction for injecting opiate users: An update and implications in China. (review). Acta Phamacologica Sinica 30(5): 513-521, 2009

The harm associated with high-risk injected opiate use and the threat of the HIV epidemic among injecting drug users has become a worldwide problem. Twenty years ago, in the face of a rapid increase in mortality rates among injecting drug users and the upcoming threat of HIV, the first harm-reduction programs were implemented in the Western world. This paper is a literature review describing four forms of harm reduction currently in use in Europe, North America, and Australia. Each represents a reasonable counterapproach to the threat of increased prevalence of HIV among injecting drug users in transitional and developing countries. The paper attempts to explain the concepts behind the most commonly used types of harm reduction and provides a brief overview of the advantages and disadvantages of each and the reasons for their implementation. The main focus of the review is on the definition and the practical aspects of harm reduction; it includes a brief introduction of Chinese harm-reduction efforts and their implications.

Newman RG. "Maintenance" treatment of addiction: To whose credit, and why it matters. (editorial). International Journal of Drug Policy 20(1): 1-3, 2009. (17 refs.)

Orsi MM; Brochu S. The place of syringe exchange programs among harm reduction strategies in Canadian penitentiaries. Canadian Journal of Public Health 100(1): 29-31, 2009. (20 refs.)

The prevalence rates of illicit drug consumption within the prison system are much higher than those in the Canadian population in general. Of the substances used in detention, those of most concern to prison and public health authorities are injection drugs, as the sharing of injection drug equipment may be responsible for the high prevalence of bloodborne diseases in prison facilities. Faced with this situation, the Correctional Service of Canada put in practice a number of harm reduction strategies targeting injection drug users, such as methadone maintenance programs and access to bleach. However, despite their use in the community, needle-exchange programs are not yet allowed in penitentiaries. This article analyzes the limits of harm reduction strategies approved by the prison authorities and discusses the sources of resistance that continue to impede the realization of a pilot project to assess the feasibility of needle-exchange programs in detention in Canada.

Oster-Aaland L; Lewis MA; Neighbors C; Vangsness J; Larimer ME. Alcohol poisoning among college students turning 21: Do they recognize the symptoms and how do they help? Journal of Studies on Alcohol and Drugs Supplement 16: 122-130, 2009. (40 refs.)

Objective: The aims of this study were to (1) determine recognition of and self-reported concern regarding alcohol poisoning symptoms versus other alcohol-related behaviors among students turning 21 years old (2) assess the frequency of helping behavior among Students in situations where peers display alcohol poisoning symptoms, (3) assess sources from which students seek help, and (4) consider reasons why students report reluctance to seek help. Method: Students (N = 306; 50% male) completed a Web-based self-report assessment during the week before their 21st birthday focusing on drinking behavior, alcohol-related consequences, concern for symptoms of alcohol poisoning, and observations of and experience with helping behavior. Results: Results indicated most students report having helped another student with symptoms of alcohol poisoning and show concern about the symptoms. Students most often seek help from other students and parents. When students do not help their peers, it is most often because of the perception that help is not needed. Heavier drinkers report a greater likelihood to help a peer showing symptoms of alcohol poisoning. Conclusions: Prevention professionals should incorporate students, friends, and parents in interventions that provide knowledge and helping strategies for alcohol poisoning symptoms. In addition, prevention efforts regarding alcohol poisoning should focus on heavy drinkers, as they are most likely to be in situations requiring help. Finally, administrators implementing medical amnesty policies should couple those policies with educational strategies aimed at recognition of alcohol poisoning symptoms.

Parascandola M; Augustson E; O'Connell ME; Marcus S. Consumer awareness and attitudes related to new potential reduced-exposure tobacco product brands. Nicotine & Tobacco Research 11(7): 886-895, 2009. (35 refs.)

