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CORK Bibliography: Harm Reduction

129 citations. January 2007 to present

Prepared: September 2008

Aceijas C; Hickman M; Donoghoe MC; Burrows D; Stuikyte R. Access and coverage of needle and syringe programmes (NSP) in Central and Eastern Europe and Central Asia. Addiction 102(8): 1244-1250, 2007. (41 refs.)

Objective To estimate access, activity and coverage of needle and syringe programmes (NSP) in Central and Eastern Europe and Central Asia. Methods Two data sets ('regional' and 'high-coverage sites') were used to estimate NSP provision (availability/number of sites), NSP utilization (syringes distributed/year), needle and syringe distribution (needles/syringes distributed/IDU/year), IDU reached (number/percentage of IDU contacted/year), regular reach (five or more contacts/month) and syringe coverage (percentage of injections/IDU/year administrable with new injecting equipment). Results Regional data set: results from 213 sites in 25 countries suggested that Czech Republic, Poland, Russia and Ukraine had > 10 NSP during 2001/2. Czech Republic, Kazakhstan, Latvia, Russia, Slovakia and Ukraine had >= 10 000 IDU in contact with NSP. Ten countries reached >= 10% of the estimated IDU population. The 25 countries distributed similar to 17 million syringes/needles. Eight countries distributed > 0.5 million syringes/year. Syringe coverage (assuming 400 injections/IDU/year) was < 5% in 19 countries, 5-15% in five and > 15% in Macedonia. Overall syringe coverage was 1.2% and when assuming 700 injections/IDU/year it decreased to 0.7%. Syringe coverage for the IDU population in contact with NSP was <= 15% in 10 countries, 15-60% in 11 and > 60% in Croatia, Macedonia, Moldova and Tajikistan. Overall syringe coverage for the population in contact with NSP was 9.8%. High-coverage data set: Soligorsk, Pskov and Sumy's NSP reached 92.3%, 92.2% and 73.3% of their estimated IDU population, respectively (regular reach: 0.2%, 1.8% and 22.7%). The distribution levels were 47.2, 51.7 and 94.2 syringes/IDU/year, respectively. Conclusion: The evidence suggests suboptimal levels of NSP implementation, programme activity and coverage. This paper provides a baseline for development of indicators that could be used to monitor NSP. Strategies to increase coverage that may go beyond NSP are urgently required, as is research into understanding how NSP can contribute to better syringe coverage among IDU.

Armitage CJ; Harris PR; Hepton G; Napper L. Self-affirmation increases acceptance of health-risk information among UK adult smokers with low socioeconomic status. Psychology of Addictive Behaviors 22(1): 88-95, 2008. (28 refs.)

This study reports an experiment designed to test whether self-affirmation can overcome defensive processing of risk information in a sample of UK adult smokers with low socioeconomic status. Participants (N = 57) were randomized to either a self-affirmation or control condition before reading a government-sponsored antismoking leaflet and completing measures of message acceptance, intention, and self-efficacy. Participants' subsequent behavior (taking leaflets) was recorded surreptitiously. Results showed that the manipulation significantly increased message acceptance, intention and behavior, and that the effects of the manipulation on behavior were mediated through message acceptance and intention. The practical and theoretical implications of the findings are discussed in relation to the possible use of self-affirmation manipulations to enhance the effectiveness of smoking cessation interventions.

Baca CT; Grant KJ. What heroin users tell us about overdose. Journal of Addictive Diseases 26(4): 63-68, 2007. (26 refs.)

This study describes overdose experiences of heroin users, both the overdoses they themselves experienced, as well as those that they witnessed. A structured interview was performed with 101 current heroin users in Albuquerque, New Mexico from January 7, 2002 to February 26, 2002. Heroin-related overdoses were found to be common in this sample of heroin users. Three or more persons were reported to be present during 80 of the 95 most recently witnessed overdoses. An ambulance was called in only 42 of the 95 witnessed overdoses. Seventy-five percent of the respondents who witnessed an overdose stated concern over police involvement was an important reason for delay or absence of a 911 call for help. One hundred of the 101 respondents reported willingness, if trained, to use rescue breathing and to inject naloxone to aid an overdose victim. New methods need to he found to reduce heroin overdose death. Scientific studies are needed on the efficacy of take-home naloxone.

Baezconde-Garbanati L; Beebe LA; Perez-Stable EJ. Building capacity to address tobacco-related disparities among American Indian and Hispanic/Latino communities: Conceptual and systemic considerations. Addiction 102(Supplement 2): 112-122, 2007. (23 refs.)

Aim: To discuss systemic and conceptual issues that surround capacity building for tobacco control in traditionally underserved communities, by presenting two case studies, one in an American Indian community and another in a Hispanic/Latino community. Design: Key informant interviews, cross-sectional surveys and case study methods were used to create community-specific conceptual frameworks for building capacity for tobacco control. These models of capacity building serve as the backdrop for the development of the two case studies. Setting, participants, measurements: Interview and survey participants were identified through convenience and snowball sampling, using a community-based participatory process in an American Indian community in Oklahoma and among the Hispanic/Latino Tobacco Education Partnership (H/LTEP) organizations in California. Using qualitative and quantitative methods, two case studies were created based on the results of interviews with key informants in each of the respective communities, outcomes of efforts to build capacity in tobacco control are presented. Findings: The extent to which American Indian and Hispanic/Latino communities have the capacity to address effectively the disproportionate burden of tobacco abuse is contingent upon the presence of leadership, collaboration, programs, distribution of funds and resources, development of policies and an underlying understanding of community strengths, history, values and participation. Common characteristics emerge from the case studies that help bridge differences in definition and measurement across both populations and programs. Conclusion: The conceptual frameworks for capacity building presented provide insight that enhances the ability of priority populations to engage in tobacco control strategies using culturally and language appropriate interventions.

Ball AL. HIV, injecting drug use and harm reduction: A public health response. Addiction 102(5): 684-690, 2007. (28 refs.)

Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term 'harm reduction' is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term 'harm reduction' and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of 'harm reduction' and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low- and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV/AIDS where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A 'model package' for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV/AIDS and associated comorbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses.

Bastos FI; Caiaffa W; Rossi D; Vila M; Malta M. The children of mama coca: Coca, cocaine and the fate of harm reduction in South America. (editorial). International Journal of Drug Policy 18(2): 99-106, 2007. (34 refs.)

The paper reviews the main findings from substance misuse research carried out over the last two decades in South America looking at the main initiatives aimed at reducing drug related harm and curbing the spread of HIV/AIDS and other sexually transmitted and blood-borne diseases. The current challenges faced by harm reduction in the region are analysed from the perspective of the history of coca and its different uses in South America. Except in Brazil and Argentina, the implementation of initiatives to reduce drug related harm in South America has been very cautious. The paper aims to link the analysis of harms associated with the use of illicit substances, with the often paradoxically harmful effects of supply-side drug policies in the world's largest coca/cocaine producing area. Despite the undeniable success of many initiatives, the broader context of harm maximization through structural violence and entrenched corruption acts as a major disincentive for the comprehensive adoption of sound public health policies.

Bearre L; Sturt P; Bruce G; Jones BT. Heroin-related attentional bias and monthly frequency of heroin use are positively associated in attenders of a harm reduction service. Addictive Behaviors 32(4): 784-792, 2007. (31 refs.)

The relationship between heroin-related attentional bias (AB) and a proxy for dependence severity (monthly frequency of heroin use-injecting or inhaling) was measured in individuals attending a heroin harm reduction service. A flicker change blindness paradigm was employed in which change detection latencies were measured to either a heroin-related or to a neutral change made to a stimulus array containing an equal number of heroin-related and neutral words. Individuals given the heroin-related change to detect showed a positive relationship between heroin-related AB and the proxy for dependence severity; those given the neutral change showed a negative relationship. Both findings complement each other - and are consistent with the sending of more attention to heroin-related stimuli than neutral, the more severe is the dependence.

Bellis MA; Watson FLD; Hughes S; Cook PA; Downing J; Clark P et al. Comparative views of the public, sex workers, businesses and residents on establishing managed zones for prostitution: Analysis of a consultation in Liverpool. Health & Place 13(3): 603-616, 2007. (56 refs.)

Drug addiction, violence and anti-social behaviour are characteristics of street prostitution. An alternative approach to zero tolerance is establishing a managed zone where sex workers operate according to regulations and can access health services. Using a consultation with sex workers (n = 50), businesses (n = 51), residents (n = 179) and the public (n = 789) we examined where a zone might be established in a UK city (Liverpool) and characteristics of the zone required by these stakeholders. All groups believed a zone would improve sex workers' safety and reduce prostitution elsewhere. Sex workers (96%) agreed to work in a zone. Location criteria from all groups were used to identify two potential business areas to host a zone but businesses in or near these areas rejected plans through fear for staff safety and reduced business. We discuss the consultation process, difficulties in locating services for marginalised groups in cities and the implications for health and judicial policy relating to prostitution.

Benowitz NL; Hall SM; Stewart S; Wilson M; Dempsey D; Jacob P. Nicotine and carcinogen exposure with smoking of progressively reduced nicotine content cigarette. Cancer Epidemiology, Biomarkers & Prevention 16(11): 2479-2485, 2007. (25 refs.)

Background: Reducing the nicotine content of cigarettes to make them non-addictive has been widely discussed as a potential strategy for tobacco regulation. A major concern with nicotine reduction is that smokers will compensate for reduced nicotine by smoking more cigarettes and/or smoking more intensively, thereby increasing their exposure to tobacco smoke toxins. This study examined whether gradual reduction in nicotine exposure increases exposure to tobacco smoke toxins. Methods: This 10-week longitudinal study of 20 healthy smokers involved smoking their usual brand followed by different types of research cigarettes with progressively lower nicotine content, each smoked for 1 week. Subjects were followed for 4 weeks after returning to smoking their usual brand (or quitting). Smoking behaviors, chemical biomarkers of tobacco smoke exposure, and cardiovascular effect biomarkers were measured. Findings: Intake of nicotine declined progressively as the nicotine content of cigarettes was reduced, with little evidence of compensation. Cigarette consumption and markers of exposure to carbon monoxide and polycyclic aromatic hydrocarbons, as well as cardiovascular biomarkers remained stable, whereas urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol excretion decreased. Twenty-five percent of participants had spontaneously quit smoking 4 weeks after completing the research cigarette taper. Implications: Our findings with reduced nicotine content cigarettes differ from those of commercial low yields for which compensatory smoking for lower nicotine delivery is substantial. Our data suggest that the degree of nicotine dependence of smokers can be lowered without increasing their exposure to tobacco smoke toxins. Gradual reduction of nicotine content of cigarettes seems to be feasible and should be further evaluated as a national tobacco regulatory strategy.

Bluthenthal RN; Anderson R; Flynn NM; Kral AH. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug and Alcohol Dependence 89(2/3): 214-222, 2007. (29 refs.)

Objective: To determine if adequate syringe coverage - "one shot for one syringe" - among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal. Design: HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days. Results: Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR] = 2.3; 95% confidence interval [CI] = 1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR = 0.5; 95%CI = 0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage. Conclusions: Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

Bluthenthal RN; Ridgeway G; Schell T; Anderson R; Flynn NM; Kral AH. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction 102(4): 638-646, 2007. (42 refs.)

Aim: To determine whether syringe exchange programs' (SEPs) dispensation policy is associated with syringe coverage among SEP clients. Design: Cross-sectional samples of SEPs and their clients. Settings: SEPs in California. Participants Twenty-four SEPs and their injection drug using (IDU) clients (n = 1576). Measurements Clients were classified as having adequate syringe coverage if they received at least as many syringes from the SEP as their self-reported injections in the last 30 days. SEPs were classified based on their syringe dispensation policy. Dispensation schemes ranging from least restrictive to most are: unlimited needs-based distribution; unlimited one-for-one exchange plus a few additional syringes; per visit limited one-for-one plus a few additional syringes; unlimited one-for-one exchange; and per visit limited one-for-one exchange. Findings Adequate syringe coverage among SEP clients by dispensation policy is as follows: unlimited needs-based distribution = 61%; unlimited one-for-one plus = 50%; limited one-for-one plus = 41%; unlimited one-for-one = 42%; and limited one-for-one = 26%. In multivariate analysis, adequate syringe coverage was significantly higher for all dispensation policies compared to per visit limited one-for-one exchange. Using propensity scoring methods, we compared syringe coverage by dispensation policies while controlling for client-level differences. Providing additional syringes above one-for-one exchange (50% versus 38%, P = 0.009) and unlimited exchange (42% versus 27%, P = 0.05) generally resulted in more clients having adequate syringe coverage compared to one-for-one exchange and per visit limits. Conclusion: Providing less restrictive syringe dispensation is associated with increased prevalence of adequate syringe coverage among clients. SEPs should adopt syringe dispensation policies that provide IDUs sufficient syringes to attain adequate syringe coverage.

Bourgois P. The mystery of marijuana: Science and the US War on drugs. (commentary). Substance Use & Misuse 43(3/4): 581-583, 2008. (10 refs.)

The author notes at the outset that the legal stance toward marijuana use cannot be justified by scientific evidence. To the contrary it is necessary to to consider how central institutional power, the media, and cultural values are in defining drug policy. It is suggested that it is critical for public health researchers to develop theoretical and practical strateifes to explore this phenomenon. While marijuana is not harmless to everyone, the pharmacological properties are not the sole determinants of harm. In many instances the greatest dangers results from the legal status. Among the collateraal damage noted is the profitability of marijuana, and associated violence, the prisons terms for selling trivial amounts , and the revolving doors of the correctional system. The author suggests that the possibility that marijuana use has reduced alcohol and narcotic drug consumption needs to be considered. In closing, the author suggests that the stance on marijuana is only one example of the neagative health effects of the war on drugs -- others are noted, particularly the aversion to harm reduction efforts

Braye K; Harwood T; Inder R; Beasley R; Robinson G. Poppy seed tea and opiate abuse in New Zealand. Drug and Alcohol Review 26(2): 215-219, 2007. (18 refs.)

The opium poppy Papaver somniferum contains an array of opiates. There is a variety of methods of preparation that can be used by people with opiate dependence, with patterns of use determined by numerous factors including cost, safety, potency and legal status. The objective of this study was to determine the frequency and nature of poppy seed tea ( PST) use by opiatedependent patients in the form of a written questionnaire. The study took place at the Community Alcohol and Drug Clinic, Wellington, New Zealand, and comprised 24 opiate- dependent patients attending the clinic. A total of 11 of 24 (46%) patients reported having used PST. In five patients currently using PST it represented the major source of opiates, and two had managed to withdraw from use of other opiates with regular PST use. Patients reported a median onset of action of 15 minures and an effect lasting a median of 24 hours. The major limitation of PST use was the foul taste. PST is used commonly by opiatedependent patients attending an alcohol and drug clinic in New Zealand. The use of PST as the major source of opiates could be considered favourably within 'harm reduction' philosophies, because of its low cost, legal availability and oral route of administration. Conversely, there is the potential for PST to act as a 'gateway drug' by inducing opioid dependence and introducing people to the culture of drug abuse.

Britton J; Macara AW. Should doctors advocate snus and other nicotine replacements? (letter). British Medical Journal 336(7640): 358-359, 2008. (0 refs.)

Callaghan RC; Strike C; Kerr T; Fischer B; Buxton J; Stevens E et al. Increasing prevalence of cocaine as the primary detoxification diagnosis among admissions presenting with current intravenous drug use - A review of detoxification records from northern British Columbia, 1999-2005. Canadian Journal of Public Health 99(3): 178-181, 2008. (27 refs.)

Objectives: This study sought to document the trends in drug use among intravenous drug users (IDUs) in northern British Columbia, and to discuss the public health implications. Method: We conducted a 7-year medical-chart review of all IDU-related admissions (n=2072) to an inpatient alcohol and drug cletoxification centre in Prince George, British Columbia. Primary cletoxification diagnosis was modeled onto year of admission using generalized estimating equations (GEE). Results: Our study demonstrated an increasing prevalence of cocaine as the primary cletoxification diagnosis in IDU-related admissions in northern BC, from 32% of all IDU admissions in 1999 to 64% in 2001, and then a relatively steady elevated rate of approximately 60% between 2001-2005. Conclusions: Given that needle exchange programs and other harm reduction services for IDUs in British Columbia are not readily available in many northern and rural areas, the risks associated with intravenous cocaine use among northern IDUs represent a serious public health challenge. Tailored harm reduction strategies should take into account the prominence of intravenous cocaine use as an HIV risk factor. In areas without well-established intravenous drug use monitoring programs, such as rural and remote areas, cletoxification treatment records may serve as important sentinels for changing drug use patterns among IDUs.

Campbell JV; Garfein RS; Thiede H; Hagan H; Ouellete LJ; Golub ET; DUIT Study Team. Convenience is the key to hepatitis A and B vaccination uptake among young adult injection drug users. Drug and Alcohol Dependence 91(Supplement 1): S64-S72, 2007. (51 refs.)

Background: Despite CDC recommendations to vaccinate injection drug users (IDUs) against hepatitis A virus (HAV) and hepatitis B virus (HBV) infections, coverage remains low. Vaccination programs convenient to IDUs have not been widely implemented or evaluated. We assessed whether convenience and monetary incentives influenced uptake of free vaccine by 18-30-year-old IDUs in five U.S. cities. Methods: IDUs recruited from community settings completed risk behavior self-interviews and testing for antibodies to HAV (anti-HAV) and hepatitis B core antigen (anti-HBc). Vaccine was offered presumptively at pre-test (except in Chicago); on-site availability and incentives for vaccination differed by site, creating a quasi -experimental design. Results: Of 3181 participants, anti-HAV and anti-HBc seroprevalence was 19% and 23%, respectively. Although 83% of participants were willing to be vaccinated, only 36% received >= I dose, which varied by site: Baltimore (83%), Seattle (33%), Los Angeles (18%), New York (17%), and Chicago (2%). Participation was highest when vaccine was available immediately on-site and lowest when offered only after receiving results. Monetary incentives may have increased participation when on-site vaccination was not available. Conclusion: IDUs were willing to be vaccinated but immediate, on-site availability was critical for uptake. Convenience should be a key consideration in designing strategies to increase vaccine coverage among IDUs.

