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CORK Bibliography: Route of Administration

88 citations. October 2010 to present

Prepared: September 2011

Afifi RA; Yeretzian JS; Rouhana A; Nehlawi MT; Mack A. Neighbourhood influences on narghile smoking among youth in Beirut. European Journal of Public Health 20(4): 456-462, 2010. (42 refs.)

Background: Increasingly neighbourhoods are identified as influencing health. Neighbourhood characteristics have been linked to cigarette use. In Lebanon, the water pipe (narghile) use is most frequent among youth. The current study is aimed at identifying differential neighbourhood influences on smoking narghile among youth. Methods: A quantitative interview was completed with 1294 adolescents, 13-20 years, in three urban disadvantaged neighbourhoods of Beirut. Individual and social factors, suggested by the literature, were associated with smoking narghile. The neighbourhood variation in the influence of these factors was then explored. Bivariate and stratified logistic regression analysis were conducted, neighbourhood being the stratification variable. Results: About 60% of respondents had ever tried a narghile, about one-fifth continued to smoke. Several individual-level and social variables predicted narghile smoking bivariately. The influences on narghile smoking varied by neighbourhood. Neighbourhood differences persisted at the multivariate level. Consistently across neighbourhoods, the influence of friends was the predominant predictor of narghile smoking. In one neighbourhood, maternal smoking was a risk factor for narghile smoking of youth, in another paternal smoking. Being female seems to be protective in two of the three neighbourhoods. Other factors also differentially influence narghile use by neighbourhood. Conclusions: The mechanisms of influence of neighbourhoods on health are not clearly understood, but a transactional paradigm seems most fitting with the results found in this research. Interventions to prevent the narghile smoking should address multiple levels of influence; and must be tailored to the particular aspects of neighbourhoods which are influential in the uptake of this behaviour.

Akl EA; Aleem S; Gunukula SK; Honeine R; Abou Jaoude P; Irani J. Survey instruments used in clinical and epidemiological research on waterpipe tobacco smoking: A systematic review. BMC Public Health 10: article 415, 2010. (13 refs.)

Background: The primary objective was to systematically review the medical literature for instruments validated for use in epidemiological and clinical research on waterpipe smoking. Methods: We searched the following databases: MEDLINE, EMBASE, and ISI the Web of Science. We selected studies using a two-stage duplicate and independent screening process. We included papers reporting on the development and/or validation of survey instruments to measure waterpipe tobacco consumption or related concepts. Two reviewers used a standardized and pilot tested data abstraction form to collect data from each eligible study using a duplicate and independent screening process. We also determined the percentage of observational studies assessing the health effects of waterpipe tobacco smoking and the percentage of studies of prevalence of waterpipe tobacco smoking that have used validated survey instruments. Results: We identified a total of five survey instruments. One instrument was designed to measure knowledge, attitudes, and waterpipe use among pregnant women and was shown to have internal consistency and content validity. Three instruments were designed to measure waterpipe tobacco consumption, two of which were reported to have face validity. The fifth instrument was designed to measure waterpipe dependence and was rigorously developed and validated. One of the studies of prevalence and none of the studies of health effects of waterpipe smoking used validated instruments. Conclusions: A number of instruments for measuring the use of and dependence on waterpipe smoking exist. Future research should study content validity and cross cultural adaptation of these instruments.

Cakic V; Potkonyak J; Marshall A. Dimethyltryptamine (DMT): Subjective effects and patterns of use among Australian recreational users. Drug and Alcohol Dependence 111(1-2): 30-37, 2010. (58 refs.)

Dimethyltryptamine (DMT) is an endogenous hallucinogen with traditional use as a sacrament in the orally active preparation of ayahuasca. Although the religious use of ayahuasca has been examined extensively, very little is known about the recreational use of DMT. In this study, Australian participants (n = 121) reporting at least one lifetime use of DMT completed an online questionnaire recording patterns of use, subjective effects and attitudes towards their DMT use. Smoking DMT was by far the most common route of administration (98.3%) with a comparatively smaller proportion reporting use of ayahuasca (30.6%). The reasons for first trying DMT were out of a general interest in hallucinogenic drugs (46.6%) or curiosity about DMT's effects (41.7%), while almost one-third (31.1%) cited possible psychotherapeutic benefits of the drug. An increase in psychospiritual insight was the most commonly reported positive effect of both smoked DMT (75.5%) and ayahuasca (46.7%), a finding that is consistent with other studies examining the ritualised use of ayahuasca in a religious context. Although previous studies of DMT use have examined ayahuasca use exclusively, the present study demonstrates the ubiquity of smoking as the most prevalent route of administration among recreational DMT users.

Dunn M; Degenhardt L; Bruno R. Transition to and from injecting drug use among regular ecstasy users. Addictive Behaviors 35(10): 909-912, 2010. (34 refs.)

There is a scant amount of research investigating injecting drug use among people not selected on the basis of their injecting behaviour, and less attention has been given to stimulant users who may have a different experience with injecting drug use than opioid users who are more commonly studied. The current study aimed to investigate initiation to, and transition from, injecting drug use among a sentinel sample of regular ecstasy users in Australia. Participants were regular ecstasy users recruited across Australia in 2007 who were administered a structured interview that contained questions regarding initiation to injecting, reasons for injecting cessation, and likelihood of future injecting. Among those with a history of injecting drug use, injecting first occurred at a similar age to that of first ecstasy use. The majority did not inject themselves at the first occasion, and two-fifths were under the influence of other drugs at the time. Two-fifths of injectors had not injected in the past 6 months, with many relating this to concerns surrounding stigma. Route of drug administration is clearly not static, and the findings from this study suggest that some who have ceased injecting may still be at risk for future injecting.

Ebbert JO; Edmonds A; Luo XH; Jensen J; Hatsukami DK. Smokeless tobacco reduction with the nicotine lozenge and behavioral intervention. Nicotine & Tobacco Research 12(8): 823-827, 2010. (13 refs.)

Introduction: Studies have evaluated smoking reduction with nicotine replacement therapy to reduce tobacco exposure and facilitate abstinence among cigarette smokers, but none have evaluated a reduction approach in smokeless tobacco (ST) users. Methods: We conducted an open-label pilot study to determine if the 4-mg nicotine lozenge with a behavioral intervention could facilitate ST use reduction among ST users compared with a behavioral intervention alone. Eligible subjects were ST users not interested in quitting. Results: One hundred and two subjects were randomized. Both interventions were associated with significant decreases in ST use and toxicant exposure and with increased abstinence, quit attempts, and duration of abstinence. However, no significant differences were observed between groups for these outcomes. Discussion: A behavioral intervention with or without the nicotine lozenge may be effective for decreasing both ST use and toxicant exposure and for increasing tobacco abstinence, quit attempts, and duration of abstinence. The use of reduction strategies for ST users not interested in quitting deserves further evaluation as an intervention strategy.

Garelik DA. Nicotine gum dependence treated with varenicline: A case report. Nicotine & Tobacco Research 12(10): 104101042, 2010. (10 refs.)

Introduction: The buccal absorption of nicotine replacement therapy is a part of the treatment to quit smoking. In some cases, this use could last more than six months. Methods and Results: We report the case of a woman, former smoker, who took nicotine gums for over five years and was treated successfully with Varenicline during six months according to the recommended posology. Discussion: Varenicline, a partial alpha 4 beta 2 nicotinic receptor agonist, could be a solution to help former smokers to stop long-term use of nicotine gums or lozenges. Further studies will be necessary to confirm this result.

Hamdan AL; Sibai A; Oubari D; Ashkar J; Fuleihan N. Laryngeal findings and acoustic changes in hubble-bubble smokers26. European Archives of Oto-Rhino-Laryngology 267(10): 1587-1592, 2010. (26 refs.)

The purpose of our investigation was to evaluate the laryngeal findings and acoustic changes in hubble-bubble smokers. A total of 42 subjects with history of hubble-bubble smoking were recruited for this study. A corresponding group with a history of cigarette smoking and controls were matched. All subjects underwent laryngeal video-endostroboscopic evaluation and acoustic analysis. In the hubble-bubble smoking group, 61.9% were males. The average age was 30.02 +/- 9.48 years and the average number of years of smoking was 8.09 +/- 6.45 years. Three subjects had dysphonia at the time of examination. The incidence of benign lesions of the vocal folds in the hubble-bubble group was 21.5%, with edema being the most common at 16.7% followed by cyst at 4.8%. The incidence of laryngeal findings was significantly higher in the hubble-bubble group compared to controls. In the cigarette-smoking group, the most common finding was vocal fold cyst in 14.8% followed by polyps in 7.4%, and edema, sulcus vocalis and granuloma. These findings were not significantly different from the hubble-bubble group except for the thick mucus, which was significantly higher in the latter. There were no significant changes in any of the acoustic parameters between hubble-bubble smokers and controls except for the VTI and MPT, which were significantly lower in the hubble-bubble group. In comparison with the cigarette-smoking group, hubble-bubble smokers had significantly higher Fundamental frequency and habitual pitch (p value 0.042 and 0.008, respectively). The laryngeal findings in hubble-bubble smokers are comparable to cigarette smokers. These laryngeal findings are not translated acoustically, as all the acoustic parameters are within normal range compared to controls.

Lankenau SE; Wagner KD; Bloom JJ; Sanders B; Hathazi D; Shin C. The first injection event: Differences among heroin, methamphetamine, cocaine, and ketamine initiates. Journal of Drug Issues 40(2): 241-262, 2010. (43 refs.)

This article describes how the drug type injected at the first injection event is related to characteristics of the initiate, risk behaviors at initiation, and future drug-using trajectories. A diverse sample (n=222) of young injection drug users (IDUs) were recruited from public settings in New York, New Orleans, and Los Angeles during 2004 and 2005. The sample was between 16 and 29 years old, and had injected ketamine at least once in the preceding two years. Interview data was analyzed both quantitatively and qualitatively. Young IDUs initiated with four primary drug types: heroin (48.6%), methamphetamine (20.3%), ketamine (17.1%), and cocaine (14%). Several variables evidenced statistically significant relationships with drug type: age at injection initiation, level of education, region of initiation, setting, mode of administration, patterns of self-injection, number of drugs ever injected, current housing status, and their hepatitis C virus (HCV) status. Qualitative analyses revealed that rationale for injection initiation and subjective experiences at first injection differed by drug type.

Mayet S; Manning V; Sheridan J; Best D; Strang J. The virtual disappearance of injectable opioids for heroin addiction under the 'British System'. Drugs: Education, Prevention and Policy 17(5): 496-506, 2010. (25 refs.)

Aims: Injectable opioids were prescribed unsupervised under the 'British System' for heroin dependence. National guidelines (1999 and 2003) confirmed that injectable opioids have a legitimate 'limited clinical place' and should be dispensed daily, with 'mechanisms for supervision'. This study assesses whether national guidelines impacted on prescriptions of injectable opioids. Methods: A 25% random sample of community pharmacists (n = 2473) in England were surveyed by a questionnaire in 2005, with 95% response (n = 2349). Opioid maintenance prescription data for anonymous patients (n = 9620) were compared to the prescription data in 1995 (n = 3721) from a matched survey. Findings: Injectable opioid prescriptions reduced significantly from 10.5% (1995) to 1.8% (2005) of all opioid maintenance prescriptions. Daily doses significantly increased, as did daily dispensing from 28.8% (1995) to 57.8% (2005), whilst weekly dispensing reduced from 39.5% (1995) to 14.5% (2005). In 2005, injectable opioids accounted for 27.2% of private opioid prescriptions, versus 1.5% National Health Service (NHS) prescriptions. Private prescriptions were for larger take-home doses than NHS prescriptions. Regional variation was present. Conclusions: Injectable opioid maintenance treatment for heroin dependence under the unsupervised 'British System' is disappearing, although not extinct. If injectable opioids are prescribed, this is more in line with national guidelines. However, many prescriptions are less than daily instalments.

Okuyemi KS; Zheng H; Guo HF; Ahluwalia JS. Predictors of adherence to nicotine gum and counseling among African-American light smokers. Journal of General Internal Medicine 25(9): 969-976, 2010. (47 refs.)

A high proportion of African-American smokers are light smokers, and they experience low smoking cessation rates and disproportionately high tobacco-related morbidity; yet no studies have examined tobacco treatment adherence in this group. To determine the predictors of adherence to nicotine gum and counseling among African-American light smokers (defined as smoking a parts per thousand currency sign10 cigarettes/day), and the effects of adherence on smoking cessation. Data were from a 2 x 2 randomized, placebo-controlled smoking cessation trial of nicotine gum (2 mg versus placebo) and counseling (motivational interviewing versus health education). Seven hundred fifty-five African-American light smokers at a community-based clinic. Demographic and health-related information, smoking behaviors, psychosocial variables, adherence to nicotine gum and counseling, and cotinine-verified 7-day abstinence from smoking at week-26 follow-up. A logistic regression model showed that having a higher body mass index (OR = 1.03, 95% CI = 1.01 to 1.05), more quit attempts in the past year (OR = 1.04, 95% CI = 1.01 to 1.07), higher baseline exhaled carbon monoxide (OR = 1.22, 95% CI = 1.01 to 1.48), and higher perceived stress (OR = 1.12, 95% CI = 1.03 to 1.22) increased the likelihood of adherence to nicotine gum. Being a high school graduate was a predictor of adherence to counseling (OR = 1.58, 95% CI = 1.02 to 2.44). Surprisingly, being adherent to nicotine gum significantly reduced the odds of smoking cessation (OR = 0.50, CI = 0.28 to 0.87). On the other hand, adherence to counseling dramatically increased the likelihood of smoking cessation (OR = 3.32, CI = 1.36 to 8.08). Individual risk factors may influence adherence to nicotine gum and counseling. Improving psychological interventions and promoting adherence to counseling may increase overall smoking cessation success among African-American light smokers.

Poyrazoglu S; Sarli S; Gencer Z; Gunay O. Waterpipe (narghile) smoking among medical and non-medical university students in Turkey18. Upsala Journal of Medical Sciences 115(3): 210-216, 2010. (18 refs.)