In recent years, there has been a proliferation of potential reduced-exposure tobacco products (PREPs) marketed that claim to be less harmful or less addictive, compared with conventional cigarettes. Tobacco control scientists have raised concerns about the potential adverse impact of marketing of these products for smoking prevention and cessation efforts. Although these products have not been widely used among smokers, there are few data available on consumers' awareness and attitudes toward these products. Data were obtained from the 2003 and 2005 Health Information National Trends Survey, a nationally representative telephone survey of adults 18 years and older regarding health communication and associated beliefs and behaviors. Our study population consisted of 6,369 respondents in 2003 and 5,586 respondents in 2005, of whom 19% were current smokers and 28% were former smokers. In 2005, 45% of respondents had heard of at least one PREP product, while only 4.8% had actually tried one. Awareness and use were substantially higher among current smokers (55.6% and 12.7%). Awareness was highest for Marlboro Ultra Smooth (MUS) (30.2%), Eclipse (18.2%), Quest (7.8%), and Ariva (5.4%), while less than 2% for any other product. Of respondents who had tried a PREP, 50% cited harm reduction or assistance in quitting as a reason for trying the product and 30% believed that the product was less harmful than their usual brand. In the combined 2003 and 2005 dataset, 54.4% of current smokers stated that they would be "very" or "somewhat" interested in trying a cigarette advertised as less harmful, while only 3.2% of former smokers and 1.1% of never-smokers were interested. Among current smokers, interest was higher in females and non-Hispanic Whites, and among daily smokers, those who smoked 20 or more cigarettes per day and those who were not considering quitting. Smokers interested in PREPs were substantially more likely to rate their perceived lung cancer risk as high (40.3% vs. 8.3%) and to worry frequently about developing lung cancer (19.7% vs. 4%). These results suggest that there is a substantial level of interest among current smokers in cigarettes marketed with claims of reduced exposure or harm. Of particular concern is that "health conscious" smokers and heavy smokers not planning to quit may be especially vulnerable to PREP marketing messages and view such products as an alternative to smoking cessation.

Philbin MM; Mantsios A; Lozada R; Case P; Pollini RA; Alvelais J et al. Exploring stakeholder perceptions of acceptability and feasibility of needle exchange programmes, syringe vending machines and safer injection facilities in Tijuana, Mexico. International Journal of Drug Policy 20(4): 329-335, 2009. (49 refs.)

Background: Injection drug use is a growing public health crisis along the U.S.-Mexican border and rising rates of blood-borne infections highlight the pressing need for harm reduction interventions. We explored the acceptability and feasibility of such interventions in Tijuana, a city adjacent to San Diego, California. Methods: Using in-depth qualitative interviews conducted from August 2006-March 2007 with 40 key stakeholders - pharmacists, legal professionals, health officials, religious officials, drug treatment providers, and law enforcement personnel - we explored the acceptability and feasibility of interventions to reduce drug-related harm in Tijuana, Mexico. Interviews were taped with consent, transcribed verbatim, and translated. Content analysis was conducted to identify themes which included barriers, structural limitations, and suggestions for implementation. Results: Topics included acceptance and feasibility of needle exchange programmes (NEPs), syringe vending machines, and safer injection facilities (SIFs), structural barriers and suggestions for implementation. Of these interventions, NEPs were deemed the most acceptable (75%); however, only half believed these could be feasibly implemented, citing barriers involving religion, police, and lack of political will, public awareness, and funding. Conclusions: Increasing HIV infection rates among injection drug users in Tijuana have prompted interest in public health responses. Our results may assist policy strategists in implementing social-structural interventions that will help create enabling environments that facilitate the scale-up and implementation of harm reduction in Tijuana.

Reid G; Aitken C. Advocacy for harm reduction in China: A new era dawns. International Journal of Drug Policy 20(4): 365-370, 2009. (29 refs.)

