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"Not safe" is not enough: smokers have a right to know more than there is no safe tobacco product.

The right to health relevant information derives from the principles of autonomy and self direction and has been recognised in international declarations. Providing accurate health information is part of the basis for obtaining "informed consent" and is a recognised component of business ethics, safety communications, and case and product liability law. Remarkably, anti-tobacco and pro-tobacco sources alike have come to emphasise the message that there is "no safe cigarette" or "no safe tobacco product". We propose that the "no safe" message is so limited in its value that it represents a violation of the right to health relevant information. There is a need to go beyond saying, "there is no safe tobacco product" to indicate information on degree of risks. The "no safe tobacco" message does not contradict, for example, the mistaken belief that so called light or low tar cigarettes are safer choices than higher tar cigarettes. We encourage a kind of "rule utilitarian" ethical position in which the principle of truth telling is observed while trying to produce the greatest good for the greatest number of people. Although harm reduction approaches to easing the burden of tobacco related diseases are founded on science based comparative risk information, the right to health information is independently related to the need to promote health literacy. This right should be respected whether or not harm reduction policies are judged advisable.

Attitude to Health↗

The field performance of frontal air bags: a review of the literature.

This article presents a broad review of the literature on frontal air bag field performance, starting with the initial government and industry projections of effectiveness and concluding with the most recent assessments of depowered systems. This review includes as many relevant metrics as practicable, interprets the findings, and provides references so the interested reader can further evaluate the limitations, confounders, and utility of each metric. The evaluations presented here range from the very specific (individual case studies) to the general (statistical analyses of large databases). The metrics used to evaluate air bag performance include fatality reduction or increase; serious, moderate, and minor injury reduction or increase; harm reduction or increase; and cost analyses, including insurance costs and the cost of life years saved for various air bag systems and design philosophies. The review begins with the benefits of air bags. Fatality and injury reductions attributable to the air bag are presented. Next, the negative consequences of air bag deployment are described. Injuries to adults and children and the current trends in air bag injury rates are discussed, as are the few documented instances of inadvertent deployments or non-deployment in severe crashes. In the third section, an attempt is made to quantify the influence of the many confounding factors that affect air bag performance. The negative and positive characteristics of air bags are then put into perspective within the context of societal costs and benefits. Finally, some special topics, including risk homeostasis and the performance of face bags, are discussed.

Accidents, Traffic↗

[Community collection of syringes by parenteral drug users complementary to syringe exchange programs].

OBJECTIVES: To contribute to harm reduction in injecting drug users (IDUs) by the implementation of a programme to withdraw abandoned syringes from public places, as well as to collaborate on the social reinsertion of IDUs. METHODS: Descriptive study of the Syringe Withdrawal Community (RECOJE in Spanish), carried out from 1997 to 1999 by IDUs, the We Are Helpful Association (ASUT in Spanish) and the Social and Health Prevention and Attention Service (SAPS in Spanish) of the Red Cross, in Ciutat Vella (Barcelona, Spain). RESULTS: 4,332 syringes were withdrawn, 849 in 1997, 1,324 in 1998 and 2,159 in 1999. The mean number of syringes withdrawn each time was 57 33. 45 different IDUs worked in RECOJE. 74.2% of the abandoned syringes were found in parks, gardens, car parks and open spaces. CONCLUSIONS: RECOJE can be a valid programme for harm reduction complementary to the exchange syringe programmes. It could improve the self-esteem, external image and organization of IDUs, contributing to their social reinsertion.

Adult↗

Taming demons: the reduction of harm resulting from use of illicit drugs.

Restricting availability is the major response to illicit drugs in most Western countries including Australia. Prohibition may reduce harm when the drug in question is in low demand, controls are difficult to subvert, and when similar drugs are less toxic or unavailable. However, the health, social and economic costs of supply reduction are substantial and increasing for both injecting drug users and the general community. Population adjusted mortality of heroin users has doubled in Australia in the last decade. The possible impact of supply reduction policy on the spread of HIV infection among IDUs is an important but largely neglected consideration. The effectiveness of supply restriction policy in decreasing the availability of drugs or in reducing drug-related harm is unlikely to be increased significantly by more vigorous implementation of supply reduction or adoption of new technology. Conversely, on the basis of existing data, greater availability of HIV prevention measures attractive to the target population (including especially drug treatment such as methadone maintenance) is likely to be effective and cost-effective. The costs and benefits of innovative methods of providing currently illicit drugs to those who are determined to use them requires careful evaluation and comparison with existing policies. Policy on illicit drugs in most countries including Australia is still dominated by concern about drug use rather than focused on the need to reduce drug-related problems which is the agreed aim of national drug policy.