Objectives. This investigation was performed in order to determine the prevalence rate of waterpipe smoking in students of Erciyes University and the effects of some socio-demographic factors. Methods. A total of 645 students who study the first three grades of the medical faculty and the engineering faculty of Erciyes University were enrolled in the study. A questionnaire including 48 questions was applied. Chi-square test and logistic regression method were performed for the statistical analyses. Results. The total prevalence rate of waterpipe smoking was found to be 32.7%. The prevalence rate of waterpipe smoking was 28.6% in the medical and 37.5% in the non-medical students. It was determined that 41.6% of the males and 20.2% of the females currently smoke waterpipe. Gender, cigarette smoking, and the presence of waterpipe smokers among family members and friends have significant effects on the prevalence of waterpipe smoking. Residence and economical status of the family and with whom the students live have no significant effect on the prevalence rate. Conclusions. Approximately one-third of the students currently smoke waterpipe. Smoking of both cigarette and waterpipe was frequently found. The measures against all tobacco products should be combined.

Prasad R; Ahuja RC; Singhal S; Srivastava AN; James P; Kesarwani V et al. A case-control study of bidi smoking and bronchogenic carcinoma. Annals of Thoracic Medicine 5(4): 238-241, 2010. (30 refs.)

OBJECTIVE: To evaluate the risks imposed by tobacco smoking, in particular, bidi smoking, in the development of lung cancer. METHODS: Two hundred eighty-four histologically confirmed patients of bronchogenic carcinoma and 852 controls matched for age, sex, and socioeconomic status were interviewed according to a predesigned questionnaire. Effects of individual variables defining the various aspects of tobacco smoking, in particular, bidi smoking, were assessed using logistic regression models. RESULTS: 81.3% cases of bronchogenic carcinoma were ever smokers as compared with 42.2% among controls. The odd ratios for ever smoking, bidi smoking, and cigarette smoking were 5.9 (confidence interval [CI] 4.3, 8.4), 6.1 (CI 4.3, 8.7), and 5.3 (CI 2.7, 10.4), respectively. CONCLUSION: Bidi smoking poses a very high risk for lung cancer even more than that of cigarette smoking.

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

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

Ramadas K; Sauvaget C; Thomas G; Fayette JM; Thara S; Sankaranarayanan R. Effect of tobacco chewing, tobacco smoking and alcohol on all-cause and cancer mortality: A cohort study from Trivandrum, India. Cancer Epidemiology 34(4): 405-412, 2010. (41 refs.)

Objective: To study the risk of all-cause, cancel and tobacco-related cancer mortality associated with tobacco chewing, tobacco smoking and alcohol use: Design: Prospective community-based cohort study initiated in 1996. Participants: 167 343 adult subjects, aged 34 and older, living in 13 panchayaths (rural municipal administrative units) in South India, were regularly followed-up for a mean duration of 65 years. Main outcome measures: Mortality from all-causes, all cancer and tobacco-related cancer Results The mortality risks associated with chewing (and 95% confidence intervals), after adjusting for age, sex, socio-economic and dietary variables, and for other habits, were 090 (0 86-0 94) for all-cause, 1 07 (0 94-1 22) for cancer and 1 22 (1 04-1 44) for tobacco-related cancer, with smoking the respective mortality risks were 1 31(1.24-1 39), 1 63 (1 37-1 94) and 1.68 (1.36-2 08), and with alcohol use the risks were 1 13 (1.06-1.20). 1 32 (1 11-1 57) and 1 47(1.19-1 80), respectively Reduced risk of all-cause mortality by chewing was observed only in the 60-84 years old group (0 90 (0 85-0 94)), and detrimental effects of chewing on cancer mortality were shown in the young and middle-age groups 34-39 years old (1 33 (0 67-2 65)), and 40-59 years old (1 26(1.03-1 55)). Conclusion: Tobacco in any form and alcohol uses were harmful and a higher quality of life could be achieved by avoiding these habits. Given the demographic, epidemiological and economic transitions and changes in pattern of tobacco and alcohol use in India, the health loss from the tobacco and alcohol will grow even larger, unless effective interventions and policies to reduce these habits are implemented.

Soller B; Lee JP. Drug-intake methods and social identity: The use of marijuana in blunts among southeast asian adolescents and emerging adults. Journal of Adolescent Research 25(6): 783-806, 2010. (61 refs.)

This article examines why Southeast Asian American adolescents and emerging adults in two urban settings prefer to use "blunts," or hollowed-out cigars filled with marijuana, over other methods of drug intake. Rationales for preferring blunts were both instrumental and social. Blunts allowed users to more easily share marijuana, the preferred drug among their peers, and protected against potential adverse effects associated with the "high." Blunts also allowed users to identify with the dominant style of drug use and differentiate themselves from users of stigmatized drugs such as crack cocaine and methamphetamine. This article highlights the importance of drug-intake methods in the formation and performance of drug-using behaviors among adolescents, emerging adults, and members of ethnic minority subgroups.

Tang L; Lim WY; Eng P; Leong SS; Lim TK; Ng AWK et al. Lung cancer in Chinese women: Evidence for an interaction between tobacco smoking and exposure to inhalants in the indoor environment. Environmental Health Perspectives 118(9): 1257-1260, 2010. (23 refs.)

BACKGROUND: Epidemiologyogic data suggest that Chinese women have a high incidence of lung cancer in relation to their smoking prevalence. In addition to active tobacco smoke exposure, other sources of fumes and airborne particles in the indoor environment, such as cooking and burning of incense and mosquito coils, have been considered potential risk factors for lung cancer. OBJECTIVES: We used a case-control study to explore effects of inhalants from combustion sources common in the domestic environment on lung cancer and their modification by active tobacco smoking. METHODS: We analyzed 703 primary lung cancer cases and 1,578 controls. Data on demographic background and relevant exposures were obtained by face-to-face interviews in the hospital. RESULTS: We observed a positive relationship with daily exposure to incense or mosquito coils and to cooking fumes only among smokers, and no association among lifetime nonsmokers. Interactions between smoking and frequency of cooking, or exposure to incense or mosquito coils were statistically significant and consistent with synergistic effects on lung cancer. The odds ratio (OR) comparing smokers without daily incense or mosquito coil exposure with nonsmokers without daily exposure was 2.80 [95% confidence interval (CI), 1.86-4.21], whereas the OR comparing smokers with daily exposure to the same referent group was 4.61 (95% CI, 3.41-6.24). In contrast, daily exposure to incense or mosquito coils was not associated with lung cancer among nonsmokers (OR = 0.91; 95% CI, 0.72-1.16). We observed the same pattern of associations for smokers without (OR = 2.31; 95% CI, 1.52-3.51) and with (OR = 4.50; 95% CI, 3.21-6.30) daily cooking exposure compared with nonsmokers, with no evidence of an association with daily cooking exposure among nonsmokers. CONCLUSION: Our results suggest that active tobacco smoking not only is an important risk factor for development of lung cancer, but also may cause smokers to be more susceptible to the risk-enhancing effects of other inhalants.

Vansickel AR; Cobb CO; Weaver MF; Eissenberg TE. A clinical laboratory model for evaluating the acute effects of electronic "cigarettes": Nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiology, Biomarkers & Prevention 19(8): 1945-1953, 2010. (41 refs.)

Background: Electronic "cigarettes" are marketed to tobacco users as potential reduced exposure products (PREP), albeit with little information regarding electronic cigarette user toxicant exposure and effects. This information may be obtained by adapting clinical laboratory methods used to evaluate other PREPs for smokers. Methods: Thirty-two smokers participated in four independent Latin-square ordered conditions that differed by product: own brand cigarette, "NPRO" electronic cigarettes (NPRO EC; 18 mg cartridge), "Hydro" electronic cigarettes (Hydro EC; 16 mg cartridge), or sham (unlit cigarette). Participants took 10 puffs at two separate times during each session. Plasma nicotine and carbon monoxide (CO) concentration, heart rate, and subjective effects were assessed. Results: Own brand significantly increased plasma nicotine and CO concentration and heart rate within the first five minutes of administration whereas NPRO EC, Hydro EC, and sham smoking did not. Own brand, NPRO EC, and Hydro EC (but not sham) significantly decreased tobacco abstinence symptom ratings and increased product acceptability ratings. The magnitude of symptom suppression and increased acceptability was greater for own brand than for NPRO EC and Hydro EC. Conclusions: Under these acute testing conditions, neither of the electronic cigarettes exposed users to measurable levels of nicotine or CO, although both suppressed nicotine/tobacco abstinence symptom ratings. Impact: This study illustrates how clinical laboratory methods can be used to understand the acute effects of these and other PREPs for tobacco users. The results and methods reported here will likely be relevant to the evaluation and empirically based regulation of electronic cigarettes and similar products.

Wikstrom AK; Cnattingius S; Stephansson O. Maternal use of Swedish snuff (Snus) and risk of stillbirth. Epidemiology 21(6): 772-778, 2010. (32 refs.)

Background: Swedish snuff has been discussed internationally as a safer alternative to tobacco smoking. International cigarette manufacturers are promoting new snuff products, and the use of Swedish snuff is increasing, especially among women of childbearing age. The effect of Swedish snuff on pregnancy complications is unknown. Methods: In this population-based cohort study, we estimated the risk of stillbirth in snuff users (n = 7629), light smokers (1-9 cigarettes/day; n = 41,488), and heavy smokers (>= 10 cigarettes/day; n = 17,014), using nontobacco users (n = 504,531) as reference. Results: Compared with nontobacco users, snuff users had an increased risk of stillbirth (adjusted odds ratio = 1.6 [95% confidence interval = 1.1-2.3]); the risk was higher for preterm (<37 weeks) stillbirth (2.1 [1.3-3.4]). For light smokers, the adjusted odds ratio of stillbirth was 1.4 (1.2-1.7) and the corresponding risk for heavy smokers was 2.4 (2.0-3.0). When we excluded women with preeclampsia or antenatal bleeding and infants who were small for gestational age, the smoking-related risks of stillbirth was markedly attenuated; the elevated risk for snuff users remained the same level. Conclusions: Use of Swedish snuff during pregnancy was associated with a higher risk of stillbirth. The mechanism behind this increased risk seems to differ from the underlying mechanism in smokers. Swedish snuff does not appear to be a safe alternative to cigarette smoking during pregnancy.

Yilmaz G; Karacan C; Besler HT; Yurdakok K; Coskun T. The urinary cotinine levels of infants and the determinants. Turkish Journal of Pediatrics 52(3): 294-300, 2010. (15 refs.)

The aim of this study was to determine the effect of the route of tobacco smoke exposure on urinary cotinine levels of infants. A cross-sectional analysis was done on 254 six-month-old infants. The infants were grouped according to the route of tobacco smoke exposure. The urinary cotinine/creatinine ratios were determined. Forty-nine percent (124/254) of mothers were smokers. Urinary cotinine levels in infants of smoking mothers were statistically significantly higher than levels in infants of non-smoking mothers. The highest mean cotinine/creatinine level was found in the breast-milk-exposed group. Linear regression analysis showed that maternal smoking increased urinary cotinine level by 541 times and breastfeeding increased it by 171 times, whereas early start of formula feeding decreased it by 63 times. Tobacco exposure by breastfeeding may be more harmful than other routes of exposure. Mothers should be encouraged to stop smoking during the breastfeeding period even if they avoid exposing their infants to passive tobacco smoke.

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

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

Zhang LN; Yang YM; Xu ZR; Gui QF; Hu QQ. Chewing substances with or without tobacco and risk of cardiovascular disease in Asia: A meta-analysis. Journal of Zhejiang University. Science B 11(9): 681-689, 2010. (23 refs.)

To assess whether people who ever use any form of chewing substance in Asia are at increased risk of cardiovascular disease (CVD). PubMed and ISI Web of Science were searched for relevant studies, with no limitation on language or study year. Studies were included if they provided quantitative estimate of the association between ever use of chewing substance and the occurrence of CVD. Two authors independently implemented inclusion criteria, abstracted study characteristics, and performed meta-analysis. Summary relative risks were estimated on the basis of a random effect model. We used Q statistic and Egger's test to examine heterogeneity across studies and potential publication bias, respectively. Eight eligible studies were included. The relative risk of CVD for ever using chewing substances with or without tobacco was 1.26 (95% confidence interval (CI) 1.12-1.40), which was unchanged when restricted to cohort studies [1.25 (1.08-1.42)] or cohort studies in Taiwan [1.31 (1.12-1.51)]. The summary relative risk for ischemic heart disease was 1.27 (1.02-1.52), and was lowered to 1.26 (0.85-1.67) after exclusion of a cross-sectional study. The overall relative risk for cerebrovascular disease was 1.32 (1.08-1.56). On the basis of the Taiwan data, the summary relative risk of CVD for betel (Areca catechu) chewing was 1.30 (1.17-1.44). Data on dose-response were limited to betel chewing in Taiwan, suggesting a relationship between risk of CVD and cumulative exposure. Two large cohorts in Taiwan reported a greater risk of CVD with betel chewing than with smoking. An association was detected between betel chewing with or without tobacco and the risk of CVD. Betel chewing may impose a greater CVD risk than smoking. More effort is needed in developing betel chewing cessation programmes. The relationship between betel chewing and subgroups of CVD requires further investigation.

Zocratto KBF; Osimani ML; Peralta LM; Latorre L; Muzzio E; Segura M et al. Sexual behavior and HBV infection among noninjecting cocaine users (NICUs). Substance Use & Misuse 45(12): 2026-2044, 2010. (30 refs.)

The aim is to estimate HBV prevalence and the associated risks among noninjecting cocaine users (NICUs). In 2002-2003, a total of 824 NICUs from Buenos Aires (Argentina) and Montevideo (Uruguay) were interviewed using a structured questionnaire. Serologic tests were carried out for Human Immunodeficiency Virus (HIV), hepatitis B (HBV), syphilis, and others. The population was divided into two serologic groups: HBV-infected and seronegative group. Univariate and binary logistic model were developed. The results seem to indicate that, among NICUs, HBV is transmitted through sexual contact. Prevention measures, including vaccine, are needed in order to control and minimize risks. The study's limitations are noted.