Background: China's initial response to drug use and HIV was largely ineffective but has improved with recent government endorsement of harm reduction interventions. This paper examines the views of senior key informants inside China who articulated core needs and objectives for the development of a harm reduction advocacy strategy. Methods: Thirty-nine key informants (KI) were interviewed, representing 19 stakeholder bodies selected from the Chinese government public health sector, public security sector, international agencies such as WHO, UNODC and UNAIDS, and international non-government organisations. Results: The concept of harm reduction is widely understood and considered valid. Support for harm reduction is increasing, but KIs perceived an imbalance between the rapid expansion of methadone maintenance treatment programs over needle and syringe programs and other interventions. Challenges for harm reduction identified by KIs included: policy inconsistencies; lack of skilled resources, training programs and technical capacity; poor coverage of interventions; and gaps in the sharing of information. KIs suggested numerous ways to strengthen the capacity of the government and communities to reduce drug related harm. Discussion: Increased acceptance of harm reduction in China, particularly among public security, implies a new level of optimism towards addressing the HIV epidemic among drug users, and parallels an impressive expansion of harm reduction interventions. Nevertheless, scaling up a response to the ongoing dual epidemic of drug use and HIV remains an enormous challenge. With appropriate technical education and training, ongoing advocacy, and a cohesive, coordinated multi-sectoral effort, the capacity of the government and community to adopt, support and promote measures to reduce HIV and other drug related harm would be markedly strengthened.

Roy E; Boudreau JF; Boivin JF. Hepatitis C virus incidence among young street-involved IDUs in relation to injection experience. Drug and Alcohol Dependence 102(1/3): 158-161, 2009. (26 refs.)

Background: Young injection drug users (IDUs) are at very high risk of hepatitis C virus (HCV) infection. Using a time scale starting at first injection, we studied the period of HCV susceptibility after initiation into drug injection among street-involved IDUs. Methods: A prospective Cohort study was carried out among street youth from 2001 to 2005. Semiannual interviews included completion of an interviewer-administered questionnaire and collection of blood samples for HCV antibody testing. HCV-negative subjects currently injecting drugs (last six months) were included in the analyses. Follow-up Started at first questionnaire where durrent injection was reported and ended at seroconversion or at last questionnaire. Poisson regression was used to assess the predictive power of time elapsed since initiation on incidence rate. Kaplan-Meier technique was used to estimate cumulative infection probabilities. Results: Among the 858 cohort participants, 145 were injecting at baseline and 60 were injecting at a subsequent questionnaire (45 youth had started injection and 15 had resumed injection). Mean age was 20 years and 62% were males. In the 395 person-years of follow-up, 61 subjects contracted HCV. The HCV incidence rate increased from 16.1/100 person-years during the first year following first injection to 22.4 in the third year, and then decreased to 7.2 in years 7-13 (p = 0.02). Median time to seroconversion after first injection was 3.3 years. Conclusion: The first years after first injection is the period during which vulnerability to HCV is greatest. Our results show the importance of intervening with new IDUs to optimize the chances to successfully prevent infection.

Samji H; Wardman D. First Nations communities and tobacco taxation: A commentary. American Indian And Alaska Native Mental Health Research 16(2): 1-10, 2009. (25 refs.)

Taxation of tobacco is a widely used strategy that promotes smoking cessation among adults and reduces cigarette consumption among continuing smokers. First Nations (FN) populations' tobacco use is estimated to be 2-3 times that of other Canadians and, in part, a reflection that tobacco products purchased on reserve by FN people are tax exempt. The purpose of this paper is to present a commentary related to the implementation and impact of a tobacco tax within an FN community.

Schaus JF; Sole ML; McCoy TP; Mullett N; O'Brien MC. Alcohol screening and brief intervention in a college student health center: A randomized controlled trial. Journal of Studies on Alcohol and Drugs Supplement 16: 131-141, 2009. (48 refs.)

