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CORK Bibliography: Harm Reduction

82 citations. October 2010 to present

Prepared: September 2011

Alwan N; Siddiqi K; Thomson H; Lane J; Cameron I. Can a community-based 'smoke-free homes' intervention persuade families to apply smoking restrictions at homes? Journal of Public Health 33(1): 48-54, 2011. (29 refs.)

Children are commonly exposed to second-hand smoke (SHS). The aim of this study is to evaluate the feasibility, acceptability and outcome of Smoke-Free Homes (SFH), a community-based intervention; and assess potential evaluation methods. SFH, designed to encourage families to implement smoking restrictions at home, was delivered over a period of 6 months through schools, healthcare settings and community events in Beeston, South Leeds, UK. It was evaluated using baseline and post-implementation surveys, focus group discussions and promise forms follow-up. We surveyed 318 households before, and 217 households after, the intervention. The proportion of all surveyed households reporting being completely smoke free significantly increased from 35% [95% confidence interval (CI) 30, 40] at baseline to 68% (95% CI: 61, 74) 6 months post-implementation (P < 0.0001). Ninety per cent of people, followed-up by telephone 3 months after signing SFH promise form, said they were still keeping their promise. Focus group discussions with children and parents conveyed acceptability of the intervention, in particular, the schools element, where children are encouraged to discuss the concept of SFH with the adults in their households. Our study shows that SFH can be implemented effectively and has the potential to improve children's health through preventing exposure to SHS in the home.

Amaral-Sabadini MB; Saitz R; Souza-Formigoni MLO. Do attitudes about unhealthy alcohol and other drug (AOD) use impact primary care professionals' readiness to implement AOD-related preventive care? (review). Drug and Alcohol Review 29(6): 655-661, 2010. (28 refs.)

Introduction and Aims. To explore the association between primary care professionals' (PCPs) attitudes towards unhealthy alcohol and other drug (AOD) use (from risky use through dependence) and readiness to implement AOD-related preventive care. Design and Methods. Primary care professionals from five health centres in Sao Paulo were invited to complete a questionnaire about preventive care and attitudes about people with unhealthy AOD use. Logistic regression models tested the association between professional satisfaction and readiness. Multiple Correspondence Analysis assessed associations between stigmatising attitudes and readiness. Results. Of 160 PCPs surveyed, 96 (60%) completed the questionnaire. Only 25% reported implementing unhealthy AOD use clinical prevention practices; and 53% did not feel ready to implement such practices. Greater satisfaction when working with people with AOD problems was significantly associated with readiness to implement AOD-related preventive care. In Multiple Correspondence Analysis two groups emerged: (i) PCPs ready to work with people with unhealthy AOD use, who attributed to such patients lower levels of dangerousness, blame for their condition and need for segregation from the community (suggesting less stigmatising attitudes); and (ii) PCPs not ready to work with people with unhealthy AOD use, who attributed to them higher levels of dangerousness, blame, perceived level of patient control over their condition and segregation (suggesting more stigmatising attitudes). Discussion and Conclusions. More stigmatising attitudes towards people with unhealthy AOD use are associated with less readiness to implement unhealthy AOD-related preventive care. Understanding these issues is likely essential to facilitating implementation of preventive care, such as screening and brief intervention, for unhealthy AOD use.

Arria AM; DuPont RL. Nonmedical prescription stimulant use among college students: Why we need to do something and what we need to do. Journal of Addictive Diseases 29(4): 417-426, 2010. (44 refs.)

This article summarizes recent research findings on nonmedical use of prescription stimulants and outlines a multi-pronged strategic approach for responding to this unique problem among college students. Students, health professionals, parents, the pharmaceutical industry, and institutions of higher education all play roles in this response. Moreover, the academic community should view the translation of research findings as an important responsibility that can help dispel the myths often perpetuated in the media. The nonmedical use of prescription stimulants is a complex behavior and should be viewed in the larger context of alcohol and drug involvement among young adults. Strategies to reduce nonmedical use of prescription stimulants might have direct application to the abuse of other prescription drugs, including opiates.

Bartlett N; Xin DM; Zhang H; Huang BM. A qualitative evaluation of a peer-implemented overdose response pilot project in Gejiu, China. International Journal of Drug Policy 22(4): 301-305, 2011. (30 refs.)

Background: A harm reduction NGO in southern Yunnan operating an emergency overdose response hotline service successfully reversed 76 overdoses through the administration of naloxone in one of the first interventions of its kind in China. Method: To explore local understandings of risk factors related to overdose, assess ongoing barriers to overdose response, and solicit client input on how to further reduce opiate overdose mortality in Gejiu, the authors conducted qualitative interviews with 30 clients, including 15 individuals who received naloxone injections to reverse an overdose and 15 individuals who called the hotline in response to the overdose of a peer. Results: Participants pointed to a number of local structural shifts in heroin use including the ageing of the opiate using population and drug mixing practises that contribute to the city's overdose toll. Concerns over medical professionals' willingness to treat drug users, protection of confidentiality, and financial costs associated with treatment frequently cause drug users to avoid contact with the city's emergency service providers. Participants suggest directly distributing naloxone to clients as one strategy to further reduce overdose mortality. Conclusion: The authors explore possible strategies, including targeted trainings and new partnerships with local hospitals, to further reduce opiate overdose mortality in this resource-poor setting.

Black H; Gill J; Chick J. The price of a drink: Levels of consumption and price paid per unit of alcohol by Edinburgh's ill drinkers with a comparison to wider alcohol sales in Scotland. Addiction 106(4): 729-736, 2011. (17 refs.)

Aim: To compare alcohol purchasing and consumption by ill drinkers in Edinburgh with wider alcohol sales in Scotland. Design: Cross-sectional. Setting: Two hospitals in Edinburgh in 2008/09. Participants: A total of 377 patients with serious alcohol problems; two-thirds were in-patients with medical, surgical or psychiatric problems due to alcohol; one-third were out-patients. Measurements: Last week's or typical weekly consumption of alcohol: type, brand, units (1 UK unit 8 g ethanol), purchase place and price. Findings: Patients consumed mean 197.7 UK units/week. The mean price paid per unit was 0.43 pound (lowest 0.09 pound/unit) (1 pound = 1.6 US$ or 1.2), which is below the mean unit price, 0.71 pound paid in Scotland in 2008. Of units consumed, 70.3% were sold at or below 0.40 pound/unit (mid-range of price models proposed for minimum pricing legislation by the Scottish Government), and 83% at or below 0.50 pound/unit proposed by the Chief Medical Officer of England. The lower the price paid per unit, the more units a patient consumed. A continuous increase in unit price from lower to higher social status, ranked according to the Scottish Index of Multiple Deprivation (based on postcode), was not seen; patients residing in postcodes in the mid-quintile paid the highest price per unit. Cheapness was quoted commonly as a reason for beverage choice; ciders, especially 'white' cider, and vodka were, at off-sales, cheapest per unit. Stealing alcohol or drinking alcohol substitutes was only very rarely reported. Conclusions: Because patients with serious alcohol problems tend to purchase very cheap alcohol, elimination of the cheapest sales by minimum price or other legislation might reduce their consumption. It is unknown whether proposed price legislation in Scotland will encourage patients with serious alcohol problems to start stealing alcohol or drinking substitutes or will reduce the recruitment of new drinkers with serious alcohol problems and produce predicted longer-term gains in health and social wellbeing.

Borden LA; Martens MP; McBride MA; Sheline KT; Bloch KK; Dude K. the role of college students' use of protective behavioral strategies in the relation between binge drinking and alcohol-related problems. Psychology of Addictive Behaviors 25(2): 346-351, 2011. (32 refs.)

Previous research has examined protective behavioral strategies (PBS), or cognitive-behavioral strategies that may be employed when using alcohol to reduce consumption and related problems, as an important predictor of alcohol use and alcohol-related problems. More recently, studies have explored the mediating and moderating role of PBS on the relationships between key alcohol-related risk factors (i.e., drinking motives, depressive symptoms, binge drinking) and alcohol problems; however, current research examining PBS as a moderator of the relationship between alcohol use and related problems has methodological limitations. The purpose of the present study was to extend previous literature to examine the moderating effect of PBS on the relationship between binge drinking and alcohol-related problems. Data were collected and analyzed from 4,154 students at 13 midwestern universities. Findings indicated that PBS moderated the binge drinking-alcohol problems relationship for each of the four measures of binge drinking. However, effects were strongest when binge drinking was measured dichotomously versus continuously. Implications and future directions are discussed.

Boyce N. Health warnings for people who use heroin. (editorial). Lancet 377(9761): problem ?e-article CD001006, 2011. (0 refs.)

Butler R; Sheridan J. Innocent parties or devious drug users: The views of primary healthcare practitioners with respect to those who misuse prescription drugs26. Harm Reduction Journal 7(e-21), 2010. (26 refs.)

Background: Many health professionals engage in providing health services for drug users; however, there is evidence of stigmatisation by some health professionals. Prescription drug misusers as a specific group, may also be subject to such judgment. This study aimed to understand issues for primary care health practitioners in relation to prescription drug misuse (PDM), by exploring the attitudes and experiences of healthcare professionals with respect to PDM. Methods: Tape-recorded interviews were conducted with a purposive sample of general practitioners (17), community pharmacists (16) and 'key experts' (18) in New Zealand. Interviews were transcribed verbatim and a thematic analysis undertaken. Participants were offered vouchers to the value of NZ$30 for their participation. Results: A major theme that was identified was that of two different types of patients involved in PDM, as described by participants - the 'abuser' and the 'overuser'. The 'abuser' was believed to acquire prescription medicines through deception for their own use or for selling on to the illicit market, to use the drugs recreationally, for a 'high' or to stave off withdrawal from illicit drugs. 'Overusers' were characterised as having become 'addicted' through inadvertent overuse and over prescribing, and were generally viewed more sympathetically by practitioners. It also emerged that practitioners' attitudes may have impacted on whether any harm reduction interventions might be offered. Furthermore, whilst practitioners might be more willing to offer help to the 'over-user', it seemed that there is a lack of appropriate services for this group, who may also lack a peer support network. Conclusions: A binary view of PDM may not be helpful in understanding the issues surrounding PDM, nor in providing appropriate interventions. There is a need for further exploration of 'over users' whose needs may not be being met by mainstream drug services, and issues of stigma in relation to 'abusers'.

Chan SSC; Leung DYP; Abdullah ASM; Wong VT; Hedley AJ; Lam TH. A randomized controlled trial of a smoking reduction plus nicotine replacement therapy intervention for smokers not willing to quit smoking. Addiction 106(6): 1155- 1163, 2011. (43 refs.)

Aims: To examine the effectiveness of smoking reduction counselling plus free nicotine replacement therapy (NRT) for smokers not willing to quit. Design, setting and participants: A total of 1154 Chinese adult smokers not willing to quit but who were interested in reducing smoking were allocated randomly to three arms. Intervention group A1 (n = 479) received face-to-face counselling on smoking reduction and adherence to NRT at baseline, 1 week and 4 weeks with 4 weeks of free NRT. Group A2 (n = 449) received the same intervention, but without the adherence intervention. Control group B (n = 226) received simple cessation advice at baseline. Measurements: Self-reported 7-day point prevalence of tobacco abstinence and reduction of cigarette consumption (>= 50%) at 6 months and continuous use of NRT for 4 weeks at 3 months. Findings: Using intention-to-treat analysis, compared to control group B, the intervention groups (A1 + A2) had achieved higher 6-month tobacco abstinence (17.0% versus 10.2%, P = 0.01) and reduction rates (50.9% versus 25.7%, P < 0.001). There was no significant difference in the 4-week NRT adherence rate at 3 months, but group A1 achieved a higher abstinence rate than group A2 at 6 months (20.9% versus 12.9%; P = 0.001). Conclusions: In smokers with no immediate plans to quit, smoking reduction programmes with behavioural support and nicotine replacement therapy are more effective than brief advice to quit. Current guidelines recommend advice to quit on medical grounds as the best clinical intervention in this group of smokers, but smoking reduction programmes offer an alternative and effective option.

Clark BJ. Secondary prevention in the intensive care unit: Does intensive care unit admission represent a "teachable moment?" (review). Critical Care Medicine 39(6): 1500- 1506, 2011. (107 refs.)

Objectives: Cigarette smoking and unhealthy alcohol use are common causes of preventable morbidity and mortality that frequently result in admission to an intensive care unit. Understanding how to identify and intervene in these conditions is important because critical illness may provide a "teachable moment." Furthermore, the Joint Commission recently proposed screening and receipt of an intervention for tobacco use and unhealthy alcohol use as candidate performance measures for all hospitalized patients. Understanding the efficacy of these interventions may help drive evidence-based institution of programs, if deemed appropriate. Data Sources: A summary of the published medical literature on interventions for unhealthy alcohol use and smoking obtained through a PubMed search. Summary: Interventions focusing on behavioral counseling for cigarette smoking in hospitalized patients have been extensively studied. Several studies include or focus on critically ill patients. The evidence demonstrates that behavioral counseling leads to increased rates of smoking cessation but the effect depends on the intensity of the intervention. The identification of unhealthy alcohol use can lead to brief interventions. These interventions are particularly effective in trauma patients with unhealthy alcohol use. However, the current literature would not support routine delivery of brief interventions for unhealthy alcohol use in the medical intensive care unit population. Conclusions: Intensive care unit admission represents a "teachable moment" for smokers and some patients with unhealthy alcohol use. Future studies should assess the efficacy of brief interventions for unhealthy alcohol use in medical intensive care unit patients. In addition, identification of the timing and optimal individual to conduct the intervention will be necessary.