Australia↗

Engaging youth about gambling using the internet: The YouthBet.net website.

OBJECTIVE: YouthBet.net's (www.youthbet.net) goal is to prevent gambling problems among youth through an interactive, multimedia website based on a public health approach. PARTICIPANTS: YouthBet.net was designed by youth for youth. A youth working group spent several months designing the look and feel of the site to ensure that it would appeal to youth aged 10-19. In total, 34 youth from the Greater Toronto Area participated in the first 3 phases of the usability testing of the site using Video Capture of User Site Interaction methodology. SETTING: Urban Toronto. INTERVENTION: Utilizing public health strategies such as health promotion, harm reduction and problem prevention, YouthBet.net features games, information and help resources to protect youth from gambling-related harm. OUTCOMES: Youth participants indicated that they liked the interactive way gambling information was presented via realistic games and quizzes, often citing that YouthBet.net would be a fun and educational tool to be used by teachers in the classroom. Participants had no difficulties navigating the site, finding content and playing games. Additionally, all youth said that they would return to the site and would recommend it to a friend if they were having a problem with gambling. CONCLUSION: YouthBet.net is one of the first comprehensive websites designed for youth gambling. Findings from this research will inform future health promotion, harm reduction and problem prevention efforts for youth gambling using Internet technology.

Adolescent↗

Evaluating acute effects of potential reduced-exposure products for smokers: clinical laboratory methodology.

Harm reduction for tobacco smokers may involve reducing their exposure to lethal smoke constituents. Assessing smoke constituent exposure and any resulting harm reduction from a potential reduced-exposure product (PREP) will involve preclinical, clinical, and epidemiological research. The purpose of this study was to evaluate a clinical laboratory model for assessing the acute effects of PREPs for smokers. Philip Morris' Accord and R.J. Reynolds' Eclipse were used as examples. Twenty overnight-abstinent smokers (> 15 'light' or 'ultra-light' cigarettes/day) participated in 4 Latin-square ordered, 2.5-hr sessions in which they completed an 8-puff smoking bout every 30 minutes. Sessions were separated by at least 24 hours and differed by product used: own brand, denicotinized tobacco cigarettes, Accord, or Eclipse. Tobacco withdrawal and carbon monoxide (CO) were assessed before and after smoking, heart rate was assessed before and during smoking, and puff volume, duration, and interpuff interval were assessed while subjects smoked. Blood was sampled at the beginning and end of each session. Relative to normal cigarettes, Accord was less effective at suppressing withdrawal and produced minimal CO boost despite the fact that, when using Accord, subjects took bigger and longer puffs. Eclipse suppressed withdrawal fully and increased CO boost by approximately 30%. Own brand, Accord, and Eclipse, but not denicotinized cigarettes, increased plasma nicotine concentration. Taken together, these results suggest that neither Accord nor Eclipse is likely to be an effective reduced-exposure product for smokers and that this clinical laboratory model is valuable.

Adolescent↗

Rural parents, teenagers and alcohol: what are parents thinking?