Objective: This study tested the effectiveness of brief primary care provider interventions delivered in a college student health center to a sample of college students who screened positive for high-risk drinking. Method: Between November 2005 and August 2006, 8,753 students who presented as new patients to the health service at a large public university were screened for high-risk drinking, and 2,484 students (28%) screened positive on the 5/4 gender-specific high-risk drinking question (i.e., five or more drinks per occasion for men and four or more for women). Students who screened positive for high-risk drinking and consented to participate (N = 363; 52% female) were randomly assigned either to a control group (n = 182) or to an experimental group (n = 181). Participants in the experimental group received two brief intervention sessions that were founded in motivational interviewing techniques and delivered by four specially trained providers within the student health center. Data on alcohol use and related harms were obtained from a Web-based Healthy Lifestyle Questionnaire, 30-day Time-line Followback alcohol-use diaries, the Rutgers Alcohol Problem Index (RAPI), and eight items from the Drinker Inventory of Consequences-2L. Results: Repeated measures analysis showed that, compared with the control group (C), the intervention group (1) had significant reductions in typical estimated blood alcohol concentration (BAC) (C = .071 vs I = .057 at 3 months; C = .073 vs I =.057 at 6 months), peak BAC (C=.142 vs I = .112 at 3 months; C = .145 vs I = 108 at 6 months). peak [lumber of drinks per silting (C = 8.03 vs I = 6.87 at 3 months; C = 7.98 vs I = 6.52 at 6 months), average number of drinks per week (C = 9.47 vs I = 7.33 at 3 months; C = 8.90 vs I = 6.16 at 6 months), number of drunk episodes in a typical week (C = 1.24 vs I = 0.85 at 3 months C = 1.10 vs I = 0.7 1 at 6 months), number of times taken foolish risks (C = 2.24 vs I = 1.12 at 3 months), and RAPI sum scores, (C = 6.55 vs I = 4.96 at 6 months C = 6.17 vs I = 4.58 at 9 months). Conclusions: Brief interventions delivered by primary care providers in a student health center to high-risk-drinking students may result in significantly decreased alcohol consumption, high-risk drinking, and alcohol-related harms.

Segal DS; Stockwell T. Low alcohol alternatives: A promising strategy for reducing alcohol related harm. International Journal of Drug Policy 20(2): 183-187, 2009. (18 refs.)

Background: Less than 1% of the beer market in British Columbia comprises beers with an alcohol content below 4%, despite the success of low alcohol beers in other countries, e.g. Australia. A small experimental study is described in which male students were given either unmarked low alcohol beer (3.8%) or regular strength beer (5.3%) to investigate their enjoyment and subjective intoxication. Methods: Thirty-four male students who reported drinking 5 or more beers in I day at least once in the last month volunteered for the study. In each drinking session, small groups of between 6 and 10 students consumed two servings of beer while playing dominoes. Each subject was his own control in the experiment by attending two group-drinking sessions, drinking a different beverage each time. The different beers were given in balanced order with half the subjects in each group drinking each type of beer. Standard measures of subjective intoxication and enjoyment were used. Blood alcohol levels were tested before, during and after drinking. Results: Although significantly higher blood alcohol levels were obtained with the higher strength beer (means of 0.026 versus 0.033 mg/100 ml at the end of the study, p < 0.001), (i) most participants reported enjoying the two sessions equally or preferred the low alcohol beer session, (ii) most did not report feeling different between the two sessions and (iii) only about half correctly guessed which was the higher alcohol content beer. There was a preference, however, for the taste of the stronger beer. Conclusion: We conclude beer drinkers cannot readily distinguish low and regular strength beers and can enjoy socializing equally with either. We recommend taxation strategies to create incentives for the manufacture, marketing and consumption of low alcohol alternatives.

Sherman SG; Gann DS; Tobin KE; Latkin CA; Welsh C; Bielenson P. "The life they save may be mine": Diffusion of overdose prevention information from a city sponsored programme. International Journal of Drug Policy 20(2): 137-142, 2009. (28 refs.)