Cohen BMZ; Butler R. BZP-party pills: A review of research on benzylpiperazine as a recreational drug. (review). International Journal of Drug Policy 22(2): 95- 101, 2011. (41 refs.)

Background: BZP-party pills are yet another 'designer drug' which mimics the stimulant qualities of amphetamines and MDMA/Ecstasy. As legal markets for the substance have developed in the last decade (especially amongst young people) so has public and governmental concern. Methods: This article provides a summary of the available international research on benzylpiperazine (BZP) and its popular use in the compound form known as 'party pills'. Through performing an analysis of the available medical and social scientific literature, the review outlines current knowledge on the compound, the prevalence of usage of BZP-party pills, as well as the associated harms, risks and rationales for use of the drug. Results: Despite moves towards legislative control of BZP-party pills, the evidence presented suggests limited social and health harms associated with the drug, although research on long term effects is a significant gap in the literature. It also remains inconclusive as to whether BZP-party pills act as a 'gateway' to illegal drugs or, conversely, play a role in harm reduction with illegal drug users turning to legal alternatives; there is some evidence for both positions. Conclusion: With increasing controls of BZP-party pills, and with the increasing numbers of 'legal highs' and new designer drugs on the market, we conclude that new legal alternatives will continue to surface to replace the drug in the future. Considering a harm reduction approach to drug taking, it is suggested that policy makers consider the creation of a legal holding category which restricts and regulates the market in legal highs whilst the social and health harms associated with each drug can be thoroughly investigated.

Coleman L; Ramm J; Cooke R. The effectiveness of an innovative intervention aimed at reducing binge drinking among young people: Results from a pilot study. Drugs: Education, Prevention and Policy 17(4): 413-430, 2010. (40 refs.)

Aims: To assess the effectiveness of a digital-story intervention (short videos made by young people) seeking to reduce the prevalence of young people's binge drinking in Caerphilly. Method: A quasi-experimental design was adopted with three intervention sites and one control site providing the sample (mainly aged 14-15 years). Three rounds of self-completion questionnaires, completed prior (T1), immediately after (T2) and 6 months after the intervention (T3). Findings: A total of 1031 questionnaires completed across the three time-points. Two-factor ANOVAs revealed a positive effect on knowledge for the intervention sample. The intervention group results showed stable attitudes towards drinking at the three time-points whilst the control group showed increasing positive attitudes towards drunkenness over the same time period. Intentions towards drunkenness were higher in the control group than the intervention group at T2 (Control - T1 Mean = 3.37, T2 Mean = 3.90; intervention - T1 Mean = 3.26, T2 Mean = 3.29). Intervention participants got drunk on fewer occasions in the last week (mean occasions last week = 1.57) compared to control participants (mean occasions last week = 2.00), with the difference approaching statistical significance (F = 1.90, p = 0.07). Conclusions: Promoting negative attitudes towards drunkenness, alongside a greater sense of control and potential regret about drunkenness are likely to be important factors when considering how to change people's intentions to drink. The study shows the potential to reduce the frequency of drinking behaviour when intentions are changed, and provides recommendations for future interventions of this nature.

Cooke R; French DP; Sniehotta FF. Wide variation in understanding about what constitutes 'binge-drinking'18. Drugs: Education, Prevention and Policy 17(6): 762-775, 2010. (18 refs.)

Two studies investigated undergraduates' knowledge of the UK government recommendations about binge drinking and sensible drinking, and also examined how labelling oneself as a binge drinker is associated with binge drinking perceptions. In Study 1, 325 undergraduates reported how many units constitute binge drinking, and labelled themselves as a 'binge drinker' or 'non-binge drinker'. Participants overestimated how many units constitute binge drinking relative to the UK government recommendations. Also, 59% labelled themselves as 'non-binge drinkers' and gave significantly higher estimates compared with 'binge drinkers'. In Study 2, 386 undergraduates defined binge drinking and reported how many units constitute sensible drinking. Only 13% of undergraduates defined binge drinking in terms of units of alcohol, and undergraduates overestimated how many units constitute sensible drinking. This research found wide variation in personal understanding of the term binge drinking and suggests a review of how to communicate recommendations about alcohol consumption to young people is needed.

Day CA; Islam MM; White A; Reid SE; Hayes S; Haber PS. Development of a nurse-led primary healthcare service for injecting drug users in inner-city Sydney. Australian Journal of Primary Health 17(1): 10-15, 2011. (45 refs.)

Injecting drug users (IDUs) experience numerous health problems, but report barriers to utilising general practitioners (GPs). A nurse-led Harm Minimisation-based Primary Healthcare (HMPH) service for IDUs was established within a needle and syringe program in inner-city Sydney with Area Health Service medical support and clinical governance. This paper aimed to describe the HMPH service, review service utilisation and assess nurses' perceptions of their work with IDUs. A review of the most recent 200 clinic files was undertaken. Service utilisation, GP and other health service use and access were extracted and analysed using SPSS. A semi-structured qualitative interview with clinic nurses regarding their experience working with IDUs and local GPs was conducted and analysed. Since its inception in mid-2006, the service has been utilised by 417 clients. Of the most recent 200 files, blood-borne virus and sexually transmitted infection screening were the primary reason for presentation (64.5%). At least one follow-up visit was attended by 90% of clients. A total of 62% of clients reported consulting a GP in the last 12 months. The service provided 102 referrals. Nurses believed that IDUs tend to utilise GPs ineffectively and that self-care is a low priority, but that they can support IDUs to overcome some barriers to GPs and facilitate access. Targeted primary health care services led by nurses with focussed medical support and co-located with needle and syringe programs can fill an important gap in delivering and facilitating health care to IDUs.

DeBeck K; Kerr T; Bird L; Zhang R; Marsh D; Tyndall M et al. Injection drug use cessation and use of North America's first medically supervised safer injecting facility. Drug and Alcohol Dependence 113(2-3): 172-176, 2011. (31 refs.)

Background: Vancouver, Canada has a pilot supervised injecting facility (SIF), where individuals can inject pre-obtained drugs under the supervision of medical staff. There has been concern that the program may facilitate ongoing drug use and delay entry into addiction treatment. Methods: We used Cox regression to examine factors associated with the time to the cessation of injecting, for a minimum of 6 months, among a random sample of individuals recruited from within the Vancouver SIF. In further analyses, we evaluated the time to enrolment in addiction treatment. Results: Between December 2003 and June 2006, 1090 participants were recruited. In Cox regression, factors independently associated with drug use cessation included use of methadone maintenance therapy (Adjusted Hazard Ratio [AHR] = 1.57 [95% Confidence Interval [CI]: 1.02-2.40]) and other addiction treatment (AHR = 1.85 [95% CI: 1.06-3.24]). In subsequent analyses, factors independently associated with the initiation of addiction treatment included: regular SIF use at baseline (AHR = 1.33 [95% CI: 1.04-1.72]): having contact with the addiction counselor within the SIF (AHR = 1.54 [95% CI: 1.13-2.08]): and Aboriginal ancestry (AHR = 0.66 [95% CI: 0.47-0.92]). Conclusions: While the role of addiction treatment in promoting injection cessation has been well described, these data indicate a potential role of SIF in promoting increased uptake of addiction treatment and subsequent injection cessation. The finding that Aboriginal persons were less likely to enroll in addiction treatment is consistent with prior reports and demonstrates the need for novel and culturally appropriate drug treatment approaches for this population.

Demirkol A; Conigrave K; Haber P. Problem drinking: Management in general practice. Australian Family Physician 40(8): 576-+, 2011. (25 refs.)

Background: Management of problem drinking presents the general practitioner with similar challenges and rewards to those associated with the management of other chronic conditions. Objective: This article presents a framework for managing alcohol problems in general practice based on national guidelines for the treatment of alcohol problems. Discussion: General practitioners are well placed to undertake the management of drinking problems following an assessment of the amount of alcohol taken and the risks this poses for the individual and the people around them. This assessment starts the process of engagement and reflection on drinking habits and will inform the appropriate management approach. Brief interventions can result in reduction in drinking in nondependent drinkers. For dependent drinkers, treatment steps include assessing need for withdrawal management and developing a comprehensive management plan, which includes consideration of relapse prevention pharmacotherapy and psychosocial interventions. The patient's right to choose what they drink must be respected, and those who continue to drink in a problematic way can still be assisted, with compassion, within a harm reduction framework.

Ford R. An analysis of nurses' views of harm reduction measures and other treatments for the problems associated with illicit drug use. Australian Journal of Advanced Nursing 28(1): 14-24, 2010. (48 refs.)

Objective: To analyse nurses' views of harm reduction measures and other treatments for the problems associated with illicit drug use. Design and setting: The study, a cross-sectional survey, sampled the entire registered nurse population of the ACT. A self-complete survey was posted to home or workplace addresses. The views of all nurses registered in the ACT were sought. Subjects: The study sample (n = 1,605: 50% response rate), was predominantly comprised of nurses working outside specialist drug and alcohol fields (94%), with a small group from specialist fields. Main outcome measures: A 6-point Likert scale comprising 7 items (illicit drug treatments). Comparison with the Australian population was achieved through use of the National Drug Strategy Household Survey database. Results: Nurses mirrored the views of the Australian population, being strongly supportive of two abstinence-based measures (naltrexone for the maintenance of abstinence - 82% and rapid detoxification therapy 77%) and one harm reduction measure (the needle and syringe program - 76%). Nurses' lower support for the methadone maintenance program (66%) was statistically significant. Conclusions: Nurses reported high approval for the needle and syringe program but were mistakenly optimistic about abstinence-based measures for problems associated with illicit drugs. They reported significantly less support for important harm reduction measures - the methadone maintenance program and safe injection rooms. Nurses' low approval rating for these harm reduction measures is at odds with the evidence. This study highlights the need for education on the evidence base for the various illicit drug treatments.

Furst RT; Curtis R; Balletto R. The transformation of drug markets and its impact on HIV outreach to injection drug users in New York City, 1987-2008. Substance Use & Misuse 46(2-3): 150-158, 2011. (25 refs.)

This oral history describes three periods of street outreach to injection drug users at risk for HIV in New York City: outreach in an era of public drug markets (1987-1993), outreach in an era of private markets (1993-2006), and network-driven outreach (2006-present). Individual interviews with administrators and supervisors of outreach workers are combined with field notes from the ethnographic research experiences of the first two authors to contextualize, compare, and contrast these distinct periods. The combination and triangulation of these sources of data allow for an analysis of both the specific and the wider social and cultural contexts in which outreach intervention efforts were situated. Through these lenses, the article examines some of the reasons why they were or were not successful and discusses prospects for the future.

Gao JN; Zheng PP; Gao JL; Chapman S; Fu H. Workplace smoking policies and their association with male employees' smoking behaviours: a cross-sectional survey in one company in China. Tobacco Control 20(2): 131-136, 2011. (23 refs.)

Objectives: The present work sought to evaluate different worksite smoking control policies and their associations with employees' smoking behaviours and attitudes among Chinese male workers. Methods: This was a cross-sectional survey with a self-administered standardised questionnaire, conducted among seven production workplaces of one multinational company in Shanghai in 2008. In total, 1043 male workers were involved. Current smoking prevalence, daily cigarette consumption, quitting intention and their potential association with workplace smoking control policies (smoke free or restricted smoking) were measured. Results: Current smoking prevalence in workplaces where smoke-free policies had been imposed for 3 years was 55.5%, about 18% lower than in workplaces that only restricted smoking. Smokers in smoke-free workplaces also smoked 3.4 cigarettes less per day, made more quit attempts, were more confident of successfully quitting and more willing to accept a company sponsored cessation programme. Those patterns declined or were not found among the workplaces where smoking control policies had been imposed for 10 years. Smoker quitting intentions were not associated with workplace smoking policies regardless of the duration of the policies imposed. Conclusions: A smoke-free workplace policy was found to have a significant association with lower smoking prevalence and daily cigarette consumption, but not with employee quitting intentions. Restrictive smoking policies had no impact on employee smoking behaviours. The impact of workplace smoking control policies may vary over time.

Givel M. In search of the less hazardous cigarette. International Journal of Health Services 41(1): 77-94, 2011. (60 refs.)

Since the 1950s, despite considerable and long-term tobacco industry and government efforts, attempts to develop a less risky cigarette that reduces harmful ingredients, generally or specifically, have failed. Moreover, even under ideal conditions with adequate scientific testing, the efficacy of purportedly reducing the severe health effects cannot be scientifically verified for up to 20 years after introduction of a product on the market. A key and central provision in the 2009 U.S. Food and Drug Administration (FDA) legislation is to reduce the risk or harm of cigarettes. Because creating a less risky cigarette is not currently possible, this renders the efficacy of the 2009 FDA legislation highly uncertain, with a large risk that the proposed program may not reduce harm.

Graham LJC; Mackinnon D. Grasping the thistle: The role of alcohol brief interventions in Scottish alcohol policy. (review). Drug and Alcohol Review 29(6): 603-607, 2010. (35 refs.)