INTRODUCTION: The fundamental role of alcohol in the lives of young Australians is mirrored in the level of drinking by adolescents. In 2001, more than one in four Australian adolescents aged 14-19 years consumed alcohol weekly. Teenagers in rural areas are more likely to consume alcohol than their metropolitan counterparts. Parents are key 'gatekeepers' of adolescent behaviour and as such are a salient group to consider in relation to adolescent alcohol use. The aim of this study was to explore parents' attitudes, beliefs, concerns and receptiveness to harm minimisation strategies with respect to teenage use of alcohol. METHODS: A convenience sample of parents with adolescent children attended a series of focus groups across the north and north-western area of the State of Victoria, Australia. Schools were approached to advertise the project and invite parents to participate. Snowball sampling was used to enhance recruitment. RESULTS: Parents described patterns of alcohol use such as 'drinking to get drunk' and the influence of both parents and peers on the consumption of alcohol by adolescents. Few parents were concerned about the long-term risks of alcohol use by teenagers; rather they were more concerned about the short-term harms, for example, road trauma and other accidents and risky behaviours such as binge drinking. Parents indicated that they perceived alcohol to be less harmful than other drugs and many indicated that alcohol was often not perceived to be a drug. A number of strategies were adopted by parents to negotiate teenagers' drinking and to minimise the risks associated with alcohol use. These included transporting teenagers to parties, providing teenagers with a mobile phone, setting clear guidelines about alcohol use and/or providing teenagers with a small amount of alcohol. These were seen by parents as strategies for reducing the risks associated with alcohol consumption. Many parents reported that they do not feel well informed about alcohol use and how and when to use harm reduction strategies. CONCLUSIONS: Rural parents are unsure how to respond to teenagers' alcohol use and drunkenness. While some parental strategies for harm reduction (such as supplying adolescents with a small amount of alcohol) may have good face validity in reducing alcohol consumption among adolescents, these strategies are not supported by previous research findings.

Adolescent↗

The 'methadone by bus' project in Amsterdam.

One of the methadone programmes of the Amsterdam Municipal Health Service is the 'methadone by bus' project. Two mobile clinics cruise the city, stopping at six different locations daily. The liquid methadone is consumed on the spot and clean needles and condoms are available. This project is based on the principles of 'harm-reduction', i.e. if it is not (yet) possible to 'cure' a hard drug user, one should at least try to minimize the harm they cause to themselves and their environment. As soon as a client refrains from the use of illegal drugs, the client can 'graduate' to other methadone programmes with a higher threshold. To prevent double prescription, all Amsterdam methadone programmes participate in the central methadone registration. The Amsterdam Municipal Health Service has contact with over 50% of the drug users. The estimated number of hard drug users has remained stable over the last 5 years, whilst the average age of drug users has increased to 32 years. In the future, increasing the average dosage and the provision of injectable drug users will be discussed to assess their role in further harm reduction.

Acquired Immunodeficiency Syndrome↗

Drug education: an appraisal of a popular preventive.

Drug education is a popular preventive. In this paper, school-based drug education programs as currently conceived and implemented are critically appraised. The evidence indicates that while such education influences knowledge and attitudes, it has little impact on behavior. It is contended that in most drug education programs the value and meaning of being a drug user is misunderstood and the benefits of drug use underestimated. It is argued that existing health promotion models have in the main failed to adopt a systemic approach to drug use and have focused too much attention on individual change at the expense of a broader social understanding of behavior. It is proposed that with regard to illicit drugs, future educational endeavors should take the form of training in "low(er) risk" drug use within a harm-reduction paradigm, and that with regard to alcohol, such strategies need to be augmented by social and legislative changes. It is concluded that if a harm-reduction and systemic approach is adopted, then education will lose some of its popularity, since such an endeavor will be a more challenging, politically difficult, and socially complex enterprise.

Adolescent↗

Effect of strategies to reduce exposure of infants to environmental tobacco smoke in the home: cross sectional survey.

OBJECTIVE: To examine parents' reported knowledge and use of harm reduction strategies to protect their infants from exposure to tobacco smoke in the home, and the relation between reported use of strategies and urinary cotinine to creatinine ratios in the infants. DESIGN: Cross sectional survey. SETTINGS: Coventry and Birmingham. MAIN OUTCOME MEASURES: Parents' reported knowledge and use of harm reduction strategies and urinary cotinine to creatinine ratios in their infants. PARTICIPANTS: 314 smoking households with infants. RESULTS: 86% of parents (264/307) believed that environmental tobacco smoke is harmful, 90% (281/314) believed that infants can be protected from it in the home, and 10% (32/314) were either unaware of measures or reported using none. 65% of parents (205/314) reported using two or more measures, but only 18% (58/314) reported not allowing smoking in the home. No difference was found in mean log e transformed urinary cotinine to creatinine ratio in infants from households that used no measures compared with households that used less strict measures. Mean log cotinine to creatinine ratios were significantly different in households banning smoking in the home compared with those using less strict or no measures. Banning smoking in the home was independently associated with a significant reduction in urinary cotinine to creatinine ratio by a factor of 2.6 (1.6 to 4.2) after adjustment for average household cigarette consumption, tenure, and overcrowding. CONCLUSIONS: Less than a fifth of parents in smoking households ban smoking in the home. Banning smoking was associated with a small but significant reduction in urinary cotinine to creatinine ratio in infants, whereas less strict measures compared with no measures had no effect on the infants' exposure to environmental tobacco smoke.