Background: Overdose remains the leading cause of death among injection drug users (IDUs) in the United States. Overdose rates are consistently high in Baltimore, MD,. The current qualitative study examines diffusion of information and innovation among participants in Staying Alive, an overdose prevention and naloxone: distribution programme in Baltimore, MD. Methods: In-depth interviews were conducted between June 2004 and August, 2005 with 25 participants who had completed the Staying Alive training and had reported using naloxone to revive an overdose victim. Interviews were taped and transcripts were transcribed verbatim. Results: Participants were 63% male, 63% African American, and the median age was 41 years old. Participants successfully shared information on overdose prevention and management, particularly the use of naloxone, to their peers and family. Conclusions: The current study demonstrates IDUs' interest in and ability to diffuse overdose prevention information and response skills to the injection drug use community. The study underscores the importance of promoting the diffusion of information and skills within overdose prevention programmes.

Simmonds L; Coomber R. Injecting drug users: A stigmatised and stigmatising population. International Journal of Drug Policy 20(2): 121-130, 2009. (40 refs.)

Background: This paper considers the way that social stigma impacts both on injecting drug user (IDU) populations and operates within them and the consequences this has for prevention and harm reduction amongst IDUs. Methods: The research from which this paper is drawn was a city case study, itself part of a larger national study to evaluate the efficacy of needle exchanges throughout England and Wales. Not initially part of the issues being explored, the interviews consistently pointed to concerns of stigma, and in this sense the theme was emergent from the qualitative process itself. Results: The primary findings relating to this issue were: IDUs concern for being recognised or 'seen' as IDUs affected service uptake and/or their interaction with services; 'normal' IDUs moreover tended to stigmatise those IDUs they believed to be 'worse' than them - primarily die homeless - despite the fact that their own behaviour was often less than 'responsible' itself. In these ways 'stigma', whether being accepted or expressed by these different groups militated against the 'harm reductive' goals of Safer Injecting Services. Conclusion: It is concluded that much can be done to reduce stigma related to IDU and drug use in general and that this may result in improved service efficacy and a reduction in associated drug related harms. It is also concluded that many IDUs seek to enhance their own self-esteem and reinforce their own sense as 'responsible members of society' rather than the outsiders they often feel themselves to be by attributing stigmatised behaviours on other 'lesser' IDUs. This practice may also contribute to them militating against their own guilt regarding their own risky behaviours, however in so doing the goal of harm reduction may be further undermined.

Stenbeck M; Hagquist C; Rosen M. The association of snus and smoking behaviour: A cohort analysis of Swedish males in the 1990s. Addiction 104(9): 1579-1585, 2009. (35 refs.)

Background: The European Union has banned sales of moist snuff (snus) in all member states, with the exception of Sweden. The ban is motivated by the potential adverse health effects of snus, but snus may also help people to avoid smoking or stop tobacco use. Aims: The purpose of this study is to investigate the association between snus and smoking behaviour. Measurements: The Swedish Survey of Living Conditions (ULF) health interview panel running from 1988/9 to 1996/7 was used to examine the gross and net flows between smoking and snus among Swedish males. Females were excluded from the analysis due to low snus prevalence. Contingency table models were used to investigate several hypotheses about the relationships between snus and smoking behaviour. Findings: We found clear associations between the two habits. For the younger cohort (age 16-44 years), snus use contributed to approximately six smoking quitters per smoking starter attributable to snus. For the older cohort (age 45-84) there were slightly more than two quitters per starter. In terms of odds ratios, in the younger group smoking cessation attributable to snus was twice as common as smoking initiation, but in the older group the odds of starting smoking attributable to snus was 2.5 times higher than for quitting. Conclusions: Snus contributed to the reduction of smoking among Swedish males in the 1990s. Snus had different effects among non-smokers and smokers in different age groups.