Issue. Scotland has experienced a substantial rise in alcohol-related harm, which is now one of the biggest public health challenges it faces. Approach. Alcohol problems in Scotland are described along with national alcohol policy response in addressing them. The role of a program of Alcohol Brief Interventions is discussed therein. Key Findings. In Scotland, considerable proportions of the population are drinking hazardously or harmfully, common across different age and socioeconomic groups. Rising consumption has been set in wider environmental changes with alcohol becoming more available and affordable. Scotland has had one of the fastest growing chronic liver disease mortality rates in the world at a time when rates in most of Western Europe are falling. Scotland's alcohol policy has an explicit aim to reduce population consumption and includes legislative measures to tackle price and availability. A national program to deliver Alcohol Brief Interventions for hazardous drinkers is a key plank of this wider strategy. A portfolio of studies will monitor and evaluate national policy and, through contribution analysis, describe the role Alcohol Brief Interventions play in reducing alcohol misuse. Implications. Effective alcohol policy recognises that determinants of health not only lie at individual level, but include wider social, environmental and economic factors. Scotland's policy is addressing these determinants with both population-based and population-targeted interventions. Conclusion. Scotland has a serious problem with alcohol. A comprehensive, evidence-based, resourced alcohol policy is being implemented, which will need continual review to ensure it remains anchored in evidence while maintaining its ambition.

Greenspan NR; Aguinaldo JP; Husbands W; Murray J; Ho P; Sutdhibhasilp N et al. "It's not rocket science, what I do": Self-directed harm reduction strategies among drug using ethno-racially diverse gay and bisexual men. International Journal of Drug Policy 22(1): 56-62, 2011. (36 refs.)

Background: Research on harm reduction has typically focused on broad-based or organisational strategies such as needle exchange and opiate substitute programmes. Less attention has been paid to the self-directed harm reduction practices of substance users themselves. Few studies have focused on sexual minority populations such as gay and bisexual men and fewer still on the marginalised groups that constitute these populations. This paper identifies self-directed harm reduction strategies among substance using ethno-racially diverse gay and bisexual men. Methods: This article presents findings from the Party Drugs Study in Toronto's gay dance club scene, a community-based qualitative study in Toronto, Canada. We present a thematic analysis of interviews with 43 gay and bisexual men from diverse ethno-racial backgrounds about their substance use in the gay dance club scene. Findings: We identify five self-directed harm reduction strategies: rationing, controlling or avoiding mixing, controlling quality, maintaining a healthy lifestyle, and following guidelines during substance use. Conclusions: We discuss our findings in relation to prior research and to critical theory. We suggest that drug users' awareness of possible harm, and their personal investment in harm reduction, constitute a viable platform from which community-based and public health organisations may promote and strengthen harm reduction among gay and bisexual men from ethno-racially diverse backgrounds.

Haber PS; Murnion BP. Training in addiction medicine in Australia. Substance Abuse 32(2, special issue): 115- 119, 2011. (0 refs.)

Barriers to entering addiction medicine (AM) have led to a persisting workforce shortage. To address this problem, the Chapter of Addiction Medicine (AChAM) was formed in 2001 as a subdivision of the Royal Australasian College of Physicians (RACP). Through consultation, AChAM has identified the scope of practice and offered fellowship to suitable established practitioners. The Chapter successfully applied to the Australian Government for recognition of AM as a medical specialty, which was finalized in November 2009. Specialist reimbursement item numbers were incorporated into that decision process and commence operating in November 2010. AChAM has designed and implemented a training scheme using a model similar to that of the RACP internal medicine training program. This comprises 3 years of basic general medical training post internship followed by 3 years of discipline-specific supervised training. The training is broadly based, with experience in both ambulatory care and inpatient care, and including physical health as well as mental health. Assessment is continuous and competency based. There is no exit examination. The overriding clinical approach rests upon the harm minimization framework consistent with long-established national drug policy in Australia and favors evidence-based treatment.

Hallinan R; Osborn M; Cohen M; Dobbin M; Wodak A. Increasing the benefits and reducing the harms of prescription opioid Analgesics. (editorial). Drug and Alcohol Review 30(3): 315- 323, 2011. (81 refs.)

Issues. Consumption of prescription opioid analgesics (POAs) in Australia has increased steadily in recent years, raising concerns of increasing harms including overdose and dependence, as has occurred in the. Approach. Exposition of the Royal Australasian College of Physicians Prescription Opioid Policy with reference to the published literature, drawing out principles for harm reduction for psychoactive pharmaceutical drugs. Key Findings. Complex professional, patient, regulatory and market factors influence health professionals balancing the benefits and harms of POAs. Owing to the potential for diversion, overlapping markets probably exist for pharmaceutical opioids used for populations with cancer pain, chronic non-cancer pain, and people dependent on pharmaceutical and illicit opioids (including those needing opioid substitution treatment). Attempts to reduce or restrict supply in one area may increase demand in others. There is a need to consider new harm reduction strategies for people with problematic pharmaceutical opioid use. These people are demographically not well characterised, and may be distinct from the more familiar population of injection drug users. Implications. Harm reduction is a valid approach for POAs. However, the role of health professionals as gatekeepers of opioid supply, the need to optimise health benefits of POAs, and the likely interplay of complex market forces among populations consuming opioids have no close parallel in harm reduction for other substances. This poses fundamentally different challenges. Conclusions. Reducing inappropriate supply and demand for POAs while maximising their benefits and minimising their harms may improve health outcomes.

Hathaway AD; Hyshka E; Erickson PG; Asbridge M; Brochu S; Cousineau MM et al. Whither RDS? An investigation of Respondent Driven Sampling as a method of recruiting mainstream marijuana users. Harm Reduction Journal 7(e-15), 2010. (45 refs.)

Background: An important challenge in conducting social research of specific relevance to harm reduction programs is locating hidden populations of consumers of substances like cannabis who typically report few adverse or unwanted consequences of their use. Much of the deviant, pathologized perception of drug users is historically derived from, and empirically supported, by a research emphasis on gaining ready access to users in drug treatment or in prison populations with higher incidence of problems of dependence and misuse. Because they are less visible, responsible recreational users of illicit drugs have been more difficult to study. Methods: This article investigates Respondent Driven Sampling (RDS) as a method of recruiting experienced marijuana users representative of users in the general population. Based on sampling conducted in a multi-city study (Halifax, Montreal, Toronto, and Vancouver), and compared to samples gathered using other research methods, we assess the strengths and weaknesses of RDS recruitment as a means of gaining access to illicit substance users who experience few harmful consequences of their use. Demographic characteristics of the sample in Toronto are compared with those of users in a recent household survey and a pilot study of Toronto where the latter utilized nonrandom self-selection of respondents. Results: A modified approach to RDS was necessary to attain the target sample size in all four cities (i.e., 40 'users' from each site). The final sample in Toronto was largely similar, however, to marijuana users in a random household survey that was carried out in the same city. Whereas well-educated, married, whites and females in the survey were all somewhat overrepresented, the two samples, overall, were more alike than different with respect to economic status and employment. Furthermore, comparison with a self-selected sample suggests that (even modified) RDS recruitment is a cost-effective way of gathering respondents who are more representative of users in the general population than nonrandom methods of recruitment ordinarily produce. Conclusions: Research on marijuana use, and other forms of drug use hidden in the general population of adults, is important for informing and extending harm reduction beyond its current emphasis on 'at-risk' populations. Expanding harm reduction in a normalizing context, through innovative research on users often overlooked, further challenges assumptions about reducing harm through prohibition of drug use and urges consideration of alternative policies such as decriminalization and legal regulation.

Hayashi K; Wood E; Suwannawong P; Kaplan K; Qi JZ; Kerr T. Methamphetamine injection and syringe sharing among a community-recruited sample of injection drug users in Bangkok, Thailand. Drug and Alcohol Dependence 115(1-2): 145- 149, 2011. (36 refs.)

Background: The recent growth in methamphetamine use internationally has raised concerns about the relationship between methamphetamine use and HIV infection. However, the risks associated with methamphetamine injection have not been fully described, particularly outside of Western countries. Therefore, we sought to examine the relationship between methamphetamine injection and syringe sharing among injection drug users (IDU) in Bangkok, Thailand. Methods: Using bivariate statistics and multivariate logistic regression, we examined the prevalence of methamphetamine injection and the relationship between more than weekly methamphetamine injection and syringe sharing among a community-recruited sample of IDU participating in the Mitsampan Community Research Project in Bangkok. Results: During June and July 2009, 311 IDU participated in this study, including 91(29.3%) women. In total, 114 (36.7%) participants reported having injected methamphetamine ("yaba") twice or more per week in the past six months. In multivariate analyses, after adjustment for potential social, demographic and behavioral confounders, syringe sharing remained independently associated with injecting methamphetamine more than once per week (adjusted odds ratio = 2.86, 95% confidence interval: 1.59-5.15). Conclusions: Over one-third of a community-recruited sample of Thai IDU reported more than weekly injection of methamphetamine, and methamphetamine injection was independently associated with syringe sharing. Essential HIV prevention services targeting IDU, such as syringe exchange and evidence-based addiction treatment, should be included in interventional efforts to address methamphetamine use in Thailand.

Heavner KK; Rosenberg Z; Tenorio F; Phillips CV. Retailers' knowledge of tobacco harm reduction following the introduction of a new brand of smokeless tobacco. Harm Reduction Journal 7(e-18), 2010. (33 refs.)

Background: Tobacco retailers are potential public health partners for tobacco harm reduction (THR). THR is the substitution of highly reduced-risk nicotine products, such as smokeless tobacco (ST) or pharmaceutical nicotine, for cigarettes. The introduction of a Swedish-style ST product, du Maurier snus (dMS) (Imperial Tobacco Canada Limited), which was marketed as a THR product, provided a unique opportunity to assess retailers' knowledge. This study examined retailers' knowledge of THR and compliance with recommendations regarding tobacco sales to young adults. Methods: Male researchers, who may have looked younger than 18 years old, visited 60 stores in Edmonton that sold dMS. The researchers asked the retailers questions about dMS and its health risks relative to those from other tobacco products. They also attempted to purchase dMS to ascertain whether retailers would ask for identification to verify that they were at least 18 years old. Results: Overall, the retailers were only moderately knowledgeable about THR and the differences between dMS and other tobacco products. About half of the retailers correctly indicated that snus is safer than cigarettes; half of whom knew it is safer because it is smoke-free. Fifty percent incorrectly believed that snus causes oral cancer. Less than fifty percent indicated that dMS differs from chewing tobacco because it is in pouches and is used without spitting or chewing (making it more promising for THR). Most (90%) of the retailers asked the researchers for identification when selling dMS. Conclusion: Tobacco retailers are potentially important sources of information about THR, particularly since there are restrictions on the promotion of all tobacco products (regardless of the actual health risks) in Canada. This study found that many retailers in Edmonton do not know the relative health risks of different tobacco products and are therefore unable to pass on accurate information to smokers.

Hesse M. Enhancement drugs: Are there limits to what we should enhance and why? (editorial)18. BMC Medicine 8(e-50), 2010. (18 refs.)

Substances, such as alcohol, opiates and cannabis, have been used by humans for millennia. Today, a much wider range of substances are used for a range of purposes, including the enhancement of performance during university studies, sexual experiences, sports, exercise, at celebrations, socializing and the experience of art and music. Substance use is also associated with a range of harmful effects to the individual and society as a whole. Prohibitions, regulation, prevention and treatment have all been used to protect against this harm. In this commentary, it is argued that public health interventions should target relevant harms and not to evaluate which aspects of human endeavors and experiences should be enhanced and which should not. It is argued that interventions should directly target the harmful effects, using the best available evidence. Two examples are given of substances that may be altered to prevent serious harm - one for alcohol and one for cannabis. In the case of alcohol, the addition of dissolved oxygen could reduce both the risk of accidents and the risk of liver damage associated with alcohol consumption. In the case of cannabis, there is strong indication that the reduction of content of tetrahydrocannabinol and the increase of cannabidiol could reduce the risk of psychoses and the addiction associated with its use. The aim of this article is to show that responsible regulation should not necessarily be restricted to preventing the use and/or (in the case of alcohol) a reduction in the amounts and frequency of its use, but should also aim to include a range of other strategies that could reduce the burden of illness associated with illicit substance use.

Hungerbuehler I; Buecheli A; Schaub M. Drug checking: A prevention measure for a heterogeneous group with high consumption frequency and polydrug use. Evaluation of Zurich's Drug Checking services. Harm Reduction Journal 8(e-article 16), 2011. (9 refs.)

Background: The increasing party culture in Zurich presents new challenges, especially regarding the consumption of alcohol and so-called party drugs. Streetwork, the youth advisory service of the city of Zurich, has provided onsite and stationary Drug Checking facilities since 2001 and 2006, respectively. Drug Checking always involves filling out an anonymous questionnaire, which allows the collection of important information about a largely unknown group of users and their consumption patterns. Methods: The questionnaires assessed sociodemographic characteristics, consumption patterns, Drug Checking experiences, information behavior and social support. The collected data were statistically analyzed by the Research Institute for Public Health and Addiction (RIPHA). Results: The majority of Drug Checking service patrons were male and between 20 and 35 years old. These patrons reported high lifetime prevalences and high consumption frequencies of legal and illegal substances, and they often reported polydrug use. Aside from tobacco and alcohol, the most consumed drugs during typical party nights were ecstasy, amphetamines, cannabis and cocaine. Party drug consumers using Drug Checking services form a heterogeneous group with respect to sociodemographic characteristics and consumption patterns. Users of the onsite Drug Checking facilities were significantly younger, were less experienced with drug testing, and reported more polydrug use than users of the stationary Drug Checking service. Conclusions: Drug Checking combined with a consultation appears to be an important harm reduction and prevention measure that reaches a group of consumers with high consumption frequency and polydrug use. Because of the heterogeneity of the target group, different prevention measures must be offered and embedded in an overall local concept.