Carruthers S. The organization of a community: Community-based prevention of injecting drug use-related health problems. Substance Use & Misuse 42(12-13): 1971-1977, 2007. (9 refs.)

In the 1980s, injection drug users in Australia mobilized and organized as communities to prevent the transmission of HIVIAIDS, hepatitis C, and other injecting-related harms. This article provides a brief history of the development and role of IDU communities in the prevention of drug use-related harms over the past 20 years and introduces the genesis of a new program that aims to improve peer-based, community-organized prevention and harm reduction initiatives. The project's limitations are noted and future needed research is suggested.

Caudill BD; Luckey B; Crosse SB; Blane HI; Ginexi EM; Campbell B. Alcohol risk-reduction skills training in a national fraternity: A randomized intervention trial with longitudinal intent-to-treat analysis. Journal of Studies on Alcohol and Drugs 68(3): 399-409, 2007. (51 refs.)

Objective: The potential effectiveness of two group-administered social-skills training interventions for reducing high-risk drinking behavior was evaluated through a prospective randomized intervention trial with 3,406 members of a national college fraternity. Method: Ninety eight of 99 chapters of a national fraternity were randomly assigned, within three strata, to receive (1) a 3-hour baseline intervention, (2) the same baseline intervention plus two booster sessions, or (3) assessments only. The current article emphasizes a rigorous intent-to-treat analysis model that compares outcomes among members assigned to receive study interventions (vs assessment-only sites) regardless of whether they actually did receive them; it also includes individuals at intervention sites even if they did not participate. This model allows us to address a social policy issue regarding the effect that introducing such an intervention may have in changing the high-risk non-native drinking environment of the fraternity itself. Results: Frequent heavy drinkers (64.2% of members) assigned to either intervention showed significant reductions at a 6-month follow-up in their frequency of drinking, heavy drinking, and drinking to intoxication; plus, they reported consuming fewer drinks overall. At 12 and 18 months postbaseline, these positive outcomes had largely dissipated. Additionally, there was an increase in drinking among lower-risk members 18 months postbaseline, which may be the result of factors other than differential attrition. Conclusions: Findings suggest that introducing such a brief intervention can effectively reduce risky drinking behavior on a short-term basis in high-risk members of a national fraternity. Future studies may wish to focus on strategies for sustaining positive outcomes for longer, plus would benefit, in general, from learning more about mechanisms of change.

Chapman S. Public Health Advocacy and Tobacco Control: Making Smoking History. Boston: Blackwell Publishing, 2007

This book is organized into two section. It lays out a strategy and accompanying tactics for denormalising smoking and the tobacco industry. Part I addresses the major challenges for tobacco control. It addresses ethical principles, the role of advocacy, the potential pitfalls for harm reduction and product regulation, increasing smoking cessation and prevention, the denormalization of smoking, and control of the tobacco industry. Part II is a compendium of key components of advocacy efforts. It begins with examination of ten basic questions for planning an advoacy strategy, followed by a dictionary-style, organized from A-Z, examination of sixty-five different elements. These range from Accuracy; to Analogies, metaphors, similes and word pictures; Celebrities, Editorials, Fact sheets, Letters to politicians, Mailing lists, Opinion polls, Private sector alliances, Slow news days, to Wolves in sheep's clothing.

Chen A; Glantz S; Tong E. Asian herbal-tobacco cigarettes: "not medicine but less harmful''? Tobacco Control 16(2): article e3, 2007. (85 refs.)

Objective: To describe the development and health claims of Asian herbal-tobacco cigarettes. Methods: Analysis of international news sources, company websites, and the transnational tobacco companies' (TTC) documents. PubMed searches of herbs and brands. Results: Twenty-three brands were identified, mainly from China. Many products claimed to relieve respiratory symptoms and reduce toxins, with four herb-only products advertised for smoking cessation. No literature was found to verify the health claims, except one Korean trial of an herb-only product. Asian herbal-tobacco cigarettes were initially produced by China by the 1970s and introduced to Japan in the 1980s. Despite initial news about research demonstrating a safer cigarette, the TTC analyses of these cigarettes suggest that these early products were not palatable and had potentially toxic cardiovascular effects. By the late 1990s, China began producing more herbal-tobacco cigarettes in a renewed effort to reduce harmful constituents in cigarettes. After 2000, tobacco companies from Korea, Taiwan, and Thailand began producing similar products. Tobacco control groups in Japan, Taiwan, and Thailand voiced concern over the health claims of herbal-tobacco products. In 2005, China designated two herbal-tobacco brands as key for development. Conclusion: Asian herbal-tobacco cigarettes claim to reduce harm, but no published literature is available to verify these claims or investigate unidentified toxicities. The increase in Asian herbal-tobacco cigarette production by 2000 coincides with the Asian tobacco companies' regular scientific meetings with TTCs and their interest in harm reduction. Asia faces additional challenges in tobacco control with these culturally concordant products that may discourage smokers from quitting.

Chinet L; Stephan P; Zobel F; Halfon O. Party drug use in techno nights: A field survey among French-speaking Swiss attendees. Pharmacology, Biochemistry and Behavior 86(2): 284-289, 2007. (27 refs.)

This study was designed to investigate the lifestyle and substance use habits of dance music event attendees together with their attitudes toward prevention of substance misuse, harm reduction measures and health-care resources. A total of 302 attendees aged 16-46 years (mean=22.70, S.D.=4.65) were randomly recruited as they entered dance music events. Rates for lifetime and current use (last 30 days) were particularly high for alcohol (95.3% and 86.6%, respectively), cannabis (68.8% and 53.8%, respectively), ecstasy (40.4% and 22.7%, respectively) and cocaine (35.9% and 20.7%, respectively). Several patterns of substance use could be identified: 52% were alcohol and/or cannabis only users, 42% were occasional poly-drug users and 6% were daily poly-drug users. No significant difference was observed between substance use patterns according to gender. Pure techno and open-air events attracted heavier drug users. Psychological problems (such as depressed mood, sleeping problems and anxiety attacks), social problems, dental disorders, accidents and emergency treatment episodes were strongly related to party drug use. Party drug users appeared to be particularly receptive to harm reduction measures, such as on-site emergency staff, pill testing and the availability of cool water, and to prevention of drug use provided via counseling. The greater the involvement in party drug use, the greater the need for prevention personnel to be available for counseling. General practitioners appeared to be key professionals for accessing health-care resources.

Cicero TJ; Dart RC; Inciardi JA; Woody GE; Schnoll S; Munoz A. The development of a comprehensive risk-management program for prescription opioid analgesics: Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS (R)). Pain Medicine 8(2): 157-170, 2007. (31 refs.)

Objective. Beginning in the late 1990's a marked increase in abuse of OxyContin(R) emerged, which led to the development and establishment of a proactive surveillance program to monitor and characterize abuse, named the Researched Abuse, Diversion and Addiction Related Surveillance (RADARS(R)) System. The main goal of RADARS(R) was to develop proactive, timely and geographically sensitive methods to assess the abuse and diversion of OxyContin(R), along with a number of other Schedule II and III opioids with the aim of using this information to guide risk reduction interventions. Thus, its major focus was the detection of abuse of OxyContin(R) and other commonly prescribed opioid analgesics at the three-digit ZIP code level across the country utilizing a number of different detection systems. Methods. The detection systems selected were: (1) Quarterly-surveys of drug abuse experts who are knowledgeable about cases of prescription drug abuse; (2) Surveys of law enforcement agencies that detect diversion of prescription drugs; and (3) Poison Control Center reports of intentional misuse or abuse of prescription opioids. Collectively, the three systems provide overlapping coverage of over 80% of the nation's 973 three-digit ZIP codes. Results. Preliminary results indicate that prescription drug abuse is prevalent nationwide, but it seems to be heavily localized in rural, suburban and small urban areas. Our results also indicate that hydrocodone and extended and immediate release oxycodone products are by far the most widely abused drugs in the country, but the abuse of all prescription opioids seems to have grown over the 14 quarters since the inception of RADARS(R). Conclusion. The next step in these studies is to develop regionally specific, risk-minimization strategies, which is the goal of all risk-management programs. If successful, RADARS(R) will serve as a prototype of such programs for any new drug approved thathas measurable abuse potential.

Coffin PO; Latka MH; Latkin C; Wu Y; Purcell DW; Metsch L; INSPIRE Study Group. Safe syringe disposal is related to safe syringe access among HIV-positive injection drug users. AIDS and Behavior 11(5): 652-662, 2007. (39 refs.)

We evaluated the effect of syringe acquisition on syringe disposal among HIV-positive injection drug users (IDUs) in Baltimore, New York City, and San Francisco (N = 680; mean age 42 years, 62% male, 59% African-American, 21% Hispanic, 12% White). Independent predictors of safe disposal were acquiring syringes through a safe source and ever visiting a syringe exchange program. Weaker predictors included living in San Francisco, living in the area longer, less frequent binge drinking, injecting with an HIV+ partner, peer norms supporting safe injection, and self-empowerment. Independent predictors of safe "handling"-both acquiring and disposing of syringes safely-also included being from New York and being older. HIV-positive IDUs who obtain syringes from a safe source are more likely to safely dispose; peer norms contribute to both acquisition and disposal. Interventions to improve disposal should include expanding sites of safe syringe acquisition while enhancing disposal messages, alternatives, and convenience.

Coggins CRE; Gaworski CL. Could charcoal filtration of cigarette smoke reduce smoking-induced disease? A review of the literature. Regulatory Toxicology and Pharmacology 50(3): 359-365, 2008. (43 refs.)

A review of the published work with charcoal-filtered cigarettes indicates that there are reductions in the concentrations for many gas-vapor phase constituents found in mainstream smoke. However, charcoal filters provided no apparent capacity for reduction of smoke particulate phase components. The reductions in gas-vapor phase smoke chemistry analytes generally correspond with findings of reduced toxicological activity, principally related to a reduction in the cytotoxic action of the volatile smoke constituents. Results of a short-term clinical study show small reductions in the biomarkers of the gas-vapor phase smoke constituents in subjects smoking charcoal-filtered cigarettes, compared to subjects smoking non-charcoal filtered cigarettes. The very limited epidemiology data (a single study) fail to demonstrate a conclusive beneficial effect of charcoal-filtered cigarette products compared to non-charcoal filtered Cigarette products. Review of the scientific literature is hindered due to the lack of documentation regarding the activity of the charcoal used in the filter, and the inconsistency in product designs used between the various different disciplines (chemistry, pre-clinical, clinical and epidemiology) that have conducted studies with charcoal filtered cigarettes. There do not appear to be any published studies using a combination of data from the different disciplines based on a consistently designed charcoal cigarette filter. Although the literature presently available would suggest that smoke filtration provided by current charcoal filter techniques alone may not be substantial enough to reduce smoking-related disease, the data are limited. Therefore, for the reduction of smoking-induced disease, it is difficult to come to a definitive conclusion regarding the potential health benefits of using charcoal as a smoke filtration technology.

Copenhaver MM; Lee IC. Examining the decay of HIV risk reduction outcomes following a community-friendly intervention targeting injection drug users in treatment. Journal of Psychoactive Drugs 39(3): 223-229, 2007. (31 refs.)

It has become crucial for risk reduction interventions targeting injection drug users (IDUs) in treatment to be ''community-friendly'' and potent over time so that limited resources may be optimally utilized. This study examined (1) the extent to which observed post-intervention effects --i ncluding enhanced HIV-related knowledge, motivation, behavioral skills, and drug- and sex-risk reduction behavior --d ecayed over time and (2) whether repeating the intervention at follow-up provided additional benefit. Approximately 10 months after completing an adapted, substantially shortened, version of an evidence-based intervention, participants completed a follow-up assessment and then repeated the intervention. No evidence of decay was found. Even so, after repeating the intervention, a trend toward additional sex-risk reduction was observed for participants it higher risk for HIV. Findings point to the potential for an adapted evidence-based intervention for IDUs to be both community-friendly and potent over time within community-based treatment settings.

Cruz MF; Patra J; Fischer B; Rehm J; Kalousek K. Public opinion towards supervised injection facilities and heroin-assisted treatment in Ontario, Canada. International Journal of Drug Policy 18(1): 54-61, 2007. (53 refs.)

In recent years, controversial interventions such as 'heroin-assisted treatment' (HAT) and 'supervised injection facilities' (SIFs) have been established in attempts to minimise the high morbidity and mortality consequences of illicit drug use. This paper examines public opinion towards HAT and SIF using data from the 2003 Centre for Addiction and Mental Health (CAMH) Monitor, a representative population survey conducted among adults residing in Ontario, Canada. Data relating specifically to SIFs and HAT were isolated from the main database (n = 885); agreement scores were collapsed to create a scale and analysed using independent sample t-tests and ANOVAs. Results revealed that 60 percent (n = 530) of the sample agreed that SIFs should be made available to injection drug users, while 40 percent (it = 355) disagreed. When asked about the provision of HAT, a similar pattern emerged. Variables significantly associated with positive opinions toward SIFs and HAT were: income; higher education; the use of cocaine or cannabis within the last 12 months; being in favour of cannabis decriminalisation; support of needle exchange in prison; view of illicit drug users as ill people; and agreement that drug users are in need of public support. Given the current political climate and the tentative position of SIFs and HAT in Canada, understanding the public's opinion is crucial for the feasibility and long-term sustainability of these interventions.

de la Fuente L; Toro C; Brugal MT; Vallejo F; Soriano V; Barrio G et al. Poor validity of self-reported HBV vaccination among young heroin users in Spain supports the policy "don't ask, draw a blood sample, vaccinate and try to schedule another visit". Journal of Clinical Virology 38(1): 87-90, 2007. (14 refs.)

Objectives: To assess the validity of self-reported hepatitis B virus vaccination status in young heroin users. Study design: Cross-sectional study among 949 street-recruited young injection heroin users (IHUs) and non-injection heroin users (NIHUs) in Madrid, Barcelona and Seville. Face-to-face interviews and dried blood spot tested for anti-HBc and anti-HBs. The validity of self-reported vaccination status was assessed comparing with the serological status. The percentage of agreement with the kappa (K) statistic and the positive predictive value were calculated. Results: The percentage of agreement between self-reported and serologic vaccination status was 51.9% overall, with little difference by city (53.1% in Barcelona, 49.0% in Madrid and 51.5% in Seville) or between IHUs (51.3%) and NIHUs (53.0%). All the K scores were lower than 0.1. The positive predictive value of self-reports was less than 25% in all categories analysed, except in the city of Barcelona (37%). Among those who indicated that they had been vaccinated, 31% were actually susceptible. Conclusions: In areas with a high prevalence of infection and rising coverage of vaccination the policy "don't ask, take a blood sample, give a dose of vaccine and try to schedule another visit" should be recommended in clinical practice.

Degenhardt L; Kinner SA; Roxburgh A; Black E; Bruno R; Fetherston J et al. Drug use and risk among regular injecting drug users in Australia: does age make a difference? Drug and Alcohol Review 27(4): 357-360, 2008. (7 refs.)

Introduction and Aims. To examine age-related differences in drug use and risk among regular injecting drug users (IDU) in Australia. Design and Methods. Cross-sectional data from the 2006 Illicit Drug Reporting System were examined for age-related differences in demographic characteristics, drug use history and current use patterns and self-reported risk behaviours. Results. IDU under 25 years of age were more likely to have initiated injecting at a younger age, to identify as Aboriginal and/or Torres Strait Islander, and to be injecting daily or more often than their older counterparts. They reported more frequent heroin use in the preceding 6 months, and were more likely to report morphine as the first drug injected than were IDU aged 35 years or over. Younger IDU were also more likely to report providing used needles to others, engaging in recent property crime and drug dealing and arrest in the last year. Conclusions. Younger IDU reported significantly different drug use patterns and higher rates of risk behaviours than their older counterparts. Treatment services need to ensure that harm and demand reduction services deliver messages to new cohorts of IDU, particularly given that their drug use patterns may be different to those of older users.

Dollar KM; Mix JM; Kozlowski LT. Little cigars, big cigars: Omissions and commissions of harm and harm reduction information on the Internet. Nicotine & Tobacco Research 10(5): 819-826, 2008. (62 refs.)

We conducted a comparative analysis of "harm," "harm reduction," and "little cigar" information about cigars on 10 major English-language health Web sites. The sites were from governmental and nongovernmental organizations based in seven different countries and included "harm" and "harm reduction" information, discussions of little cigars, quantitative estimates of health risks, and qualifying behavioral characteristics (inhalation, number per day). Of the 10 Web sites, 7 offered statements explicitly indicating that cigars may be safer than cigarettes. None of the Web sites reviewed described that little cigars are likely as dangerous as cigarettes. Some Web sites provided quantitative estimates of health risks and extensive discussions of qualifying factors. Reading grade levels were higher than desirable. Extensive and complex information on the reduced risks of cigars compared with cigarettes is available on Web sites affiliated with prominent health organizations. Yet these sites fail to warn consumers that popular cigarette-like little cigars and cigarillos are likely to be just as dangerous as cigarettes, even for those who have never smoked cigarettes. Improvement of these Web sites is urgently needed to provide the public with high-quality health information.

Dunnagan T; Haynes G; Linkenbach J; Summers H. Support for social norms programming to reduce alcohol consumption in pregnant women. Addiction Research & Theory 15(4): 383-396, 2007. (33 refs.)

This investigation examined the difference between the amount of alcohol consumed by pregnant Montana women (actual norms) and the amount they perceived was consumed by other Montana women of their same age (peer norms). On the basis of a stratified cluster sampling, 712 women completed a survey based on social norms theory. Results revealed that prior to the pregnancy women perceived that other women of their same age normally drank more than four times as much alcohol as they actually consumed. However, during their pregnancy women perceived that other women of their same age normally drank over 102 times as much alcohol as they actually consumed. Similar patterns were seen for the more than usual consumption. The results of the investigation showed a consistent and dramatic pattern of overestimation of peer alcohol use norms compared to actual norms. These findings support the application of intervention strategies designed to correct misperceptions of drinking norms in pregnant women as a way to reduce actual drinking rates.

editor. Adding harm reduction to tobacco control. (editorial). Lancet 370(9594): 1189-1189, 2007. (0 refs.)