Bastos FI. Commentary on Caiaffa, et al (2011): The renewed challenge of hepatitis C virus epidemiology among non-injecting drug users. (editorial). Addiction 106(1): 152-153, 2011. (8 refs.)

Caiaffa WT; Zocratto KF; Osimani ML; Martinez PL; Radulich G; Latorre L et al. Hepatitis C virus among non-injecting cocaine users (NICUs) in South America: can injectors be a bridge? Addiction 106(1): 143-151, 2011. (38 refs.)

Aim: To investigate the factors associated with hepatitis C virus (HCV) infection among non-injecting cocaine users (NICUs) and to compare practices associated with HCV and HIV infection. Design: An intercountry cross-sectional study. Setting: Buenos Aires and Montevideo metropolitan areas. Participants: A total of 871 NICUs. Measurements: NICUs were interviewed and their blood was drawn and used for HCV, HIV, HBV surface antigen (HbsAg), HB-anticore and Venereal Disease Research Laboratory (VRDL) antibody assays. Bivariate and multivariate logistic regression analyses included comparisons of HCV and HIV mono-infected participants with HCV-HIV seronegatives. Findings: Prevalence rates were 8.8 [95% confidence interval (CI): 6.9-10.8) for HCV and 7.9 (95% CI: 6.1-9.7) for HIV. HCV-infected NICUs were twice as likely as HCV-HIV seronegatives to have shared straws for cocaine snorting or sniffing, even when adjusted for other variables. HCV prevalence rates ranged from 3.6% among NICUs who denied sharing straws and having had an injection drug user (IDU) or an HIV-positive sexual partner to 12.6% among participants who reported ever having shared straws or having had either an IDU- or HIV-positive sexual partner (chi 2(trend) = 6.56, P = 0.01). Conclusions: Non-injecting cocaine users from South America are vulnerable to multiple infections and HCV infection appears to occur through the sharing of straws. HCV infection is associated with intimate relationships with IDUs or HIV-seropositive partners, supporting the hypothesis that HCV risk may be due primarily to risk-taking behaviour associated with drugs in this population.

Cobb CO; Shihadeh A; Weaver MF; Eissenberg T. Waterpipe tobacco smoking and cigarette smoking: A direct comparison of toxicant exposure and subjective effects. Nicotine & Tobacco Research 13(2): 78-87, 2011. (47 refs.)

Waterpipe tobacco smoking is increasing worldwide and is believed by many users to be less harmful and addictive than cigarette smoking. In fact, waterpipe tobacco and cigarette smoke contain many of the same chemicals, and users are exposed to the dependence-producing drug nicotine as well as other smoke toxicants. The subjective effect profile of these 2 tobacco use methods has not been compared directly, though this information is relevant to understanding the risk of dependence development. Fifty-four participants who reported waterpipe and cigarette smoking completed 2, 45-min, counter-balanced sessions in which they completed a waterpipe use episode (mean smoking time = 43.3 min) or a cigarette (mean = 6.1 min). Outcome measures included plasma nicotine, carboxyhemoglobin (COHb), and subjective effects, including those relevant to predicting dependence potential. Mean (+/- SEM) peak plasma nicotine concentration did not differ by session (waterpipe = 9.8 +/- 1.0 ng/ml; cigarette = 9.4 +/- 1.0 ng/ml). Mean peak COHb concentration differed significantly (waterpipe = 4.5% +/- 0.3%; cigarette = 1.2% +/- 0.1%). Subjective effect changes for waterpipe and cigarette were comparable in magnitude but often longer lived for waterpipe. Relative to a cigarette, waterpipe tobacco smoking was associated with similar peak nicotine exposure, 3.75-fold greater COHb, and 56-fold greater inhaled smoke volume. Waterpipe and cigarette influenced many of the same subjective effect measures. These findings are consistent with the conclusion that waterpipe tobacco smoking presents substantial risk of dependence, disease, and death, and they can be incorporated into prevention interventions that might help deter more adolescents and young adults from experimenting with an almost certainly lethal method of tobacco use.

Ferrant O; Papin F; Clinic B; Lacroix C; Saussereau E; Remoue JE et al. Fatal poisoning due to snorting buprenorphine and alcohol consumption. Forensic Science International 204(1-3): E8-E11, 2011. (24 refs.)

High dosage buprenorphine (Subutex (R)) has been prescribed as a replacement therapy for major opioid dependencies in France since 1996. However, several studies have underlined its lethal risk, especially when administered intravenously, or when combined with benzodiazepines, alcohol or other central nervous system depressants. We report three fatal buprenorphine-related poisonings after snorting, among outside protocol individuals, observed at the Forensic Medicine Unit of Caen University Hospital. Medico-legal autopsies and complementary examinations were performed. The results are presented and discussed. Lethal poisoning after snorting buprenorphine was considered the most probable cause of death. These observations illustrate the risk of fatal poisoning by buprenorphine per-nasal route, which has rarely been reported in the literature although snorting is particularly prized by individuals outside the substitution therapy. We also observed the combination of buprenorphine and alcohol. By evaluating the pharmacological characteristics of this substance, as well as the data previously published in the literature, we have attempted to explain the pathophysiological mechanisms of this particular mode of poisoning that can easily be fatal.

Kleykamp BA; Jennings JM; Eissenberg T. Effects of transdermal nicotine and concurrent smoking on cognitive performance in tobacco-abstinent smokers. Experimental and Clinical Psychopharmacology 19(1): 75-84, 2011. (61 refs.)

Smokers experience cognitive decrements during tobacco abstinence and boosts in performance on resumption of smoking. Few studies have examined whether smoking cessation treatments such as transdermal nicotine (TN) ameliorate these decrements or attenuate the cognitive effects of smoking. Identifying the effects of nicotine on these tobacco-related changes in performance could guide the development of more efficacious treatments. The purpose of this double-blind, randomized, laboratory study was to use process-specific cognitive tasks to examine the effects of TN and tobacco smoking on attention and working memory in overnight-abstinent smokers (N = 124; 54 women). Each participant completed 4 sessions lasting 6.5 hr corresponding to 0-, 7-, 14-, or 21-mg TN doses, and smoked a single cigarette 4 hr after TN administration. Outcome measures were administered before and after smoking and included tasks measuring attention (alerting, orienting, and executive function), working memory (verbal and spatial), and psychomotor function. Analysis of variance (p < .05) revealed that TN improved verbal and spatial working memory performance, as well as psychomotor function. Smoking, independent of TN dose, improved alerting, verbal working memory, and psychomotor function. Lastly, TN partially attenuated the effects of smoking on some working memory outcomes. These findings lend evidence to the idea that TN ameliorates some abstinence-related cognitive decrements and suggest that TN does not completely attenuate the cognitive effects of a concurrently smoked cigarette. Consequently, TN's efficacy as a smoking cessation treatment might be improved if these limitations are better addressed by either modifying or supplementing existing treatments.

Lam PK; Wong TW; Lau CC. Pneumomediastinum after smoking cocaine: A case report and review of literature. Hong Kong Journal of Emergency Medicine 18(1): 26-30, 2011. (26 refs.)

Cocaine abuse has become more affordable and popular amongst drug abusers locally in recent years. Spontaneous pneumomediastinum is an uncommon but a well-reported complication after smoking "crack" cocaine in the West. We report a case of spontaneous pneumomediastinum after smoking cocaine. The patient was managed conservatively and he recovered uneventfully. A review of literature on the mechanism, clinical presentation and management is presented.

Lund KE; Scheffels J; McNeill A. The association between use of snus and quit rates for smoking: results from seven Norwegian cross-sectional studies. Addiction 106(1): 162-167, 2011. (24 refs.)

Aim: Swedish studies have shown that experience of using snus is associated with an increased probability of being a former smoker. We examined whether this result is also found in Norway. Design: Seven cross-sectional data sets collected during the period 2003-08. Setting: Norway. Participants: A total of 10 441 ever (current or former) smokers Measurements: Quit ratios for smoking were compared for people with different histories of snus use. Motive for snus use was examined among combination users (snus and cigarettes). Smoking status was examined among snus users. Findings: Compared to smokers with no experience of using snus, the quit ratio for smoking was significantly higher for daily snus users in six of seven data sets, significantly higher for former snus users in two of five data sets and significantly lower for occasional snus users in six of seven data sets. Of combination users who used snus daily, 55.3% [confidence interval (CI) 44.7-65.9] reported that their motive for using snus was to quit smoking totally. This motive was reported significantly less often by combination users who used snus occasionally (35.7%, CI 27.3-44.2). Former smokers made up the largest proportion of daily snus users in six of seven data sets. In the remaining data set, that included only the age group 16-20 years, people who had never smoked made up the largest segment of snus users. Conclusions: Consistent with Swedish studies, Norwegian data shows that experience of using snus is associated with an increased probability of being a former smoker. In Scandinavia, snus may play a role in quitting smoking but other explanations, such as greater motivation to stop in snus users, cannot be ruled out.

Mariani JJ; Brooks D; Haney M; Levin FR. Quantification and comparison of marijuana smoking practices: Blunts, joints, and pipes. Drug and Alcohol Dependence 113(2-3): 249-251, 2011. (14 refs.)

The quantification method for collecting self-reported marijuana use data is not standardized as it is for alcohol or cigarettes, which presents a methodologic challenge for marijuana use disorder treatment studies. Serum and urine markers of marijuana use have a long half-life, limiting their utility as a clinical trial outcome measure. Structured calendar-based interview procedures can accurately measure the frequency of self-reported marijuana use, but are unable to reliably address issues such as quantity of use or potency. This study compared the quantity and assigned-dollar value among users of blunts, joints, and pipes enrolled in two clinical trials testing pharmacotherapies for marijuana dependence. The timeline follow-back method was modified to incorporate using a surrogate substance to represent marijuana to enable participants to estimate the amount and value used. Blunt users were mostly black and Hispanic, while users of joints and pipes were primarily white. Participants reported that they placed 50% more marijuana in blunts than in joints and placed more than twice the amount of marijuana in blunts than in pipes. These findings demonstrate the feasibility of using a surrogate weight estimation procedure to augment calendar-based methods of measuring self-reported marijuana use. Individual variability in use practices limits the utility of this method to estimating within-subject comparisons, rather than between subject comparisons.

Marshall MM; Kirk GD; Caporaso NE; McCormack MC; Merlo CA; Hague JC et al. Tobacco use and nicotine dependence among HIV-infected and uninfected injection drug users. Addictive Behaviors 36(1-2): 61-67, 2011. (44 refs.)

Introduction: Urban US populations are burdened by intersecting epidemics of HIV infection injection drug use and cigarette smoking Given the substantial morbidity attributable to tobacco in these populations we characterized smoking behaviors nicotine addiction and tobacco exposure among HIV-infected and HIV uninfected injection drug users (IDUs) in Baltimore Maryland Methods: Smoking behaviors among participants in the ALIVE Study were assessed using interviewer administered questionnaires Smoking history and nicotine dependence (Fagerstrom Index scores) were compared by HIV and drug injecting status. Serum cotinine (a nicotine metabolite) was measured for a sample of participants by enzyme immunoassay Results: Among 1052 participants (29 7% HIV-infected 39 8% active injectors) 85 2% were current smokers and 9 3% were former smokers. Smoking prevalence age at smoking initiation and cumulative tobacco exposure were similar by HIV status. Median Fagerstrom scores of 4 for HIV infected and HIV uninfected smokers indicated moderate nicotine dependence. Daily cigarette consumption was identical by HIV status (median 10 cigarettes) although HIV infected participants were less likely to smoke 1+ pack daily compared to HIV-uninfected participants (18 0% vs 26 9% p = 0 001). Compared to former injectors active injectors had higher smoking prevalence (90 5% vs 81 7% p = 0 0001) greater daily cigarette consumption (30 7% vs 19 6% smoked 1+ pack daily p = 0 0001) and slightly higher Fagerstrom scores (median 5 vs 4). Cotinine levels paralleled self reported cigarette consumption. Discussion" Tobacco use is extremely common among inner-city IDUs. Smoking behavior and nicotine dependence did not materially differ by HIV status but were associated with active drug injection. Cessation efforts should target the dual dependence of cigarettes and drugs experienced among this population.

Maziak W. The global epidemic of waterpipe smoking. (review). Addictive Behaviors 36(1-2): 1-5, 2011. (57 refs.)

In the past decade waterpipe (WP) smoking (a ka hookah, shisha, and narghile) has been steadily spreading among the youth around the world. The allure of this tobacco use method for the youth can stem from its pleasant smooth smoke social ambience and the perception of reduced harm. The material in this review is based on detailed Medline search for articles appearing especially in the past two years that are of relevance to WP epidemiology health and addictive effects and WP-related tobacco control policies It shows that WP smoking is continuing to spread among the youth worldwide and perhaps represents the second global tobacco epidemic since the cigarette Available evidence suggests that the prevalence of current (past month) WP smoking range from 6 to 34% among Middle Eastern adolescents 5%-17% among American adolescents and that WP use is increasing globally.Studies on the health effects of WP smoking are limited by methodological quality as well as by the novelty of WP epidemic relative to the long latency of important smoking-related health outcomes. Still, research indicates substantial WP harmful effects similar to those of cigarettes as well as to the potential of providing a bridge to cigarette smoking or relapse. Developing effective interventions to curb WP use among the youth requires a detailed understanding of how dependence develops in WP users and how it is shaped by WP's unique features, such as the following the predominantly intermittent use with prolonged sessions, preparation time, accessibility, potent sensory cues, and convivial experience of group use. It also requires assessing effective policy options, such as factual and visible health warnings on all its parts, as well as youth access and indoor smoking restrictions. WP smoking is currently showing all signs of a burgeoning global epidemic with serious implications for public health and tobacco control worldwide. Investment in research and policy initiatives to understand and curb WP use needs to become a public health priority.

Moon JM; Chun BJ. Fentanyl intoxication caused by abuse of transdermal fentanyl. Journal of Emergency Medicine 40(1): 37-40, 2011. (14 refs.)