Ivsins A; Roth E; Nakamura N; Krajden M; Fischer B. Uptake, benefits of and barriers to safer crack use kit (SCUK) distribution programmes in Victoria, Canada-A qualitative exploration. International Journal of Drug Policy 22(4): 292-300, 2011. (75 refs.)

Background: Crack use is prevalent amongst street drug users in Canadian cities, and associated with severe drug use, health and social problems. Whilst few targeted interventions are available for crack use, the common use and sharing of hazardous makeshift paraphernalia are a key concern, as these risks may be associated with oral injury and blood-borne virus (BBV) - e.g., hepatitis C virus (HCV) - transmission amongst users. Recently, distribution programmes of so-called 'safer crack use kits' (SCUMs) have been initiated in select Canadian cities, primarily to reduce the use of unsafe materials and paraphernalia sharing amongst crack users. This study explored uptake and benefits of, barriers to, and possible improvements to two recently implemented SCUK distribution programme in Victoria, Canada. Methods: N=31 regular crack smokers were recruited through community-based efforts between June and August 2010, and assessed via an interviewer-administered protocol involving quantitative and qualitative data items. Descriptive analyses were completed with the quantitative data, and thematic content analyses were conducted with the qualitative data in order to identify and extract prominent themes and issues. Results: The sample indicated high levels of socio-economic marginalization, poly-substance use, health problems, lengthy crack use histories and common crack paraphernalia sharing. Most participants exclusively utilized the SCUK programme including glass-stems in addition to other paraphernalia materials. Participants described: lesser need to share - or to commit property crimes to obtain resources for - crack to paraphernalia, increased health awareness, and increased personal and community safety as benefits experienced from SCUK use. Limitations in SCUK resources and distribution, shortcomings in materials, and police interference were cited as barriers to current SCUK program delivery. Conclusions: SCUM distribution in Victoria appears to result in a variety of individual and community health benefits. These benefits could be solidified by addressing current programme limitations, including better resourcing, expanding geographic distributions and eliminating police interference.

Jamison RN; Ross EL; Michna E; Chen LQ; Holcomb C; Wasan AD. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: A randomized trial. Pain 150(3): 390-400, 2010. (48 refs.)

Chronic pain patients who show aberrant drug-related behavior often are discontinued from treatment when they are noncompliant with their use of opioids for pain. The purpose of this study was to conduct a randomized trial in patients who were prescribed opioids for noncancer back pain and who showed risk potential for or demonstration of opioid misuse to see if close monitoring and cognitive behavioral substance misuse counseling could increase overall compliance with opioids. Forty-two patients meeting criteria for high-risk for opioid misuse were randomized to either standard control (High-Risk Control; N = 21) or experimental compliance treatment consisting of monthly urine screens, compliance checklists, and individual and group motivational counseling (High-Risk Experimental; N = 21). Twenty patients who met criteria indicating low potential for misuse were recruited to a low-risk control group (Low-Risk Control). Patients were followed for 6 months and completed pre- and post-study questionnaires and monthly electronic diaries. Outcomes consisted of the percent with a positive Drug Misuse Index (DMI), which was a composite score of self-reported drug misuse (Prescription Drug Use Questionnaire), physician-reported abuse behavior (Addiction Behavior Checklist), and abnormal urine toxicology results. Significant differences-were found between groups with 73.7% of the High-Risk Control patients demonstrating positive scores on the DMI compared with 26.3% from the High-Risk Experimental group and 25.0% from the Low-Risk Controls (p < 0.05). The results of this study demonstrate support for the benefits of a brief behavioral intervention in the management of opioid compliance among chronic back pain patient at high-risk for prescription opioid misuse.

Jarvinen M; Miller G. Methadone maintenance as last resort: A social phenomenology of a drug policy. Sociological Forum 25(4): 804-823, 2010. (42 refs.)

Drawing on qualitative interviews with drug addicts in Copenhagen, Denmark, this article offers a phenomenological reading of a methadone maintenance program. The program is set within the principles of harm reduction, meaning that its aim is not to cure the participants' addiction but to keep them stable on substitution medicine and slow the deterioration of their lives. We analyze the program's implications for participants' sense of agency and constraint and for their orientations toward the past, present, and future. A major concern is with the program as a last resort policy that challenges neoliberal ideals of self-governance and self-development. While the program increases the participants' sense of stability by providing them with methadone and by allowing them to better address their economic, housing, and other needs of everyday life, it also represents a context of physical, emotional, and social dependence. The interviews cast the program as a paradox that simultaneously increases participants' sense of stability and vulnerability. In essence, the Danish methadone program has the effect of both helping the participants by reducing the drug-related harm in their lives and of fostering conditions of inferiorization and enduring nonbecoming.

Jones L; Pickering L; Sumnall H; McVeigh J; Bellis MA. Optimal provision of needle and syringe programmes for injecting drug users: A systematic review. (review). International Journal of Drug Policy 21(5): 335-342, 2010. (38 refs.)

The introduction of needle and syringe programmes (NSPs) during the 1980s is credited with averting an HIV epidemic in the United Kingdom and Australia, but hepatitis C (HCV) incidence continues to rise among injecting drug users (IDUs). NSPs incorporating additional harm reduction strategies have been highlighted as an approach that may impact on HCV incidence. This systematic review sought to determine which approaches to the organisation and delivery of NSPs are effective. Fifteen databases were searched for studies published since 1990. Two reviewers screened all titles and abstracts, and data extraction and quality assessment of individual studies were undertaken independently by one reviewer and checked for accuracy by a second. Sixteen studies met the criteria for inclusion. Based on 11 studies there was no evidence of an impact of different NSP settings or syringe dispensation policies on drug injecting behaviours, but mobile van sites and vending machines appeared to attract younger IDUs and IDUs with higher risk profiles. Two studies of interventions aimed at encouraging IDUs to enter drug treatment reported limited effects, but one study found that the combination of methadone treatment and full participation in NSPs was associated with a lower incidence of HIV and HCV. In addition, one study indicated that hospital-based programmes may improve access to health care services among IDUs. Currently, it is difficult to draw conclusions on 'what works best' within the range of harm reduction services available to IDUs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery NSPs impact on effectiveness.

Kaner E. NICE work if you can get it: Development of national guidance incorporating screening and brief intervention to prevent hazardous and harmful drinking in England. Drug and Alcohol Review 29(6): 589-595, 2010. (54 refs.)

This paper describes the development of the first set of national guidance focused on the prevention of alcohol problems in England. These guidelines were produced by the National Institute for Health and Clinical Excellence (NICE) working with a multidisciplinary program development group of scientists, practitioners and lay members. In this work, screening and brief alcohol interventions represent a key element of a comprehensive public health strategy to prevent alcohol-related risk and harm across the population. The first controlled trials of brief alcohol intervention were published in the mid to late 1980's and there are now around 60 published trials in this field. After 25 years of accumulated evidence in this field, brief alcohol interventions have yet to make a significant impact on routine clinical practice. While it is imperative to have good science to make the case for brief intervention delivery, this work is in vain if practitioners are unwilling or unable to use these interventions with their patients. Evidence from the alcohol field and other clinical areas indicates that national prioritisation of brief alcohol intervention activity, by a body, such as NICE, is likely to be a key driver of implementation by practitioners. This paper summarises a suite of complementary system-level and practice recommendations, which were published by NICE in June 2010, and considers their likely impact on screening and brief alcohol in England.

Kazemi DM; Sun LM; Nies MA; Dmochowski J; Walford SM. Alcohol screening and brief interventions for college freshmen a harm reduction approach. Journal of Psychosocial Nursing and Mental Health Services 49(1): 35-42, 2011. (33 refs.)

This study examined the effectiveness of the Brief Alcohol Screening and Intervention for College Students using theory-driven harm reduction brief motivational interviewing (BMI) for decreasing high-risk drinking and negative consequences. Three surveys were administered to 102 volunteer freshmen college students at baseline and 3 months postintervention. The BMI intervention was administered at baseline and 2 weeks later. Descriptive statistics and summary graphs were used to determine longitudinal changes in drinking quantity, frequency, and negative outcomes. Number of drinks, hours of drinking, and negative consequences decreased, indicating a significant decrease in alcohol consumption and negative consequences. This study contributes valuable implications for the design of theory-driven harm reduction, evidence-based interventions for high-risk drinking among freshmen college students.

Kidd SA; Kirkpatrick H; George L. Getting to know Mark, a homeless alcohol-dependent artist, as he finds his way out of the river. Addiction Research & Theory 19(2): 102-111, 2011. (37 refs.)

Managed Alcohol Programs (MAPs) are a relatively recent addition to the repertoire of harm reduction approaches for persons experiencing severe alcohol dependence. In these settings, clients, who are typically homeless, are provided with a maintenance amount of alcohol while residing in a shelter setting. This case study examines the living experience of a homeless alcohol-dependent client of a MAP in an effort to articulate the process factors related to engagement with this form of treatment. The participant, a 48-year-old white male, participated in a series of qualitative interviews that took place prior to admission, immediately following admission, following re-admission, and after completion of the program over the course of 18 months. A grounded theory approach to data analysis was undertaken. The findings suggest that the primary utility of the MAP was in stabilizing a range of problems such that he was provided with the time, energy, and resources necessary to engage in the critically important task of constructing valued identity, place, and meaning and purpose in life.

Kidorf M; King VL; Pierce J; Kolodner K; Brooner RK. Benefits of concurrent syringe exchange and substance abuse treatment participation. Journal of Substance Abuse Treatment 40(3): 265-271, 2011. (45 refs.)

Participation in syringe exchange programs (SEPs) is associated with many individual and public health benefits but may have little impact on reducing drug use without concurrent treatment engagement. This study evaluated rates of drug use, other risk behaviors, and illegal activities in newly registered SEP participants (N = 240) enrolled versus not enrolled in substance abuse treatment over a 4-month observation window and examined the effect of days in treatment on these outcomes. After controlling for baseline differences, SEP registrants enrolled in treatment (n = 113) reported less days of opioid and cocaine use, injection drug use, illegal activities, and incarceration than those not enrolled in treatment (n = 127). For those enrolled in treatment, days of treatment was strongly correlated with each of these outcomes. These findings provide good evidence for a dose response effect of treatment in syringe exchangers and suggest that substance abuse treatment significantly expands the harm reduction benefits of SEP participation.

King JP; Davis TC; Bailey SC; Jacobson KL; Hedlund LA; Di Francesco L et al. Developing consumer-centered, nonprescription drug labeling: A study in acetaminophen. American Journal of Preventive Medicine 40(6): 593- 598, 2011. (19 refs.)

Background: In the U. S., acetaminophen overdose has surpassed viral hepatitis as the leading cause of acute liver failure, and misuse contributes to more than 30,000 hospitalizations annually. Half to two thirds of acetaminophen overdoses are unintentional, suggesting the root cause is likely poor understanding of medication labeling or failure to recognize the consequences of exceeding the recommended maximum daily dosage. Purpose: Elicit subject feedback about active ingredient and dosing information on over-the-counter (OTC) acetaminophen and elicit feedback on proposed plain-language text and icons. Methods: Six focus groups, preceded by individual interviews, were conducted in April 2010 among 45 adults in two cities from two clinics and an adult basic education center. The individual interviews evaluated knowledge of OTC pain relievers, attention to product label information and literacy level while the group discussion elicited preference for label messages and icons. Analyses were conducted from April to June 2010. Results: Forty-four percent read at or below the 6th-grade level. Individual interviews revealed that <50% of participants routinely examine product label information. Only 31% know acetaminophen is in Tylenol (R). The groups achieved consensus on a preferred icon for acetaminophen, desired explicit statement of potential liver damage in the warning against simultaneous use of acetaminophen products, and indicated preference for an icon and wording for maximum dose. Conclusions: With the high prevalence of OTC use, a consumer-centered approach to developing icons and messages to promote awareness and safe use of acetaminophen could benefit consumers.

Ko NY; Hsu ST; Chen CH; Lee HC; Ko WC. Heroin dependence and bloodborne virus transmission behaviors for HIV infection among newly incarcerated injection drug users in Taiwan. Substance Use & Misuse 46(5): 591-598, 2011. (29 refs.)

The purpose of the study was to determine heroin dependence and risky behaviors associated with human immunodeficiency virus (HIV) infection among newly incarcerated injection drug users (IDUs). Three self-administrated questionnaires were collected among 450 newly incarcerated male heroin users during 2005-2007. Inmates were categorized as heroin-dependent if they met three or more of the six ICD-10 criteria. Heroin-dependent inmates had higher scores of bloodborne virus transmission risk than non-dependent IDUs (12.8 +/- 16.0 vs. 7.2 +/- 11.5, p < 0.001). Multiple logistic regression analysis indicated that heroin dependence was a significant moderator of the association between risky injection behaviors and HIV infection. It is crucial to integrate substance treatment with behavioral interventions into harm reduction programs to prevent bloodborne virus transmission among IDUs.