Edman J; Stenius K, eds. On the Margins: Nordic alcohol and drug treatment 1885-2007. NAD Monograph no. 50. Helsinki, Finland: Nordic Alcohol and Drug Council, 2007. (Chapter refs.)

The goal of this volume is to describe the character and dynamics of the alcohol and drug treatment systems in Denmark, Finland, Iceland, Norway and Sweden. How and why have new ideas and institutions emerged during its history? Who have been the actors and what have been the structures behind changes or resistance to change? What can explain the continuities and the reforms? Instead of describing the long national trajectories, the book presents thirteen snapshots from the history of treatment in the five Nordic countries. The settings described in these articles vary from countryside sanatoriums for the voluntary treatment of middle-class alcoholics in late 19th century Sweden, to large, prison-like institutions in all the Nordic countries, used for compulsory treatment emphasising work and moral edification, to the contemporary public injecting rooms in the city of Oslo. The actors include entrepreneurs, doctors, jurists, temperance activists, bureaucrats and social reformists. These snapshots are framed by an introductory chapter and a concluding article, drawing some general conclusions about the development of alcohol and drug treatment in the Nordic countries. Within the frame of the gradually developing Nordic welfare states, alcohol and drug treatment has mostly consisted of measures directed towards the poor, marginal groups of society - with the exception of the earliest history and also contemporary Iceland. The history of alcohol and drug treatment can thus be read as one expression of Nordic inclusion and exclusion, illustrated both by the comparatively large size of the treatment system, and by the strict demands on conformity within the frame of the ideally alcohol- and drug-free society. The development during the last decades, with the acceptance of harm-reduction and a new tolerance for the continuing use of substances introduces something thoroughly new in Nordic contexts. Will it also contribute to a true reformulation of the role of treatment?

Fielden S; Marsh D. It is time for Canadian community early warning systems for illicit drug overdoses. Harm Reduction Journal 4: article 10, 2007. (39 refs.)

Although fatal and non-fatal overdoses represent a significant source of morbidity and mortality, current systems of surveillance and communication in Canada provide inadequate measurement of drug trends and lack a timely response to drug-related hazards. In order for an effective early warning system for illicit drug overdoses to become a reality, a number of elements will be required: real-time epidemiologic surveillance systems for illicit drug trends and overdoses, inter-agency networks for gathering data and disseminating alerts, and mechanisms for effectively and respectfully engaging with members of drug using communities. An overdose warning system in an urban area like Vancouver would ideally be imbedded within a system that monitors drug trends and overdoses by incorporating qualitative and quantitative information obtained from multiple sources. Valuable information may be collected and disseminated through community organizations and services associated with public health, emergency health services, law enforcement, medical laboratories, emergency departments, community-based organizations, research institutions and people with addiction themselves. The present paper outlines considerations and conceptual elements required to guide implementation of such systems in Canadian cities such as Vancouver.

Forsyth AJM. Banning glassware from nightclubs in Glasgow (Scotland): Observed impacts, compliance and patrons views. Alcohol and Alcoholism 43(1): 111-117, 2008. (22 refs.)

Aim: To examine the impact of a glassware ban policy on disorder-related harm within licensed premises (nightclubs) and how this action was viewed by their patrons. Methods: Field observations were conducted in a sample of eight nightclubs following the introduction of this policy across all such venues within a city centre. These observations involved both quantitative and qualitative data collection observing violence in a naturalistic setting, and were supplemented by taped in-depth interviews with nightclub patrons. Results: Exemptions to the ban had enabled some premises (three out of eight) to continue to serve alcoholic drinks in glass vessels, and injurious violence resulting from these practices was observed. Disorder in all-plastic venues was observed to incur less injury risk. Patrons also reported feeling safer in these nightclubs than in others. Conclusions: This research demonstrated the potential of such policy to reduce the severity of alcohol-related violence in the night-time economy. It is recommended that future bans of this nature be tailored towards the elimination of all types of glassware from such premises.

Foxcroft D. The need for values: Science and art in alcohol harm reduction. (editorial). Addiction 102(9): 1350-1351, 2007. (7 refs.)

Fry C; Treloar C; Maher L. Applied communitarian ethics for harm reduction: Promoting a dialogue within the field. Drug and Alcohol Review 26(5): 553-555, 2007. (13 refs.)

This piece responds to critical points raised in commentaries on our 2005 HRD paper on the topic of harm reduction ethics, and clarifies other aspects of our original arguments that were misinterpreted. In our view, the goal of ethical engagement in harm reduction is not necessarily the production of an agreed moral framework, but instead reflection and awareness raising around the various values and beliefs underlying harm reduction, and consideration of how these influence policy, practice and research decisions and outcomes. This 'discursive authenticity' as Hathaway has called it, can help to define a new territory of authority for drug users as participants in harm reduction policy, practice and research.

Gartner CE; Hall WD. Should Australia lift its ban on low nitrosamine smokeless tobacco products? Medical Journal of Australia 188(1): 44-46, 2008. (26 refs.)

In Australia, 2.9 million people continue to smoke daily, and tobacco still accounts for 8% of disease burden. Tobacco harm-reduction strategies, such as the use of Swedish snus, have been suggested as a way to further reduce this disease burden. In Australia, the most dangerous tobacco products (cigarettes) are the least regulated, while oral tobacco products, including snus, cannot be sold legally. Recent epidemiological modelling indicates that there are only small differences in life expectancy between smokers who quit and those who switch to snus. There is a case on public health and ethical grounds for allowing inveterate smokers who want to reduce their health risks to access snus. At a minimum, the recent increase in tax on smokeless tobacco should be reversed, and the ban on the commercial importation and supply of low nitrosamine smokeless tobacco should be reconsidered in light of the epidemiological evidence on its potential to reduce tobacco-related disease in smokers.

Geens A; Snelson D; Al-Madfai H; Graham M; Djialli D; Hillier D. The role of ventilation in maintaining indoor air quality with particular reference to environmental tobacco smoke: A comprehensive review. (review). International Journal of Innovative Computing Information and Control 3(3): 761-787, 2007. (45 refs.)

A number of legislative bodies across Europe (Ireland, Scotland Wales England and Norway) have already made or are currently considering (France) making policy decisions on the issue of smoking in public places. These policy alternatives have been discussed in Town & Country Planning. Scientific evidence relating to this debate has been reported in a diverse range of publications such as the British Medical Journal (BMJ), Indoor Air and the Building Services Journal: the magazine of CIBSE (BSJ). On inspection much of this commentary concludes negatively on the performance of ventilation systems. In this paper a critical review is undertaken of some of the more recent and most frequently cited publications. The paper aims to provide insights for policy makers, students in relevant disciplines, facilities and estate managers and those managing buildings with potential for smoker occupancy such as long stay health care premises and those who are interested in this debate.

Giesbrecht N. Reducing the damage from alcohol in populations: Are current popular interventions of sufficient potency and scope? (editorial). Addiction 102(9): 1354-1355, 2007. (14 refs.)

Gilbert P; Herzig K; Thakar D; Viloria J; Bogetz A; Danley DW; Jackson R; Gerbert B. How health care setting affects prenatal providers' risk reduction practices: A qualitative comparison of settings. Women & Health 45(2): 41-57, 2007. (48 refs.)

Background: We sought to understand how systemic factors might facilitate or impede providers' ability to screen for and intervene on prenatal behavioral risks. Methods: We convened eight focus groups of 60 prenatal care providers to explore methods for assessing and counseling pregnant women about tobacco, alcohol, and illicit drug use. Because practice setting was often mentioned as either an inducement or barrier to risk prevention, we conducted a re-analysis of focus group transcripts to examine systemic factors. Results: Practice setting strongly influenced providers' behavior, and settings differed by continuity of care, availability of resources, and organized support for risk prevention. The most striking contrasts were found between private practice and a large HMO. Conclusion: Each setting had features that facilitated prevention counseling. Understanding such systemic factors could lead to improved risk prevention practices during pregnancy across all health care settings.

Gill J; O'May F. Practical demonstration of personal daily consumption limits: A useful intervention tool to promote responsible drinking among UK adults? Alcohol and Alcoholism 42(5): 436-441, 2007. (24 refs.)

Aim: The aim of this study was to investigate the utility of a short, practical pouring exercise as a means of illustrating the details of the UK Sensible Drinking guidelines. Methods: Participants (N = 297, 53% male) recruited at four Edinburgh employment sites, each completed a short non-standardized questionnaire and poured their usual measure of wine or spirit into a glass (purchased from four high street outlets). The actual and estimated unit content of their poured drinks and reactions to feedback were noted. Participants were informed of their daily limit of consumption in terms of this drink. Results: On average, drinks contained 2.05 UK units. Only 27% (N = 79) of respondents estimated the unit content of their drink within 10% of the true value. Of drinkers, 20.5% (N = 61) indicated that the results of the pouring test would influence their future pouring (70% of these were women). When informed of daily limits of consumption in terms of personal drink measure, 46% (N = 132) of drinkers indicated they would usually exceed this. Conclusion: A practical demonstration of health guidelines presented in terms of personal drinking habits may contribute to dissemination of responsible drinking messages. Preliminary evidence suggests women may be particularly open to this approach. The utility of this intervention is underscored by recent figures highlighting the increasing preference for home drinking.

Green TC; Heimer R; Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: An evaluation of six overdose training and naloxone distribution programs in the United States. Addiction 103(6): 979-989, 2008. (42 refs.)

Aims This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose-response in the United States. Design and participants: Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites (n = 62). Setting US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico. Measurements: Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics. Findings Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately (t(60) = 3.76, P < 0.001) and instances where naloxone was indicated (t(59) = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0). Conclusions: Results suggest that naloxone training programs in the United States improve participants' ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality.

Gullu H; Caliskan M; Ciftci O; Erdogan D; Topcu S; Yildirim E et al. Light cigarette smoking impairs coronary microvascular functions as severely as smoking regular cigarettes. Heart 93(10): 1274-1277, 2007. (19 refs.)

Background: Smoking is the most prevalent and most preventable risk factor for cardiovascular diseases. Smoking low-tar, low-nicotine cigarettes (light cigarettes) would be expected to be less hazardous than smoking regular cigarettes owing to the lower nicotine and tar yield. Objective: To compare the chronic and acute effects of light cigarette and regular cigarette smoking on coronary flow velocity reserve (CFVR). Methods: 20 regular cigarette smokers (mean (SD) age 24.8 (5.0)), 20 light cigarette smokers (mean age 25.6 (6.4)), and 22 non-smoker healthy volunteers (mean age 25.1 (4.2)) were included. First, each subject underwent echocardiographic examination, including CFVR measurement, after a 12 hour fasting and smokeless period. Two days later, each subject smoked two of their normal cigarettes in a closed room within 15 minutes. Finally, within 20-30 minutes, each subject underwent an echocardiographic examination, including CFVR measurement. . Results: Mean (SD) CFVR values were similar in light cigarette and regular cigarette smokers and significantly lower than in the controls (2.68 (0.50), 2.65 (0.61), 3.11 (0.53), p = 0.013). Before and after smoking a paired t test showed that smoking two light cigarettes acutely decreased the CFVR from 2.68 (0.50) to 2.05 (0.43) (p = 0.001), and smoking of two regular cigarettes acutely decreased CFVR from 2.65 (0.61) to 2.18 (0.48) (p = 0.001). Conclusion: Smoking low-tar, low-nicotine cigarettes impairs the CFVR as severely as smoking regular cigarettes. CFVR values are similar in light cigarette and regular cigarette smokers and significantly lower than in controls.

Gustafson DL; Goodyear L; Keough F. When the dragon's awake: A needs assessment of people injecting drugs in a small urban centre. International Journal of Drug Policy 19(3): 189-194, 2008. (27 refs.)

Background: St. John's, Newfoundland and Labrador is one of the smallest Canadian provincial capitals. Like other Canadian coastal communities, St. John's has been affected by dramatic economic and institutional restructuring that negatively impacted community health. Marginalized populations including people who inject drugs are more negatively affected by the gap between health needs and available services. Methods: A mixed methods needs assessment began with a survey and key informant and focus group interviews to determine attitudes, knowledge, and practices of people with current or previous experience injecting drugs. An environmental scan of programmes and services was conducted followed by a community consultation with key stakeholders, community agencies, study participants, the media, and members of the public to share and validate findings, solicit feedback, and gather data about future knowledge transfer activities. Results: This paper examines two of the five barriers to health and health services for people injecting drugs: First, there was a discrepancy amongst people injecting drugs between awareness and use of safer practices, and second, there was a limited formalized network of health and social programmes and services. Conclusion: Accurate and timely information about safer practices, whilst an essential component of a harm reduction approach, is insufficient to reduce the risk of negative health outcomes for people injecting drugs. Funding new programmes and services, although desirable, is not always feasible in small urban centres with limited human and material resources. Recommendations for promoting health, reducing harm, and building local capacity must consider these limitations. Registered nurses are well positioned to provide leadership through collaborative community-based research, education and advocacy.

Haden M. Controlling illegal stimulants: A regulated market model. (commentary). Harm Reduction Journal 5(1): doi:10.1186/1477-7517-5-1, 2008. (91 refs.)

Prohibition of illegal drugs is a failed social policy and new models of regulation of these substances are needed. This paper explores a proposal for a post-prohibition, public health based model for the regulation of the most problematic drugs, the smokable and injectable stimulants. The literature on stimulant maintenance is explored. Seven foundational principles are suggested that could support this regulatory model of drug control that would reduce both health and social problems related to illegal stimulants. These are as follows: Principle 1, the goal is to reduce harm. Principle 2, social capital needs to be increased. Principle 3, the culture of drug use needs to be understtod and influenced. Principle 4, the goal is to use the least restrictive intervention. Principle 5, prevention and treatment are vital. Principle 6, learn the lessons from alcohol and tobacco control. Prinicple 7, changes need to occur incrementally. Some details of this model are examined and the paper concludes that drug policies need to be subject to research and based on evidence.

Hall W. What's in a name? (editorial). Addiction 102(5): 692-692, 2007. (1 refs.)

Hallinan R; Byrne A; Dore GJ. Harm reduction, hepatitis C and opioid pharmacotherapy: An opportunity for integrated hepatitis C virus-specific harm reduction. Drug and Alcohol Review 26(4): 437-443, 2007. (39 refs.)

While harm reduction advocates, policy makers and practitioners have a right to be proud of the impact of interventions such as needle and syringe programmes on HIV risk, we can be less sanguine about the ongoing high levels of HCV transmission among injecting drug users (IDUs) and the expanding burden of hepatitis C virus (HCV)-related liver disease. In this Harm Reduction Digest Drs Byrne and Hallinan from the Redfern Clinic and Dr Dore from the National Centre in HIV Epidemiology and Clinical Research offer a model of integrated HCV prevention and treatment services within the setting of opioid pharmacotherapy. In their experience, this common-sense approach provides an opportunity to reduce the burden of HCV and improve overall patient management. They believe that the key elements of a HCV-specific harm reduction model include: regular HCV testing; clinical assessment and determination of need for HCV treatment referral; use of broader HCV treatment inclusion criteria; and flexibility in opioid pharmacotherapy dosing. In an environment when our macro harm reduction interventions seem to have, at best, modest impact on HCV transmission, good clinical practice may be our most effective strategy against the HCV epidemic. This paper provides some practical suggestions as to how this can be done.

Hamilton G; Cross D; Resnicow K; Shaw T. Does harm minimisation lead to greater experimentation? Results from a school smoking intervention trial. Drug and Alcohol Review 26(6): 605-613, 2007. (60 refs.)

Introduction and Aims. Declines in adolescent smoking prevalence have slowed recently, resulting in increased interest and literature in tobacco harm minimisation. To date, harm reduction strategies have focused largely on modifying the product and alternative (safer) mechanisms of nicotine delivery. There has been little exploration of primary harm minimisation to prevent the onset of regular smoking among young people. A major concern expressed about harm reduction interventions and young people is that they may increase experimentation among non-users. Design and Methods. The Smoking Cessation for Youth Project was a 2-year school-based cluster randomised controlled trial conducted in 30 Western Australian schools. Results on the primary outcome showed a significant reduction in regular smoking among 4636 13-15-year-olds receiving a harm minimisaton versus standard intervention. This paper addresses the intervention effects on 2078 students who had not smoked at baseline. Results. At 20-month follow-up, smoking initiation was slightly lower among intervention students than comparison students ( who received a largely abstinence-based intervention), although this difference did not attain statistical significance ( OR = 0.86; 95% confidence interval: 0.68, 1.09). Discussion and Conclusions. This study provided limited evidence to suggest that harm minimisation is a superior approach to abstinence-based interventions for non-smokers. However, this intervention did not contribute to increased experimentation among non-smokers. Although more trials are required, these results indicate that fears of potential negative iatrogenic effects from school-based harm minimisation interventions may be unwarranted.

Hammett TM; Wu Z; Duc TT; Stephens D; Sullivan S; Liu W et al. 'Social evils' and harm reduction: the evolving policy environment for human immunodeficiency virus prevention among injection drug users in China and Vietnam. Addiction 103(1): 137-145, 2008. (42 refs.)

Aims: This paper reviews the evolution of government policies in China and Vietnam regarding harm reduction interventions for human immunodeficiency virus (HIV) prevention, such as needle/syringe provision and opioid substitution treatment. Methods: The work is based upon the authors' experiences in and observations of these policy developments, as well as relevant government policy documents and legislation. Results: Both countries are experiencing HIV epidemics driven by injection drug use and have maintained generally severe policies towards injection drug users (IDUs). In recent years, however, they have also officially endorsed harm reduction. We sought to understand how and why this apparently surprising policy evolution took place. Factors associated with growing support for harm reduction were similar but not identical in China and Vietnam. These included the emergence of effective 'champions' for such policies, an ethos of pragmatism and receptivity to evidence, growing collaboration across public health, police and other sectors, the influence of contingent events such as the severe acute respiratory syndrome (SARS) epidemic and pressure from donors and international organizations to adopt best practice in HIV prevention. Conclusions: Ongoing challenges and lessons learned include the persistence of tensions between drug control and harm reduction that may have negative effects on programs until a fully harmonized policy environment is established. Excessive reliance on law enforcement and forced detoxification will not solve the problems of substance abuse or of HIV among drug users. Ongoing evaluation of harm reduction programs, as well as increased levels of multi-sectoral training, collaboration and support are also needed.