Adult↗

Previous participation in outpatient methadone program and residential treatment outcome: a research note from Hong Kong.

Methadone maintenance programs are good examples of harm-reduction efforts because heroin addicts stabilized on methadone have been found to be able to reduce illicit drug use and criminality and improve their life condition, even though they have not achieved abstinence. While excluding the criterion of abstinence allows the harm-reduction approach to distinguish itself from traditional treatment, little research attention has been paid to the relationship between methadone programs and abstinence-oriented treatment programs. This research note reports some of the findings of a study of 77 former male clients of SARDA, a voluntary residential treatment agency in Hong Kong, pertaining to such a relationship. Findings suggest that a client's previous participation in the Outpatient Methadone Program of the Department of Health could facilitate successful outcome in his subsequent participation in SARDA's treatment program and help him to continue his drug-free status in the post-SARDA treatment period. Conceptual and policy implications of the findings are discussed. [Translations are provided in the International Abstracts Section of this issue.]

Ambulatory Care↗

What drug policies cost: drug policy spending in the Netherlands in 2003.

AIM: To estimate the public spending on drug policy in the Netherlands. METHODS: Calculation and extrapolation of expenditures from 2003 budgets of all Ministries of the national government, annual reports from other governments and agencies and White Papers, supported by interviews with and information obtained otherwise from policy makers. Expenditures were allocated to four drug policy functions, i.e. prevention, treatment, harm reduction and enforcement. Where exact data on expenditures were lacking, approximations were made representing expert judgement. RESULTS: The total drug policy spending estimate in 2003 was 2,185 million Euros. Allocation to functions amounted to 42 million Euros for prevention, 278 million for treatment, 220 million for harm reduction and 1,646 million for enforcement. CONCLUSIONS: Drug law enforcement is clearly the dominant expenditure. This can be said with certainty despite the noted pitfalls in estimating drug policy expenditures. Many of the available data are not precise. To achieve better figures, a much more detailed analysis would be needed (which is not planned for the foreseeable future). Even then, it would be hard to separate the drug component from more general budgets.

Costs and Cost Analysis↗

Injection drug use and HIV/AIDS in China: review of current situation, prevention and policy implications.

Illicit drug abuse and HIV/AIDS have increased rapidly in the past 10 to 20 years in China. This paper reviews drug abuse in China, the HIV/AIDS epidemic and its association with injection drug use (IDU), and Chinese policies on illicit drug abuse and prevention of HIV/AIDS based on published literature and unpublished official data. As a major drug trans-shipment country with source drugs from the "Golden Triangle" and "Gold Crescent" areas in Asia, China has also become an increasingly important drug consuming market. About half of China's 1.14 million documented drug users inject, and many share needles. IDU has contributed to 42% of cumulatively reported HIV/AIDS cases thus far. Drug trafficking is illegal in China and can lead to the death penalty. The public security departments adopt "zero tolerance" approach to drug use, which conflict with harm reduction policies of the public health departments. Past experience in China suggests that cracking down on drug smuggling and prohibiting drug use alone can not prevent or solve all illicit drug related problems in the era of globalization. In recent years, the central government has outlined a series of pragmatic policies to encourage harm reduction programs; meanwhile, some local governments have not fully mobilized to deal with drug abuse and HIV/AIDS problems seriously. Strengthening government leadership at both central and local levels; scaling up methadone substitution and needle exchange programs; making HIV voluntary counseling and testing available and affordable to both urban and rural drug users; and increasing utilization of outreach and nongovernmental organizations are offered as additional strategies to help cope with China's HIV and drug abuse problem.

Journal Article↗

Policy approaches to support local community control over the supply and distribution of kava in the Northern Territory (Australia).