Korhonen T; Goodwin A; Miesmaa P; Dupuis EA; Kinnunen T. Smoking cessation program with exercise improves cardiovascular disease biomarkers in sedentary women. Journal of Women's Health 20(7): 1051-1064, 2011. (64 refs.)

Background: Several cardiovascular disease (CVD) biomarkers sensitive to tobacco exposure have been identified, but how tobacco use cessation impacts them is less clear. We sought to investigate the effects of a smoking cessation program with an exercise intervention on CVD biomarkers in sedentary women. Methods: This is a cohort study on a subsample of a 2 x 2 factorial randomized controlled trial (RCT) (exercise setting: home vs. facility; level of exercise counseling: prescription only vs. prescription and adherence counseling) conducted January 2004 through December 2007. The analyses were completed in October 2010. In the greater Boston area, 130 sedentary female smokers aged 19-55 completed a 15-week program. All participants received nicotine replacement therapy (transdermal patch) and brief behavioral counseling for 12 weeks. They all received an exercise prescription on a moderate intensity level. All exercise interventions lasted for 15 weeks, from 3 weeks precessation until 12 weeks postcessation. Main outcome measures. were selected CVD biomarkers hypothesized to be affected by smoking cessation or exercise measured at baseline and 12 weeks postcessation. Results: Independent of tobacco abstinence, improvement was seen in inflammation (white blood cells [WBC]), prothrombotic factor (red blood cells [RBC]), and cardiovascular fitness level (maximum oxygen consumption [Vo(2)max]). This suggests that even if complete abstinence is not achieved, reduction in tobacco exposure and increase in exercise can improve the cardiovascular risk profile. A significant decrease was seen for total cholesterol and the total cholesterol high-density lipoprotein cholesterol (HDL-C): ratio only among the abstainers. The heart rate was reduced among all participants, but this decrease was more profound among abstainers. A significant weight gain and body mass index (BMI) increase were observed among abstainers and those who relapsed. We also found an increase in hemoglobin A1c (Hb A1c), although significant only when the groups were combined. Conclusions: A smoking cessation intervention including exercise reduced tobacco-induced cardiovascular damage selectively within 3 months.

Lavoie D. Alcohol identification and brief advice in England: A major plank in alcohol harm reduction policy. (review). Drug and Alcohol Review 29(6): 608-611, 2010. (14 refs.)

Screening and brief interventions form a vital plank in England's plans to reduce alcohol-related harm. This article clarifies the use of terminology in England to describe various drinking categories and screening and brief interventions. It details efforts to implement these interventions, including recent incentive packages that have been put in place to encourage primary care to implement these interventions. It describes the Screening and Intervention Programme for Sensible Drinking research program that is underway to clarify tools and methods to introduce and support these interventions.

lBonar EE; Rosenberg H; Hoffmann E; Kraus SW; Kryszak E; Young KM et al. Measuring university students' self-efficacy to use drinking self-control strategies. Psychology of Addictive Behaviors 25(1): 155-161, 2011. (33 refs.)

Using a Web-based, self-administered questionnaire, we assessed 498 university-student drinkers' self-efficacy to use 31 different behavioral strategies to reduce excessive drinking in each of three different locations (bar, party, own dorm/apartment). Averaging all 31 items within each drinking situation to create a single scale score revealed high internal consistency reliabilities and moderate inter-item correlations. Testing the association of self-efficacy with drinking location, sex, and frequency of recent binge drinking, we found that respondents reported higher self-efficacy to use these strategies when drinking in their own dorm/apartment than when drinking in bars and at parties; women reported higher mean self-efficacy than men; and drinkers who engaged in 3-or-more binges in the previous 2 weeks reported lower self-efficacy than those who reported either 0 or 1-or-2 binges in the same time period. This questionnaire could be used to identify self-efficacy deficits among clients with drinking problems and as an outcome measure to assess the degree to which interventions influence reported confidence to use specific drinking-reduction strategies in high-risk drinking situations.

Le Houezec J; McNeill A; Britton J. Tobacco, nicotine and harm reduction. Drug and Alcohol Review 30(2): 119-123, 2011. (28 refs.)

Issues. Tobacco smoking, sustained by nicotine dependence, is a chronic relapsing disorder, which in many cases results in lifelong cigarette use and consequent death of one out of two lifelong smokers from a disease caused by their smoking. Most toxicity due to cigarette smoking is related to the burning process. Approach. Models of harm reduction applied to tobacco suggest that use of non-combustible, less toxic, nicotine-containing products as a substitute for cigarette smoking would reduce the death toll arising from tobacco use. Available options include medicinal nicotine and smokeless tobacco products. Key Findings. The potential role of nicotine replacement therapy (NRT) products in a harm reduction strategy is currently severely restricted by strict regulations on dose, safety and potential addictiveness. As a result, NRT products are designed to provide much less nicotine, and deliver it to the brain more slowly, than cigarettes, which are widely accessible and poorly regulated. Smokeless tobacco (snus) has proved to be an acceptable reduced hazard alternative to smoking in Sweden, but supply of snus is illegal elsewhere in the European Union. Implications. To increase accessibility and reach more smokers, barriers to the use of NRT use need to be removed and more effective NRTs need urgently to be developed. Smokeless tobacco could also play an important role in harm reduction, but current European Union regulations and concerns over exploitation by tobacco companies currently preclude wider use. Conclusion. To improve public health there is an urgent need for an appropriate regulatory framework and regulatory authority at the European level, controlling both tobacco and nicotine products to ensure that the least harmful products are the most accessible.

Lee HS; Zerai A. "Everyone deserves services no matter what": Defining success in harm-reduction-based substance user treatment. Substance Use & Misuse 45(14): 2411-2427, 2010. (16 refs.)

This article reports qualitative interview data from a study of participant-generated outcomes of two harm reduction programs in the United States. We address the question: "What does success in harm-reduction-based substance user treatment look like?" Providers in this study understood harm reduction to adhere to notions of "any positive change," client centeredness, and low-threshold services. Participants reported changes in demarginalization, engagement in the program, quality of life, social functioning, changes in substance use, and changes in future goals and plans. The nature of these changes is difficult to articulate within traditional notions of success (i.e., abstinence, program completion, etc.). We conclude that participants in harm reduction programs experience tangible positive changes but that legitimation of these changes calls for a reconceptualization of "outcomes" and "success" in the current context of substance user treatment and research.

Mackenzie R. The neuroethics of pleasure and addiction in public health strategies moving beyond harm reduction: Funding the creation of non-addictive drugs and taxonomies of pleasure. Neuroethics 4(2, special issue): 103-117, 2011. (119 refs.)

We are unlikely to stop seeking pleasure, as this would prejudice our health and well-being. Yet many psychoactive substances providing pleasure are outlawed as illicit recreational drugs, despite the fact that only some of them are addictive to some people. Efforts to redress their prohibition, or to reform legislation so that penalties are proportionate to harm have largely failed. Yet, if choices over seeking pleasure are ethical insofar as they avoid harm to oneself or others, public health strategies should foster ethical choice by moving beyond current risk management practices embodied in the harm reduction movement. The neuroscience of pleasure has much to offer neuroethics and public health strategies. Distinguishing between 'wanting' and 'liking' fosters new understandings of addiction. These hold promise for directing the search for pharmacotherapies which prevent addiction and relapse or disrupt associated neuromechanisms. They could inform new research into creating lawful psychoactive substances which give us pleasure without provoking addiction. As the health and well being of human and other animals rests upon the experience of pleasure, this would be an ethical objective within public health strategy. Were ethical and neurobiological obstacles to ending addiction to be overcome, problems associated with excessive consumption, the lure of unlawful psychoactive substances and the paucity of lawful means to achieve pleasurable altered states would remain. Non-addictive designer drugs, which reliably provided lawful access to pleasures and altered states, would ameliorate these public health concerns insofar as they fostered citizens' informed, ethical choices according to a neurobiological taxonomy of pleasures.

Malchy LA; Bungay V; Johnson JL; Buxton J. Do crack smoking practices change with the introduction of safer crack kits? Canadian Journal of Public Health 102(3): 188-192, 2011. (28 refs.)

Objectives: Crack smoking has increased in Vancouver despite the harms associated with its use. Many people who smoke crack share their equipment, thereby increasing their risk for infectious disease. This project explored the effects of outreach distribution of "safer crack kits" on smoking practices. Methods: Two cross-sectional surveys were conducted, the first prior to kit distribution and the second a year later. Participants were individuals who smoked crack and lived in Vancouver's inner city. Crack smoking practices and use of items in the crack kit were documented. Results: The results of the second survey (i.e., following 12 months of kit distribution) showed an increase in availability and use of safer use items; mouthpieces and condoms provided in the kit were used by 79% and 59% of recipients, respectively. Unsafe practices were reported post distribution: although 42% used brass screens, the majority reported that they usually used Brillo (R); over 40% of respondents reported using syringe plungers to scrape crack resin; and participants reported sharing crack-use paraphernalia. Conclusion: While kit distribution made safer use items more accessible, its impact on safer use practice was limited. Our findings highlight the need for targeted distribution of safer use items. Future research should explore the dynamics of unsafe crack smoking practices and ways to leverage safer use messaging.

Martinus T; McAlaney J; McLaughlin LJ; Smith H. Outdoor music festivals: Cacophonous consumption or melodious moderation? Drugs: Education, Prevention and Policy 17(6): 795-807, 2010. (27 refs.)

Large outdoor music festivals have emerged as part of a general expansion of licensed recreational activities, but in research terms they have been largely impenetrable due to commercial sensitivities. These sensitivities notwithstanding, the number and scale of such events necessitate a greater understanding of alcohol and drug use and the potential to promote normative protective behaviours in this context. This study examines self-reported alcohol and drug behaviours of 1589 attendees at a music festival in Scotland during the summer of 2008. Similarities between the outdoor rock music festivals and the dance club scene are considered alongside the challenges associated with risk reduction in these settings. Results show that alcohol was consumed by the majority of samples; however, negative consequences were reported by a minority of respondents, suggesting evidence of controlled hedonism within a situation traditionally associated with unrestrained excess. Similarly, the majority of samples did not use drugs. The majority also report a number of self-regulating protective behaviours suggesting that alcohol and drug use is contained within a developing social culture of 'controlled intoxication'. Results further suggest that although music festivals are transitory events, there is a degree of consistency amongst attendees. Music festivals may therefore be atypical but potentially effective environments to increase protective behaviours using normative messaging and modern communications media. This study was resourced exclusively by local alcohol and drug partnerships.

Mcauley A; Lindsay G; Woods M; Louttit D. Responsible management and use of a personal take-home naloxone supply: A pilot project. Drugs: Education, Prevention and Policy 17(4): 388-399, 2010. (26 refs.)

Aims: To assess if Scottish drug users, their family and friends could be trained in critical incident management and the safe and effective administration of naloxone. The project also sought to monitor whether drug users can manage their own personal take-home naloxone (THN) supply and use it appropriately in an emergency opiate overdose situation. Methods: Twenty-three clients were trained alongside 18 'buddies' and 19 clients were issued with naloxone packs following successful completion of training. Findings: Three overdoses were witnessed by three participant clients during the pilot with two reported 'saves'; pilot training procedure was followed on both occasions. Each reported overdose was validated by police and ambulance service records. Eighty-nine percent (n = 17) were followed up at 2 months; 94% (n = 16) of these claimed to still have their THN; 89% (n = 17) followed up at 6 months; 100% (n = 17) of these claimed to still have their THN. Results: This data suggests that Scottish drug users can be trained to identify and respond to an opiate overdose utilizing basic life support and naloxone administration skills similar to their counterparts from other parts of the world. Moreover these results suggest that a majority of opiate users can responsibly manage their own personal THN supply when trained appropriately.

Mendez D; Alshanqeety O; Warner KE; Lantz PM; Courant PN. The impact of declining smoking on radon-related lung cancer in the United States. American Journal of Public Health 101(2): 310-314, 2011. (15 refs.)

Objectives. We examined the effect of current patterns of smoking rates on future radon-related lung cancer. Methods. We combined the model developed by the National Academy of Science's Committee on Health Risks of Exposure to Radon (the BEIR VI committee) for radon risk assessment with a forecasting model of US adult smoking prevalence to estimate proportional decline in radon-related deaths during the present century with and without mitigation of high-radon houses. Results. By 2025, the reduction in radon mortality from smoking reduction (15 percentage points) will surpass the maximum expected reduction from remediation (12 percentage points). Conclusions. Although still a genuine source of public health concern, radon-induced lung cancer is likely to decline substantially, driven by reductions in smoking rates. Smoking decline will reduce radon deaths more than remediation of high-radon houses, a fact that policymakers should consider as they contemplate the future of cancer control.

Miech R; Koester S; Dorsey-Holliman B. Increasing US mortality due to accidental poisoning: The role of the baby boom cohort. Addiction 106(4): 806-815, 2011. (30 refs.)