Fentanyl has an analgesic effect 100 times greater than that of morphine; therefore, transdermal administration of fentanyl has been widely used to control pain. Due to misconceptions regarding the proper use of fentanyl, its simple method of administration, and the absence of regulatory rules regarding its use, both medical providers and non-medical providers have abused fentanyl. We report on three cases of fentanyl intoxication and suggest solutions to prevent its abuse in the future. Three patients were intoxicated by transdermal fentanyl, which resulted in respiratory depression. Two of these cases were attributed to non-medical use of the drug and the other occurred while using fentanyl as directed by medical personnel. Physicians should use transdermal fentanyl only to control chronic pain, and rules should be established to prevent abuse of fentanyl that occurs due to its ease of use and the absence of any established policy regarding the prescription and disposal of this drug.

Noel JK; Rees VW; Connolly GN. Electronic cigarettes: a new 'tobacco' industry? (editorial). Tobacco Control 20(1): 81-81, 2011. (7 refs.)

Senbanjo R; Hunt N; Strang J. Cessation of groin injecting behaviour among patients on oral opioid substitution treatment. Addiction 106(2): 376-382, 2011. (25 refs.)

Aims: To identify factors that might influence cessation of groin injecting (GI) among patients receiving oral opioid substitution treatment (OST). Design: A cross-sectional survey. Setting: Drug treatment centres in South East England. Participants: Groin injectors (GIs) attending an ultrasound 'health-check' clinic. Measurements: Clinical data and ultrasound images; comparing 65 patients who had injected drugs in the femoral vein (fv) in the previous month (current GIs) with 49 former groin injectors (former GIs). Findings: Most of the 114 clinic attendees were men (69.3%) and white European (95.6%). Mean age, duration of GI and time in treatment were 36.4 years, 54.8 months and 20.5 months, respectively. Former GIs were significantly older (P < 0.001) and had been injecting (P < 0.05) and in treatment (P < 0.05) for longer than current GIs. History of deep vein thrombosis (DVT, P < 0.05) and septicaemia (P < 0.05); moderate/severe chronic venous disease (CVD, P < 0.01); and 'very severe' fv damage on ultrasonography (P < 0.05) were more common among former GIs. A logistic regression model correcting for the effects of covariants revealed age (B 0.08; Wald 7.1; P < 0.01) and severity of venous disease (B 1.1; Wald 4.1; P < 0.05) as the strongest predictors of behaviour change. Conclusions: GI cessation is associated with longer time in treatment, increasing age and the presence of CVD and severely damaged fv. GI appears to be an intractable behaviour that often persists despite OST and severe health complications. Persistent GI should prompt a review of whether OST is optimized and whether other interventions are needed to promote behaviour change prior to the development of serious harm.

Strain EC; Harrison JA; Bigelow GE. Induction of opioid-dependent individuals onto buprenorphine and buprenorphine/naloxone soluble-films. Clinical Pharmacology & Therapeutics 89(3): 443-449, 2011. (22 refs.)

A sublingual soluble-film formulation of buprenorphine/naloxone (B/N) has been approved by the US Food and Drug Administration for the treatment of opioid dependency. This preparation provides unit-dose, child-resistant packaging amenable to tracking and accountability, offers more rapid dissolution, and has a potentially preferred taste vs. tablets. This study compared the ability of buprenorphine (B) and B/N films to suppress spontaneous withdrawal in opioid-dependent volunteers. Participants were maintained on morphine and underwent challenge sessions to confirm sensitivity to naloxone-induced opioid withdrawal. Subjects were randomized to receive either B (16 mg, n = 18) or B/N (16/4 mg, n = 16) soluble films for 5 days. The primary outcome measure was the Clinical Opiate Withdrawal Scale (COWS) score. Thirty-four subjects completed induction onto soluble films. There was a significant decrease in COWS scores but no significant differences between the groups. The results support the use of B and B/N soluble films as safe and effective delivery methods for opioid induction.

Winstock AR; Mitcheson LR; Deluca P; Davey Z; Corazza O; Schifano F. Mephedrone, new kid for the chop? Addiction 106(1): 154-161, 2011. (34 refs.)

Aims: Mephedrone (4-methylmethcathinone) is a novel synthetic stimulant drug that has recently become popular in the United Kingdom and elsewhere in Europe. It has a short history of human consumption and little is known about its prevalence and pattern of use. This study aimed to obtain preliminary data on its use and effects among dance drug users in the United Kingdom. Design: Cross-sectional anonymous online survey of mephedrone recruited as part of larger study exploring patterns of drug use among those associated with the dance music scene. Setting: UK-based dance music and clubbing website. Participants: A total of 947 ever users of mephedrone recruited as part of a wider study on dance drug use patterns. Measurements: Assessment of demographics, ever and current drug use and patterns and selected effects following use of mephedrone. Findings: A total of 947 (41.3%) of 2295 participants reported ever having used mephedrone. Mephedrone was the sixth most frequently used drug in the last month after tobacco, alcohol, cannabis, cocaine and 3,4-methylenedioxymethamphetamine (MDMA). Users were typically younger (P < 0.001) and male (P < 0.01); 15.1% reported using weekly or more frequently; 49.5% reported using between 0.5 and 1 g during a typical session; 69.5% reported that intranasal use was the most common route of use. Intranasal use was associated with increased abuse liability; 54.6% of those who have also used cocaine reported that the quality of the high obtained with mephedrone was better, with those using intranasally being significantly more likely than those who took the drug orally to report that mephedrone was more addictive (P < 0.02) and more risky (P < 0.02) than cocaine. Route of use was unrelated to any stimulant-related adverse effect apart from palpitations (P < 0.005). Conclusions: Mephedrone appears to be used primarily intranasally and to have comparable abuse potential to cocaine, with more than half those who use both reporting that mephedrone gives a better quality high.

Andresen T; Upton RN; Foster DJR; Christrup LL; Arendt-Nielsen L; Drewes AM. Pharmacokinetic/pharmacodynamic relationships of transdermal buprenorphine and fentanyl in experimental human pain models. Basic & Clinical Pharmacology & Toxicology 108(4): 274-284, 2011. (40 refs.)

Pharmacokinetic/pharmacodynamic (PK/PD) modelling can be used to characterize the relationship between dose regimen of opioids, plasma concentration and effect of opioids, which in turn can lead to more rational treatment regimens of pain. The aim of this study was to investigate the concentration-effect relationship for transdermal buprenorphine and fentanyl in experimentally induced pain. Twenty-two healthy volunteers were randomized to receive transdermal patches with fentanyl (25 mu g/hr, 72 hr), buprenorphine (20 mu g/hr, 144 hr) or placebo. The experimental pain tests were pressure at the tibial bone, cutaneous thermal stimulation, cold pressor test (conditioning stimulus (3 +/- 0.3 degrees C cold water), nerve growth factor-induced muscle soreness and intradermal capsaicin-induced hyperalgesia and allodynia. Experiments were carried out at baseline, 24, 48, 72 and 144 hr after application of patches. Time-course of placebo was described first and was afterwards added to the description of the time-courses of buprenorphine and fentanyl. This was either described by zero (no drug effect), linear or E-max model concentration-effect relationships. Time-dependent changes in pain measures in the placebo arm were described by linear or quadratic functions. The time-course of fentanyl and buprenorphine plasma concentrations was complex but could be represented by cubic spline interpolation in the models. Buprenorphine significantly attenuated bone-associated pain, heat pain, nerve growth factor-induced soreness and cold pressor pain. Fentanyl significantly attenuated cold pressor pain for the administered dose regimens. Although the PK/PD relationship for both drugs could be described with similar models, tissue-differentiated analgesic effects between buprenorphine and fentanyl was shown.

Butt S; Chou SN; Browne K. A rapid systematic review on the association between childhood physical and sexual abuse and illicit drug use among males. (review). Child Abuse Review 20(1): 6-38, 2011. (57 refs.)

This paper aims to review studies in relation to the association between childhood physical (CPA) and sexual abuse (CSA) and illicit drug use among the male clinical and general community populations using a systematic approach. Primary studies were identified using online databases which were searched comprehensively using a set of pre-determined search criteria and terms. Other sources included expert contact and the reference list of a relevant review. Associations between exposure (CPA/CSA) and outcome (illicit drug use) were considered with regards to an array of factors. A total of 5012 references were initially identified out of which 18 studies met the necessary criteria for reviewing. The review demonstrates tentative support for factors such as earlier drug initiation, intravenous drug use and greater frequency of use among some of the samples. It also demonstrates the difficulties involved in drawing conclusions due to the complex and multifaceted nature of drug use and the variability in the quality of the research available in this area. Limitations of the current review are highlighted and recommendations offered for future research with consideration given to practical implications in clinical and forensic settings.

Buxton JA; Sebastian R; Clearsky L; Angus N; Shah L; Lem M et al. Chasing the dragon: Characterizing cases of leukoencephalopathy associated with heroin inhalation in British Columbia. Harm Reduction Journal 8: article 3, 2011. (34 refs.)

An association between leukoencephalopathy, a disease of the white matter of the brain, and smoking heroin is well recognized. This paper describes 27 cases of leukoencephalopathy identified in two cities in British Columbia, Canada 2001-2006; the largest number of geographically and temporally defined reported cases in North America. Twenty cases of leukoencephalopathy were identified in and around Vancouver with onset dates December 2001 to July 2003; seven further cases were identified in Victoria September 2005-August 2006. Twenty (74%) of all cases were male, two couples were reported and eleven cases (55%) had Asian ethnicity. One case reported smoking heroin on a single occasion and developed mild symptoms; all other cases were hospitalized. Thirteen (48%) cases died; all had smoked heroin for a minimum of 3 years. Testing of one available heroin sample identified no substance other than common cutting agents. Although a specific etiology was not identified our study supports the theory of an intermittent exposure to a toxic agent added to the heroin or a combustion by-product. It also suggests a dose response effect rather than genetic predisposition. Collaboration with public health, health professionals, law enforcement and persons who use illegal drugs, will facilitate the early identification of cases to enable timely and complete follow-up including obtaining samples. Testing of implicated heroin samples may allow identification of the contaminant and therefore prevent further cases. It is therefore important to ensure key stakeholders are aware of our findings.

Des Jarlais DC; Arasteh K; Friedman SR. HIV among drug users at Beth Israel Medical Center, New York City, the first 25 years. Substance Use & Misuse 46(2-3): 131-139, 2011. (55 refs.)

New York City experienced the first and largest HIV epidemic among injecting drug users (IDUs). Using data collected from IDUs entering the Beth Israel drug detoxification program, we trace the history of this epidemic from the mid-1970s through the early 2000s. The epidemic can best be described in terms of successive stages: (1) introduction and rapid transmission of HIV in the IDU population; (2) stabilization of HIV prevalence at a high level (over 50%); (3) a decline in incidence and prevalence, following large-scale implementation of syringe exchange programs; and (4) a sexual transmission phase, in which HIV prevalence is approximately equal among injecting and noninjecting heroin and cocaine users, and sexual transmission is more important than injecting-related transmission among IDUs. Given the current spread of HIV among IDUs in many places in the world, New York City provides a very strong example for implementation of large-scale comprehensive syringe exchange programs as early as possible in HIV epidemics among IDUs.

Hagan H; Perlman DC; Des Jarlais DC. Sexual risk and HIV infection among drug users in New York City: A pilot study. Substance Use & Misuse 46(2-3): 201-207, 2011. (28 refs.)

Measures of sexual health were assessed during 2008-2009 in a New York City sample of 102 injection and noninjection users of heroin, cocaine, or crack. There was considerable overlap and transitioning between crack smoking and injecting. Crack users were also significantly more likely to be gay, lesbian, or bisexual than other drug users. In multivariate analysis, HIV infection was independently associated with crack use and with being gay or bisexual. In New York City, HIV prevention for drug users has focused on syringe access, safe injection, and drug user treatment, but further progress in HIV control will require strategies to address sexual health among people who use drugs. The study's limitations are noted.

Lenz TL; Gillespie N. Transdermal patch drug delivery interactions with exercise. Sports Medicine 41(3): 177-183, 2011. (20 refs.)

Transdermal drug delivery systems, such as the transdermal patch, continue to be a popular and convenient way to administer medications. There are currently several medications that use a transdermal patch drug delivery system. This article describes the potential untoward side effects of increased drug absorption through the use of a transdermal patch in individuals who exercise or participate in sporting events. Four studies have been reported that demonstrate a significant increase in the plasma concentration of nitroglycerin when individuals exercise compared with rest. Likewise, several case reports and two studies have been conducted that demonstrate nicotine toxicity and increased plasma nicotine while wearing a nicotine patch in individuals who exercise or participate in sporting events compared with rest. Healthcare providers, trainers and coaches should be aware of proper transdermal patch use, especially while exercising, in order to provide needed information to their respective patients and athletes to avoid potential untoward side effects. Particular caution should be given to individuals who participate in an extreme sporting event of long duration. Further research that includes more medications is needed in this area.

Maziak W; Rastam S; Shihadeh AL; Bazzi A; Ibrahim I; Zaatari GS et al. Nicotine exposure in daily waterpipe smokers and its relation to puff topography. Addictive Behaviors 36(4): 397-399, 2011. (16 refs.)

Waterpipe tobacco smoking is increasing in popularity worldwide and available evidence point to its addictive and harmful potential. This study is conducted to assess nicotine exposure in daily waterpipe smokers, and its correlation with puff topography parameters. Sixty-one waterpipe tobacco smokers (56 males: mean age +/- SD, 30.9 +/- 9.5 years: mean number of weekly waterpipe smoking episodes 7.8 +/- 5.7) abstained from smoking for at least 24 h, and then smoked tobacco from a waterpipe ad libitum in a laboratory setting. During the session puff topography parameters were monitored continuously, and pre- and post-smoking expired-air CO was measured. Before and after smoking, venous blood was sampled for the assessment of plasma nicotine using Gas Chromatography-Mass Spectrometry. The average pre- and post-smoking expired-air CO was 4 +/- 1.7 and 35.5 +/- 32.7 ppm, respectively (i.e., a CO boost of 31.5 ppm, p<.001). Mean plasma nicotine concentration increased from 3.07 +/- 3.05 ng/ml pre-smoking to 15.7 +/- 8.7 ng/ml post-smoking (p<.001). Plasma nicotine boost was correlated with total session time (Pearson correlation coefficient r=.31, p=.04), cumulative puff duration (r=.37, p=.01), mean puff duration (r=.34, p=.02), and total smoke inhaled in the session (r=.34, p=.02). These data show considerable nicotine exposure in daily waterpipe smokers, and that nicotine exposure is a function of waterpipe smoking patterns.