Strathdee SA; Patterson TL. Supply reduction's hidden casualties: A view from the trenches. (editorial). Addiction 104(3): 340-341, 2009. (17 refs.)

Tobin KE; Sherman SG; Beilenson P; Welsh C; Latkin CA. Evaluation of the Staying Alive programme: Training injection drug users to properly administer naloxone and save lives. International Journal of Drug Policy 20(2): 131-136, 2009. (14 refs.)

Background: In response to the high rates of opiate-related overdoses and deaths in the United States, a number of overdose prevention programmes have been implemented that include training drug users to administer naloxone, an opiate antagonist. The purpose of this study was to evaluate the Staying Alive (SA) programme in Baltimore, Maryland, which trained drug users to prevent and respond to opiate overdose using techniques including mouth-to-mouth resuscitation and administration of naloxone. Methods: Participants for the SA programme were recruited from multiple locations by Baltimore City Health Department Needle Exchange programme staff. A 1-h training was conducted by two facilitators. Participants who successfully completed the programme were provided with a kit that contained naloxone. Participants in the evaluation study were enrolled prior to the training session. The present analysis includes 85 participants who completed a pre- and post-test evaluation survey. Results: At both time points, 43 participants reported having witnessed an overdose. Post-training, naloxone was administered by 19 with no reported adverse effects. Post-training, a greater proportion of participants reported using resuscitation skills taught in the SA programme along with increased knowledge specifically about naloxone. Conclusions: Results from this study provide additional evidence to support the effectiveness of overdose prevention training programmes that include skills building for drug users to administer naloxone.

Tomar SL; Fox BJ; Severson HH. Is smokeless tobacco use an appropriate public health strategy for reducing societal harm from cigarette smoking? (review). International Journal of Environmental Research and Public Health 6(1): 10-24, 2009. (84 refs.)

Four arguments have been used to support smokeless tobacco (ST) for harm reduction: (1) Switching from cigarettes to ST would reduce health risks; (2) ST is effective for smoking cessation; (3) ST is an effective nicotine maintenance product; and (4) ST is not a "gateway" for cigarette smoking. There is little evidence to support the first three arguments and most evidence suggests that ST is a gateway for cigarette smoking. There are ethical challenges to promoting ST use. Based on the precautionary principle, the burden of proof is on proponents to provide evidence to support their position; such evidence is lacking.

van Beek I. Harm reduction: An ethical imperative. (editorial). Addiction 104(3): 342-343, 2009. (9 refs.)

Velasquez MM; von Sternberg K; Johnson DH; Green C; Carbonari JP; Parsons JT. Reducing sexual risk behaviors and alcohol use among HIV-positive men who have sex with men: A randomized clinical trial. Journal of Consulting and Clinical Psychology 77(4): 657-667, 2009. (64 refs.)

This randomized clinical trial (N = 253) evaluated the efficacy of a theory-based intervention designed to reduce both alcohol use and incidence of unprotected sexual behaviors among HIV-positive men who have sex with men with alcohol use disorders. An integrated, manualized intervention, using both individual counseling and peer group education/support, was compared with a control condition in which participants received resource referrals. The intervention was based on the transtheoretical model's stages and processes of change, and motivational interviewing was used to enhance client readiness for change. Major findings include treatment effects for reduction in number of drinks per 30-day period, number of heavy drinking days per 30-day period, and number of days on which both heavy drinking and unprotected sex occurred. Practitioners employing this intervention may achieve enhanced client outcomes in reduction of both alcohol use and risky sexual behavior.

Weatherburn DJ. Dilemmas in harm minimization: A response to the critics. (editorial). Addiction 104(3): 345-346, 2009. (7 refs.)

Webster L. Update on abuse-resistant and abuse-deterrent approaches to opioid formulations. (review). Pain Medicine 10(Supplement 2): S124-S133, 2009. (57 refs.)