Harding R; Stockley CS. Communicating through government agencies. Annals of Epidemiology 17(5, Supplement S): S98-S102, 2007. (38 refs.)

A comparison of worldwide recommendations on alcohol consumption reveals wide disparity among countries. This could imply that many of the recommendations do not adequately accommodate the science, given that the science is equally valid worldwide. Such a view, however, would be an oversimplification of the problem that those who formulate such guidelines face. The objective of guidelines is to influence and change behavior among target populations. It follows, therefore, that several factors then become relevant: behavior that is thought to be in need of change, the culture and mindset of the target populations, and the kind of message that is likely to be effective. There are some tensions between advice intended only to reduce the prevalence of misuse and that which also seeks to reflect the evidence on the beneficial health effects of moderate consumption.

Havens JR; Walker R; Leukefeld CG. Prevalence of opioid analgesic injection among rural nonmedical opioid analgesic users. Drug and Alcohol Dependence 87(1): 98-102, 2007. (35 refs.)

Objective: The purpose of this study was to examine the prevalence and correlates of opioid analgesic injection (OAI) in a cohort of rural opioid analgesic users. Methods: Cross-sectional study of 184 participants from rural Appalachian Kentucky. Results: The majority of participants were male (54.9%), white (98.4%) and the median age was 30 years (interquartile range: 24-37). The self-reported lifetime prevalence of injection drug use (IDU) was 44.3%, with 35.3% of respondents reporting injection of oral opioid analgesic formulations. The prevalence of self-reported hepatitis C (HCV) was 14.8%, significantly greater than those not injecting opioid analgesics (1.7%) (p < 0.001). Receptive needle sharing, distributive needle sharing and sharing of other injection paraphernalia was reported by 10.5%, 26.3%, and 42.1% of those currently injecting, respectively. Conclusions: Opioid analgesic injection was more prevalent in this rural population than has been found in previous reports. This study suggests a rising problem with injecting among rural opioid users, a problem more typically associated with urban drug users. Educating injectors of opioid analgesics on safe needle practices is necessary in order to curb the transmission of HIV, HCV, and other infectious diseases. Further study on the longitudinal course of opioid analgesic injection in this population appears warranted.

Heller DI; Stancliff S. Providing naloxone to substance users for secondary administration to reduce overdose mortality in New York City. Public Health Reports 122(3): 393-397, 2007. (22 refs.)

Overdose on illicit drugs is a substantial and growing public health problem. In New York City (NYC) between 1990 and 2001, overdose deaths increased by 48%, from 541 to 799 fatalities; in contrast, homicides decreased by 71%, from 2,081 to 609 during this same time period. Certain populations are at particularly high risk of overdose: among users of single-adult homeless shelters in NYC, overdose morbidity and mortality markedly exceeds rates in the general population. 2 Overdose has been identified as a primary cause of excess mortality among substance users with acquired immunodeficiency syndrome (AIDS) in NYC. A substantial increase in overdose risk has been identified following release from prison or jail, as substance users' tolerance for opioids decreases during incarceration. This article describes an initiative to provide prefilled naloxone dispensers and overdose-related education and training directly to substance users themselves, to enable them to, if necessary, directly initiate overdose reversal and prevent morbidity and mortality among their peers. Most overdoses are witnessed by others, which provides an opportunity for peers to adopt the role of overdose responder in the absence of emergencymedical services.

Howard DE; Griffin M; Boekeloo B; Lake K; Bellows D. Staying safe while consuming alcohol: A qualitative study of the protective strategies and informational needs of college freshmen. Journal of American College Health 56(3): 247-254, 2007. (32 refs.)

Objective: In this qualitative study, the authors examined how students attempt to minimize harm to themselves and others when drinking. Participants: The authors recruited freshmen at a large, mid-Atlantic US public university during the fall semester of 2005 to participate in 8 focus groups. Methods: The moderator's guide was developed through an iterative process that included input from experts and pilot testing. The researchers audiotaped focus group conversations, transcribed them, and subjected them to an interrater reliability check. Analysis was based on the framework of Information-Motivation-Behavioral Skills Model and a phenomenological approach. Results: College students have a repertoire of coping strategies they use in an attempt to safeguard themselves and their friends from harm when drinking. Strategies encompass planning a safe context for drinking, using safety measures to minimize harm when drinking, and taking care of someone who has consumed too much alcohol. Conclusions: A harm-reduction focus that acknowledges and builds on existing protective strategies may be a promising avenue for alcohol interventions.

Islam M; Conigrave K. Assessing the role of syringe dispensing machines and mobile van outlets in reaching hard-to-reach and high-risk groups of injecting drug users (IDUs): A review. (review). Harm Reduction Journal 4: article 14, 2007. (70 refs.)

Reaching hard-to-reach and high-risk injecting drug users (IDUs) is one of the most important challenges for contemporary needle syringe programs (NSPs). The aim of this review is to examine, based upon the available international experience, the effectiveness of syringe vending machines and mobile van/bus based NSPs in making services more accessible to these hard-to-reach and high-risk groups of IDUs. A literature search revealed 40 papers/reports, of which 18 were on dispensing machines (including vending and exchange machines) and 22 on mobile vans. The findings demonstrate that syringe dispensing machines and mobile vans are promising modalities of NSPs, which can make services more accessible to the target group and in particular to the harder-to-reach and higher-risk groups of IDUs. Their anonymous and confidential approaches make services attractive, accessible and acceptable to these groups. These two outlets were found to be complementary to each other and to other modes of NSPs. Services through dispensing machines and mobile vans in strategically important sites are crucial elements in continuing efforts in reducing the spread of HIV and other blood borne viruses among IDUs.

Islam MM; Conigrave KM. Increasing prevalence of HIV, and persistent high-risk behaviours among drug users in Bangladesh: Need for a comprehensive harm reduction programme. Drug and Alcohol Review 26(4): 445-454, 2007. (58 refs.)

Introduction and Aims. The aim of this study was to examine trends in HIV and related risk behaviours in drug users in Bangladesh, the effects of prevention and harm reduction initiatives that have already been undertaken and to highlight immediate needs. Design and Methods. Journal publications, conference abstracts and proceedings were collected and reviewed. As there were relatively few published papers, the grey literature was also reviewed. Experts involved in the development and evaluation of current programmes or policy were contacted for official reports, policy documents or unpublished materials. The trends in injecting and sexual risk behaviours were tabulated. Results. Periodic behavioural and serosurveillance on recognised sentinel groups shows clearly that HIV prevalence among injecting drug users has been increasing steadily. In the capital city, the HIV prevalence among injecting drug users is close to the level of a concentrated epidemic (4.9%). While harm reduction strategies have brought a scope of reduction of injecting-related risk behaviours, the persistent high rates of needle sharing and high prevalence of sexual risk behaviours remains alarming. Non-injecting drug users have maintained a low prevalence of HIV but their high-risk sexual behaviours and transformation into injecting drug users with time are of concern. Discussion and Conclusions. There are substantial gaps between current needs and the ongoing prevention and harm reduction activities. There is a pressing need for a comprehensive harm reduction programme and review of any policies and laws which may impede this.

Jorgensen MH; Curtis T; Christensen PH; Gronbaek M. Harm minimization among teenage drinkers: Findings from an ethnographic study on teenage alcohol use in a rural Danish community. Addiction 102(4): 554-559, 2007. (20 refs.)

Aim To examine strategies of harm minimization employed by teenage drinkers. Design, setting and participants Two periods of ethnographic fieldwork were conducted in a rural Danish community of approximately 2000 inhabitants. The fieldwork included 50 days of participant observation among 13-16-year-olds (n = 93) as well as 26 semistructured interviews with small self-selected friendship groups of 15-16-year-olds (n = 32). Findings The teenagers participating in the present study were more concerned about social than health risks. The informants monitored their own level of intoxication, but in order to reduce alcohol consumption they depended upon support from their peers. The informants preferred drinking in the company of well-known and trusted peers, and during drinking episodes they supervised and intervened in each others' drinking to the extent that they deemed it necessary and possible. In regulating the social context of drinking they relied on their personal experiences more than on formalized knowledge about alcohol and harm, which they had learned from prevention campaigns and educational programmes. Conclusions: In this study we found that teenagers may help each other to minimize alcohol-related harm, and teenage peer groups should thus be considered a resource for health promotion.

Joseph AM; Hecht SS; Murphy SE; Lando H; Carmella SG; Gross M et al. Smoking reduction fails to improve clinical and biological markers of cardiac disease: A randomized controlled trial. Nicotine & Tobacco Research 10(3): 471-481, 2008. (24 refs.)

Cigarette reduction has been proposed as a treatment goal for smokers who are not interested in stopping completely. This randomized controlled trial was designed to determine the effect of a smoking reduction intervention on smoking behavior, symptoms of heart disease, and biomarkers of tobacco exposure. It included 152 patients with heart disease who did not intend to stop smoking in the next 30 days. Participants were randomly assigned to smoking reduction (SR) or usual care (UC). SR subjects received counseling and nicotine replacement therapy to encourage >= 50% reduction in cigarettes per day (CPD). They were followed at 1, 3, 6, 12 and 18 months to assess smoking, heart disease symptoms, quality of life and nicotine, cotinine, carbon monoxide (CO), white blood cell (WBC) count, fibrinogen, hs-C-reactive protein (hs-CRP), F-2-isoprostane, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides (total NNAL), and 1-hydroxypyrene (1-HOP). At 6 months SR participants reduced by 10.9 CPD, compared with 7.4 CPD in UC (difference NS). At 18 months, 9/78 SR vs. 9/74 UC participants quit smoking. There were no significant differences between treatment groups in angina, quality of life or adverse events, nicotine, cotinine, CO, WBC count, fibrinogen, hs-CRP, F-2-isoprostane, total NNAL or 1-HOP levels at any time point. To determine if smoking reduction, regardless of treatment condition, was associated with improved outcomes, we compared all subjects at 6 months to baseline (mean reduction in CPD from 27.4 to 18.1, p<.01). There were no significant changes in outcome variables except CO, which decreased by 5.5ppm (p<.01). There were also no significant improvements considering only subjects who reduced by >= 50%, or those who had no history of reduction prior to enrollment in the study. The SR intervention did not significantly reduce CPD or toxin exposure, or improve smoking cessation or clinical outcomes compared to UC. These results emphasize the importance of abstinence for smokers with heart disease to minimize health risks from tobacco.

Kelly BC. Club drug use and risk management among "bridge and tunnel" youth. Journal of Drug Issues 37(2): 425-443, 2007. (22 refs.)

Club drugs present a range of risks similar to the range of psychoactive effects resulting from the use of the substances in this classification. These drugs remain in wide use amongst those in rave and club subcultures. This paper explores a range of risk management practices used by youth who utilize club drugs within rave and club subcultures. Through the use of ethnographic methods during a two-year period of fieldwork, the author collected data on club drug use and risk taking among "Bridge and Tunnel" youth. The resulting paper provides a descriptive typology of a series of risk management practices and explores how these practices are strategically deployed in an effort to maximize enjoyment and minimize danger.

Kerr T; Small W; Moore D; Wood E. A micro-environmental intervention to reduce the harms associated with drug-related overdose: Evidence from the evaluation of Vancouver's safer injection facility. International Journal of Drug Policy 18(1): 37-45, 2007. (32 refs.)

Background: Conventional drug overdose prevention strategies have been criticised for failing to address the macro- and micro-environmental factors that shape drug injecting practices and compromise individual ability to reduce the risks associated with drug-related overdose. This in turn has led to calls for interventions that address overdose risks by modifying the drug-using environment, including the social dynamics within them. Safer injection facilities (SIFs) constitute one such intervention, although little is known about the impact of such facilities on factors that mediate risk for overdose. Methods: Semi-structured qualitative interviews were conducted with fifty individuals recruited from a cohort of SIF users in Vancouver, the Scientific Evaluation Of Supervised Injecting (SEOSI). Audio recorded interviews elicited injection drug users' (IDU) accounts of overdoses as well as perspectives regarding the impact of SIF use on overdose risk and experiences of overdose. Interviews were transcribed verbatim and a thematic analysis was conducted. Results: Fifty IDU, including 21 women, participated in this study. The perspectives of participants suggest that the Vancouver SIF plays an important role in mediating various risks associated with overdose. In particular, the SIF addresses many of the unique contextual risks associated with injection in public spaces, including the need to rush injections due to fear of arrest. Further, SIF use appears to enable overdose prevention by simultaneously offsetting potential social risks associated with injecting alone and injecting in the presence of strangers. The immediate emergency response offered by nurses at the SIF was also valued highly, especially when injecting adulterated drugs and drugs of unknown purity and composition. Conclusion: The perspectives of IDU participating in this study suggest that SIFs can address many of the micro-environmental factors that drive overdose risk and limit individual ability to employ overdose prevention practices. Although challenges related to coverage remain in many settings, SIFs may play a unique role in managing overdoses, particularly those occurring within street-based drug scenes.

Kirkos WC; Carrique T; Griffen K; La Barge AP. The York Region methamphetamine strategy. (editorial). Canadian Medical Association Journal 178(13): 1655-1656, 2008. (3 refs.)

Kleinig J. The ethics of harm reduction. Substance Use & Misuse 43(1): 1-16, 2008. (23 refs.)

The article attempts to set harm minimization within drug settings into a larger framework of harm minimization practices. It seeks to provide a plausible account of harm reduction and then explores four ethical challenges for harm reduction strategies.

Kozlowski LT. Effect of smokeless tobacco product marketing and use on population harm from tobacco use -- Policy perspective for tobacco-risk reduction. American Journal of Preventive Medicine 33(6, Supplement S): S379-S386, 2007. (74 refs.)

This article presents policy perspectives on the marketing of smokeless tobacco products to reduce population harm from tobacco use. Despite consensus that smokeless tobacco products as sold in the United States are less dangerous than cigarettes, there is no consensus on how to proceed. Diverse factions have different policy concerns. While the tobacco industry is exempted from U.S. Food and Drug Administration (FDA) oversight, the pharmaceutical industry whose nicotine replacement therapy (NRT) medicines compete with smokeless tobacco as noncombustible nicotine-delivery systems are regulated by the FDA. Some public health experts support smokeless tobacco use to reduce population harm from tobacco; other public health experts oppose promoting smokeless tobacco for harm reduction. Adult consumers can freely purchase currently-marketed smokeless tobacco products and even more-deadly cigarettes. Concerns with and advantages of smokeless tobacco products are discussed. In that noncombustible medicinal nicotine-delivery systems have been proven to be effective smoking-cessation aids, smokeless tobacco, as another source of psychoactive doses of nicotine, could be used similarly, in a dose-response fashion as a smoking-cessation aid (consistent with FDA principles for evaluating generic versions of drugs). Price measures should be used on tobacco products to make costs to consumers proportional to product health risks (which would make smokeless tobacco much cheaper than cigarettes), and smokeless tobacco should be encouraged as an option for smoking cessation in adult smokers, particularly for those who have failed to stop smoking using NRT or other methods.

Kushlick D. Addicts' adventures in wonderland. (editorial). Addiction Research & Theory 15(2): 123-126, 2007

Viewed from a public health and wellbeing perspective, you could be forgiven for thinking that drug policy is developed at the Mad Hatter's tea party. Huge numbers of legal drug users are effectively ignored, whilst relatively tiny numbers of illegal users have enormous time and resources spent on stopping them using. I am going to suggest that policy is not rationally based upon sound public health or harm reduction principles, but rather that it is skewed to the point of ridiculousness by the Government's denial of the counter-productive effects of drug prohibition.

Lachenmeier DW; Rehm J; Gmel G. Surrogate alcohol: What do we know and where do we go? Alcoholism: Clinical and Experimental Research 31(10): 1613-1624, 2007. (85 refs.)

Consumption of surrogate alcohols (i.e., nonbeverage alcohols and illegally produced alcohols) was shown to impact on different causes of death, not only poisoning or liver disease, and appears to be a major public health problem in Russia and elsewhere. A computer-assisted literature review on chemical composition and health consequences of "surrogate alcohol" was conducted and more than 70 references were identified. A wider definition of the term "surrogate alcohol" was derived, including both nonbeverage alcohols and illegally produced alcohols that contain nonbeverage alcohols. Surrogate alcohol may contain substances that cause severe health consequences including death. Known toxic constituents include lead, which may lead to chronic toxicity, and methanol, which leads to acute poisoning. On the other hand, the role of higher alcohols (e.g., propanol, isobutanol, and isoamyl alcohol) in the etiology of surrogate-associated diseases is currently unclear. Whether other constituents of surrogates have contributed to the high all-cause mortality over and above the effect of ethanol in recent studies also remains unclear. Given the high public health importance associated with the consumption of surrogate alcohols, further knowledge on its chemical composition is required as well as research on its links to various disease endpoints should be undertaken with priority. Some interventions to reduce the harm resulting from surrogate alcohol could be undertaken already at this point. For example, the use of methanol or methanol-containing wood alcohol should be abolished in denatured alcohol. Other possible surrogates (e.g., automobile products) should be treated with bittering agents to avoid consumption.

Laker CJ. How reliable is the current evidence looking at the efficacy of harm reduction and motivational interviewing interventions in the treatment of patients with a dual diagnosis? Journal of Psychiatric and Mental Health Nursing 14(8): 720-726, 2007. (41 refs.)

Current policy from the Department of Health advocates for an integrated approach to treating patients with a dual diagnosis. However, pragmatic and clinically effective brief interventions that can be delivered by nurses across mental health settings remain underdeveloped. Motivational interviewing has had some successful exposure in the field of dual diagnosis; however, harm reduction remains unexplored both conceptually and in terms of clinical intervention. This literature review examines the notion of harm reduction as a method of identifying and reducing the harm associated with the misuse of drugs and alcohol in relation to mental health problems. Currently there is a paucity of good quality evidence for integrated interventions in the treatment of dually diagnosed patients. Therefore, the papers are analysed in respect of their methodological quality and contribution to the evidence base to inform both future research and mental health nursing practice.

Lampropoulos B. Substance abuse and harm minimisation in adolescents. Australian Family Physician 36(8): 602-604, 2007. (11 refs.)