Neaigus A; Miller M; Gyarmathy VA; Friedman SR. HIV heterosexual sexual risk from injecting drug users among HIV-seronegative noninjecting heroin users. Substance Use & Misuse 46(2-3): 208-217, 2011. (46 refs.)

Noninjecting heroin users (NIUs) were recruited in New York City during 1996-2003. Cumulative logistic regression was used to analyze the correlates of HIV sexual risk from injecting drug users (IDUs) among HIV seronegative NIUs engaging in heterosexual vaginal or anal sex in the past 30 days (N = 347). Participants were 67% male and 70% African American or Latino, with a mean age of 32.6 years. Hierarchical categories of IDU partner sexual risk included (1) no unprotected sex and no IDU sex partners (21%), (2) unprotected sex but not with IDUs (55%), (3) IDU sex partners but no unprotected sex with them (6%), and (4) unprotected sex with IDUs (17%). Independent correlates (p < .05) of HIV sexual risk from IDU partners included female versus male gender (adjusted odds ratio [AOR] = 2.01), ex-IDU versus never IDU (AOR = 1.90), and lower versus higher perceived social distance from IDUs (AOR = 1.60). Interventions should target female NIUs, ex-IDUs, and NIU members of IDU social and sexual networks. The study's limitations are noted.

O'Connor RJ; Norton KJ; Bansal-Travers M; Mahoney MC; Cummings KM; Borland R. US smokers' reactions to a brief trial of oral nicotine products. Harm Reduction Journal 8: article 1, 2011. (44 refs.)

Background: It has been suggested that cigarette smokers will switch to alternative oral nicotine delivery products to reduce their health risks if informed of the relative risk difference. However, it is important to assess how smokers are likely to use cigarette alternatives before making predictions about their potential to promote individual or population harm reduction. Objectives: This study examines smokers' interest in using a smokeless tobacco or a nicotine replacement product as a substitute for their cigarettes. Methods: The study included 67 adult cigarette smokers, not currently interested in quitting, who were given an opportunity to sample four alternative oral nicotine products: 1) Camel Snus, 2) Marlboro Snus, 3) Stonewall dissolvable tobacco tablets, and 4) Commit nicotine lozenges. At visit 1, subjects were presented information about the relative benefits/risks of oral nicotine delivery compared to cigarettes. At visit 2, subjects were given a supply of each of the four products to sample at home for a week. At visit 3, subjects received a one-week supply of their preferred product to see if using such products reduced or eliminated cigarette use. Results: After multiple product sampling, participants preferred the Commit lozenges over the three smokeless tobacco products (p = 0.011). Following the one week single-product trial experience, GEE models controlling for gender, age, level of education, baseline cigarettes use, and alternative product chosen, indicated a significant decline in cigarettes smoked per day across one week of single-product sampling (p < 0.01, from 11.8 to 8.7 cigarettes per day), but no change in alternative product use (approximately 4.5 units per day). Biomarkers of exposure showed no change in cotinine, but a 19% reduction in exhaled CO (p < 0.001). Conclusions: Findings from this study show that smokers, who are currently unwilling to make a quit attempt, may be willing to use alternative products in the short term as a temporary substitute for smoking. However, this use is more likely to be for partial substitution (i.e. they will continue to smoke, albeit at a lower rate) rather than complete substitution. Of the various substitutes offered, smokers were more willing to use a nicotine replacement product over a tobacco-based product.

Rastam S; Eissenberg T; Ibrahim I; Ward KD; Khalil R; Maziak W. Comparative analysis of waterpipe and cigarette suppression of abstinence and craving symptoms. Addictive Behaviors 36(5): 555-559, 2011. (10 refs.)

This study's objective is to examine the relative effectiveness of cigarettes and waterpipe (WP) in reducing tobacco abstinence symptoms in dual cigarette/WP smokers. Sixty-one dual cigarette/WP smokers participated (mean age +/- SD 22.0 +/- 2.6 year; mean cigarettes/day 22.4 +/- 10.1: mean WPs/week 5.2 +/- 5.6). After 12-hour abstinence participants completed two smoking sessions (WP or cigarette), while they responded to subjective measures of withdrawal, craving, and nicotine effects administered before smoking and 5, 15, 30 and 45 min thereafter. For both tobacco use methods, scores on measures of withdrawal and craving were high at the beginning of session (i.e., before smoking) and were reduced significantly and comparably during smoking. Analysis of smoking and recovery (post-smoking) phases showed similarity in the way both tobacco use methods suppressed withdrawal and craving, but the recovery of some of these symptoms can be faster with cigarette use. This study is the first to show the ability of WP to suppress abstinence effects comparably to cigarettes, and its potential to thwart cigarette cessation.

Roohafza H; Sadeghi M; Shahnam M; Bahonar A; Sarafzadegan N. Perceived factors related to cigarette and waterpipe (ghelyan) initiation and maintenance in university students of Iran. International Journal of Public Health 56(2): 175-180, 2011. (20 refs.)

To investigate the perceived factors leading to cigarette and waterpipe (ghelyan) smoking initiation and maintenance in Iranian university students. A cross-sectional study was conducted on 233 students aged 20-25 enrolled in Isfahan University and Kashan University in 2007. Demographic factors as well as cigarette and ghelyan status, and perceived factors related to cigarette or ghelyan smoking initiation and maintenance were recorded. Principal component analysis was carried out to cluster perceived smoking initiation and maintenance factors. In a multiple logistic regression model, perceived psychological factors were more significant to cigarette smoking initiation and maintenance than ghelyan smoking among girls (odds ratio, OR = 1.90; P < 0.04) although perceived psychological factors (OR = 2.20; P < 0.001) and social factors (OR = 2.42; P < 0.001) were more significant in cigarette smoking initiation than ghelyan smoking initiation among boys (OR = 2.42; P < 0.001). Moreover, study appears that in boys, perceived entertainment factors could play more significant role in ghelyan smoking initiation compared with cigarette smoking initiation (OR = 0.42; P < 0.001). Whereas the factors related to smoking initiation and maintenance are different in both genders and in both tobacco products, identification of cigarette and ghelyan smoking may guide policy makers to develop comprehensive interventions.

Schmidt MM; Sharma A; Schifano F; Feinmann C. "Legal highs" on the net: Evaluation of UK-based Websites, products and product information. Forensic Science International 206(1-3): 92-97, 2011. (43 refs.)

Background: A vast array of substances are marketed as "legal highs" in the UK. These products are mainly marketed online and are packaged and produced to mimic illicit drugs. Little is known about the full range of products available at present and no studies have evaluated the product information provided to consumers. Aims & Hypothesis: To describe the available legal high products marketed by UK-based Internet retailers and evaluate the product information provided to consumers. Methods: Websites were identified using the terms "buy legal highs + UK" and two search engines. The first 100 hits and a random sample of 5% of the remaining results were screened. Websites based in the UK were included and all products were entered on a database. Information on product name, list price, claimed effects, side effects, contraindications and interactions was extracted. A descriptive analysis was conducted using SPSS v14. Results: 115 Websites met the inclusion criteria but due to duplicate listings this was reduced to 39 unique Websites. 1308 products were found and evaluated. The average product price was 9.69 British pounds. Products took the form of pills (46.6%), smoking material (29.7%) and single plant material/extract (18.1%). Most products claimed to be stimulants (41.7%), sedatives (32.3%), or hallucinogens (12.9%). 40.1% of products failed to list ingredients, 91.9% failed to list side effects, 81.9% failed to list contraindications and 86.3% failed to list drug interactions. Top 5 products (with active ingredients in brackets) by frequency were Salvia divinorum (Salivinorin A), Kratom (Mitragynine), Hawaiian Baby Woodrose Seeds (Lysergic Acid Amide), Fly Agaric (Ibotenic Acid, Muscimol) and Genie (JWH018, CP47497). Conclusions: Products marketed as "legal highs" are easily available from UK-based Internet retailers and are reasonably affordable. Safety information provided to consumers is poor. Uninformed users risk serious adverse effects.

Stapleton JA; Sutherland G. Treating heavy smokers in primary care with the nicotine nasal spray: Randomized placebo-controlled trial. Addiction 106(4): 824-832, 2011. (28 refs.)

Aims: Of six established nicotine replacement therapy (NRT) formulations, only the gum and patch have been tested without specialist clinic support in placebo-controlled trials. We aimed to broaden the evidence base by examining if the nicotine nasal spray (NNS) could be effective with only brief support in general practice. Design: Randomized placebo-controlled trial. Setting: Twenty-seven English general practices. Participants: A total of 761 heavy smokers received brief support and 12 weeks of treatment with NNS (506) or placebo (255). Measurements: The primary outcome was biochemically verified complete abstinence from smoking throughout weeks 3-12. Findings: NNS compared with placebo more than doubled the number who successfully stopped smoking [15.4% versus 6.7%, odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.5-4.4]. Many participants reported minor irritant adverse symptoms. NNS was particularly effective among those who were more highly dependent on nicotine (OR = 6.17, 95% CI = 2.13-17.9). Of those who failed to stop during the first week (417, 54.8%), only one (0.2%) achieved later success. Conclusions: NNS is effective when given in primary care. The benefit was lower than in a specialist clinic but similar to that with the nicotine patch in primary care. Unlike most other NRT formulations, bupropion or varenicline, NNS was especially helpful for more dependent smokers. Continuing treatment of those initially failing was not beneficial. An initial 1-week prescription to those more dependent on nicotine is likely to be the most cost-effective NNS treatment protocol. These results should offer support to the effectiveness of the other NRT formulations untested in this setting.

Tverdal A; Bjartveit K. Health consequences of pipe versus cigarette smoking. Tobacco Control 20(2): 123-130, 2011. (30 refs.)

Objectives: To estimate the risk of dying from all causes and from specified smoking-related diseases in men who were exclusive daily pipe smokers at two consecutive examinations, and in men who switched from smoking cigarettes only to pipe only. Design A prospective cohort study. Setting: Three counties in Norway. Participants 16 932 men, aged 20-49, screened for cardiovascular disease risk factors in the mid-1970s, re-screened after 3-13 years, and followed throughout 2007. Outcomes: Absolute mortality and relative risks adjusted for confounding variables, of dying from all causes and ischaemic heart disease, stroke, cardiovascular disease, lung cancer and other smoking-related cancer. Results: Altogether, the men were observed for 403 327 years, and during the observation period, 4933 deaths occurred. With sustained never smokers as reference, the sustained smokers of a pipe only had adjusted relative risk (95% CI), of dying from any cause that was 1.99 (1.73 to 2.27). At comparable tobacco consumption, no significant difference in risk between pipe and cigarette smokers appeared. As to survival, no difference was found between sustained smokers of a pipe only and of cigarettes only. Men who switched from cigarettes only to pipe only had a risk which was not significantly different from the risk in sustained smokers of cigarettes only. Conclusions: Between pipe and cigarette smokers, no or only minor differences were found in mortality from any cause and the specified smoking-related diseases. Pipe smoking is not safer than cigarette smoking.

Vlahov D; Ompad DC; Fuller CM; Nandi V. Comparison of HIV risk by duration of injection drug use. Substance Use & Misuse 46(2-3): 181-191, 2011. (58 refs.)

Early studies documented an inverse association between the HIV risk and duration of injection among injection drug users (IDUs). Results from subsequent studies have been inconsistent. To examine this issue, we conducted interviews with 395 street-recruited active IDUs from 38 neighborhoods in New York City during 2005 and 2008. We observed no significant differences in drug or risky sex behaviors by duration of drug use among these IDUs. Despite this, continuing to tailor HIV prevention programs for these recent-onset IDUs is prudent. The study's limitations are noted.

Ahmed B; Jacob P; Allen F; Benowitz N. Attitudes and practices of hookah smokers in the San Francisco Bay area. Journal of Psychoactive Drugs 43(2): 146-152, 2011. (22 refs.)

As many as 10 million people will die annually by the year 2030 due to tobacco-related causes. While much research has focused on cigarettes, the increasing popularity of smoking hookah (water pipe) has received much less attention. Epidemiological studies have been carried out in India, Pakistan, Syria, Kuwait, and Lebanon, but there are few in the United States. Hookah smoking is typically a social activity and there are many myths and rumors about the relative safety of smoking hookah compared to cigarettes. The aim of this study was to identify the knowledge, attitudes, and practices of hookah smokers in the San Francisco Bay Area. We sampled 50 participants (25 male and 25 female) who were mostly college students at the University of California, Berkeley. Hookah smoking was occasional among those sampled, with only six participants (12%) reporting weekly hookah smoking. The majority of respondents considered hookah smoking to be harmful to their health (88%), yet 52% had no intention of quitting. More definitive studies conveying the possible harm of hookah smoking are necessary to serve as a basis for health education programs and policy changes towards this potentially harmful activity.

Akl EA; Gunukula SK; Aleem S; Obeid R; Abou Jaoude P; Honeine R et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: A systematic review. (review). BMC Public Health 11: e244, 2011. (65 refs.)

