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PubMed2004

A nicotine delivery device without the nicotine? Tobacco industry development of low nicotine cigarettes.

BACKGROUND: Defining harm reduction and regulating potentially reduced exposure products (PREPs), including low nicotine products, are key issues in tobacco control policy. The US Congress has been considering legislation authorising the Food and Drug Administration (FDA) to regulate tobacco products. OBJECTIVE: To investigate tobacco industry perceptions, interests, motivations, and knowledge regarding the marketability of low nicotine tobacco products. METHODS: Qualitative analysis of internal tobacco industry documents identified in the Legacy Tobacco Documents Library between February 2002 and June 2004. Search terms included low-, no-, reduced-nicotine; denicotinization; low-, reduced- alkaloids; Next; de-nic; and key names of people, organisations, projects, and their common abbreviations and acronyms. RESULTS: The tobacco industry has made repeated efforts to develop low nicotine cigarettes. Reasons for doing so include consumer appeal and economic importance in a highly competitive cigarette market for "healthier" products. The industry considered the development of a new "denic" market segment a critical challenge. CONCLUSIONS: The tobacco industry exploits consumer misunderstanding of the health effects of nicotine in development and marketing efforts. The industry has risked the development of a less addictive product to expand the market reach of tobacco products based on perceived health benefits and appeal to quitters.

Alkaloids↗

PubMed2007

The check-up: in-person, computerized, and telephone adaptations of motivational enhancement treatment to elicit voluntary participation by the contemplator.

Countless barriers come between people who are struggling with substance abuse and those charged with providing substance abuse treatment. The check-up, a form of motivational enhancement therapy, is a harm reduction intervention that offers a manner of supporting individuals by lowering specific barriers to reaching those who are untreated. The check-up was originally developed to reach problem drinkers who were neither seeking treatment nor self-initiating change. The intervention, marketed as an opportunity to take stock of one's experiences, involves an assessment and personalized feedback delivered with a counseling style termed motivational interviewing. Check-ups can be offered in care settings to individuals who, as a result of screening, manifest risk factors for specific disorders such as alcoholism. They can also be free-standing and publicized widely to the general public. This paper will discuss illustrations of in-person, computerized, in-school, and telephone applications of the free-standing type of check-up with reference to alcohol consumers, adult and adolescent marijuana smokers, and gay/bisexual males at risk for sexual transmission of HIV. The paper's major focus is to highlight how unique features of each application have the potential of reducing barriers to reaching specific at-risk populations. Also considered are key policy issues such as how check-up services can be funded, which venues are appropriate for the delivery of check-up interventions, pertinent competency criteria in evaluating staff who deliver this intervention, how marketing can be designed to reach contemplators in untreated at-risk populations, and how a check-up's success ought to be defined.

Adolescent↗

PubMedDate not supplied

My place, your place, or a safer place: the intention among Montréal injecting drug users to use supervised injecting facilities.

BACKGROUND: Supervised injection facilities (SIF), a harm reduction intervention, may reduce several risks of public injection drug use. The prospect of conducting a scientific, multi-site pilot project of these facilities is being explored at federal and local levels in Canada. Experiences with SIF in Europe and Australia indicate that successful outcomes for the community ultimately hinge upon the responsiveness and relevance of the facilities to the needs of their primary target group: people who inject drugs in public places. Consideration of the factors and conditions found to influence a potential user's uptake of SIF, therefore, is imperative. This study sought to assess the acceptability of SIF and to determine factors associated with willingness of injecting drug users (IDU) to use SIF in a city considering their establishment. METHODS: From April 2001 to February 2002, following key informant interviews, a cross-sectional study was conducted among publicly injecting IDU participating in an ongoing HIV surveillance study in Montréal. Univariate and bivariate analyses preceded logistic regression. RESULTS: Participants were 11 key informants and 251 publicly injecting IDU. Key informants generated the Montréal-specific SIF model subsequently presented to IDU. 76% of IDU were willing to use at least one of three proposed SIF sites. Exploratory multivariable models indicated drug-use characteristics and SIF attributes as determinants of outcome: predominant cocaine injection, history of overdose, knowing about SIF, relieving and empowering feelings toward using SIF, and comfort with disclosure of one's injecting drug use. CONCLUSION: User consultations are essential to assess relevance and plan SIF acceptable to IDU.

Chi-Square Distribution↗

PubMed2005

You might as well smoke; the misleading and harmful public message about smokeless tobacco.