BACKGROUND Adolescent substance use is prevalent among Australian school students. Although a degree of risk taking is a normal developmental task it can lead to serious consequences. For some it is a short lived risk taking experience. For others it is a flag for other life difficulties and a possible trajectory to addiction. OBJECTIVE This article outlines an approach to engaging with the adolescent to identify substance abuse and the context in which it occurs. The process outlined allows for identification of multiple concerns and opportunities to reduce harm. DISCUSSION The key to addressing adolescent substance use is engagement. This involves allowing for time with the adolescent alone and with a support person if they wish, discussing confidentiality issues and using a framework for obtaining a comprehensive psychosocial history. This enables identification of multiple concerns, comorbid conditions and opportunities to reduce harm.

Larney S; Mathers B; Dolan K. Illicit Drug Treatment in Prison: Detoxification, drug-free units, therapeutic communities and opioid substitution treatment. NDARC Technical Report No. 266. Sydney: National Drug and Alcohol Research Centre (Australia), 2007. (59 refs.)

While it is recognized that providing drug treatment to drug-using offenders may contribute to reducing re-offending, treatment availability is often limited. However, prisoners retain the right to adequate healthcare, including access to effective treatment for drug dependence, and treatment equivalent to the care available in the community. This is of particular importance as prisons are important sites of HIV transmission due to sharing of injecting equipment and unprotected sexual activity. This report summarizes the published literature on illicit drug detoxification and treatment interventions in prisons. The first topic discussed is detoxification with attention to opiates and psychostimulants, and discussion of pharmacotherapies, symptomatic treatment, psychiatric complications, and the need for psychological support. Discussion then turns to drug-free wings, therapeutic communities and their impact on drug use, criminal recidivism, and factors associated with treatment completion. It concludes with consideration of opioid substitution treatment, in the community and prison setting, its rationale, and the use of methadone maintenance, buprenorphine maintenance and LAAM.

Leonard L; DeRubeis E; Pelude L; Medd E; Birkett N; Seto J. "I inject less as I have easier access to pipes" - Injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed. International Journal of Drug Policy 19(3): 255-264, 2008. (35 refs.)

Among injection drug users (IDUs) in Ottawa, the capital of Canada, prevalence rates of HIV (20.6 percent) and hepatitis C HCV (75.8 percent) are among the highest in Canada. Recent research evidence suggests the potential for HCV and HIV transmission through the multiperson use of crack-smoking implements. On the basis of this scientific evidence, in April 2005, Ottawa's needle exchange programme (NEP) commenced distributing glass stems, rubber mouthpieces, brass screens, chopsticks, lip balm and chewing gum to reduce the harms associated with smoking crack. This study aims to evaluate the impact of this initiative on a variety of HCV- and HIV-related risk practices. Active, street-recruited IDUs who also smoked crack consented to personal interviews and provided saliva samples for HCV and HIV testing at four time points: 6-months pre-implementation (N= 112), 1-month (N= 114), 6-months (N= 157) and 12-months (N = 167) post-implementation. Descriptive and univariate analyses were completed. Following implementation of the initiative, a significant decrease in injecting was observed. Pre-implementation, 96 percent of IDUs reported injecting in the month prior to the interview compared with 84 percent in the 1 month, and 78 percent in the 6- and 12-month post-implementation interviews (p <.01). Conversely, approximately one-quarter of participants at both the 6- and 12-month post-implementation evaluation points reported that they were smoking crack more frequently since the availability of clean equipment-25 and 29 percent, respectively. In addition to a shift to a less harmful method of drug ingestion, HCV- and HIV-related risks associated with this method were reduced. Among crack-smoking IDUs sharing pipes, the proportion sharing "every time" declined from:37 percent in the 6-month pre-implementation stage, to 31 percent in the 1-month, 12 percent in the 6-month and 13 percent in the 12-month post-implementation stages (p <.01). Since distributing safer crack-smoking materials by a NEP contributes to transition to safer methods of drug ingestion and significantly reduces disease-related risk practices, other NEPs should adopt this practice.

Levy DE; Thorndike AN; Biener L; Rigotti NA. Use of nicotine replacement therapy to reduce or delay smoking but not to quit: Prevalence and association with subsequent cessation efforts. Tobacco Control 16(6): 384-389, 2007. (22 refs.)

Objective: To assess the prevalence of nicotine replacement therapy (NRT) use for purposes other than quitting smoking and examine the relation of this non-standard NRT use (NSNRT) with subsequent smoking cessation efforts. Design: A population based cohort study of adult smokers who were interviewed by telephone at baseline (2001-2) and at two year follow-up. The association between NSNRT use to cut down on smoking or to delay smoking before baseline and cessation attempts and smoking outcomes at two year follow-up was assessed using logistic regression to adjust for multiple potential confounding factors. Setting: Massachusetts,. Subjects: 1712 adult smokers in Massachusetts who were selected using a random digit dial telephone survey. Main outcome measures: Quit attempt in 12 months before follow-up, NRT use at quit attempt in 12 months before follow-up, smoking cessation by follow-up, or 50% reduction in cigarettes smoked per day between baseline and follow-up. Results: 18.7% of respondents reported ever having used NSNRT. In a multiple logistic regression analysis, there was no statistically significant association between past NSNRT use and quit attempts (ORcut down = 0.89, 95% CI 0.59 to 1.33; ORdelay = 1.29, 95% CI 0.73 to 2.29), smoking cessation (ORcut down = 0.74, 95% CI 0.43 to 1.24; ORdelay = 1.22, 95% CI 0.60 to 2.50) or 50% reduction in cigarettes smoked per day (ORcut down = 0.93, 95% CI 0.62 to 1.38; ORdelay = 0.80, 95% CI 0.43 to 1.49) at follow- up. Past use of NRT to cut down on cigarettes was associated with use of NRT at a follow-up quit attempt (ORcut down = 2.28, 95% CI 1.50 to 3.47) but past use of NRT to delay smoking was not (ORdelay = 1.25, 95% CI 0.67 to 2.34). Conclusions: Use of NRT for reasons other than quitting smoking may be more common than was previously estimated. This population based survey finds no strong evidence that NRT use for purposes other than quitting smoking is either harmful or helpful.

Limbu B. The role of community-based nurses in harm reduction for HIV prevention: A South East and South Asia case study. International Journal of Drug Policy 19(3): 211-213, 2008. (13 refs.)

International studies have explored the use of community-based nurses for harm reduction programs and HIV prevention. However, none have explored this role within the countries of Nepal, Myanmar, and China where the legal and political environment may adversely affect uptake of services by people who use injection drugs. Based on experiences as a nurse and harm reduction technical adviser for the development of community-based nursing initiatives in Nepal, Myanmar and China, I review some of the strengths and challenges associated with harm reduction programs in these countries. Community-based nurses play an important role in increasing the access and uptake of public health services by people who inject drugs. Within the context of harm reduction programs, community-based nurses develop a unique trust with people who inject drugs by providing non-discriminatory health care. Nurses act as information bridges between communities of people who use injection drugs, law enforcement, political and health care stakeholders. In doing so, they facilitate timely policy and programmatic responses. However, community-based nurses are prone to burnout due to long working hours and a limited pool of human resources. Community-based nurses have proven essential to the effective implementation of harm reduction program for HIV prevention in Nepal, Myanmar and China. Increased attention and support to these health care professionals have the potential to strengthen existing programs targeting people who inject drugs.

Madden A; Cavalieri W. Hepatitis C prevention and true harm reduction. (editorial). International Journal of Drug Policy 18(5): 335-337, 2007. (11 refs.)

Matheson C; Bond CM; Tinelli M. Community pharmacy harm reduction services for drug misusers: National service delivery and professional attitude development over a decade in Scotland. Journal of Public Health 29(4): 350-357, 2007. (16 refs.)

Community pharmacy contributes to drug misuse management and reduced spread of blood-borne disease through distributing clean needles and substitute drug dispensing. This paper reports a third Scotland-wide survey of pharmacies enabling service delivery to be charted over a decade. A cross-sectional postal questionnaire of all Scottish pharmacies (n = 1166) was undertaken. Descriptive data were collected on services provided, attitudes, training and demography. Data were compared with data from 1995 and 2000. Needle exchange provision increased slightly to 12.5% from 9.7% (2000) and 8.6% (1995). The mean number of needle exchange clients increased significantly to 37.7 from 20.3 (2000) and 12.5 (1995). Methadone was dispensed by 79.1% of respondents, and 90.9% of those supervised self-administration. The total number of methadone patients increased to 12,400 from 8,809 in 2000 and 3,387 in 1995. Of those taking methadone, 57% have supervised self-administration. A quarter dispensed buprenorphine to 190 patients. Attitudes improved significantly but training levels have not changed since 2000. More commitment to harm reduction was evident through improved attitudes and increased services. Service delivery has increased more for dispensing services than for needle exchange. Strategies for delivering future needle exchange and substitute dispensing services are required if demand approaches capacity.

McLellan AT. Reducing heavy drinking: A public health strategy and a treatment goal? (editorial). Journal of Substance Abuse Treatment 33(1): 81-83, 2007. (9 refs.)

Mehrabadi A; Craib KJP; Patterson K; Adam W; Moniruzzaman A; Ward-Burkitt B et al. The Cedar Project: A comparison of HIV-related vulnerabilities amongst young aboriginal women surviving drug use and sex work in two Canadian cities. International Journal of Drug Policy 19(2): 159-168, 2008. (58 refs.)

Background: In Canada, Aboriginal women and youth continue to be overrepresented amongst new cases of HIV, and are considered at increased risk for sex and drug-related harm. Young women involved in sex work are particularly vulnerable. The purpose of this study is to determine HIV-related vulnerabilities associated with sex work amongst young Aboriginal women in two Canadian cities. Methods: This study is based on a community-based cohort of Aboriginal young people (status and non-status First Nations, Inuit and Metis) between the ages of 14 and 30 who used injection or non-injection illegal drugs (street drugs) in the previous month. Participants lived in Vancouver, Canada, or Prince George, a remote, northern Canadian city. Between October 2003 and July 2005, 543 participants were recruited by word of mouth, posters, and street outreach. A baseline questionnaire was administered by Aboriginal interviewers, and trained nurses drew blood samples for HIV and HCV antibodies and provided pre- and post-test counselling. This study included 262 Young women who participated at baseline. Analyses were conducted to compare socio-demographics, drug use patterns, injection practices, sexual experiences, and HIV and HCV prevalence between young women who reported being involved in sex work in the last 6 months (n = 154) versus young women who did not (n = 108). Logistic regression was used to identify factors independently associated with recent sex work involvement. Results: Both sexual violence and drug using patterns were found to be markedly different for women having recently been involved in sex work. Multivariate analysis revealed daily injection of cocaine (AOR = 4.4; 95% CI: 1.9, 10.1 and smoking crack (AOR = 2.9; 95% CI: 1.6, 5.2) in the previous 6 months, and lifetime sexual abuse (AOR = 2.5; 95% CI: 1.4, 4.4) to be independently associated with sex work. Interpretation: Harm reduction and treatment programs that address historical and lifetime trauma amongst Aboriginal people and prioritize emotional and physical safety for young Aboriginal women involved in sex work are required.

Mendoza-Baumgart MI; Tulunay OE; Hecht SS; Zhang Y; Murphy S; Le C et al. Pilot study on lower nitrosamine smokeless tobacco products compared with medicinal nicotine. Nicotine & Tobacco Research 9(12): 1309-1323, 2007. (49 refs.)

Smokeless tobacco (ST) products have the potential to be used as a harm reduction method for cigarette smokers. These products can deliver significantly less toxicants than cigarettes, although they are not toxicant free nor harmless. It is important to examine potential health risks and benefits of these products. These two small pilot studies examined the effects of two different ST products (Exalt and Ariva) compared with medicinal nicotine, another potential harm reduction product. Dependent, healthy adult cigarette smokers, who were motivated to quit smoking, underwent 1 week of baseline smoking measurement. They were then asked to quit smoking and were randomly assigned to use either an ST product or a medicinal nicotine lozenge (MNL, Commit) for 2 weeks, then crossed over to use the other product for 2 weeks. In the last week, following the sampling phase, subjects could choose the product they wished to use. Assessments were made repeatedly during baseline cigarette use and throughout the 5 weeks of treatment. Outcome measures included biomarkers for tobacco exposure and subjective, physiological, and behavioral responses. Tobacco-specific carcinogen uptake was greater from Exalt than from the MNL, and was comparable between the MNL and Ariva. Physiological effects and subjective effects on withdrawal and craving were comparable among Exalt, Ariva, and the MNL. Ariva was preferred over the MNL, which was preferred over Exalt. With the exception of medicinal nicotine products, low-nitrosamine ST products have the greatest potential to result in reduced toxicant exposure compared with other combustible reduced exposure products and have promise for reducing individual risk for disease. However, the population effect of marketing of such products as reduced exposure/reduced risk is unknown. The need for further research in this area and regulation of tobacco products is evident.

Minc A; Butler T; Gahan G. The Jailbreak Health Project. Incorporating a unique radio programme for prisoners. International Journal of Drug Policy 18(5): 444-446, 2007. (1 refs.)

Several studies in NSW have identified prisoners to be at high risk for blood borne viruses. The prevalence of hepatitis C among men in NSW correctional centres is 40% and over 60% among women. It is even higher among those with histories of injecting drug use. As part of the state's strategy to minimise the spread of blood borne viruses and promote healthy lifestyles among prisoners, the Community Restorative Centre broadcasts a weekly half hour radio programme to prisoners and the community. The project is funded through the NSW Health Department and aims to provide support to prisoners, ex-prisoners and their families. Jailbreak's success hinges on the participation of the very people [prisoners] the show wishes to target. The radio show is aimed specifically at broadcasting health promotion and harm-minimisation messages to prisoners and their supporters although this is not obvious. When you tune in to Jailbreak you will hear a diverse range of opinion, music and poetry from people caught up in the criminal justice system. Nevertheless at the heart of this exciting and challenging project is the delivery of engaging, relevant and clear health messages to prison inmates, ex-inmates and families in relation to HIV, hepatitis and sexual health. Since 2002, valuable health information, often in the form of personal stories, vignettes and quiz questions, can be heard in and around Sydney on 2SER 107.3 FM or online at http: www.2ser.com. Jailbreak has not been without controversy and has to balance the security focus of correctional authorities and the illegality of substance use in correctional centres with the need to convey messages to prisoners in relation to harm-minimisation.

Mukamal KJ. Impact of race and ethnicity on counseling for alcohol consumption: A population-based, cross-sectional survey. Alcoholism: Clinical and Experimental Research 31(3): 452-457, 2007. (30 refs.)

Background: Counseling for alcohol use is of proven utility, but whether disparities in provision of counseling exist is uncertain. Methods: Using the 1999 Behavioral Risk Factor Surveillance System, a population-based telephone survey, we examined participant-reported physician counseling for alcohol use among 15,498 adults in 5 U.S. states. Participants reported their usual alcohol intake, risky drinking (intake of 5 or more drinks on occasion, greater than 60 drinks per month, or driving after drinking), and whether a doctor had spoken with them about alcohol use. Results: Race and ethnicity were strongly associated with reported receipt of alcohol counseling. Compared with whites, black and Hispanic adults had 2-fold higher odds of reporting receiving counseling among all participants, among problem drinkers, and among abstainers. There were modest differences according to sex, income, self-reported health, and education, but not body mass index. Multivariable adjustment and restriction to participants who reported a recent checkup did not alter these findings. No such disparity was noted for general diet counseling. Conclusions: Clear racial and ethnic differences exist in physician counseling for alcohol use, with higher prevalence estimates among racial and ethnic minority populations. Although the cause of these differences is uncertain, systematic application of preventive medical services such as alcohol screening and counseling is needed for all patients.

Norden P. Keeping them connected: Reducing drug-related harm in Australian schools from a Catholic perspective. Drug and Alcohol Review 27(4): 451-458, 2008. (9 refs.)

In this Harm Reduction Digest, Father Peter Norden of Jesuit Social Services (Australia) summarises the findings of a report of a consultation into how Catholic schools in Australia address substance use by school students. The report showed that while in the past the 'zero tolerance' approach had been the norm, more recently there had been a growing awareness in Catholic schools that it is possible to respond to the needs of drug-using students while being respectful of the duty of care to other students. Moreover, harm reduction was accepted as a serious objective for drug policy and practice in Australian Catholic schools. The paper canvases the key issues that emerged from the consultation and suggests what 'good practice' looks like, providing useful guidance for both Catholic and non-Catholic schools alike. For those of us outside the Catholic school system, the paper provides an enlightening read about how substance use can be best addressed within schools.

Obot IS. Harm reduction - What is it? (editorial). Addiction 102(5): 691-691, 2007. (5 refs.)

O'Byrne P; Holmes D. Evaluating crack pipe distribution in Canada: A systems change case study. Addiction Research & Theory 16(2): 181-192, 2008. (45 refs.)

Over the last two decades, the incidence/prevalence rates of Hepatitis C virus have increased; this has resulted in the development of novel approaches to disease control, with many of these strategies taking a harm reduction approach. In Canada, one response has been crack pipe distribution (CPD). This article presents the results of a case study that compares CPD implementation in two Canadian cities: Ottawa and Toronto. The consequent analysis uses a systems perspective and thus, the implementation of CPD is examined within the larger context of social change that is necessary for public health services to transform their underlying philosophy from abstinence-based to harm reduction.

O'Hare P. Merseyside, the first harm reduction conferences, and the early history of harm reduction. International Journal of Drug Policy 18(2): 141-144, 2007. (10 refs.)

In the mid 1980s, Liverpool implemented pioneering approaches to dealing with the problems caused by the use of drugs. The Mersey Harm Reduction Model concentrated on reducing the harms rather than, as previously was the case, trying to reduce drug use itself. This policy was given great impetus by the emergence of HIV and the danger of infection from using contaminated injection equipment. It became imperative to reduce this kind of risk behaviour by providing clean injecting equipment, prescribing methadone (and in a small percentage of cases, heroin) and by using outreach workers to go into the community and help people where they lived and to attract them into services. The police played a key role. Service uptake was rapid and included many who had never had previous contact with services. An HIV epidemic did not happen amongst injecting drug users in Mersey. In 1991, the approach was applied to the new phenomenon of the use of MDMA with the publication of the leaflet 'Chill Out'. The First International Conference on the Reduction of Drug Related Harm took place in Liverpool in 1990 as a response to the interest shown in what was happening in the region and the International Harm Reduction Association was born out of these conferences.