Background: The objective of this study was to systematically review the medical literature for the prevalence of waterpipe tobacco use among the general and specific populations. Methods: We electronically searched MEDLINE, EMBASE, and the ISI the Web of Science. We selected studies using a two-stage duplicate and independent screening process. We included cohort studies and cross sectional studies assessing the prevalence of use of waterpipe in either the general population or a specific population of interest. Two reviewers used a standardized and pilot tested form to collect data from each eligible study using a duplicate and independent screening process. We stratified the data analysis by country and by age group. The study was not restricted to a specific context. Results: Of a total of 38 studies, only 4 were national surveys; the rest assessed specific populations. The highest prevalence of current waterpipe smoking was among school students across countries: the United States, especially among Arab Americans (12%-15%) the Arabic Gulf region (9%-16%), Estonia (21%), and Lebanon (25%). Similarly, the prevalence of current waterpipe smoking among university students was high in the Arabic Gulf region (6%), the United Kingdom (8%), the United States (10%), Syria (15%), Lebanon (28%), and Pakistan (33%). The prevalence of current waterpipe smoking among adults was the following: Pakistan (6%), Arabic Gulf region (4%-12%), Australia (11% in Arab speaking adults), Syria (9%-12%), and Lebanon (15%). Group waterpipe smoking was high in Lebanon (5%), and Egypt (11%-15%). In Lebanon, 5%-6% pregnant women reported smoking waterpipe during pregnancy. The studies were all cross-sectional and varied by how they reported waterpipe smoking. Conclusion: While very few national surveys have been conducted, the prevalence of waterpipe smoking appears to be alarmingly high among school students and university students in Middle Eastern countries and among groups of Middle Eastern descent in Western countries.

Betz T; Steinbauer M; Uhl C; Toepel I. Necrosis of the leg after intraarterial drug injection. European Journal of Vascular Medicine 40(2): 163- 166, 2011. (21 refs.)

Inadvertent intraarterial injections in the context of drug abuse can cause damage to the vascular system. The clinical picture depends on the drug properties and ranges from partial ischemia to necrosis of the affected extremity. There are no current evidence-based guidelines regarding the management of intraarterial drug injections. In many cases the concept of solving vasospasm after injection is based on the use of intraarterial application of prostaglandins. We report a case in which a mixture of drugs was injected into the left femoral artery. The patient arrived 24 hours later with ischemia of the left leg at our emergency department. Angiography showed that there was no blood flowing in the leg. Despite intraarterial application of vasodilatators, regional neurolysis and thrombolyis with urokinase major amputation was unavoidable. The outcome after inadvertent injection depends on certain drug properties and the delay between injection and the beginning of therapy.

Blank MD; Cobb CO; Kilgalen B; Austin J; Weaver MF; Shihadeh A; Eissenberg T et al. Acute effects of waterpipe tobacco smoking: A double-blind, placebo-control study. Drug and Alcohol Dependence 116(1-3): 102-109, 2011. (47 refs.)

Background: Waterpipe tobacco smoking usually involves heating flavored tobacco with charcoal and inhaling the resulting smoke after it has passed through water. Waterpipe tobacco smoking increases heart rate and produces subjective effects similar to those reported by cigarette smokers. These responses are thought to be nicotine-mediated, though no placebo-control studies exist. Accordingly, this double-blind, placebo-control study compared the acute physiological and subjective effects of waterpipe tobacco smoking to those produced when participants used a waterpipe to smoke a flavor-matched, tobacco-free preparation. Methods: Occasional waterpipe tobacco smokers (n = 37; 2-5 monthly smoking episodes for >= 6 months) completed two double-blind, counterbalanced sessions that differed by product: preferred brand/flavor of waterpipe tobacco or flavor-matched, tobacco-free preparation. For each 45-min, ad lib smoking episode blood and expired air CO were sampled, cardiovascular and respiratory response were measured, and subjective response was assessed. Results: Waterpipe tobacco smoking significantly increased mean (+/-SEM) plasma nicotine concentration (3.6 +/- 0.7 ng/ml) and heart rate (8.6 +/- 1.4 bpm) while placebo did not (0.1 +/- 0.0 ng/ml; 1.3 +/- 0.9 bpm). For carboxyhemoglobin (COHb) and expired air CO, significant increases were observed for tobacco (3.8 +/- 0.4%; 27.9 +/- 2.6 ppm) and for placebo (3.9 +/- 0.4%; 27.7 +/- 3.3 ppm) with no differences across condition. Independent of condition, symptoms of nicotine/tobacco abstinence (e.g., "urges to smoke", "anxious") were reduced and direct effects (e.g., "dizzy", "satisfy") increased. Discussion: These results from the first placebo-control study of waterpipe tobacco smoking demonstrate that waterpipe-induced heart rate increases are almost certainly mediated by nicotine though the subjective effects observed in these occasional smokers were not.

Buster MCA; van den Brink W; van Brussel GHA; van Ree JM. Influence of treatment with inhalable heroin on pulmonary function. European Addiction Research 17(3): 136-138, 2011. (7 refs.)

This study aims to asses the influence of inhalable heroin on pulmonary function in chronic heroin-dependent patients treated with inhalable heroin. Among 32 patients (all cigarette smokers), a spirometric test was conducted at baseline and after an average period of 10 months of treatment with medically prescribed heroin. Patients showed a high frequency of pulmonary dysfunction at baseline [34%, with percentage of forced expiratory volume in 1 s (% FEV1) <80%]. However, after excluding those who started pulmonary treatment (n = 2) or who used heroin intravenously only (n = 2), no statistically significant differences in % FEV1 between baseline and follow-up were observed (n = 28; mean % FEV1 86% at baseline vs. 91% at follow-up; p = 0.09). This small and relatively brief study suggests that 10 months of co-prescribed inhalable heroine base does not seem to (further) deteriorate pulmonary function in chronic, cigarette smoking treatment refractory heroin addicts. Screening for and treatment of pulmonary dysfunction is recommended for methadone patients with and without co-prescribed heroin.

Chan WC; Leatherdale ST; Burkhalter R; Ahmed R. Bidi and hookah use among Canadian youth: A examination of data from the 2006 Canadian Youth Smoking Survey. Journal of Adolescent Health 49(1): 102-104, 2011. (10 refs.)

Purpose: To examine the prevalence and associated factors of bidi and hookah use among Canadian youth. Methods: Data from 41,886 grade 7 to 12 youth were used to examine factors associated with bidi and hookah use. Results: Youth who are current or former cigarette smokers, have tried marijuana or alcohol, were more likely to use bidi or hookah. Conclusions: Results suggest bidi and hookah use may be an emerging issue in tobacco control among youth. Findings also support an integrated approach where future prevention efforts should address multiple risk behaviors.

Gahr M; Freudenmann R; Schonfeldt-Lecuona C. Non-suicidal self-injury by intravenous application of nicotine in a patient with borderline personality disorder resulting in substance dependence. Addiction 106(6): 1186- 1187, 2011. (4 refs.)

Background: Non-suicidal self-injury in many different forms is a classic struggle for those diagnosed with borderline personality disorder (BPD). Some common ways of NSSI are cutting, scratching and head-banging. Case description: A 23-year old woman with BPD presented in our clinic with a 4-month history of intravenous application of a liquid dosage form of nicotine that is generally used for nasal application. Accordingly, the patient developed nicotine dependency (ICD-10 F17.25). Before her admission to our ward the daily intravenous nicotine application was around 33 mg. The in-patient detoxification proceeded without a remarkable withdrawal syndrome. Conclusion: A case of regular intravenous administration of nicotine has been observed, apparently resulting in nicotine dependence in a person with borderline personality disorder. The original intent appears to have been self-harm.

Goodwin AK; Kaminski BJ; Griffiths RR; Ator NA; Weerts EM. Intravenous self-administration of gamma-hydroxybutyrate (GHB) in baboons. Drug and Alcohol Dependence 114(2-3): 217- 224, 2011. (60 refs.)

Background: Abuse of gamma-hydroxybutyrate (GHB) poses a public health concern. In previous studies, intravenous (IV) self-administration of GHB doses up to 10 mg/kg was not maintained in non-human primates under limited-access conditions, which was inconsistent with the usual good correspondence between drugs abused by humans and those self-injected by laboratory animals. Methods: Self-administration of GHB was studied in 10 baboons using procedures standard for our laboratory to assess drug abuse liability. Each self-injection depended on completion of 120 or 160 lever responses. Sessions ran continuously; a 3-h timeout limited the number of injections per 24 h to 8. Self-injection was established at 6-8 injections/day with cocaine (0.32 mg/kg/injection) prior to substitution of each GHB dose (3.2-178 mg/kg/injection) or vehicle for 15 days. Food pellets were available 24 h/day. Results: GHB maintained significantly greater numbers of injections when compared to vehicle in 6 of the 9 baboons that completed GHB evaluations that included 32 mg/kg/injection or higher. The baboons that self-administered GHB at high rates were ones for which GHB was the first drug each had tested under the 24-h/day cocaine baseline procedure. Self-injection of the highest doses of GHB decreased food-maintained responding. Conclusions: High-dose GHB can function as a reinforcer in non-human primates under 24-h access, but self-administration history may be important. The findings are consistent with the demonstrated abuse liability of GHB in humans, and remove GHB as an exception to the typical good correspondence between those drugs abused by humans and those self-administered by nonhuman primates.

Griffiths MA; Harmon TR; Gilly MC. Hubble bubble trouble: The need for education about and regulation of hookah smoking. Journal of Public Policy & Marketing 30(1, special issue): 119- 132, 2011. (57 refs.)

A Middle Eastern tradition, hookah smoking involves burning flavored tobacco heated by charcoal, creating smoke that is filtered through water and ingested through the mouth using a hose. Hookah lounges are increasingly locating around college campuses in the United States, and websites offering hookah paraphernalia target U.S. high school and college students. In two studies involving interviews with college-age hookah smokers and analysis of website marketing practices, the authors investigate consumer beliefs and attitudes toward hookah smoking and the way it is portrayed online. The findings indicate that it is a social phenomenon, with young people introducing peers to the practice and websites promoting shared consumption experiences. Contrary to medical evidence, young people believe smoking sweetened tobacco through a hookah is nonaddictive and safer than cigarettes. Hookah lounges often are exempt from age restriction laws because many double as cafes and other eating establishments. Traditional tobacco warnings are not present in lounges or on websites. The findings highlight potential health dangers of hookah smoking and the need for education regarding this practice and demonstrate that regulatory oversight is needed.

Hansson J; Galanti MR; Magnusson C; Hergens MP. Weight gain and incident obesity among male snus users. BMC Public Health 11(e-article 371), 2011. (27 refs.)

Background: Snus is a moist smokeless tobacco product which has recently reached beyond its original market of Scandinavia. Snus is now being increasingly used in both the United States and South Africa. The effect of snus use on weight is unknown. This study has therefore investigated the relationship between the use of snus, weight gain (>= 5%) and the incidence of obesity (body mass index >= 30 kg/m(2)). Methods: The study participants (n = 9,954 males living in Stockholm County, Sweden) were recruited in 2002 and reassessed in 2007. Tobacco use was categorized according to information obtained in both the baseline and follow-up surveys. Outcomes were assessed by comparing self-reported weight and body mass index between the baseline and follow-up surveys. Results: Stable current snus use (according to both surveys), compared to never having used any kind of tobacco, seemed to be associated with both weight gain (odds ratio = 1.31, 95% confidence interval: 1.04-1.65) and incident obesity (odds ratio = 1.93, 95% confidence interval: 1.13-3.30) after adjustment for age, baseline weight, alcohol consumption, physical activity, education, consumption of fruit and berries, and the frequency of having breakfast. No associations with incident obesity or weight gain were seen for stable former users of snus (according to both surveys) or among men who quit or began using snus during follow-up. Conclusions: These data suggest that the use of snus is moderately associated with weight gain and incident obesity among men.

Havens JR; Oser CB; Knudsen HK; Lofwall M; Stoops WW; Walsh SL et al. Individual and network factors associated with non-fatal overdose among rural Appalachian drug users. Drug and Alcohol Dependence 115(1-2): 107- 112, 2011. (43 refs.)

Background: Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States - especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users. Methods: Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses. Results: Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network. Conclusions: Rural drug users with history of overdose were more likely to have injected with prescription opioids - which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.

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

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

Horyniak D; Dietze P; Larance B; Winstock A; Degenhardt L. The prevalence and correlates of buprenorphine inhalation amongst opioid substitution treatment (OST) clients in Australia. International Journal of Drug Policy 22(2): 167- 171, 2011. (21 refs.)

Background: Diversion and injection of buprenorphine (Subutex (R)) and buprenorphine-naloxone (Suboxone (R)) have been well documented. Recent international research and local anecdotal evidence suggest that these medications are also used by other routes of administration, including smoking and snorting. Methods: A cross-sectional sample of 440 opioid substitution treatment (OST) clients was recruited through pharmacies and clinics in three Australian jurisdictions, and interviewed face-to-face using a structured questionnaire. Eligible participants were those aged 18 or over, who had resided in their home state for at least six months, and had been in their current treatment episode for at least 4 weeks. We compared differences in characteristics between clients who had ever inhaled (smoked or snorted) buprenorphine (including buprenorphine-naloxone) and other OST clients. Logistic regression was used to identify correlates of buprenorphine inhalation. Sixty-eight clients who had never used buprenorphine were excluded from analysis. Results: Sixty-five clients (18%) reported having ever inhaled buprenorphine, with Subutex (R) smoking being most common, reported by 50 clients (77%). In multivariable logistic regression, those who reported ever inhaling buprenorphine were significantly more likely to: be aged 35 or younger, have ever been in prison and have ever injected buprenorphine. Clients from New South Wales and Victoria were significantly less likely to have ever inhaled buprenorphine than those from South Australia. Conclusions: Our data indicates that the inhalation of buprenorphine has occurred in a significant minority of Australian OST clients. The motivations, contexts and potential health consequences of buprenorphine use by these atypical routes of administration, particularly in a correctional setting, warrant further exploration.

Katz N; Dart RC; Bailey E; Trudeau J; Osgood E; Paillard F. Tampering with prescription opioids: Nature and extent of the problem, health consequences, and solutions. American Journal of Drug and Alcohol Abuse 37(4): 205-217, 2011. (40 refs.)

Background: Transdermal and solid oral prescription opioid (PO) formulations can be abused by ingesting (with or without tampering), snorting, or injection (both requiring tampering). Objective: To determine the patterns of tampering with POs for abuse. Methods: Information was collected from published studies and databases. Results: Tampering with POs for abuse is common practice. Ingestion is the most prevalent method of abuse, followed by snorting and injection. From 1992 to 2002, injecting POs has decreased in favor of ingesting and snorting. Methods of abuse vary widely by product. Abuse methods with the highest morbidity are injection and inhalation. Conclusions: The seriousness of health outcomes associated with tampering with POs warrants the development of PO formulations that prevent or deter tampering.