The health consequences of kava abuse in Arnhem Land Aboriginal populations in the Northern Territory (NT) and the persistence of an illegal kava trade with its associated social harms have been a cause for concern for 20 years. Despite these concerns, some Arnhem Land groups seek to continue using kava and to control its sale, distribution and the profits from the enterprise. In response, policy makers in the NT have embraced principles of harm reduction and created regulatory mechanisms to address broader public concerns and to support local management of kava supply while reinforcing control over the consequences of its use. This paper describes the kava regulatory system now being implemented in the NT which features kava management plans developed in consultation between Aboriginal communities and licensing authorities. It complements the earlier Harm Reduction Digest 9 by McDonald & Jowitt which looked at Kava in the South Pacific.

Catchment Area, Health↗

[Listen to one another and act in concert (the Renewal Project)].

The organization of work on the project "Harm Reduction for Intravenous Drug Users in Kazan" is substantiated. Difficulties in the realization of such projects due to the lack of coordination between different services, also taking part in controlling the spread of drug addiction and ensuring the treatment of addicts, are emphasized. The coordination of actions of various state structures will make it possible to enhance the effectiveness of programs of harm reduction. The expediency of the development of the general state program of primary prophylaxis, realized by trained specialists with the use of effective technology, is discussed.

Acquired Immunodeficiency Syndrome↗

Effectiveness of needle/syringe exchange program in Tbilisi.

IDUs are under the high risk of HIV and other blood born diseases. In Georgia injecting drug use is associated with two third of registered HIV/AIDS cases. Majority of them are also infected with B and C Hepatitis. One of the main components of HIV/AIDS prevention among drug users is considered to be harm reduction programs, among them syringe exchange program. We conducted observational cohort study and performed interviewing participants of syringe exchange program using structured questionnaire. The interviewing was conducted at intake, after 3 months and at the end of the program. During interviewing we used risk assessment questionnaire which we have little adapted (Risk Assessment Battery, Navaline, et al, 1994). The data were statistically analysed using SPPS-11, 5 program. The aim of the study was to assess the efficacy of outreach and needle exchange programs in terms of reduction of HIV risk behavior of injection drug users in Tbilisi. The results of the study show visible reduction in injection risk behavior for clients being in the program for at least three months. There was not seen any significant change in the level of sexual risk behavior, which might suggest the need for targeting this behavior during the further interventions. The results of the study suggest a visible potential benefit to drug users and communities that could be gained through the wide scale implementation of harm reduction programs in Georgia.

Acquired Immunodeficiency Syndrome↗

Human immunodeficiency virus/acquired immunodeficiency syndrome prevention in injection drug users and their partners and children: lessons learned in Latin America--the Argentinean case.

Thirty-nine percent of Argentineans living with acquired immunodeficiency syndrome were infected with human immunodeficiency virus through the injection of drugs. However, it was not until the 1990s that harm reduction programs were created. Research and outreach projects have been developed to identify and interact with the hidden injection drug user (IDU) population. Implementation of rapid assessment and response methodology contributed to the founding of Argentina's first syringe exchange program. Community-based outreach is the appropriate method for working with the impoverished population of Buenos Aires. Seroprevalence studies and focused prevention campaigns targeting IDUs and their sex partners and children have been developed. Collaborations between government and nongovernmental organizations in various cities supported the distribution of prevention and harm reduction messages to 900 IDUs within a 3-month period. Ongoing research, community-based interventions, and collaborative work among different organizations allow for more frequent and more consistent contact with the IDU population of Argentina.

Acquired Immunodeficiency Syndrome↗

[The concepts of risk and prevention from the perspective of injecting drug users].

This paper provides an exploratory analysis, using a qualitative approach, to perceptions by injecting drug users (IDUs) on: (a) risks associated with injecting practices; (b) risks of HIV/AIDS; and (c) prevention of HIV/AIDS. The study was conducted in five harm reduction programs in Brazil (the AjUDE-Brasil Project). Forty semi-structured interviews were carried out. The study focuses on the concept of "risk". IDUs were mainly concerned over becoming ill and exposure to overdose and violence. IDUs dealt with individual problems in very specific ways in order to minimize them. They admitted that they were well informed about HIV/AIDS but lacked knowledge on reinfection and other bloodborne diseases. IDUs intended to follow guidelines established by health campaigns, but their addiction usually made it difficult. IDUs also suggested alternative harm reduction strategies and displayed a peculiar reading of concepts concerning sharing their injecting paraphernalia.

Acquired Immunodeficiency Syndrome↗