Paivinen H; Bade S. Voice: Challenging the stigma of addiction: A nursing perspective. International Journal of Drug Policy 19(3): 214-219, 2008. (23 refs.)

Voice is a collection of art, poetry and narratives created by women living with a history of substance use and addiction. The intent of this collection is to explore women's understanding of harm reduction, to challenge the effects of stigmatization and to explore the experiences of those who have historically been silenced or devalued. Voice was conceived by a group of Kamloops nurses who came together and used their knowledge of mainstream systems, aesthetic knowing, feminism and substance use to guide the development and implementation of this project. During weekly gatherings, women with histories of substance use and addiction worked alongside a nurse in the co-creation of artistic expressions. Gender sensitivity, trust, equality and respect were vital to the success of this process. A selection of the women's art was presented at several venues, including an International Conference on Drug Related Harm, a Nursing Conference and a local art gallery. The positive community response to the women's work contributed to feelings of great pride and enhanced the women's confidence in their ability to express themselves. Throughout this process, women had the opportunity to develop social networks and to become aware of the value that their creative knowledge has to the community in which they live. Gender sensitive programming that is inclusive, participative and promotes women's health is required to fully understand women's experience of substance use and addiction in relation to harm reduction. Participation in projects such as Voice supports and encourages women to make sense of the world they live in and encourages health-promoting activities. The promising outcomes of this project might well be developed by nurses in other settings to further promote the health of women who have traditionally been stigmatized.

Patel V; Aroya R; Chatterjee S; Chisholm D; Cohen A; De Silva M et al. Global Mental Health 3 - Treatment and prevention of mental disorders in low-income and middle-income countries. (review). Lancet 370(9591): 991-1005, 2007. (179 refs.)

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policyrnakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Patton R; Strang J; Birtles C; Crawford MJ. Alcohol: A missed opportunity. A survey of all accident and emergency departments in England. Emergency Medicine Journal 24(8): 529-531, 2007. (24 refs.)

Aim: To determine the extent to which the recommendations of the alcohol harm reduction strategy for England and the Choosing Health white paper for the provision of screening and brief interventions for hazardous and harmful drinkers have been adopted by accident and emergency departments. Method: Telephone/postal survey of all 191 Type 1 departments in England. The survey was part of a larger study investigating the impact of the changes in the licensing act (2004) on alcohol-related attendances. Results: 4 departments use formal screening tools and 24 ask general questions about consumption (98.9% response rate). Blood alcohol levels were measured as required by 100 departments. No departments routinely measure blood alcohol, and 84 departments never assess blood alcohol levels. Alcohol-related attendances were formally recorded by 131 departments. Access to an alcohol health worker or a clinical nurse specialist was reported by 32 departments. Discussion: Although departments may be willing to address hazardous alcohol consumption, the low numbers of departments utilising formal screening tools suggests that patients who may benefit from help or advice remain undetected.

Pauly B. Harm reduction through a social justice lens. International Journal of Drug Policy 19(1): 4-10, 2008. (68 refs.)

Background: People who are street involved such as those experiencing homelessness and drug use face multiple inequities in health and access to health care. Morbidity and mortality are significantly increased among those who are street involved. Incorporation of a harm reduction philosophy in health care has the potential to shift the moral context of health care delivery and enhance access to health care services. However, harm reduction with a primary focus on reducing the harms of drug use fails focus on the harms associated with the context of drug use such as homelessness, violence and poverty. Methods: Ethical analysis of the underlying values of harm reduction and examination of different conceptions of justice are discussed as a basis for action that addresses a broad range of harms associated with drug use. Results: Theories of distributive justice that focus primarily on the distribution of material goods are limited as theoretical frameworks for addressing the root causes of harm associated with drug use. Social justice, reconceptualised and interpreted through a critical lens as described by Iris Marion Young, is presented as a promising alternative ethical framework. Conclusions: A critical reinterpretation of social justice leads to insights that can illuminate structural inequities that contribute to the harms associated with the context of drug use. Such an approach provides promise as means of informing policy that aims to reduce a broad range of harms associated with drug use such as homelessness and poverty.

Pauly B. Shifting moral values to enhance access to health care: Harm reduction as a context for ethical nursing practice. International Journal of Drug Policy 19(3): 195-204, 2008. (66 refs.)

Background: People who are street involved including those experiencing homelessness and substance use are at increased risk of morbidity and mortality. Such inequities are exacerbated when those facing the greatest inequities in health have the least access to health care. These concerns have rarely been addressed in bioethics and there has been a lack of explicit attention to the dominant societal and organizational values that structure such injustices. The purpose of this paper is to describe the underlying value tensions that impact ethical nursing practice and affect equity in access to health care for those who are street involved. Methods: In this paper, findings from a larger qualitative ethnographic study of ethical practice in nursing in the context of homelessness and substance use are reported. The original research was undertaken in two 'inner city' health care centres and one emergency department (ED) to gain a better understanding of ethical nursing practice within health care interactions. Data were collected over a period of 10 months through face-to-face interviews and participant observation. Results: In order to facilitate access to health care for those who are street-involved nurses had to navigate a series of value tensions. These value tensions included shifting from an ideology of fixing to reducing harm; stigma to moral worth; and personal responsibility to enhancing decision-making capacity. A context of harm reduction provided a basis for the development of relationships and shifted the moral orientation to reducing harm as a primary moral principle in which the worth of individuals and the development of their capacity for decision-making was fostered. Conclusions: Implementation of a harm reduction philosophy in acute care settings has the potential to enhance access to healthcare for people who are street involved. However, explicit attention to defining the harms and values associated with harm reduction is needed. While nurses adopted values consistent with harm reduction and recognized constraints on personal responsibility, there was little attention to action on the social determinants of health such as housing. The individual and collective role of professional nurses in addressing the harms associated with drug use and homelessness requires additional examination.

Pauly B; Goldstone I. Harm reduction in nursing practice: Current status and future directions. International Journal of Drug Policy 19(3): 179-182, 2008. (39 refs.)

Peele S. The bizarre effort to eliminate underage drinking in the United States: A harm reduction approach to youthful drinking. (editorial). Addiction Research & Theory 15(3): 227-229, 2007. (6 refs.)

Peterson GM; Northeast S; Jackson SL; Fitzmaurice KD. Harm minimization strategies: Opinions of health professionals in rural and remote Australia. Journal of Clinical Pharmacy and Therapeutics 32(5): 497-504, 2007. (16 refs.)

Background and objective: There is some evidence that the problem of illicit drug use (IDU) is increasing in rural areas of Australia. Lack of access to harm minimization (HM) strategies is potentially exacerbated by a shortage of health care facilities and health care professionals in rural areas. This study was conducted to determine barriers to implementation, access to, and success of HM strategies, as seen by health professionals presently working in rural Australia. Methods: Four hundred rural pharmacists Australia-wide and 425 doctors in rural Victoria and Tasmania were sent postal surveys to assess their opinions on the level of IDU in their area, the types of drugs commonly used, the adequacy of HM strategies and facilities, and the barriers faced by doctors, pharmacists and clients. Results: The overall response rate was almost 50%. Slightly less than half of surveyed health professionals felt that IDU was increasing in their area, with heroin perceived to be the most prevalent drug used in all States except Tasmania and the Northern Territory. Both methadone prescribers and dispensers believed the methadone maintenance programmes were highly valuable to the community, but not without problems (e.g. risk of overdose). A lack of time or staff was the greatest influence on doctors not participating in the methadone programmes, whereas safety concerns were prominent with pharmacists. The majority of doctors felt HM facilities were inadequate, with needle-syringe exchange being the most frequently nominated HM strategy lacking. Conclusion: Despite best intentions, there are still problems with HM strategies in these areas. Improving the number and expertise of health professionals in rural areas, and providing adequate support for them, would address some of these problems.

Phillips KT; Rosenberg H; Sanikop A. English and American drug clients' views of the acceptability advantages, and disadvantages of treatment and harm reduction interventions. Journal of Drug Issues 37(2): 377-401, 2007. (24 refs.)

Although drug abusers present to clinics and drop-in centers requesting various treatments and harm reduction interventions, clinicians and administrators have little direct empirical evidence of the degree to which clients find various therapies acceptable or the perceived advantages and disadvantages of specific interventions. A structured interview was administered to 48 male and female outpatient or detoxification ward clients in Nottingham, England, and 40 female residential treatment program clients in Northwest Ohio, to assess the acceptability of and related attitudes regarding a broad range of interventions. Large proportions of respondents in both samples, and especially in the English sample, reported somewhat or complete acceptance of various abstinence-oriented treatments and harm reduction interventions for those still taking drugs. Respondents also discriminated among these interventions, as evidenced by differing levels of acceptance of many and outright rejection of other interventions. Although there were differences in acceptance and experience of the specific interventions between the two samples, respondents in both countries provided balanced appraisals of the advantages and disadvantages of each intervention.

Pisinger C; Godtfredsen NS. Is there a health benefit of reduced tobacco consumption? A systematic review. (review). Nicotine & Tobacco Research 9(6): 631-646, 2007. (50 refs.)

This review presents the available evidence on the health effects of reduced smoking. Smoking reduction was defined as reduction of the daily intake of tobacco without quitting. Only published papers were reviewed. Case reports and studies without a thorough definition of smoking reduction or health outcome were excluded. We searched in personal databases, BioMail Medline Search, Medline, the Cochrane Database of Systematic Reviews, and EMBASE. We followed the QUORUM standards for systematic reviews, and both authors read and discussed all publications. A total of 25 studies (31 publications) were identified: 8 articles reported on effects on the cardiovascular system; 11 on the airways; 7 on carcinogens, DNA damage, and lung cancer; 3 on birth weight; and 4 on other health effects. Some papers assessed more than one outcome. In most studies, reduction was defined as less than 50010 of baseline tobacco consumption. Most of the studies were small, with the populations selected and short follow-up periods. The limited data suggest that a substantial reduction in smoking improves several cardiovascular risk factors and respiratory symptoms. In addition, smoking reduction is associated with a 25% decline in biomarkers and incidence of lung cancer and a small, mostly nonsignificant, increase in birth weight. There seem to be no substantial beneficial effects on lung function. The evidence on other health effects and mortality is too limited to draw conclusions. A substantial reduction in smoking seems to have a small health benefit, but more studies are needed to determine the long-term effects of smoking reduction.

Pizzey R; Hunt N. Distributing foil from needle and syringe programmes (NSPs) to promote transitions from heroin injecting to chasing: an evaluation. Harm Reduction Journal 5(1): e-article 24, 2008. (19 refs.)

Background: The report presents evaluation results from an intervention using specially produced foil packs to promote a transition from heroin injecting to inhalation (chasing) with injecting drug users (IDUs) attending four needle and syringe programmes (NSPs) in south west England. Methods: Service activity/uptake measures, brief structured interviews. Results Out of 320 attenders, 54% took the foil packs when they became available. Over the period of the evaluation, NSP transactions increased by 32.5% from 1,672 to 2,216. Additionally, 32 new clients (non-injecting heroin users) started attending the service to obtain the foil packs. This group would not otherwise have been in contact with the treatment service. More detailed data from one site are reported for 48 recent injectors who took foil within the NSP where the piloting first commenced. Prior to the introduction of the foil packs, 46% of this sub-group reported chasing heroin in the previous four weeks. At follow up, 85% reported using the foil to chase heroin on occasions when they would otherwise have injected. Among the people who took it, client satisfaction with the quality and size of the foil packs was good and respondents viewed its availability as a valuable extension to the NSP's services. Conclusions: These findings suggest that distributing foil packs can be a useful means of engaging NSP attenders in discussions about ways of reducing injecting risks and can reduce injecting in settings where there is a pre-existing culture of heroin chasing. Further research should see whether these findings can be reproduced in other cultural contexts and evaluate whether the observed behavioural changes are sustained and lead to reductions in harm including blood-borne infections and overdose.

Purcell DW; Garfein RS; Latka MH; Thiede H; Hudson S; Bonner S; DUIT Study Team. Development, description, and acceptability of a small-group, behavioral intervention to prevent HIV and hepatitis C virus Infections among young adult injection drug users. Drug and Alcohol Dependence 91(Supplement 1): S73-S80, 2007. (44 refs.)

Young injection drug users (IDUs) who are not infected with HIV or hepatitis C virus are at great risk of acquiring one or both of these infections through their sexual or injection behaviors. We describe the development of a behavioral intervention designed to decrease sexual and injection risk behaviors among young IDUs. The intervention was developed through a dynamic and iterative process that involved extensive development activities, focus groups with the target population to pilot individual activities and intervention sessions, and later, pilot testing of the entire intervention. The six-session intervention that emerged from the development process relied on both social-cognitive theories and peer influence models. We also designed a control intervention, trained facilitators to deliver the interventions, and conducted quality assurance of intervention delivery. To better understand intervention trial findings, we asked participants about their intervention experiences and examined potential contamination across arms. Both interventions were delivered with high fidelity and participants in both groups reported positive experiences. More perceived impact was reported for injection risk behaviors than for sexual risk behaviors among participants in the intervention arm. Minimal evidence of contamination was found. Lessons learned can help future researchers to develop stronger interventions for this high-need population.

Razani N; Mohraz M; Kheirandish P; Malekinejad M; Malekafzali H; Mokri A et al. HIV risk behavior among injection drug users in Tehran, Iran. Addiction 102(9): 1472-1482, 2007. (25 refs.)

Aims: Iran faces parallel human immunodeficiency virus (HIV) and injection drug use epidemics; more than 62% of known HIV cases occur among injection drug users (IDU). We conducted a formative study of IDU in Tehran to explore risk behavior in the wake of the recent harm reduction efforts. Participants and design Key informant interviews (n = 40), focus group discussions (nine groups of IDU, n = 66) and a review of existing published and unpublished literature were conducted. Participants included IDU, physicians, policy makers, police, IDU advocates and their families. IDU were diverse in gender, education, income and neighborhood of residence. Interviews were transcribed and analyzed using grounded theory. A typology of IDUs in Tehran, categorized according to self-defined networks as well as HIV risks, is presented. This categorization is based on the groups identified by IDUs, compared to those identified by other key informants, and on a secondary data review. Findings: Homeless, female, young IDU and users of a more potent form of heroin were identified as having increased risks for HIV. Participants described shortening transitions from smoked opium to injected opiates. Whereas a majority of participants considered needle sharing less common than previously, sharing continues in locations of group injection, and in states of withdrawal or severe addiction. System-wide barriers to harm reduction were discussed, and include the cost or stigma of purchasing needles from pharmacies, over-burdened clinics, irregular enforcement of laws protecting IDU and lack of efforts to address the sexual risks of IDU. Conclusions: This research is one of the first to describe a diversity of IDU, including women and higher socio-economic class individuals, in Tehran. While efforts in harm reduction in Iran to date have been notable, ongoing risks point to an urgent need for targeted, culturally acceptable interventions.

Rees VW; Wayne GF; Thomas BF; Connolly GN. Physical design analysis and mainstream smoke constituent yields of the new potential reduced exposure product, Marlboro UltraSmooth. Nicotine & Tobacco Research 9(11): 1197-1206, 2007. (18 refs.)

Potential reduced exposure products (PREPs) purport to lower toxicant emissions, but without clinical and long-term health outcome data, claims for reduced harm status of PREPs depend heavily on standard machine yield smoke constituent data. Two prototypes of the new carbon-filtered PREP Marlboro UltraSmooth (MUS) were investigated using both standard (FTC/ISO) and intensive (Health Canada) machine methods to measure gas/ vapor- and particulate-phase smoke constituents. Basic physical design characteristics that may influence smoke constituent yields, such as ventilation, pressure drop (resistance to draw), quantity of tobacco, and quantity and type of carbon, were measured. The possible presence of added chemical flavorant compounds was investigated using gas chromatography-mass spectroscopy. MUS prototypes were found to have several key differences in physical design compared with a conventional cigarette, including higher ventilation, lower draw, resistance, and in the case of the Salt Lake City prototype, the use of vitreous carbon beads and the presence of chemical flavorants on both the beads and an embedded filter fiber. When tested under the standard regimen, gas-phase constituents of MUS prototypes were reduced compared with a conventional low-yield cigarette. However, far smaller reductions in gas-phase constituents were observed under the intensive regimen, suggesting that the carbon technology used in MUS is less effective when smoked under more intensive conditions. Particulate-phase constituents were not reduced by the carbon filter under either machine-smoking regimen. The data suggest that MUS has been designed to reduce toxic yields while preserving consumer appeal. However, MUS is less effective in reducing toxic smoke constituents when smoked under intensive conditions.

Reid G; Devaney ML; Baldwin S. Harm reduction programmes in the Asia-Pacific region. Drug and Alcohol Review 27(1): 95-98, 2008. (33 refs.)

Introduction and Aims. This paper reports on the public health intervention of harm reduction to address drug use issues in the Asia-Pacific region. Design and Methods. It is based on the report 'Situational analysis of illicit drug issues and responses in Asia and the Pacific', commissioned by the Australian National Council on Drugs Asia Pacific Drug Issues Committee. A comprehensive desk-based review based on published and unpublished literature and key informant data. Results. Drug use in the Asia-Pacific region is widespread, resulting in serious adverse health consequences. Needle and syringe programmes are found in some parts of Asia, but not in the six Pacific Island countries reviewed. Outreach and peer education programmes are implemented, but overall appear minor in size and scope. Substitution therapy programmes appear to be entering a new era of acceptance in some parts of Asia. Primary health care specifically for drug users overall is limited. Discussion and Conclusions. Harm reduction programmes in the Asia-Pacific region are either small in scale or do not exist. Most programmes lack the technical capacity, human resources and a limited scope of operations to respond effectively to the needs of drug users. Governments in this region should be encouraged to endorse evidence-based harm reduction programmes.

Reid G; Kamarulzaman A; Sran SK. Malaysia and harm reduction: The challenges and responses. International Journal of Drug Policy 18(2): 136-140, 2007. (43 refs.)