Klesges RC; Ebbert JO; Morgan GD; Sherrill-Mittleman D; Asfar T; Talcott WG et al. Impact of differing definitions of dual tobacco use: Implications for studying dual use and a call for operational definitions. Nicotine & Tobacco Research 13(7): 523-531, 2011. (54 refs.)

Concomitant use of two forms of tobacco is an increasing public health concern, yet there is little consensus regarding a consistent definition of so-called "dual use." We defined dual use as cigarette and smokeless tobacco (ST) consumption with either product used daily or nondaily. We analyzed a cohort of 36,013 Air Force recruits. We categorized dual tobacco use across 2 dimensions, type of tobacco products (cigarettes, ST, or others), and the frequency of use (daily vs. nondaily). We determined how varying the definition impacted the prevalence estimates and evaluated the prevalence estimate based on our recommended definition of dual use. Multivariate logistic regression analysis was used to evaluate the risk profile of dual users of ST and cigarettes versus mono users of ST and mono users of cigarettes. Varying definitions of dual use vary prevalence estimates 50-fold (0.5%-25.3%). Including only ST and cigarettes narrows the prevalence estimate to less than 4-fold (2.0%-9.7%). Dual users are more likely to be young Caucasian males, with lower education, and from families with relatively higher incomes. Compared with mono users, dual users of cigarettes and ST have a distinct pattern of risk profiles. Depending on the definition of dual use, markedly different prevalence and risk profiles are observed. Dual users of ST and cigarettes are a unique group of tobacco users. We propose a common definition of dual use to advance our understanding of this unique group.

Li L; Sangthong R; Chongsuvivatwong V; McNeil E; Li JH. Multiple substance use among heroin-dependent patients before and during attendance at methadone maintenance treatment program, Yunnan, China. Drug and Alcohol Dependence 116(1-3): 246-249, 2011. (24 refs.)

Background: Multiple substance use is a common problem among heroin users. This study aims to describe patterns of multiple substance use one year before and during attendance at methadone maintenance treatment (MMT) programs and associated variables of continued heroin use in MMT clinics in Yunnan, China. Methods: The study was conducted among 168 heroin addicts who had received treatment for at least one year at two MMT clinics in Kunming city. A structured questionnaire, a medical record, and computer database were used to obtain history of substances use, significant clinical information, and treatment details, respectively. Results: Heroin, tobacco, and alcohol were the most commonly used substances both before and during MMT. After one year in MMT, use of heroin, alcohol, tramadol, and triazolam significantly decreased whereas use of ephedrine increased. Simultaneous substance use was halved but the decrease was not statistically significant. The proportion of injecting users was reduced from 61% to 43%. History of heroin use in the preceding 6 months during MMT increased the odds of continued heroin use (OR = 5.8, 95% Cl =12.9-11.3]). An average 10 mg higher methadone dose increment was associated with a reduced odds of heroin use by 10%. Conclusion: MMT did not reduce the number of substances used, but the number of injecting heroin users after the first year of treatment decreased. Heroin use in the preceding.6 months during MMT treatment and lower methadone dose were associated with continued heroin use in MMT.

Lipkus IM; Eissenberg T; Schwartz-Bloom RD; Prokhorov AV; Levy J. Affecting perceptions of harm and addiction among college waterpipe tobacco smokers. Nicotine & Tobacco Research 13(7): 599-610, 2011. (37 refs.)

The spread of waterpipe tobacco use among youth may be due in part to perceptions that waterpipe tobacco use is safer than other tobacco products, such as cigarettes. In two pilot studies, we sought to modify college waterpipe smokers' perceived risks and worry about waterpipe tobacco smoking. We conducted two web-based studies that varied whether college waterpipe users received information on (a) spread of and use of flavored tobacco in waterpipe and (b) harms of waterpipe smoking. Study 1 (N = 91) tested the "incremental" effects on perceptions of risk and worry of adding information about harms of waterpipe smoking to information on the spread of waterpipe and use of flavorings in the tobacco. Study 2 (N = 112) tested the effects on perceptions of risk and worry of reviewing information about harms of waterpipe smoking compared to a no information control group. In Study 1 only, we assessed as part of a 6-month follow-up (n = 70) the percentage of participants who reported no longer using waterpipe. Pooling data from both studies, participants who received information about the harms of waterpipe smoking reported greater perceived risk and worry about harm and addiction and expressed a stronger desire to quit. In Study 1, 62% of participants in the experimental group versus 33% in the control group reported having stopped waterpipe use. These are the first studies to show that perceptions of addiction and harm from waterpipe use can be modified using minimally intensive interventions; such interventions show promise at decreasing waterpipe use.

Lunell E; Curvall M. Nicotine delivery and subjective effects of Swedish portion snus compared with 4 mg nicotine polacrilex chewing gum. Nicotine & Tobacco Research 13(7): 573-578, 2011. (28 refs.)

Snus availability has been claimed to have contributed to the low rates of smoking among Swedish men and made possible the transfer to a less harmful form of nicotine dependence. Fourteen cigarette smokers were randomly assigned to 2 types of 1 g Swedish portion snus and 4 mg nicotine polacrilex (NP) chewing gum in open-label, single-dose crossover study. Nicotine delivery and pharmacokinetics were estimated, and self-reports of subjective effects were obtained using Visual Analogue Scales (VASs). Extracted dose from the NP gum averaged 2.56 mg compared with 2.12 and 2.18 mg, respectively, for Swedish portion snus. This resulted in a slightly larger area under the curve (AUC) for the NP chewing gum. The rise of the nicotine plasma concentration was faster for Swedish snus. Median T(max) was shorter, 30 min for snus compared with 45 min for the NP gum. The lower C(max) of NP gum compared with the snus products in spite of larger AUC may be explained by slower absorption from the chewing gum. The faster absorption of nicotine from Swedish portion snus was mirrored in a higher VAS score for "head rush." Craving/urges to smoke decreased similarly for all treatments. Salivation and throat burn were rated higher for the 4 mg NP gum compared with both types of snus. Swedish snus produced higher maximum blood nicotine concentration in shorter time and with a quicker onset of "head rush" compared with 4 mg NP chewing gum in spite of a smaller extracted dose. The quicker onset of "head rush" and supposedly higher satisfaction from snus may partly explain the widespread use of snus for stopping smoking in Sweden.

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

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

Marshall BDL; Wood E; Shoveller JA; Buxton JA; Montaner JSG; Kerr T. Individual, social, and environmental factors associated with initiating methamphetamine injection: Implications for drug use and HIV prevention strategies. Prevention Science 12(2): 173-180, 2011. (65 refs.)

The purpose of this study was to determine the incidence and predictors of initiating methamphetamine injection among a cohort of injection drug users (IDU). We conducted a longitudinal analysis of IDU participating in a prospective study between June 2001 and May 2008 in Vancouver, Canada. IDU who had never reported injecting methamphetamine at the study's commencement were eligible. We used Cox proportional hazards models to identify the predictors of initiating methamphetamine injection. The outcome was time to first report of methamphetamine injection. Time-updated independent variables of interest included sociodemographic characteristics, drug use patterns, and social, economic and environmental factors. Of 1317 eligible individuals, the median age was 39.9 and 522 (39.6%) were female. At the study's conclusion, 200 (15.2%) participants had initiated injecting methamphetamine (incidence density: 4.3 per 100 person-years). In multivariate analysis, age (adjusted hazard ratio [aHR]: 0.96 per year older, 95%CI: 0.95-0.98), female sex (aHR: 0.58, 95%CI: 0.41-0.82), sexual abuse (aHR: 1.63, 95%CI: 1.18-2.23), using drugs in Vancouver's drug scene epicentre (aHR: 2.15 95%CI: 1.49-3.10), homelessness (aHR: 1.43, 95%CI: 1.01-2.04), non-injection crack cocaine use (aHR: 2.06, 95%CI: 1.36-3.14), and non-injection methamphetamine use (aHR: 3.69, 95%CI: 2.03-6.70) were associated with initiating methamphetamine injection. We observed a high incidence of methamphetamine initiation, particularly among young IDU, stimulant users, homeless individuals, and those involved in the city's open drug scene. These data should be useful for the development of a broad set of interventions aimed at reducing initiation into methamphetamine injection among IDU.

Mravcik V; Skarupova K; Orlikova B; Zabransky T; Karachaliou K; Schulte B. Use of gelatine capsules for application of methamphetamine: A new harm reduction approach. International Journal of Drug Policy 22(2): 172- 173, 2011. (10 refs.)

Background: In order to reduce injecting drug use, low-threshold facilities in the Czech Republic have started to distribute empty gelatine capsules as an oral alternative of drug application for those injecting methamphetamine. This report reviews implementation of this intervention and its possible benefits and limitations. Methods: Between December 2008 and January 2009,109 low-threshold facilities were asked to complete a questionnaire about the capsule programmes. Two focus groups were conducted, one with professionals involved in distribution and one with peer outreach workers who were interviewed on their experience of using the capsules. Results: A total of 50 facilities (46%) responded to the questionnaire; 16 (32%) distributed the capsules regularly and 19(38%) were planning to introduce this practice. The main target groups were injecting users of methamphetamine whose veins had been damaged, and methamphetamine users wishing to reduce injecting. The advantages of capsules, as perceived by service staff and peer outreach workers, were their easy use and the satisfactory effect of the oral application; health risks related to the oral use of methamphetamine were considered drawbacks. Conclusion: Capsule distribution is a promising harm reduction approach for injectors of methamphetamine or other stimulants; nonetheless its benefits and limitations should be further analysed in an in-depth longitudinal study.

Nakhostin-Roohi B; Valizadeh S. Worrisome prevalence of waterpipe smoking among athletes. Medicina Dello Sport 64(1): 63-69, 2011. (15 refs.)

Aim. The aim of this study was to evaluate the prevalence of waterpipe smoking in athletes of Ardabil, a city in the Northwest of Iran. Methods. The members of 16 sport associations (N.=1647) were randomized from 49 sport associations. A cluster sampling technique was used. The sampling unit was sport association. Results. Of the 1647 participants, 14.7% and 10.5% of athletes were habitual and recreational users respectively; 24.4% of non-smokers stated they were in the exposure of waterpipe smoke. The most habitual smokers were wrestlers (42%), whereas the most recreational users were swimmers (26.1%). Prevalence of waterpipe smoking among football players was lower than among other athletes (non-smokers: 91.3% and habitual smokers: 0.0%). Just 36.8% of athletes believed waterpipe use affect their performance. Conclusion. According to the knowledge of athletes about risks connected with waterpipe smoking data are not sufficient and most of the athletes would suffer from misunderstanding about risks of the waterpipe use. Knowledge promotion about waterpipe risks among athletes and the increase of recreational facilities may be a suitable manner to prevent this increasing phenomenon among athletes.

Nielsen S; Bruno R; Lintzeris N; Fischer J; Carruthers S; Stoove M. Pharmaceutical opioid analgesic and heroin dependence: How do treatment-seeking clients differ in Australia? Drug and Alcohol Review 30(3): 291- 299, 2011. (34 refs.)

Introduction and Aims. Non-prescribed use of pharmaceutical opioid analgesics (POA) has been escalating internationally. In Australia, few studies have examined if POA users have similar characteristics and treatment needs to heroin users. The aim of this study was to compare those presenting for treatment where heroin versus POA were the primary drugs of concern. Design: and Methods. A convenience sample of 192 treatment entrants were recruited from alcohol and drug treatment services in four Australian jurisdictions. A structured interview collected data on demographic characteristics, substance use, self-perceived mental and physical health, crime and harms resulting from drug use. Multivariate analyses were performed to identify characteristics which may differentiate those seeking treatment for heroin compared with POA. Results. Most treatment entrants sampled reported a history of injection drug use and use of both heroin and POA. However, those with primary POA problems were less likely to report an overdose history (adjusted odds ratio 0.90, 95% confidence interval 0.81-0.99) and more likely to initiate opioid use for pain (adjusted odds ratio 2.52, 95% confidence interval 1.04-6.12) than those with primary heroin problems. Latent Class Analysis found that, while most of the POA group were similar to heroin users in demographics, health and injecting drug use, there was a small, distinct group of primary POA problem users that did not typically inject and who commonly initiated opioid use for pain and also experienced elevated physical and mental health disability. Discussion and Conclusions. While some differences existed, this study of Australian treatment seekers found many similar characteristics between those with primary problems with heroin and POA. Few non-injecting POA were recruited in this sample. This finding contrasts with reports of a growing population of opioid-dependent people with characteristics that are distinct from traditional opioid-dependent populations, which may reflect the orientation of current treatment systems in Australia towards injection drug users.

Palmiere C; Brunel C; Sporkert F; Augsburger M. An unusual case of accidental poisoning: Fatal methadone inhalation. Journal of Forensic Sciences 56(4): 1072-1075, 2011. (28 refs.)

In this report, the authors present a case of unusual, accidental methadone intoxication in a 40-year-old man, who had inhaled methadone powder. The drug dealer was a pharmacy technician; methadone had been stolen from a pharmacy and sold as cocaine. After having inhaled methadone powder, he suffered cardiopulmonary arrest. He was admitted to hospital where he died after 24 h of intensive care. The autopsy revealed congestion of internal organs and cerebral and pulmonary edema. Microscopically, the heart showed no changes. The toxicological analyses performed on blood and urine taken at the hospital revealed methadone, cannabinoids, and ethanol. The blood methadone concentration was 290 mu g/L. The urine methadone concentration was 160 mu g/L. Midazolam and lidocaine, which were administered to the patient at the hospital, were also detected in the blood. The cause of death was determined to be methadone intoxication. The literature has been reviewed and discussed. To date, and to our knowledge, only very few cases of accidental death resulting from methadone inhalation have been described up to the case presented herein.

Qian HZ; Stinnette SE; Rebeiro PF; Kipp AM; Shepherd BE; Samenow CP et al. The relationship between injection, and noninjection drug use and HIV disease progression. Journal of Substance Abuse Treatment 41(1): 14-20, 2011. (30 refs.)