Aims: In this study we examine whether the recent, sharp increase in mortality in the United States due to accidental poisoning since 2000 is the result of the aging of the baby boom cohort or, instead, a historical trend apparent among decedents of all ages. Design: We conducted an age-period-cohort analysis using data from the US Vital Statistics and the US Census covering the period 1968-2007. Setting and participants The United States population aged 15-64 years. Measurements: Cause of death and demographic data as recorded on death certificates. Findings: The increase in mortality due to accidental poisoning since the year 2000 stems primarily from a historical period effect across all ages for whites, but results in large part from a rate spike in the baby boom cohort among blacks. For all demographic groups baby boomers had higher odds of death due to accidental poisoning than the cohorts that came before and after them. Historical influences acting across all ages led to an increase in accidental poisoning mortality that was almost 10-fold for whites and threefold for blacks over the study period. Conclusions: While the recent, sharp increase in accidental poisoning mortality stems in part from the aging of the baby boom cohort, substantially more of the increase results from influences unique to recent years that have affected all age groups. These results point to the need to bolster overdose prevention programs and policies as the historical increase in accidental poisoning mortality appears to continue unabated.

Miles M; Francis K; Chapman Y. Challenges for midwives: Pregnant women and illicit drug use. Australian Journal of Advanced Nursing 28(1): 83-90, 2010. (45 refs.)

Objective: The purpose of the paper is to introduce illicit drug use as a societal problem and describes the response of the Australian Government. Specifically the paper examines the use of illicit drugs by pregnant women and the role of midwives in supporting these women throughout pregnancy and birth. Setting: Maternity services, specifically antenatal care clinics. Conclusion: In Australia the rate of pregnant women who use illicit drugs is escalating. These pregnancies are high obstetric risk with potential for harm to both the mother and the baby. Pregnancy however is seen as 'window of opportunity'; a time to provide education, choices and support. The literature describes that for health professionals working with pregnant women who are illicit drug users is challenging and for some health professionals their interaction can be negative. Australia advocates harm minimisation and encourages harm reduction strategies. Midwives are in a position to implement these strategies within the maternity setting. Further research is recommended as well as professional development programs for midwives to upgrade knowledge and cultivate engagement skills to enable appropriate and positive interaction with pregnant women who use illicit drugs.

Misch DA. Changing the culture of alcohol abuse on campus: Lessons learned from secondhand smoke. Journal of American College Health 59(3): 232-234, 2011. (13 refs.)

Alcohol abuse is the single greatest public health hazard on American college and university campuses, but the culture of abusive alcohol consumption continues to be highly resistant to change. The author argues that secondhand smoke campaigns can be used as models to change the culture of alcohol abuse on campus. He proposes the implementation of "secondhand alcohol" campaigns and describes their essential components and advantages.

Monshouwer K; Van Laar M; Vollebergh WA. Buying cannabis in 'coffee shops'. Drug and Alcohol Review 30(2): 148-156, 2011. (27 refs.)

Issues. The key objective of Dutch cannabis policy is to prevent and limit the risks of cannabis consumption for users, their direct environment and society ('harm reduction'). This paper will focus on the tolerated sale of cannabis in 'coffee shops'. Approach. We give a brief overview of Dutch policy on coffee shops, its history and recent developments. Furthermore, we present epidemiological data that may be indicative of the effects of the coffee shop policy on cannabis and other drug use. Key Findings. Dutch coffee shop policy has become more restrictive in recent years and the number of coffee shops has decreased. Cannabis prevalence rates in the adult population are somewhat below the European average; the rate is relatively high among adolescents; and age of first use appears to be low. On a European level, the use of hard drugs in both the Dutch adult and adolescent population is average to low (except for ecstasy among adults). Implications and Conclusions. International comparisons do not suggest a strong, upward effect of the coffee shop system on levels of cannabis use, although prevalence rates among Dutch adolescents give rise to concern. Furthermore, the coffee shop system appears to be successful in separating the hard and soft drugs markets. Nevertheless, in recent years, issues concerning the involvement of organised crime and the public nuisance related to drug tourism have given rise to several restrictive measures on the local level and have sparked a political debate on the reform of Dutch drug policy.

Moore SC. Substitution and complementarity in the face of alcohol-specific policy interventions. Alcohol and Alcoholism 45(5): 403-408, 2010. (62 refs.)

Aim: Policy responses to the growing burden of alcohol-related disease fail to consider the interrelated nature of substance misuse and the potential for complex interactions in response to alcohol-specific interventions. This paper considers possible aggregate level responses to the alcohol policy and whether alcohol policy can be expected to reduce overall harm. Methods: A review and discussion of the relevant literature was conducted. Results: Evidence indicates that those at greatest risk consume stronger alcoholic beverages more frequently, that they are likely to complement their consumption with a range of intoxicants and that they are more likely to substitute alcohol with other substances. Conclusions: Policies aimed at reducing alcohol consumption can be successful. However, evidence suggests a significant minority of consumers are likely to substitute or complement consumption with a range of intoxicants suggesting that policy is unlikely to reduce all-cause mortality and morbidity. Further research into the nature of substitution and complementarity is required.

Moore SC; Brennan IR; Murphy S; Byrne E; Moore SN; Shepherd JP et al. The reduction of intoxication and disorder in premises licensed to serve alcohol: An exploratory randomised controlled trial. BMC Public Health 10: e-607, 2010. (29 refs.)

Background: Licensed premises offer a valuable point of intervention to reduce alcohol-related harm. Objective: To describe the research design for an exploratory trial examining the feasibility and acceptability of a premises-level intervention designed to reduce severe intoxication and related disorder. The study also aims to assess the feasibility of a potential future large scale effectiveness trial and provide information on key trial design parameters including inclusion criteria, premises recruitment methods, strategies to implement the intervention and trial design, outcome measures, data collection methods and intra-cluster correlations. Design: A randomised controlled trial in licensed premises that had experienced at least one assault in the year preceding the intervention, documented in police or hospital Emergency Department (ED) records. Premises were recruited from four study areas by piloting four recruitment strategies of varying intensity. Thirty two licensed premises were grouped into matched pairs to reduce potential bias and randomly allocated to the control or intervention condition. The study included a nested process evaluation to provide information on intervention acceptability and implementation. Outcome measures included police-recorded violent incidents, assault-related attendances at each premises' local ED and patron Breath Alcohol Concentration assessed on exiting and entering study premises. Results: The most successful recruitment method involved local police licensing officers and yielded a 100% success rate. Police-records of violence provided the most appropriate source of data about disorder at the premises level. Conclusion: The methodology of an exploratory trial is presented and despite challenges presented by the study environment it is argued an exploratory trial is warranted. Initial investigations in recruitment methods suggest that study premises should be recruited with the assistance of police officers. Police data were of sufficient quality to identify disorder and street surveys are a feasible method for measuring intoxication at the individual level.

Murray JM; Ritter A. Findings regarding reduced prevalence with hepatitis C treatment are still valid: A reply to Vickerman, et al (editorial). Drug and Alcohol Dependence 113(2-3): 86-87, 2011. (4 refs.)

Vickerman, et al (this issue) replicate our hepatitis C (HCV) treatment model, with variation to two parameters: the underlying prevalence of HCV and the percentage that fail HCV treatment. Given these changes to the parameters it is unsurprising that they find a greater treatment effect. Pleasingly, however, it is in the same direction as our result, adding confidence to our findings. Dialogue about underlying assumptions, alternate parameters and model construction is encouraging because we believe that this can enhance model veracity and provide more reliable estimates upon which health policy can be formulated. Unfortunately Vickerman et al do not model what we see as the central policy question of our two-group model: the impact on HCV prevalence of providing HCV treatment to injecting drug users in methadone maintenance versus those not in methadone maintenance treatment. Our original findings suggest that policy should preferentially direct treatment to current injectors.

Narayanan S; Vicknasingam B. Responses to the illicit drug problem: Insights from supply and demand analysis. Australian Economic Review 43(1): 88-99, 2010. (29 refs.)

This article has three objectives. First, it applies supply and demand analyses to better understand an important problem of immediate interest to young students of economics: illicit drug use. More specifically, it demonstrates how the tools of supply and demand can be used to evaluate the various approaches to achieving the commonly espoused objective of reducing drug use and the more ambitious one of achieving a 'drug-free society' that has driven the anti-drug campaigns of the United Nations (UN). Second, familiarity with the consequences of the available policy initiatives facilitates a better understanding of what an optimal policy might be and the challenge of implementing it. Finally, the principles enunciated will be used to better understand two case studies: one drawn from the Malaysian experience and the other from Australia. The author concludes that the tools of supply and demand clearly suggest the superiority of demand-reducing initiatives as compared to supply restrictions. The outcome of successful demand reduction will reduce both price and quantity used and is therefore unambiguously an improvement. In contrast, supply reduction can only hope to succeed if some special conditions exist: high price elasticity of demand and supply and a very low or negative social marginal value from drug use. These insights not withstanding, the enforcement approach has been widely embraced, not only because actions to limit supply are easier to identify and put into place but because drug supply is seen as a source of unmitigated evil and the need for authorities to be seen to be doing something about it. Yet, years of enforcement and the large amount of resources committed to stemming the inflow of drugs has yielded mixed results: some countries have shown better results than others, but none has succeeded in eradicating supply entirely . Despite the fact that the 'legalise-and-tax' approach can reproduce the price and quantity effects of a supply reduction efficiently and cheaply, the authorities are confronted with a moral dilemma because legalising the long-criminalised drug trade will unleash a powerful emotional backlash in most communities. The most workable solution appears to be an approach that retains traditional supply-side restraints but commits itself to transferring more resources to the implementation of fresh and imaginative demand reduction efforts such as harm reduction and education.

Narayanan S; Vicknasingam B; Robson NMH. The transition to harm reduction: Understanding the role of non-governmental organisations in Malaysia. International Journal of Drug Policy 22(4): 311-317, 2011. (34 refs.)

Background: The transition of drug policy from prohibition to harm reduction has never been easy. The deeply entrenched belief in prohibition shared by policy makers and religious leaders provided little room for alternatives, and change came only slowly. The non-governmental organisations (NGOs) in Malaysia played a pivotal role in effecting such a change. Understanding how they did so may be instructive for other similarly placed countries. Methods: Data collected via reviews of published secondary sources, media reports and in-depth interviews with pioneers of harm reduction drawn from NGOs, medical practitioners and the police were analysed to construct the paper. Results: The policy change was the outcome of competition between three groups in the drug policy subsystem - the state, the Muslim religious lobby and the NGOs. Developments such as the poor outcomes from the prohibition programmes and the outbreak of HIV/AIDS did not change policy but did lead to a rethink of core beliefs in the state alliance and spawned a state-NGO partnership. The subsequent failure to meet the Millennium Development Goal with respect to HIV/AIDS in 2005 - was seen as a failure of the Health Ministry which then led the final charge for a policy change arguing that a health crisis was imminent. The NGOs played a pivotal role in this process by educating their partners in the state coalition, by drawing academics and medical practitioners into advocacy and by engaging the religious lobby (albeit with varying success). They were also frontline players in implementing harm reduction programmes and successfully deflected criticisms from unconvinced Islamic groups away from the state. Conclusion: Given their central role in the needle-syringe exchange programme, the NGOs are well positioned to convince injecting drug users to opt for voluntary medical treatment. This can potentially reduce both the harm from drug use and the prevalence of it.

Neale J; Nettleton S; Pickering L. What is the role of harm reduction when drug users say they want abstinence? International Journal of Drug Policy 22(3): 189-193, 2011. (24 refs.)

Quantitative survey data indicate that most drug users starting treatment want abstinence rather than harm reduction (McKeganey et al., 2004). This finding has been seized upon by those seeking 'evidence' that abstinence is the bedrock of recovery and harm reduction is a negative and oppositional philosophy. However, all research involves questions of meaning, definition and value and an alternative research paradigm and different study design can provide important additional insights into treatment aspirations, including the desire for abstinence. Qualitative interviews conducted with 30 recovering heroin users (15 males and 15 females) in Southern England in 2009 confirm that those starting treatment often report a desire for abstinence. Nonetheless, drug users are frequently uncertain about their ability to achieve this and can have very different and inconsistent understandings of what being abstinent means. We suggest that the work of the critical theorist Habermas (1970, 1991) could improve our understanding of abstinence and is consistent with recent efforts to achieve a working definition of recovery. Importantly, our qualitative data also reveal that drug users have treatment aspirations that extend far beyond their drug consumption. They additionally want to improve relationships, engage in meaningful activities, acquire material possessions, and achieve better mental and physical health. Moreover, these broader life goals are often inextricably linked to their drug taking. From this, we conclude that both abstinence and harm reduction discourses should more routinely prioritise the many diverse 'wellness' goals that so clearly motivate treatment clients. The harm reduction field will then likely find that it has more in common with abstinence-oriented services and the broader recovery agenda than it might otherwise have imagined.

Neira-Leon M; Barrio G; Bravo MJ; Brugal MT; de la Fuente L; Domingo-Salvany A et al. Infrequent opioid overdose risk reduction behaviours among young adult heroin users in cities with wide coverage of HIV prevention programmes. International Journal of Drug Policy 22(1): 16-25, 2011. (59 refs.)