In Malaysia the response to illicit drug use has been largely punitive with the current goal of the Malaysian government being to achieve a drug-free society by 2015. This paper outlines the results of a desk-based situation assessment conducted over a 3-week period in 2004. Additional events, examined in 2005, were also included to describe more recent policy developments and examine how these came about. Despite punitive drug policy there has been a substantial rise in the number of drug users in the country. Over two-thirds of HIV/AIDS cases are among injecting drug users (IDUs) and there has been an exponential rise in the number of cases reported. Further, data suggest high risk drug use practices are widespread. Harm reduction initiatives have only recently been introduced in Malaysia. The successful piloting of substitution therapies, in particular methadone and buprenorphine, is cause for genuine hope for the rapid development of such interventions. In 2005 the government announced it will allow methadone maintenance programmes to operate beyond the pilot phase and needle and syringe exchange programmes will be established to serve the needs of IDUs.

Reiling DM; Nusbaumer MR. An exploration of the potential impact of the designated driver campaign on bartenders' willingness to over-serve. International Journal of Drug Policy 18(6): 458-463, 2007. (30 refs.)

Much has been written about the impact of the presence of a designated driver on patrons' consumption, but heretofore, its impact on the behaviour of the server has been virtually ignored. The goal of this paper, then, was to explore the potential impact of the presence of a designated driver on alcoholic beverage servers' self-reported willingness to knowingly serve an already intoxicated customer. chi(2) analysis of survey data collected from 938 licensed servers, in the state of Indiana, USA, was performed. Approximately 43% of the bartenders surveyed reported that they either would be or might be willing to over-serve an already intoxicated customer. Of those who answered the follow-up question as to under what conditions they would be willing to over-serve, almost 80% reported that they would do so if the patron were accompanied by a designated driver. The statistical significance of the relationship between these two variables (.000) raises the question of whether the Designated Driver Campaign has the latent function of enabling some servers to neutralize their responsibility for over-serving by disregarding other types of intoxication-related harm.

Rezaishiraz H; Hyland A; Mahoney MC; O'Connor RJ; Cummings KM. Treating smokers before the quit date: Can nicotine patches and denicotinized cigarettes reduce cravings? Nicotine & Tobacco Research 9(11): 1139-1146, 2007. (24 refs.)

The present study investigated whether treatment with the combination of denicotinized cigarettes and 21-mg nicotine patch for 2 weeks before a designated quit date could lessen cravings for smoking, thereby helping smokers abstain from smoking. The study was a randomized controlled clinical trial conducted at Roswell Park Cancer Institute, Buffalo, New York, in 2004 and 2005. Patients included 98 adult heavy smokers (using 20 or more cigarettes/day). Half of the subjects received 2 weeks of combination of denicotinized cigarettes (Quest 3) and 21-mg nicotine patch for 2 weeks before the quit date. The remaining smokers were switched to light cigarettes (Quest 1) during the 2 weeks before the quit date. After the quit date, all subjects received counseling for smoking cessation and were provided nicotine patches for up to 8 weeks after the quit date. Self-reported cravings for smoking, withdrawal symptoms, and smoking abstinence were measured at predetermined intervals using phone-based surveys and in clinical visits. The group that used denicotinized cigarettes and nicotine patch before quitting reported less frequent and less intense cravings for cigarettes in the 2 weeks before and after the designated quit date. Self-reported withdrawal symptoms and quit rates did not differ significantly between the groups. The use of a denicotinized cigarette combined with the nicotine patch appears to lessen cravings to smoke in the immediate postcessation period. A larger, better-powered study is needed to test if this treatment combination has merit for increasing quit rates.

Rhodes T; Briggs D; Kimber J; Jones S; Holloway G. Crack-heroin speedball injection and its implications for vein care: Qualitative study. Addiction 102(11): 1782-1790, 2007. (49 refs.)

Background: We report on an exploratory qualitative study investigating drug injectors' narratives of vein damage and groin (femoral vein) injection associated with the injection of crack-heroin speedball. Methods: We undertook 44 in-depth qualitative interviews among injectors of crack-heroin speedball in Bristol and London, England, in 2006. Findings: The data suggest an emerging culture of crack-based speedball injection. Injectors' narratives link speedball injection with shifts towards groin injection articulated as an acceptable risk, and not merely as a last resort in the face of increased vein deterioration associated with speedball. Accounts of vein damage linked to speedball emphasize 'missed hits' related to the local anaesthetic action of crack, the excess use of citric in the preparation of speedball injections and 'flushing' when making a hit. We find that groin injection persists despite an awareness of health risks and medical complications. Conclusions We emphasize an urgent need for reviewing harm reduction in relation to vein care in the context of shifts to crack-based speedball injection, and the use of the femoral vein, among UK injectors. There is an additional need for interventions to promote safer groin and speedball injecting as well as to prevent transitions toward groin and crack injection.

Rhodes T; Kimber J. Safer groin-injecting interventions are needed and justifiable as part of a harm reduction approach. (letter). Addiction 102(12): 1987-1988, 2007. (10 refs.)

Rich JD; Hogan JW; Wolf F; DeLong A; Zaller ND; Mehrotra M et al. Lower syringe sharing and re-use after syringe legalization in Rhode Island. Drug and Alcohol Dependence 89(2/3): 292-297, 2007. (24 refs.)

Increased access to sterile syringes reduces the transmission of HIV, viral hepatitis and other infectious diseases, without increasing injection drug use. In Rhode Island, in 2000, syringes were legalized to reduce spread of disease but remained outlawed in Massachusetts until 2006. Drug users undergoing inpatient detoxification in Rhode Island and Massachusetts were surveyed about their syringe usage between October 2001 and August 2003. Two hundred forty-seven Rhode Island, and 226 Massachusetts inpatients completed surveys. Of these, 61 % (n = 15 1) from Rhode Island and 46% (n = 105) from Massachusetts reported injecting within 6 months. Respondents from Rhode Island reported reusing a syringe in the last 30 days less often than Massachusetts respondents (0.35 versus 0.50; 95% CI on difference 0.01-0.29). Syringe re-use and sharing among drug injectors in Rhode Island was markedly lower than in Massachusetts. This difference is attributed at least in part to the legalization of non-prescription sterile syringes in Rhode Island in 2000. Laws and policies that increase legal syringe availability can decrease injection related transmission of HIV and other infectious diseases.

Rivara FP; Relyea-Chew A; Wang J; Riley S; Boisvert D; Gomez T. Drinking behaviors in young adults: The potential role of designated driver and safe ride home programs. Injury Prevention 13(3): 168-172, 2007. (30 refs.)

Objectives: To determine the drinking and driving habits reported in people aged 21 - 34 years. Design: Random digit dialing survey. Setting: Seattle and Spokane, Washington; Portland, Oregon. Participants: 917 individuals aged 21 - 34 years, who had a valid driver's license, who had consumed at least one alcoholic drink in the last year and who lived in Seattle, Spokane or Portland. Outcome measures: Driving after drinking, use of a designated driver and serving as a designated driver. Results: 62% drank alcohol at least weekly, and 31% binged at least once per month in the last year. 21% drove after drinking too much in the last month. Two-thirds of individuals reported being a designated driver at least once in the last year, and in most instances, this had been decided before the group went out for the evening. Over three-quarters of individuals reported that they drank less than they usually do the last time they were a designated driver. When using a designated driver, almost half of the individuals reported drinking more on that occasion than usual, with approximately half of those having at least three more drinks than usual. Conclusions: These results point to the need for interventions to combat the problem of drunk driving and prevent its associated morbidity and mortality. Rigorous evaluation of the effect of designated driver and safe ride home programs are needed.

Ross MW; Timpson SC; Williams ML; Bowen A. The impact of HIV-related interventions on HIV risk behavior in a community sample of African American crack cocaine users. AIDS Care 19(5): 608-616, 2007. (54 refs.)

While there are reports of the impact of specific interventions designed to reduce HIV drug and sexual risk behaviors, there are few reports of the impact of HIV interventions in a community-based sample. We report on baseline data from a sample of African American crack smokers who were about to participate in an intervention designed to reduce HIV-related risk behaviors. The majority were male ( 80%), single ( 70%) and homeless ( 52%). Data indicated that 29% of the sample had been in a previous HIV intervention in the past 12 months, the majority in a correctional setting or CBO program. There were few systematic demographic differences between the two groups. Those who had been in an intervention reported using male and female condoms significantly more frequently on all measures of condom use, had positive condom use outcome expectations for male condoms and higher affective and situational condom-related self-efficacy beliefs. These data suggest that, at a community level, the spectrum of HIV risk-reduction programs does produce a significant improvement in condom use and related cognitions, although there is a need to cover a greater proportion of the population. Previous exposure to interventions must be a critical covariate in assessing the impact of future interventions.

Roy E; Denis V; Gutierrez N; Haley N; Morissette C; Boudreau JF. Evaluation of a media campaign aimed at preventing initiation into drug injection among street youth. Drugs: Education, Prevention and Policy 14(5): 401-414, 2007. (32 refs.)

Aims: A campaign to prevent initiation into drug injecting among street youth who have never injected drugs (NIDUs) was carried out in Montreal, Canada in 2005. Evaluation objectives were (1) to assess the campaign's ability to reach NIDU street youth and (2) to understand the campaign's effects on this population. Methods: A survey was conducted, as well as semi-structured interviews. Findings: The campaign enjoyed a high degree of visibility. It spoke to young NIDUs, causing them to reflect on both drug injecting and their own non-injection drug use. The campaign had a positive impact in terms of their views on drug injecting. Despite its limited scope, young NIDUs also considered the campaign to be a tool with the potential to contribute to preventing initiation into drug injecting among their peers. Conclusions: Media prevention campaigns are able to reach hidden populations through the use of bold and innovative techniques. Such campaigns can also contribute to influencing the attitudes and perceptions of these populations. However, more comprehensive injection prevention programs need to be established.

Roy E; Haley N; Leclerc P; Boudreau JF; Boivin JF. Risk factors for initiation into drug injection among adolescent street youth. Drugs: Education, Prevention and Policy 14(5): 389-399, 2007. (45 refs.)

Young injectors are a group with high-risk behaviours, particularly with respect to HIV infection and hepatitis C. A leading strategy to prevent these infections could be the prevention of injection, especially among the youngest individuals. We report analyses on initiation into drug injection from a prospective cohort study of street youth conducted in Montreal, Canada. Among 118 non-injector participants under 18 years of age followed for an average of 1.31 years, we estimated an incidence rate of injection of 22.7 per 100 person-years. Independent predictors of initiation were: a lifetime history of use of >= 4 types of drugs, recent daily alcohol drinking, a recent episode of homelessness, a lifetime history of rape, and recent involvement in survival sex. The observed high rate of initiation into injection clearly indicates that interventions to prevent injection should target especially adolescent street youth. These interventions should address simultaneously individual and structural factors, such as substance abuse and living conditions.

Saitz R. Treatment of alcohol and other drug dependence. Liver Transplantation 13(11, Supplement 2): S59-S64, 2007. (18 refs.)

Addiction (e.g., alcohol or drugs) is a chronic disease. Specific behavioral and pharmacological treatments have proven efficacy. Addressing addiction includes intervention for risky and problem use. Clinicians who are not addiction specialists can play important roles in addressing addiction.

Seddon T. Women, harm reduction and history: Gender perspectives on the emergence of the 'British System' of drug control. International Journal of Drug Policy 19(2): 99-105, 2008. (37 refs.)

Taking Kohn's classic book "Dope Girls" as its starting point, this paper explores the particular place of women and gender issues in the emergence of the 'British System' of drug control in the early twentieth century. The 'British System' refers to the approach put in place in the 1920s in Britain, notably by the 1926 Rolleston Report. In essence, it involved the medically based prescription of opiates to addicts, often on a long-term basis. It is viewed by many as one of the beginnings of the general principle of harm reduction within drug policy. This paper will examine how female figures - chorus girls, actresses, night club girls, prostitutes - were central to British drugs discourse in the 1920s, with the representation of some individual women in particular, most famously the actress Billie Carleton, featuring very prominently. It will be argued that this gendering of drugs discourse can be best understood in the wider context of social change, namely the transition from liberalism to welfarism at the turn of the twentieth century. It is suggested that this historical analysis provides a radical new perspective on some fundamental issues for contemporary approaches to harm reduction for women, a perspective that has far-reaching implications and challenges some 'taken-for-granted' assumptions.

Sharma M; Burrows D; Bluthenthal R. Coverage of HIV prevention programmes for injection drug users: Confusions, aspirations, definitions and ways forward. (commentary). International Journal of Drug Policy 18(2): 92-98, 2007. (43 refs.)

The concept of coverage first emerged in the 1960s as a key indicator for measuring the proportion of populations that were covered by health care. In the area of HIV interventions among injecting drug users, the term "coverage" has been used for widely different aspects of reach and effectiveness of programmes. This paper reviews an array of ways of thinking about coverage from the scientific and grey literature and discusses methods of estimating coverage, finding that some measures of coverage refer to individuals, others to populations and others to populations covered by services. Nomenclature for these various types of "coverage" are discussed and recommendations are provided for future attempts to measure coverage of harm reduction interventions.

Sheridan J; Butler R; Wilkins C; Russell B. Legal piperazine-containing party pills: A new trend in substance misuse. Drug and Alcohol Review 26(3): 335-343, 2007. (63 refs.)

In this Harm Reduction Digest Sheridan, Butler, Wilkins and Russell address the emergent phenomenon of so-called 'legal party pills' which have become a significant drug issue in New Zealand and elsewhere. Although banned in a number of countries, they are currently legally available in New Zealand where they are marketed as 'safe' alternatives' to 'illicit' drugs often used in the dance scene such as MDMA and amphetamines. The authors describe the availability and use of these substances in New Zealand, summarize what is known about their effects, and speculate on harm reduction interventions and mechanisms of control and their possible sequelae. The paper provides a timely account of an emerging drug issue of relevance to harm reduction internationally.

Shiffman S; Hughes JR; Ferguson SG; Pillitteri JL; Gitchell JG; Burton SL. Smokers' interest in using nicotine replacement to aid smoking reduction. Nicotine & Tobacco Research 9(11): 1177-1182, 2007. (35 refs.)

In recent years the public health community has considered the risks and benefits of encouraging smokers to reduce their smoking, perhaps with the aid of nicotine replacement therapy (NRT). Little is known, however, about whether smokers themselves are interested in smoking reduction; whether they see reduction as an endpoint, or primarily as a route to cessation; or whether they are receptive to the notion of using NRT to achieve reduction. We conducted a population-based national telephone survey of 1,000 current daily cigarette smokers (499 male, 501 female). Most smokers (57%) reported previously trying to reduce their smoking, and many (26%) said that they plan to reduce within the next year. Almost half of those planning to quit in the next 12 months (44%) preferred to quit via gradual cessation and most (68%) indicated that they would consider using a reduction product or medication. Respondents reported. that they would prefer a product with a cessation endpoint rather than a reduction endpoint (63% vs. 21%). Interest in reduction was highest among smokers who were less interested in quitting and among heavier smokers. We conclude that many smokers are interested in gradually reducing prior to quitting and that promoting reduction is unlikely to undermine motivation to quit smoking.

Simao MO; Kerr-Correa F; Smaira SI; Trinca LA; Floripes TMF; Dalben I et al. Prevention of "risky" drinking among students at a Brazilian University. Alcohol and Alcoholism 43(4): 470-476, 2008. (51 refs.)

Aim: The aim of this paper was to compare the quantity and frequency of alcohol use and its associated negative consequences between two groups of college students who were identified as being "risky drinkers." Subjects were randomly allocated in a clinical trial to intervention or control groups. Methods: Risky drinking use was defined as Alcohol Use Disorders Identification Test (AUDIT) >= 8 and/or Rutgers Alcohol Problem Index (RAPI) >= 5 problems in the previous year. Students who had undergone the Brief Alcohol Screening and Intervention for College Students (BASICS) (N = 145 at baseline; 142 at 12 months, and 103 at 24 months, loss of 29.7%) were compared with a control group (N = 121 at baseline; 121 at 12 months and 113 at 24 months, loss of 9.3%), the nonintervention group. Variables included drinking frequency, quantity and peak consumption, dependence assessment, and family and friends' abuse assessment. Results: Treated students at a 24-month follow-up decreased quantity of alcohol use per occasion and lowered AUDIT and RAPI scores. Conclusions: This is the first brief intervention work on risky drinking with college students in Brazil and the results are encouraging. However, it is difficult to conduct individual prevention strategies in a country where culture fosters heavy drinking through poor public policy on alcohol and lack of law enforcement.

Slater S; Giovino G; Chaloupka F. Surveillance of tobacco industry retail marketing activities of reduced harm products. Nicotine & Tobacco Research 10(1): 187-193, 2008. (18 refs.)

With the introduction of potential reduced exposure products (PREPs) and the interest in studying tobacco harm reduction, sound research and surveillance are needed to examine and understand the distribution and availability of PREPs in communities, as well as the tobacco industry's marketing practices surrounding these products. We examined the availability and marketing of PREPs in a national sample of tobacco retail stores. We also compared the price of PREPs to those of premium brand cigarettes and examined the distribution of PREPs in comparison with premium brand cigarettes by store type, urbanization, region, and race/ethnicity. We found that PREPs are not widely available, are priced similarly to leading cigarette brands, and have few promotional offers. We also found some significant differences in the distribution of PREPs and cigarettes, as well as in the distribution of Ariva and Omni, by store type and community demographics. The fact that this study used data collected nationally emphasizes the importance of these findings and helps shed some light on the tobacco industry's PREP marketing strategies. This study's national sample provides a unique perspective that needs to be replicated if and when other PREPs are widely marketed.

Small D. Fools rush in where angels fear to tread: Playing God with Vancouver's Supervised Injection Facility in the political borderland. (editorial). International Journal of Drug Policy 18(1): 18-26, 2007. (43 refs.)