Background: Injection drug use is associated with poor HIV outcomes even among persons receiving highly active antiretroviral therapy (HAART), but there are limited data on the relationship between noninjection drug use and HIV disease progression. Methods: We conducted an observational study of HIV-infected persons entering care between January 1, 1999, and December 31, 2004, with follow-up through December 31, 2005. Results: There were 1,712 persons in the study cohort: 262 with a history of injection drug use, 785 with a history of noninjection drug use, and 665 with no history of drug use; 56% were White, and 24% were females. Median follow-up was 2.1 years, 33% had HAART prior to first visit, 40% initiated first HAART during the study period, and 306 (17.9%) had an AIDS-defining event or died. Adjusting for gender, age, race, prior antiretroviral use, CD4 cell count, and HIV-1 RNA, patients with a history of injection drug use were more likely to advance to AIDS or death than nonusers (adjusted hazard ratio [HR] = 1.97, 95% confidence interval [CI] = 1.43-2.70, p < .01). There was no statistically significant difference of disease progression between noninjection drug users and nonusers (HR = 1.19, 95% CI = 0.92-1.56, p = .19). An analysis among the subgroup who initiated their first HAART during the study period (n = 687) showed a similar pattern (injection drug users: HR = 1.83, 95% CI = 1.09-3.06, p = .02; noninjection drug users: HR = 1.21, 95% CI = 0.81-1.80, p = .35). Seventy-four patients had active injection drug use during the study period, 768 active noninjection drug use, and 870 no substance use. Analyses based on active drug use during the study period did not substantially differ from those based on history of drug use. Conclusions: This study shows no relationship between noninjection drug use and HIV disease progression. This study is limited by using history of drug use and combining different types of drugs. Further studies ascertaining specific type and extent of noninjection drug use prospectively, and with longer follow-up, are needed.

Romito LM; Saxton MK; Coan LL; Christen AG. Retail promotions and perceptions of RJ Reynolds' novel dissolvable tobacco in a US test market. Harm Reduction Journal 8(e-article 10), 2011. (40 refs.)

Background: With declining cigarette sales, tobacco manufacturers have been developing and marketing new smokeless products, such as R. J. Reynolds' dissolvable tobacco, Camel Sticks, Strips and Orbs. This study assessed the availability, price and point-of-purchase promotional strategies for Camel Dissolvables, and investigated consumer awareness, interest and perception of these products in the Indiana test market. Methods: An exploratory retail audit of point-of-purchase promotions was conducted in a random sample of retailers from 6 store categories (n = 81) in the test market area. Data included: store type, location, product placement, forms/flavors carried, price, types and locations of advertisements and promotions, and ad messages. An Awareness-Attitude-Usage (AAU) survey was used to gauge consumer awareness and knowledge of tobacco products including Camel Dissolvables. Respondents were shown promotional materials from a package onsert and perceptions and interest in the Camel Dissolvables were assessed. An Intended Target Survey (ITS) compared subjects' perceptions of ad targets for several non-tobacco products, as well as Camel Snus, Camel No. 9 and Camel Dissolvables. Respondents were asked to identify each ad's intended target category, perceived targetedness, and purchase intent. Results: The products were carried by 46% of stores, most frequently gas stations (100%) and convenience stores (75%). They were shelved near smokeless tobacco (70%), cigarettes (25%) or candy (5%). Prices ranged from $3.59 - $4.19 per package; most stores carried at least 1 promotional item. Ad messages included: "Dissolvable Tobacco" (60%). "Free Trial" (24%), "Special Price" (24%), "What's Your Style?" (22%). At 14% of stores, free trial packs of Camel Dissolvables were offered with another Camel purchase. Awareness was reported by 42% of respondents (n = 243), and trial by 3%. Consumer interest was very low, but younger respondents (< 40 years) were more familiar with Camel Dissolvables (60% vs. 45% for those > 40 years, p < .01). Males, as well as current and former smokers had higher rates of interest and trial; only 1% of never smokers reported trial. In the ITS, only for the 3 tobacco product ads, was perceived targetedness for smokers significantly higher than for non-smokers. Smokers and nonsmokers perceived that the ads targeted smokers. Conclusions: Current retail promotional strategies for Camel Sticks, Strips & Orbs appear to be targeting a select audience, primarily current smokers. Overall, consumer awareness, interest and trial were low.

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

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

Sarin E; Samson L; Sweat M; Beyrer C. Human rights abuses and suicidal ideation among male injecting drug users in Delhi, India. International Journal of Drug Policy 22(2): 161- 166, 2011. (56 refs.)

Background: Human rights abuses, denial of care, police surveillance, and violence directed at IDUs have been found to impact HIV prevention efforts due to decreased attendance in harm reduction programs. The association of mental health status with rights abuses has not been examined extensively among drug users. In India, drug control laws are often in conflict with harm reduction policies, thus increasing the likelihood of rights abuses against IDUs. The purpose of this study was to describe human rights abuses occurring among IDUs in Delhi and examine their association with suicidal ideation. Methods: 343 IDUs were recruited in two research sites in Delhi through respondent driven sampling and were interviewed with a cross sectional survey questionnaire that included items on human rights and socio demographics. Results: IDUs in the study experienced many human rights abuses. Notably among these were denial of admission into hospital (38.5%), denial of needles and syringes (20%), police arrests for carrying needles and using drugs (85%), verbal abuse (95%) and physical abuse (88%). Several human rights abuses were associated with suicidal ideation. These include being denied needles and syringes (OR: 7.28, 95% CI: 3.03-17.49); being arrested by police for carrying needles and using drugs (OR: 2.53,95% CI: 1.06-6.03), and being physically abused (OR: 1.66, 95% CI: 1.05-2.23). The likelihood of suicidal ideation is also strongly related to the cumulative number of abuses. Conclusions: These findings demonstrate that there is a high prevalence of human rights abuses among IDUs in Delhi. Given the alarming rate of suicidal ideation and its close relationship with human rights abuses it is essential that IOU interventions are executed within a rights-based framework.

Smith JR; Novotny TE; Edland SD; Hofstetter CR; Lindsay SP; Al-Delaimy WK. Determinants of hookah use among high school students. Nicotine & Tobacco Research 13(7): 565-572, 2011. (43 refs.)

Hookah use is increasing among young people, but there are limited data on its use among high school-age populations. We examined hookah use initiation, prevalence, cessation, and psychosocial risk factors of hookah use among high school students. A cross-sectional survey of 689 students from three high schools in San Diego County was used to compare characteristics of hookah ever-users to nonusers and factors associated with current and former hookah use. Hookah ever-use in the study population was 26.1%, previous month hookah use was 10.9%, and current hookah use was 10.3%. Most students first learned about hookah from friends (50.3%) or saw a hookah lounge (20.9%). Students believed hookah to be more socially acceptable than cigarettes and less harmful than cigarettes, cigars, and smokeless tobacco. Hookah ever-users were significantly more likely than nonusers to have smoked cigarettes, to know of a hookah lounge in their community, and to believe hookah is safer and more socially acceptable than cigarettes. In comparison to former users, current users were more likely to have recently smoked a cigarette, to know of a hookah lounge in their community, and to believe hookah is more socially acceptable than cigarettes. Hookah use is becoming a commonly acceptable behavior among adolescents, and risk perception is a significant factor. Presence of hookah lounges are associated with increased hookah use among high school students and should be a target of further regulation.

Sutfin EL; Mccoy TP; Reboussin BA; Wagoner KG; Spangler J; Wolfson M. Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug and Alcohol Dependence 115(1-2): 131- 136, 2011. (38 refs.)

Background: Known most commonly in the U.S. as "hookah," waterpipe tobacco smoking appears to be growing among college students. Despite beliefs that waterpipe use is safer than Cigarette smoking, research to date (albeit limited) has found health risks of waterpipe smoking are similar to those associated with cigarette smoking, including lung cancer, respiratory illness, and periodontal disease. The goals of this study were to estimate the prevalence of use among a large, multi-institution sample of college students and identify correlates of waterpipe use, including other health-risk behaviors (i.e., cigarette smoking, alcohol, marijuana, and other illicit drug use) and availability of commercial waterpipe tobacco smoking venues. Methods: A cross-sectional sample of 3770 college students from eight universities in North Carolina completed a web-based survey in fall 2008. Results: Forty percent of the sample reported ever having smoked tobacco from a waterpipe, and 17% reported current (past 30-day) waterpipe tobacco smoking. Correlates associated with current waterpipe use included demographic factors (male gender, freshman class); other health-risk behaviors (daily and nondaily cigarette smoking, alcohol use, marijuana use, other illicit drug use); perceiving waterpipe tobacco smoking as less harmful than regular cigarettes; and having a commercial waterpipe venue near campus. Conclusions: The results highlight the popularity of waterpipe tobacco smoking among college students and underscore the need for more research to assess the public health implications of this growing trend.

Tranah GJ; Holly EA; Wang F; Bracci PM. Cigarette, cigar and pipe smoking, passive smoke exposure, and risk of pancreatic cancer: A population-based study in the San Francisco Bay Area. BMC Cancer 11: 138, 2011. (34 refs.)

Background: To examine the influence of cigarette, cigar and pipe smoking, cessation of cigarette smoking and passive smoke exposure on the risk of pancreatic cancer. Methods: Exposure data were collected during in-person interviews in a population-based case-control study of pancreatic cancer (N = 532 cases, N = 1701 controls) in the San Francisco Bay Area. Odds ratios (ORs) were adjusted for potential confounders. Results: The adjusted odds ratio (OR) of pancreatic cancer among current smokers was 1.9 (95% confidence interval (CI), 1.4-2.7). A significant, positive trend in risk with increasing pack-years of smoking was observed (P-trend <0.0001). Compared with participants who continued to smoke, former smokers had no statistically significant elevation in risk of pancreatic cancer 10 years after smoking cessation, with risk reduced to that of never smokers regardless of prior smoking intensity. Both men and women experienced similar increased risk of pancreatic cancer with increasing smoking duration. Cigar and pipe smoking and exposure to passive smoke were not associated with pancreatic cancer. Conclusions: Cigarette smoking is associated with an increased risk of pancreatic cancer. Smokers who had quit for >= 10 years no longer experienced an increased risk. Future work will help to determine the effect of declining smoking rates on pancreatic cancer incidence.

Valdez A; Neaigus A; Kaplan C; Cepeda A. High rates of transitions to injecting drug use among Mexican American non-injecting heroin users in San Antonio, Texas (never and former injectors). Drug and Alcohol Dependence 114(2-3): 233- 236, 2011. (29 refs.)

Objective: To assess the incidence and rate of transition to injecting among Mexican American noninjecting heroin users. Methods: in a prospective cohort study of street-recruited MA-NIU in San Antonio, Texas, 2002-2005, participants were administered structured interviews and tested for Human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). The analysis sample comprised former injection drug users (last injected >6 months ago, n = 47) and those who had never injected drugs and tested HCV negative (n = 219). A transition to injecting was defined as the first injection of illicit drugs since baseline interview. Transition rates were based on person-years at-risk (PYAR). Proportional hazards regression was used to estimate crude and adjusted (for significant differences between former and never injectors) hazard ratios and 95% confidence intervals of injecting history on transitioning to injecting. Results: Sixty-three (24%) participants transitioned to injecting at a rate of 22.3/100 PYAR (95% Cl: 17.2-28.2). Former-injectors were significantly more likely to transition than never injectors (43% or 20/47 vs. 20% or 43/219; p<0.001), and did so at a faster rate (40.4/100 PYAR, 95% Cl: 24.6-60.0 vs. 18.5/100 PYAR, 95% Cl: 13.4-24.4), with the crude HR = 1.931 (95% Cl: 1.116, 3.341) and adjusted HR = 2.263 (95% Cl: 1.192-4.294). Conclusions: The rate of transitioning to injecting was high and greater among former injectors. Of particular concern is the high rate of injecting initiation among never injectors. Future analyses will examine factors associated with injecting initiation, including individual susceptibility and behaviors, social networks, and the cultural and drug market context.

Waness A; Abu El-Sameed Y; Mahboub B; Noshi M; Al-Jahdali H; Vats M et al. Respiratory disorders in the Middle East: A review. (review). Respirology 16(5): 755-766, 2011. (147 refs.)

The spectrum of pulmonary pathology in the Middle East is as versatile as its civilizations and cultures. In this review, we outline the key challenges confronting pulmonologists in the Middle East. We shed light on the diverse conditions commonly encountered in the region, from the centuries-old illnesses of tuberculosis, to contemporary problems such as lung complications from chemical warfare. We specifically highlighted unique aspects related to respiratory illnesses in the Middle East, for example, climate factors in the desert region, cultural habits, for example, water-pipe smoking and disorders unique to the region, such as Behet's disease. Pulmonologists are also faced with the consequences of modernization, including large immigrant population and associated social and health issues, rising incidence of obesity and sleep apnoea, and drug-resistant tuberculosis. Tackling these health issues will require an integrated approach involving public health, primary care as well as specialist pulmonology input, taking into consideration the unique cultural and environmental factors to ensure effective management and compliance to medical care.

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

Williams CT; Liu W; Levy JA. Crossing over: Drug network characteristics and injection risk along the China-Myanmar border. AIDS and Behavior 15(5): 1011-1016, 2011. (28 refs.)

Border areas are important locations for understanding HIV transmission. This study examines individual and network correlates of border crossing and equipment sharing among methadone maintenance clients in Ruili City, a Chinese city on the Myanmar border. Data are from 298 clients enrolled in the Ruili Methadone Treatment Center. Clients were interviewed about drug use, HIV/AIDS knowledge, treatment motivation, and their social networks. Multinomial and logistic regression analysis were performed. Thirty percent of clients reported injecting in Myanmar. Compared to drug networks that usually inject in China, networks that inject equally in both places (border crossing) are more likely to share equipment. The association between HIV positive status and border-crossing was marginally significant and robust. Results indicate some added degree of risk among clients and drug networks who border-cross to use drugs. More research is needed to understand this phenomenon.

Wolfe D; Carrieri MP; Dasgupta N; Wodak A; Newman R; Bruce RD. Concerns about injectable naltrexone for opioid dependence. (editorial). Lancet 377(9776): 1468- 1470, 2011. (12 refs.)