The number of opioid analgesic prescriptions has increased since 1990. Opioids are being prescribed for longer periods of time for both cancer- and noncancer-associated moderate to severe chronic pain. Concurrent with the increased prescribing of opioids has been an increase in their diversion from prescribed use and their abuse; frequently, this abuse occurs after the opioid analgesic has been physically or chemically manipulated to increase the concentration or bioavailability of the active ingredient. Formulations of opioids have been designed to resist the extraction of the active opioid from prescribed products through the incorporation of physical barriers or to deter the reinforcing effects of opioids through the incorporation of antagonists or other ingredients that only become active when the analgesic is used improperly. However, none of these formulations are currently commercially available in the United States. This paper describes the formulations now under development and their potential clinical utility and impact on society. These emerging opioid formulations designed to reduce the risk of misuse and/or abuse may be useful to physicians in meeting the important goals of maximizing pain relief and minimizing prescription opioid abuse.

Wodak A. Harm reduction is now the mainstream global drug policy. (editorial). Addiction 104(3): 343-345, 2009. (19 refs.)

Zeller M; Hatsukami D. The strategic dialogue on tobacco harm reduction: A vision and blueprint for action in the US. Tobacco Control 18(4): 324-332, 2009. (70 refs.)

The issues related to tobacco harm reduction continue to challenge the tobacco control research and policy communities. The potential for combusting tobacco products to reduce exposure and risk remains largely unknown, but this has not stopped manufacturers from offering such products making these claims. The role of oral tobacco products in a harm reduction regimen has also been a source of dialogue and debate. Within the last few years, major cigarette manufacturing companies have begun selling smokeless products for the first time, claiming to target current cigarette smokers. Other cigarette manufacturers are also offering smokeless products in markets around the world. The harm reduction debate has at times been divisive. There has been no unifying set of principles or goals articulated to guide tobacco control efforts. In particular, the research needs are extraordinarily high in order to drive evidence-based policy in this area and avoid the mistakes made with "light" cigarettes. This paper discusses recommendations from a strategic dialogue held with key, mostly US-based tobacco control researchers and policy makers to develop a strategic vision and blueprint for research, policy and communications to reduce the harm from tobacco for the US. Short-term and long-term objectives are described.

Zhu SH; Wang JB; Hartman A; Zhuang Y; Gamst A; Gibson JT et al. Quitting cigarettes completely or switching to smokeless tobacco: do US data replicate the Swedish results? Tobacco Control 18(2): 82-87, 2009. (41 refs.)

Background: Swedish male smokers are more likely than female smokers to switch to smokeless tobacco (snus) and males' smoking cessation rate is higher than that of females. These results have fuelled international debate over promoting smokeless tobacco for harm reduction. This study examines whether similar results emerge in the United States, one of few other western countries where smokeless tobacco has long been widely available. Methods: US data source: national sample in Tobacco Use Supplement to Current Population Survey, 2002, with 1-year follow-up in 2003. Analyses included adult self-respondents in this longitudinal sample (n = 15 056). Population-weighted rates of quitting smoking and switching to smokeless tobacco were computed for the 1-year period. Results: Among US men, few current smokers switched to smokeless tobacco (0.3% in 12 months). Few former smokers turned to smokeless tobacco (1.7%). Switching between cigarettes and smokeless tobacco, infrequent among current tobacco users (< 4%), was more often from smokeless to smoking. Men quit smokeless tobacco at three times the rate of quitting cigarettes (38.8% vs 11.6%, p < 0.001). Overall, US men have no advantage over women in quitting smoking (11.7% vs 12.4%, p = 0.65), even though men are far likelier to use smokeless tobacco. Conclusion: The Swedish results are not replicated in the United States. Both male and female US smokers appear to have higher quit rates for smoking than have their Swedish counterparts, despite greater use of smokeless tobacco in Sweden. Promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programmes may not result in any positive population effect on smoking cessation.