Healthcare does not exist in a social vacuum. Nowhere is this more obvious than in the case of people living with active addiction who are treated as social lepers: feared, despised and socially banished from the wider human family. People with addictions, and their families, fight for survival in the moral borderland between two competing understandings of their condition. According to one understanding, addiction is a concern for the criminal justice system while according to the other it is primarily a population health issue. In one orientation, addicts are troublesome offenders, while in the other they are wounded persons in need of medical attention. These competing values form a cultural web of belief that extends far beyond healthcare to the highest political office of Canadian society. This paper examines the politics of addiction over a 6-year period beginning at the municipal level in Vancouver and culminating with a confrontation between the Prime Minister of Canada and the tiny neighbourhood that provides a home for North America's only Supervised Injection Facility. Not wanting to let the medical facts get in the way of a political stand, Prime Minister Stephen Harper and his Health Minister, Tony Clement, played God this summer by playing politics with the lives of people in the shadows of Canadian society.

Small W; Rhodes T; Wood E; Kerr T. Public injection settings in Vancouver: Physical environment, social context and risk. International Journal of Drug Policy 18(1): 27-36, 2007. (64 refs.)

While epidemiological investigations have documented elevated health harms associated with public injecting, further ethnographic research focused specifically on public injecting settings is required to develop greater understanding of how these environments influence the production of drug-related harm. We undertook preliminary ethnographic research, incorporating a structured environmental survey, observations and interviews with 50 local injectors, in Vancouver's Downtown Eastside (DTES). Our study aimed to document the physical locations and social context of public injecting settings, exploring how such venues interplay with injection-related health risks. Findings show that DTES public injecting locations comprise a large network of alleyways, which are often unsanitary and constrain efforts to inject in a hygienic fashion. Due to fears of being intercepted by the police, physically assaulted, or robbed, injectors are preoccupied with "hurrying and worrying" when injecting in public. Although individuals are concerned with matters of hygiene and avoiding infections associated with injecting, the perceived risks of public injection settings are primarily related to the presence of street predators and the police. Ecological features of public injecting environments serve to complicate the task of injecting, encourage 'rushing' during the injection process, and decrease the likelihood that public injectors will employ safer injecting practices. Future interventions must specifically target these micro risk environments. Innovative strategies are urgently needed to ensure that police operations in the open drug scene do not compromise public injectors' efforts to protect their health. Additionally, structural factors which perpetuate the large public injecting scene should be addressed through policy interventions that increase access to housing and public toilets as well as expanding the scope and capacity of the local drug consumption facilities.

Stein MD; Dubyak P; Herman D; Anderson BJ. Perceived barriers to safe-injection practices among drug injectors who remain HCV-negative. American Journal of Drug and Alcohol Abuse 33(4): 517-525, 2007. (15 refs.)

Fifty-nine hepatitis C ( HCV) seronegative drug injectors ( IDUs) were interviewed regarding their injection equipment sharing behaviors. Participants were 75% male, 66% Caucasian, had injected an average of nine years, and were very knowledgeable about HCV transmission risk. One-third used needles or works after another injector within the past six months. Lower perceived personal risk and lower perceived availability of clean needles were significantly associated with sharing. Injectors were more likely to share when emotionally upset or experiencing withdrawal symptoms. Despite, or perhaps because of, their HCV seronegative status, IDUs continue to share. Tailoring messages to modifiable perceptions of risk may be useful in reducing continued drug equipment sharing.

Strasser AA; Lerman C; Sanborn PM; Pickworth WB; Feldman EA. New lower nicotine cigarettes can produce compensatory smoking and increased carbon monoxide exposure. Drug and Alcohol Dependence 86(2/3): 294-300, 2007. (43 refs.)

Potential reduced exposure products (PREPs) are marketed as a means to reduce exposure to tobacco toxicants. Quest (R) cigarettes, a new type of PREP, use genetically modified tobacco to provide a nicotine step-down approach, and are available as 0.6, 0.3 and 0.05 mg nicotine cigarettes. However, these cigarettes deliver equivalent levels of tar (10 mg). Prior research on low nicotine cigarettes suggests smokers will compensate for lower nicotine delivery by increasing their puffing behavior to extract more nicotine. This study tested the hypothesis that compensatory smoking will occur with this PREP as nicotine levels decrease, increasing exposure to tobacco toxins. Fifty smokers completed a within-subject human laboratory study investigating the effect of cigarette nicotine level on smoking behavior. Cigarette nicotine level was double-blinded and order of presentation counter-balanced. Breath carbon monoxide (CO) boost was used as a biomarker of smoke exposure; total puff volume to assess smoking behavior. Total puff volume was greatest for the 0.05 mg nicotine cigarette and CO boost was moderately greater after smoking the 0.3 and 0.05 mg cigarettes compared to the 0.6 mg nicotine cigarette. These data provide novel behavioral and biochemical evidence of compensatory smoking when smoking lower nicotine cigarettes. Although marketed as a PREP, increases in CO boost suggest this product can potentially be a harm-increasing product.

Sullivan SG; Wu ZY. Rapid scale up of harm reduction in China. (review). International Journal of Drug Policy 18(2): 118-128, 2007. (68 refs.)

In the last 20 years, China has seen a resurgence in drug use, particularly heroin, and with it a growing epidemic of HIV/AIDS. Faced with this dual epidemic, the government has begun testing harm reduction strategies in recent years. These have included methadone maintenance treatment (MMT) programmes, needle-syringe programmes (NSP), outreach, and increasing access to HIV testing. MMT and NSP have moved from the pilot stage to scale-up, with 320 MMT clinics and 93 NSPs now open. Both will number more than 1000 by the end of 2008. There are some good examples of outreach programmes in some areas, however more needs to be done to facilitate greater involvement from non-government organizations. Similarly, HIV testing for drug users is widely available, but novel approaches to increasing its uptake need to be explored. Management of scale-up and reaching China's vast and dispersed drug-using population remain key challenges. The introduction of harm reduction has been a massive turn-around in thinking by the government, particularly law enforcement agencies, and achieving this has required considerable cooperation and understanding between the Ministries of Health, Public Security, and Justice, and the Food and Drug Administration. With their support, rapid scale-up to effectively reach a majority of drug users can be achieved in the coming years.

Sweanor D; Alcabes P; Drucker E. Tobacco harm reduction: How rational public policy could transform a pandemic. (editorial). International Journal of Drug Policy 18(2): 70-74, 2007. (9 refs.)

Nicotine, at the dosage levels smokers seek, is a relatively innocuous drug commonly delivered by a highly harmful device, cigarette smoke. An intensifying pandemic of disease caused or exacerbated by smoking demands more effective policy responses than the current one: demanding that nicotine users abstain. A pragmatic response to the smoking problem is blocked by moralistic campaigns masquerading as public health, by divisions within the community of opponents to present policy, and by the public-health professions antipathy to any tobacco-control endeavours other than smoking cessation. Yet, numerous alternative systems for nicotine delivery exist, many of them far safer than smoking. A pragmatic, public-health approach to tobacco control would recognize a continuum of risk and encourage nicotine users to move themselves down the risk spectrum by choosing safer alternatives to smoking - without demanding abstinence.

Tobin KE; Hua W; Costenbader EC; Latkin CA. The association between change in social network characteristics and non-fatal overdose: Results from the SHIELD study in Baltimore, MD, USA. Drug and Alcohol Dependence 87(1): 63-68, 2007. (33 refs.)

Background: Social network factors have been reported to be associated with non-fatal overdose. Yet, few studies have examined how changes in social network characteristics may influence overdose risk. The purpose of this study was to examine the relationship between changes in social network and non-fatal overdose. Methods: Data for this study came from 659 participants enrolled in the Self-Help in Eliminating Life-Threatening Diseases (SHIELD) study, who reported details about their non-fatal overdose experience between enrollment and a follow-up visit. Social network characteristies were described at both time points and net change in network composition was calculated. Results: The sample was predominately male (56%), African-American (96%) and unemployed (78%). Experience of non-fatal overdose between time points was reported by 15%. Older age was associated with non-fatal overdose. Interaction between incarceration status and drug use was statistically significant. Protective factors were having a denser network at baseline and a network that became denser after adjusting for gender, homelessness. incarceration, drug use and total network size. Conclusions: Drug users' social networks are an important target for overdose prevention interventions. Further research on overdose risk and movement of specific network members in and out of networks is warranted.

Toomey TL; Lenk KM; Wagenaar AC. Environmental policies to reduce college drinking: An update of research findings. (review). Journal of Studies on Alcohol and Drugs 68(2): 208-219, 2007. (124 refs.)

Objective: We provide an overview of environmental strategies that may reduce college drinking. The identified environmental strategies fall into three categories: (1) reducing alcohol use and related problems among underage college students, (2) reducing risky alcohol use and related problems among all college students, and (3) de-emphasizing the role of alcohol and creating positive expectations on campus. At the time of our 2002 review, few studies had assessed environmental policies and strategies in the context of college student alcohol use and related problems. The present article summarizes recent research on the effects of environmental policies and strategies affecting college students. Method: We updated our previous literature searches to identify peer-reviewed research studies evaluating the effects of environmental strategies on college and general populations. Results: We identified 110 new studies addressing environmental strategies published between 1999 and 2006. Thirty-six of these studies focused on the college population. The extant research indicates that many environmental strategies are promising for reducing alcohol-related problems among the general population. Several recent studies suggest that these strategies, particularly combined strategies, also may be effective in decreasing alcohol-related problems among college populations. Conclusions: Further research is needed to continue expanding our understanding of environmental strategies to identify the most effective individual and combined strategies.

Toumbourou JW; Stockwell T; Neighbors C; Marlatt GA; Sturge J; Rehm J. Adolescent health, 4. Interventions to reduce harm associated with adolescent substance use. (review). Lancet 369(9570): 1391-1401, 2007. (128 refs.)

A major proportion of the disease burden and deaths for young people in developed nations is attributable to misuse of alcohol and illicit drugs. Patterns of substance use established in adolescence are quite stable and predict chronic patterns of use, mortality and morbidity later in life. We integrated findings of systematic reviews to summarise evidence for interventions aimed at prevention and reduction of harms related to adolescent substance use. Evidence of efficacy was available for developmental prevention interventions that aim to prevent onset of harmful patterns in settings such as vulnerable families, schools, and communities, and universal strategies to reduce attractiveness of substance use. Regulatory interventions aim to increase perceived costs and reduce availability and accessibility of substances. Increasing price, restricting settings of use, and raising legal purchase age are effective in reducing use of alcohol and tobacco and related harms. Screening and brief intervention are efficacious, but efficacy of a range of treatment approaches has not been reliably established. Harm-reduction interventions are effective in young people involved in risky and injecting substance use.

Tresidder J; Toumbourou JW. Evidence-based options for reducing alcohol-related harm: Comment on Jorgensen, et al. (editorial). Addiction 102(4): 512-513, 2007. (15 refs.)

This editorial is in response to an article in this issue, "Harm minimization among teenage drinkers: Findings from an ethnographic study on teenage alcohol use in a rural Danish community" by Jorgensen et al.

Van den Berg C; Smit C; Van Brussel G; Coutinho R; Prins M. Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: Evidence from the Amsterdam Cohort Studies among drug users. Addiction 102(9): 1454-1462, 2007. (23 refs.)

Objatives To investigate the impact of harm-reduction programmes on HIV and hepatitis C virus (HCV) incidence among ever-injecting drug users (DU) from the Amsterdam Cohort Studies (ACS). Methods The association between use of harm reduction and seroconversion for human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) was evaluated using Poisson regression. A total of 714 DU were at risk for HIV and/or HCV during follow-up. Harm reduction was measured by combining its two most important components -- methadone dose and needle exchange programme (NEP) use-and looking at five categories of participation, ranging from no participation (no methadone in the past 6 months, injecting drug use in the past 6 months and no use of NEP) to full participation (>= 60 mg methadone/day and no current injecting or >= 60 mg methadone/day and current injecting but all needles exchanged). Results: Methadone dose or NEP use alone were not associated significantly with HIV or HCV seroconversion. However, with combination of these variables and after correction for possibly confounding variables, we found that full participation in a harm reduction programme (HRP) was associated with a lower risk of HIV and HCV infection in ever-injecting drug users (DU), compared to no participation [incidence rate ratio 0.43 (95% CI 0.21-0.87) and 0.36 (95% CI 0.13-1.03), respectively]. Conclusions: In conclusion, we found that full participation in HRP was associated with a lower incidence of HCV and HIV infection in ever-injecting DU, indicating that combined prevention measures-but not the use of NEP or methadone alone-might contribute to the reduction of the spread of these infections.

Vlahov D; Wang C; Ompad D; Fuller CM; Caceres W; Ouellet L et al. Mortality risk among recent-onset injection drug users in five US cities. Substance Use & Misuse 43(3/4): 413-428, 2008. (16 refs.)

To quantify the risk of death among recent-onset ( 5 years) injection drug users, we enrolled 2089 injection drug users (IDUs) age 35 years (minimum age = 18 years) between 1997 and 1999. Median age was 24 years, 62.4% were male, 54.5% were non-Hispanic White, mean duration of injecting was 3 years, and 45.4% injected daily within the prior 6 months. Using the National Death Index, we identified 68 deaths over a follow-up period through December 2002 with a mortality rate of 7.10/1000 person years. Using age-, sex-, and race-adjusted data to the census and mortality, we calculated standardized mortality ratios (SMRs) over time. The adjusted SMR (with national data as the reference) for IDUs was 3.66 for 1997, which increased to 9.78 by 1998, decreased slightly to 7.08 by 1999, and continuously declined to 2.54 by 2002. These data confirm considerable excess mortality among recent onset injection drug users compared to non-IDU peers in the general population and indicate need for interventions such as increased quality and accessibility to drug abuse treatment and overdose prevention to prevent premature death among young IDUs.

Walsh N; Gibbie TM; Higgs P. The development of peer educator-based harm reduction programmes in northern Vietnam. Drug and Alcohol Review 27(2): 200-203, 2008. (13 refs.)

Introduction. Injecting drug use remains an important risk factor for transmission in Vietnam, with an estimated 50% of the 290 000 people living with HIV/AIDS reporting injecting drug use as a risk factor. Despite this, effective harm reduction interventions are generally lacking. This paper describes the implementation of peer-based harm reduction programmes in two rural provinces of Vietnam. Design and Methods. Peer educators were trained in basic HIV prevention, including harm reduction. After significant preparation work with the Provincial AIDS Committees of Bac Giang and Thanh Hoa and other relevant national, provincial and local authorities, the interventions were commenced. Harm reduction interventions were delivered through outreach as well as on-site. This included needle and syringe distribution and collection. Results. Community advocacy occurred throughout the life of the project. Local authorities and peers believed that while there was a general reduction in stigma and discrimination, legal barriers associated particularly with the carrying of injecting equipment remained. This impacted upon the ability of peer educators to work with their clients. Conclusion. Peer-based delivery of harm reduction intervention is acceptable. Harm reduction interventions, including needle and syringe programmes, are feasible and acceptable in these two rural Vietnamese provinces. Community acceptance and uptake of these interventions is key to successful expansion across the region. Active participation by families of drug users seems crucial. This initiative demonstrates that despite a difficult policy environment, peer-delivered needle and syringe programmes are feasible within a rural Asian environment as long as there is adequate local political and community support.

Yamamoto RT; Teter CJ; Barros TL; McCarthy E; Mileti C; Juliano T et al. Antiandrogen pretreatment alters cocaine pharmacokinetics in men. Journal of Addiction Medicine 1(4): 198-204, 2007

Among cocaine users, men experience more adverse brain and vascular effects than their female counterparts. This could be caused by testosterone, which may potentiate some of cocaine's effects. We examined whether antiandrogen (flutamide, FL) pretreatment alters cocaine's acute behavioral, physiologic, and pharmacokinetic effects in men with histories of occasional cocaine use. Participants (N = 8) were pretreated with oral FL (250 mg) and placebo on separate study days followed by intravenous (IV) cocaine (0.4 mg/kg). Vital signs, subjective ratings, and blood samples for cocaine and metabolites were obtained at baseline and for 90 minutes after cocaine administration. FL, itself, had no effects on physiologic or subjective responses; however, after cocaine, heart rate recovered faster with FL pretreatment. Flutamide reduced peak plasma cocaine levels (Wilcoxon signed-rank z = 2.1, P < 0.04) and area under the curve (AUC; z = 1.96, P < 0.05). Additionally, FL reduced EME levels (z = 1.96, P < 0.05) and AUC for BE and EME (z = 2.38, P < 0.02 and z = 1.96, P < 0.05, respectively). These results suggest that FL may alter cocaine pharmacokinetics in men. Because cocaine and BE are vasoconstrictive, the data imply that FL might reduce some of cocaine's cardiovascular effects.

Zador DA. Facilitating groin injecting behaviour: Harm reduction or harm production? (editorial). Addiction 102(11): 1791-1792, 2007. (8 refs.)

Zhu SH; Pulvers K; Zhuang YR; Baezconde-Garbanati L. Most Latino smokers in California are low-frequency smokers. Addiction 102(Supplement 2): 104-111, 2007. (57 refs.)

Aims: We examine the phenomenon of low-frequency smoking (non-daily smoking or smoking <= 5 cigarettes daily) among California Latinos and address its implications for addiction theory and population tobacco control. Design, setting and participants: Data gathered in 2001 and 2003 through the California Health Interview Survey (CHIS), the largest general health survey in California. The present study focused on Latino current smokers (n = 1254 for CHIS 2001; n = 946 for CHIS 2003). Measurement Latino smokers reporting either non-daily smoking or smoking <= 5 cigarettes daily were identified and grouped into one category: low-frequency smokers. Findings: Weighted by population parameters, more than 70% of Latino smokers in California were found to be low-frequency smokers [70.7% (CI = 67.2%, 73.9%) in 2001 and 70.8% (CI = 67.1%-74.2%) in 2003]. This high proportion cut across all demographic dimensions in both surveys, suggesting pervasiveness and reliability of this phenomenon. Proportions for non-daily smokers and low-rate daily smokers were 48.6% and 22.1% in 2001 and 54.9% and 15.9% in 2003. In both surveys, more than 80% of non-daily smokers consumed <= 5 cigarettes on their smoking days. Conclusions: The fact that most Latino smokers are low-frequency smokers calls for a new theoretical framework-beyond withdrawal-based theories-to account for the prevalence of this behavior on the population level. It also calls into question the harm-reduction approach as a tobacco control strategy for California Latino populations. Strategies emphasizing that every cigarette can hurt, and encouraging complete cessation, seem more fitting for this group of smokers.