Background: Opioid overdose risk reduction behaviours include some preventive behaviours to avoid overdoses (PB) and others to avoid death after overdose, such as never using heroin while alone (NUA). Few studies have examined the prevalence and predictors of these behaviours. Aim: To establish the prevalence and predictors of PBs and NUA among heroin users, both injectors and non-injectors, in three Spanish cities. Methods: 516 injecting and 475 non-injecting heroin users aged 18-30 were street-recruited in 2001-2003 and interviewed by face-to-face computer-assisted interview. PBs and NUA in the last 12 months were explored using open-ended and precoded questions, respectively. Specific predictors for three PB categories were investigated: control of route of drug administration, control of quantity or type of heroin used, and control of co-use of other drugs. Bivariate and logistic regression methods were used. Results: Overall, the most prevalent PBs were: using a stable and not excessive amount of heroin (12.7%), injecting or using the whole heroin dose slowly or dividing it into smaller doses (12.4%), reducing or stopping heroin injection (8.3%), and not mixing heroin with tranquillisers (5.1%). Most PBs were significantly more prevalent among injectors than non-injectors. No one mentioned reducing the amount of heroin after an abstinence period. Some 36.2% had NUA. In multiple regression analysis, knowledge of risk factors for opioid overdose was a predictor of specific PBs, although this was not always the case. Use of syringe exchange programmes was a predictor of PB among injectors. However, attending methadone maintenance treatment (MMT) or other drug-dependence treatment was not a predictor of any opioid overdose reduction behaviour. Only ever having witnessed or experienced an overdose predicted PB in both injectors and non-injectors. Conclusions: The proportion of heroin users with opioid overdose risk reduction behaviours is very low. Additional specific measures to prevent overdose are needed, as well as increased emphasis on reducing the risk of overdose in programmes to prevent HIV and other blood-borne infections in heroin injectors.

Nelson TF; Toomey TL; Lenk KM; Erickson DJ; Winters KC. Implementation of NIAAA College Drinking Task Force Recommendations: How are colleges doing 6 years later? Alcoholism: Clinical and Experimental Research 34(10): 1687-1693, 2010. (20 refs.)

Background: In 2002, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) College Drinking Task Force issued recommendations to reduce heavy drinking by college students, but little is known about implementation of these recommendations. Current discussion about best strategies to reduce student drinking has focused more on lowering the minimum legal drinking age as advocated by a group of college and university presidents called the Amethyst Initiative than the NIAAA recommendations. Methods: A nationally representative survey of administrators was conducted at 351 4-year colleges in the United States to ascertain familiarity with and progress toward implementation of NIAAA recommendations. Implementation was compared by enrollment size, public or private status, and whether the school president signed the Amethyst Initiative. Results: Administrators at most colleges were familiar with NIAAA recommendations, although more than 1 in 5 (22%) were not. Nearly all colleges use educational programs to address student drinking (98%). Half the colleges (50%) offered intervention programs with documented efficacy for students at high risk for alcohol problems. Few colleges reported that empirically supported, community-based alcohol control strategies including conducting compliance checks to monitor illegal alcohol sales (33%), instituting mandatory responsible beverage service (RBS) training (15%), restricting alcohol outlet density (7%), or increasing the price of alcohol (2%) were operating in their community. Less than half the colleges with RBS training and compliance checks in their communities actively participated in these interventions. Large colleges were more likely to have RBS training and compliance checks, but no differences in implementation were found across public/private status or whether the college president signed the Amethyst Initiative. Conclusions: Many colleges offer empirically supported programs for high-risk drinkers, but few have implemented other strategies recommended by NIAAA to address student drinking. Opportunities exist to reduce student drinking through implementation of existing, empirically based strategies.

Parry R; Prior B; Sykes AJ; Tay JL; Walsh B; Wright N et al. Smokefree streets: A pilot study of methods to inform policy. Nicotine & Tobacco Research 13(5): 389- 394, 2011. (27 refs.)

Introduction: Smokefree street policies are relatively rare, and little has been published on the methods for establishing an evidence base to inform such policy making. We aimed to (a) pilot methods for such data collection in New Zealand, a country where local governments are actively pursuing outdoor smokefree policies and (a) to provide data on smoking behavior, attitudes toward smokefree policies, and levels of smoke exposure on streets in Wellington. Methods: Three methods were piloted: (a) systematic observation of smoking behavior by observers walking a standard route of major streets, the "Golden Mile" (GM) in Wellington (n = 42 observation runs); (b) measurement of fine particulate levels (PM2.5) along this route and with purposeful sampling in selected settings; and (c) an attitudinal survey of pedestrians along sections of this route. Results: Each of the 3 methods proved to be feasible in this urban setting. A total of 932 smokers were observed during 21 hr of observation, an average of 7 smokers every 10 min of walking. Air monitoring indicated fine particulate exposure. Levels of (mean) PM2.5 were 1.5 times higher during periods when smoking was observed than when they were not (9.3 vs. 6.3 mu g/m(3), p = .002). Dose-response patterns were observed for smoking proximity and for smoker numbers. Surveying pedestrians (n = 220) with a brief questionnaire achieved an 81% response rate and was able to identify variation in support for a smokefree GM by different groups (overall support was 55.9%, 95% CI = 49.3%-62.4%). Reasons for support were also identified, for example, perceived health hazards, at 34.1%, was the main reason. Conclusions: These methods can provide information that may contribute to the smokefree streets policymaking process and may also be relevant to informing other smokefree outdoor policies.

Pennay A; Lubman DI; MacLean S. Risky drinking among young Australians: Causes, effects and implications for GPs. Australian Family Physician 40(8): 584-588, 2011. (29 refs.)

Background: Rates of risky drinking among young Australians have increased substantially over the past 2 decades, resulting in significant community concern. Objective: To explore the social, cultural and economic contexts that underlie risky drinking among young people and the implications of these for general practitioners. Discussion: Effective strategies for reducing alcohol related harm among young people must be developed in the context of the social and cultural forces to which risky drinking is inextricably linked. It is important that GPs not only play the role of health provider (by identifying risky drinking where possible and providing harm reduction advice), but also act as public health advocates, using their position as respected health experts to encourage a shift in alcohol policy, legislation, marketing and promotion.

Pennay A; Moore D. Exploring the micro-politics of normalisation: Narratives of pleasure, self-control and desire in a sample of young Australian 'party drug' users. Addiction Research & Theory 18(5): 557-571, 2010. (52 refs.)

This article explores the micro-politics of recreational use of illicit 'party drugs' in a social network of young Australians. These young people often engage in extended sessions of concurrent alcohol and other drug use, and regularly emphasise the pleasures associated with this use. However, as well-integrated young people, they are also exposed to the discourses of non-using friends, family and the wider society, which represent illicit drug use as a potential moral threat. Some group members invoked the need for self-control in relation to illicit drug use and had developed a number of strategies to cease or regulate their use. However, they struggled to regulate pleasure and drew on popular understandings of 'excessive' drug use as indicative of flawed neo-liberal subjectivity. Other group members rejected the need for self-control, choosing instead to emphasise the value of unrestrained bodily pleasure facilitated by the heavy use of illicit drugs. These co-existing discourses point to the complex ways in which illicit drug users try to challenge the stigma associated with their drug use. Our analysis suggests that future accounts of illicit drug use, and harm reduction initiatives, need to be more attentive to the micro-politics of normalisation. How should harm reduction respond to those who articulate its ethos but pursue pleasure in practice? What should harm reduction say to those who reject regulation on the grounds that it stifles pleasure? Discussing ways to incorporate pleasure into harm reduction should be central to the future development of policy and practice.

Pensuksan WC; Taneepanichskul S; Williams MA. A peer-drinking group motivational intervention among Thai male undergraduate students. International Journal of Drug Policy 21(5): 432-436, 2010. (21 refs.)

Background: Excessive alcohol consumption, particularly among young males, is an important global health problem, in part because of the increased risks of intentional and non-intentional injuries, uses of illicit drug, crime, and psychiatric disorders. There are no data available to evaluate the extent to which interventions are effective in reducing hazardous/harmful alcohol consumption among young males in Thailand. We examined the efficacy of alcohol harm reduction strategies administered as a peer-drinking group motivational intervention (PD-GMI) among Thai male undergraduates. Methods: We used a quasi-experimental study design that included two student groups assessed at baseline and at two time points post-intervention. Participants were students enrolled in two public universities and who reported alcohol consumption during the current academic year. Students in one university were assigned to an assessment-only study group (n = 110); and students in the other university were assigned to a 2-h PD-GMI (n = 115). This intervention was designed to (1) increase the awareness of risks associated with hazardous/harmful alcohol consumption; (2) enhance students' motivation to change their drinking behaviours; and (3) encourage harm reduction strategies during episodes of alcohol consumption. Alcohol consumption and adverse consequences were assessed using the Alcohol Use Disorders Identification Test (AUDIT) and the Rutgers Alcohol Problem Index (RAPI). Results: Students receiving the intervention had significant reductions in mean AUDIT scores; 50.4% at baseline to 1-month and 61.2% at baseline to 3-month post-intervention. Their mean RAPI scores were also reduced; 42.0% at baseline to 1-month and 42.9% at baseline to 3-month post-intervention. Reductions in alcohol consumption and the prevalence of harmful alcohol consumption patterns were statistically significant among students in the intervention group versus those in the control group. The reductions remained after adjustments for baseline differences. Conclusions: These results suggest the efficacy of the PD-GMI intervention for reducing alcohol consumption and adverse consequences among Thai male students.

Poehlmann J; Dallaire D; Loper AB; Shear LD. Children's contact with their incarcerated parents research findings and recommendations. American Psychologist 65(6): 575-598, 2010. (94 refs.)

Approximately 1.7 million children have parents who are incarcerated in prison in the United States, and possibly millions of additional children have a parent incarcerated in jail. Many affected children experience increased risk for developing behavior problems, academic failure, and substance abuse. For a growing number of children, incarcerated parents, caregivers, and professionals, parent child contact during the imprisonment period is a key issue. In this article, we present a conceptual model to provide a framework within which to interpret findings about parent child contact when parents are incarcerated. We then summarize recent research examining parent child contact in context. On the basis of the research reviewed, we present initial recommendations for children's contact with incarcerated parents and also suggest areas for future intervention and research with this vulnerable population.

Rachlis B; Lloyd-Smith E; Small W; Tobin D; Stone D; Li K et al. Harmful microinjecting practices among a cohort of injection drug users in Vancouver Canada. Substance Use & Misuse 45(9): 1351-1366, 2010. (59 refs.)

Objectives: We sought to identify factors associated with harmful microinjecting practices in a longitudinal cohort of IDU. Methods: Using data from the Vancouver Injection Drug Users Study (VIDUS) between January 2004 and December 2005, generalized estimating equations (GEE) logistic regression was performed to examine sociodemographic and behavioral factors associated with four harmful microinjecting practices (frequent rushed injecting, frequent syringe borrowing, frequently injecting with a used water capsule, frequently injecting alone). Results: In total, 620 participants were included in the present analysis. Our study included 251 (40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The median age was 31.9 (interquartile range: 23.4-39.3). GEE analyses found that each harmful microinjecting practice was associated with a unique profile of sociodemographic and behavioral factors. Discussion: We observed high rates of harmful microinjecting practices among IDU. The present study describes the epidemiology of harmful microinjecting practices and points to the need for strategies that target higher risk individuals including the use of peer-driven programs and drug-specific approaches in an effort to promote safer injecting practices.

Roux P; Carrieri MP; Keijzer L; Dasgupta N. Reducing harm from injecting pharmaceutical tablet or capsule material by injecting drug users. Drug and Alcohol Review 30(3): 287- 290, 2011. (33 refs.)

Background. It has long been known that drug users may use a variety of pharmaceutical preparations by injection, many of which are not intended for intravenous administration (e.g. buprenorphine, methylphenidate, oxycodone). The introduction of tablet fillers such as talc or starch, in the blood circulation may cause, besides local injection site complications, pulmonary emboli. To reduce the harmful consequences of injecting such solutions, drug users have been encouraged to use filters. This research studied the effectiveness of an injection drug user syringe filter (IDUSF) in eliminating these particles. Methods. Generic buprenorphine and methylphenidate (Ritaline (R)), both containing talc, are frequently diverted for use by injection in France. The aim of our laboratory-based study was to compare the effectiveness of an IDUSF (Sterifilt (R), filter pore size = 10 mu m) versus no filtration, at reducing the number of particles in solutions of dissolved generic buprenorphine and Ritaline (R). Results. Compared with a non-filtered solution drawn up through a 30G needle, filtering of the generic buprenorphine solution eliminated approximately 85% of all particles between 1 and 5 mu m in diameter and 97% of particles between 5 and 18 mu m. In the Ritaline (R) solution, these values were two-thirds and 95%, respectively. Conclusion. Preliminary results indicate that IDUSF are effective in significantly filtering out large particles, which are responsible for major harms like pulmonary emboli. One strategy for alleviating these consequences is to promote the implementation of IDUSF in harm reduction programs, accompanied by training of social workers, peers and drug users.

Rutqvist LE; Curvall M; Hassler T; Ringberger T; Wahlberg I. Swedish snus and the GothiaTek (R) standard. (review). Harm Reduction Journal 8(e-article 11), 2011. (38 refs.)

Some smokeless tobacco products, such as Swedish snus, are today considered to be associated with substantially fewer health hazards than cigarettes. This risk differential has contributed to the scientific debate about the possibilities of harm reduction within the tobacco area. Although current manufacturing methods for snus build on those that were introduced more than a century ago, the low levels of unwanted substances in modern Swedish snus are largely due to improvements in production techniques and selection of raw materials in combination with several programs for quality assurance and quality control. These measures have been successively introduced during the past 30-40 years. In the late 1990s they formed the basis for a voluntary quality standard for Swedish snus named GothiaTek (R). In recent years the standard has been accepted by the members of the trade organization European Smokeless Tobacco Council (ESTOC) so it has now evolved into an industrial standard for all smokeless tobacco products in Europe. The initial impetus for the mentioned changes of the production was quality problems related to microbial activity and formation of ammonia and nitrite in the finished products. Other contributing factors were that snus came under the jurisdiction of the Swedish Food Act in 1971, and concerns that emerged in the 1960s and 1970s about health effects of tobacco, and the significance of agrochemical residues and other potential toxicants in food stuffs. This paper summarizes the historical development of the manufacture of Swedish snus, describes the chemical composition of modern snus, and gives the background and rationale for the GothiaTek (R) standard, including the selection of constituents for which the standard sets limits. The paper also discusses the potential future of this voluntary standard in relation to current discussions about tobacco harm reduction and regulatory science in tobacco control.

Sellman JD; Connor JL; Joyce PR. How to reduce alcohol-related problems in adolescents: What can parents do and what can the government do? (editorial). Australian and New Zealand Journal of Psychiatry 44(9): 771-773, 2010. (10 refs.)

Shi Y; Warner DO. Pediatric surgery and parental smoking behavior. Anesthesiology 115(1): 12-17, 2011. (24 refs.)

Background: Secondhand smoke exposure poses health risks to children, including increased risks for anesthesia. In adult smokers, surgery serves as a teachable moment to motivate quitting. For parents who smoke, having a child undergo surgery may also serve as a teachable moment for smoking behavioral change. This study determined if there is an association between children undergoing a surgical procedure and changes in their parents' smoking behavior. Methods: Secondary analyses were performed using logistic regression analysis of 2005 survey data from the National Health Interview Survey. Analyses included 9,289 parent respondents who provided information on both themselves and their children. Results: Of the sampled children, 1,112 (12.6%, 95% CI: 11.7, 13.4) lived in a home with at least one person who smoked inside in a usual week. In multivariate analysis of the relationship between parent and child surgical history in the past 12 months and smoking behavior, surgery in either the parent (odds ratio 2.19, 95% CI: 1.55, 3.08) or child (odds ratio 2.61, 95% CI: 1.56, 4.35) was associated with an increased likelihood of a quit attempt by the parent. However, these attempts were more likely to be successful if the parents (odds ratio 2.35, 95% CI: 1.35, 4.07), not their child (odds ratio 0.51, 95% CI: 0.20, 1.28), had surgery within the past 12 months. Conclusions: Parents who smoke were more likely to make a quit attempt within the past 12 months if their children had surgery within this time, but they were not more likely to succeed in maintaining abstinence and thus could benefit from assistance.

Skidmore JR; Murphy JG. The effect of drink price and next-day responsibilities on college student drinking: A behavioral economic analysis. Psychology of Addictive Behaviors 25(1): 57-68, 2011. (52 refs.)

More than [3/4] of U.S. college students report a heavy drinking, episode (FIDE; 5 (for men) and 4 (for women) drinks during an occasion) in the previous 90 days. This pattern of drinking is associated with various risks and social problems for both the heavy drinkers and the larger college community. According to behavioral economics, college student drinking is a contextually bound phenomenon that is impacted by contingencies such as price and competing alternative reinforcers, including next-day responsibilities such as college classes. This study systematically examines the role of these variables by using hypothetical alcohol purchase tasks to analyze alcohol consumption and expenditures among college students who reported recent heavy drinking (N = 207, 53.1% women). The impact of gender and the personality risk factor sensation seeking (SS) were also assessed. Students were asked how many drinks they would purchase and consume across 17 drink prices and 3 next-day responsibility scenarios. Mean levels of hypothetical consumption were highly sensitive to both drink price and next-day responsibility, with the lowest drinking levels associated with high drink prices and a next-day test. Men and participants with greater levels of SS reported more demand overall (greater consumption and expenditures) than women and students with low SS personality. Contrary to our hypotheses women appeared to be less sensitive to increases in price than men. The results suggest that increasing drink prices and morning academic requirements may be useful in preventing heavy drinking among college students.

Small W; Shoveller J; Moore D; Tyndall M; Wood E; Kerr T. Injection drug users' access to a supervised injection facility in Vancouver, Canada: The influence of operating policies and local drug culture. Qualitative Health Research 21(6): 743- 756, 2011. (74 refs.)

North America's first supervised injection facility (SIF) was established in Vancouver, Canada, in 2003. Although evaluation research has documented reductions in risk behavior among SIF users, there has been limited examination of the influence of operational features on injection drug users' access to these facilities. We conducted an ethnographic study that included observational research within the SIF, 50 in-depth individual interviews with SIF users, and analysis of the regulatory frameworks governing the SIF. The government-granted exemption allowing the facility to operate legally imposes key operating regulations, as well as a cap on capacity, which results in significant wait times to enter the injecting room. Regulations that prohibit practices that are common in the local drug culture also negatively affect SIF utilization. Restructuring policies that shape the operation of the SIF could enhance access to the facility and permit SIF services to better accommodate local drug use practices.

Smye V; Browne AJ; Varcoe C; Josewski V. Harm reduction, methadone maintenance treatment and the root causes of health and social inequities: An intersectional lens in the Canadian context. Harm Reduction Journal 8(17), 2011. (79 refs.)

Background: Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment (MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT, particularly how Harm Reduction and MMT are experienced differently by people dependent on how they are positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of domination and oppression. Methods: A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients accessing mainstream mental health and addictions care and primary health care settings and healthcare providers; Results: All client-participants had profound histories of abuse and violence, most often connected to the legacy of colonialism (e. g., residential schooling) and ongoing colonial practices (e. g., stigma & everyday racism). Participants lived with co-occurring illness (e. g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday experiences both within and outside the system that further marginalize them. In this paper, we focus on three intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing enactment of peoples' agency, and homelessness; Conclusions: Harm reduction must move beyond a narrow concern with the harms directly related to drugs and drug use practices to address the harms associated with the determinants of drug use and drug and health policy. An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of and commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.

Sproule BA. Decreasing the harms of prescription opioids: A case for pharmacists. (editorial). Drug and Alcohol Review 30(3): 327- 329, 2011. (11 refs.)

Teschke R; Sarris J; Glass X; Schulze J. Kava, the anxiolytic herb: Back to basics to prevent liver injury? British Journal of Clinical Pharmacology 71(3): 445-448, 2011. (23 refs.)

The use of the anxiolytic herb kava has caused toxic liver injury in Western countries and economic problems in South Pacific Islands due to tthe regulatory ban on kava. This analysis shows poor quality of kava raw material as a cause for its toxicity and suggests preventative measures by going back to the traditional use of kava for the sake of the patients and the South Pacific economy.

Velander F; Schineanu A; Midford R. Attitudes and knowledge of alcohol related harm minimization initiatives in a rural Australian city: A baseline survey. Drugs: Education, Prevention and Policy 17(4): 354-369, 2010. (21 refs.)

Aims: This study investigates the knowledge and attitudes towards alcohol related harm minimization initiatives in Kalgoorlie-Boulder, Western Australia, as part of a community project aimed at reducing harms associated with excessive drinking. Methods: Baseline data were collected from a stratified, community sample, using a purpose designed instrument. The community's readiness was determined by interviewing key stakeholders and community leaders, using the 'Readiness for Change' interview instrument. Findings: There were substantial levels of binge drinking accompanied by low awareness of alcohol as a local problem and lack of knowledge about interventions that are currently operating in the community. Support for measures designed to reduce problems associated with excessive use of alcohol was polarized. Community readiness to tackle alcohol related issues was low indicating a need for awareness raising. Conclusions: These findings are critical to informing the development of interventions to ensure they are tailored to this community's needs and abilities. Since knowledge and awareness of alcohol related issues are low in Kalgoorlie-Boulder, the first step in changing community attitudes is to create greater awareness of these issues and their consequences, and provide information on potential interventions to address the current problems.

Vickerman P; Martin N; Hickman M. Can Hepatitis C virus treatment be used as a prevention strategy? Additional model projections for Australia and elsewhere. (editorial). Drug and Alcohol Dependence 113(2-3): 83-85, 2011. (15 refs.)

Zeiler et al (2010) use a simple model to project the potential prevention utility of using pegylated interferon and ribavirin to treat active injecting drug users (IDUs) for HCV infection. Their analysis shows that increasing the level of HCV treatment in Australia could dramatically reduce the prevalence of HCV infection among IDUs. We argue that their projections are under-estimating the possible impact of HCV treatment because their assumed prevalence of active HCV infection in Australia is too high (assumed prevalence of acute plus chronic is 60%) and their model effectively assumes a treatment efficacy of 33%. We replicate their model and show that if these issues are corrected (assuming 45% prevalence of active HCV infection, i.e. similar to 60% antibody prevalence and 50% treatment efficacy), then substantially greater impact can be achieved. In addition, we show that the effect of HCV treatment on the primary prevention of HCV increases in populations with lower background HCV prevalence. We also query their finding that HCV treatment should be preferentially targeted to IDUs not on methadone maintenance treatment.

Wan MP; Wu CL; Chan TT; Chao CYH; Yeung LL. Removal and leakage of environmental tobacco smoke from a model smoking room. Journal of Occupational and Environmental Hygiene 7(10): 573-584, 2010. (21 refs.)

Experimental studies on the removal of accumulated environmental tobacco smoke (ETS) and the effectiveness of ETS leakage control were carried out in a model smoking room using carbon monoxide, nicotine, 3-ethenylpyridine, respirable suspended particulates, and ultrafine particles (UFP) as the ETS tracers. The study investigated the effectiveness of the designated smoking room, equipped with a displacement ventilation system under different ventilation rates (10-58 L/sec per person,) in removing the ETS tracers. The extent of ETS leakage through different door operating scenarios under various ventilation rates was intensively studied. In particular a manikin installed on a motorized rail was used to study the effect of human movement on the leakage of the ETS tracers. A double-door anteroom design was incorporated into the smoking room to study its effectiveness in ETS leakage prevention. It shows that at least 5 Pa of negative pressure, a fresh air supply rate 3-5 times higher than a typical office, direct air exhaust without air recirculation, and keeping the door closed are important for reducing ETS leakage. However with the smokers moving in and out and the opening of the door, noticeable leakage of ETS can occur The double-door anteroom design can improve leakage prevention. Among the five tracers, nicotine required the longest purging time to remove, after the smoking activity was stopped in the smoking room, due to its highly sorptive property. At least 4.4-6 hr of purging is needed for minimizing ETS exposure by non-smokers entering the smoking room. The peak size of particulate matter inside the smoking room is about 80 100 nm, suggesting the importance of including UFP as an indicator for monitoring the exposure and leakage of ETS. The impact of manikin movement on contaminant transport was studied, providing useful information on the effects of human activities on indoor air quality multicompartmental modeling.

Washam C. Can cigarette alternatives deliver a safer fix? (editorial). Environmental Health Perspectives 119(7): A286-A287, 2011. (14 refs.)

Wood DM; Who S; Alldus G; Huggett D; Nicolaou M; Chapman K et al. The development of the recreational drug outreach educational concept 'Drug Idle'. Journal of Substance Use 15(4): 237-245, 2010. (11 refs.)

Background: Recreational drug use in common, particularly in those attending nightclubs. Their knowledge about the potential toxicity of drugs and how to manage this is variable. Methods: We therefore established a multidisciplinary local network of key stakeholders interested in the prevention and management of recreational drug toxicity. Through this network we designed a unique outreach educational concept, 'Drug Idle', for recreational drug users and their friends. This was run within nightclub environments in a user-friendly, non-judgemental forum. We describe here the development of this educational concept and how it was evaluated and adapted on the basis of feedback from attendees. Results: 149 attended the three Drug Idle events as part of this study. All of those trialling the finalized concept thought all three components of the concept were useful, 96.0% that it was of appropriate duration and 98.8% that they would recommend future events to a friend. Conclusions: We believe that wider use of this outreach educational concept will help to improve the knowledge of those using recreational drugs, especially concerning management of drug toxicity. Additionally, it will provide them with information that will enable them to make informed decisions about the risk of continuing use of recreational drugs.

Young AM; Havens JR; Leukefeld CG. Route of administration for illicit prescription opioids: A comparison of rural and urban drug users. Harm Reduction Journal 7(e-24), 2010. (68 refs.)

Background: Nonmedical prescription opioid use has emerged as a major public health concern in recent years, particularly in rural Appalachia. Little is known about the routes of administration (ROA) involved in nonmedical prescription opioid use among rural and urban drug users. The purpose of this study was to describe rural-urban differences in ROA for nonmedical prescription opioid use. Methods: A purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric disorders, and self-reported nonmedical use and ROA (swallowing, snorting, injecting) for the following prescription drugs: buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, OxyContin (R) and other oxycodone. Results: Among urban participants, swallowing was the most common ROA, contrasting sharply with substance-specific variation in ROA among rural participants. Among rural participants, snorting was the most frequent ROA for hydrocodone, methadone, OxyContin (R), and oxycodone, while injection was most common for hydromorphone and morphine. In age-, gender-, and race-adjusted analyses, rural participants had significantly higher odds of snorting hydrocodone, OxyContin (R), and oxycodone than urban participants. Urban participants had significantly higher odds of swallowing hydrocodone and oxycodone than did rural participants. Notably, among rural participants, 67% of hydromorphone users and 63% of morphine users had injected the drugs. Conclusions: Alternative ROA are common among rural drug users. This finding has implications for rural substance abuse treatment and harm reduction, in which interventions should incorporate methods to prevent and reduce route-specific health complications of drug use.