BACKGROUND: Compared to smoking cigarettes, use of Western smokeless tobacco (ST) products is associated with a very small risk of life-threatening disease (with estimates in the range of a few percent of the risk from smoking, or even less). This means that smokers can realize substantial health benefits by switching to ST, an obvious substitute. But consumers and policy makers have little chance of learning that ST is much less dangerous than smoking because popular information provided by experts and advocates overstates the health risks from ST relative to cigarettes. METHODS: To examine the extent of this overstatement in one medium, we conducted a systematic review of websites containing information about ST and health risks. We examined the content of 316 relevant websites identified by a Google search. RESULTS: We found that when any substantive information about the risk from ST is given, the risk is almost universally conflated with the risk from cigarettes. Accurate comparative risk information was quite rare, provided by only a handful of websites, all appearing low in our search results (i.e., of low popularity and thus unlikely to be found by someone searching for information). About 1/3 of the websites, including various authoritative entities, explicitly claimed that ST is as bad as or worse than cigarettes. Most of the other sites made statements that imply the risks are comparable. CONCLUSION: Through these websites, and presumably other information provided by the same government, advocacy, and educational organizations, ST users are told, in effect, that they might as well switch to smoking if they like it a bit more. Smokers and policy makers are told there is no potential for harm reduction. These messages are clearly false and likely harmful, representing violations of ethical standards.

Communications Media↗

PubMed2004

Adolescent alcohol misuse: methodological issues for enhancing treatment research.

AIMS: The objective of this article is to present an overview of the current state of the field of adolescent alcohol treatment research and to discuss several priorities for future research directions. METHOD: The authors identified trends in adolescent alcohol treatment research from multiple sources, including searches of the National Institutes of Health grantee listings, proceedings from annual meetings of the Research Society on Alcoholism and relevant English-language journal articles available in MEDLINE and PSYCHLIT databases over the past decade. RESEARCH RECOMMENDATIONS: This field must build on its major strength, which has been its success in appreciating the unique developmental characteristics of adolescence and meaningfully incorporating them into adolescent alcohol treatment approaches. Priorities for future research include: empirically investigating the potential value of harm reduction approaches for promoting public health and reducing total harm for adolescents; developing efficacious interventions across a wide range of intensities and settings; increasing the reach and relevance of randomized treatment efficacy trials and their products, with a particular focus on enhancing the recruitment and retention of diverse treatment samples; increasing a focus on key individual difference variables such as co-occurring diagnoses, that may serve as the basis for treatment tailoring; and exploration of the potential benefits of transdisciplinary research.

Adolescent↗

PubMed1997

Dutch drug policy: a model for America?

While debates over drug policy in America have focused on choices between demand reduction and supply reduction, the Dutch have pioneered the alternative strategy of harm reduction. The Dutch have built their policy around the principles of separation of markets, low threshold treatment, and normalization of treatment. These policies are worthy of examination as a possible model for drug policy reform in America.

Crime↗

PubMed2006

Toxicant exposure in cigarette reducers versus light smokers.

BACKGROUND: The extent of exposure to tobacco toxicants in smokers who have reduced their cigarette intake compared with smokers who are light smokers is relatively unknown. The goal of this study is to investigate the occurrence of compensatory smoking in reducers compared with light smokers by measuring toxicant exposure. METHODS: Participants in two smoking reduction intervention studies (N = 64) were selected for comparison with a group of light smokers (N = 62) who smoked the same number of cigarettes as the reducers. A compensatory smoking score was defined (biomarker level for reducer/biomarker level for light smoker) and calculated for urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and its glucuronides (total NNAL), metabolites of the tobacco-specific lung carcinogen 4-(methylnitrosamino)-I-(3-pyridyl)-1-butanone, to measure the degree of smoking compensation in reducers when compared with the light smokers. RESULTS: The mean level of creatinine-adjusted total NNAL for reducers was over twice that of light smokers even when they smoked about the same number of cigarettes per day. The difference of the mean total NNAL concentrations between light smokers and reducers was highly significant (P < 0.0001). Wide variability in total NNAL concentrations was also observed in reducers, with the extent of this variability between light smokers and reducers being significantly different (P = 0.0005). The level of individual reduction was shown to be a consistent predictor of compensatory smoking (r = 0.50; adjusted Ps = 0.002), with greater cigarette reduction associated with more compensation. CONCLUSIONS: Compensatory smoking limits the harm reduction value of decreased smoking of cigarettes.

Administration, Cutaneous↗

PubMed1999

Differentiating drugs by harm potential: the rational versus the feasible.

In an ideal harm reduction model, drugs would be ranked according to their potential to cause harm, with varying implications for control policies and interventions. In such a public health oriented approach, the maximum protection of the public from harm would be balanced with the least possible restriction of freedom. In reality, however, the accuracy and completeness of the necessary information for such a ranking is highly limited. Many other factors not readily incorporated in a rational model, such as values, beliefs, and traditions, also affect drug policy decisions. Thus, rather than relying on acquisition of the necessary knowledge, it may be preferable to focus efforts on developing effective nonlegal measures to reduce drug use and harm. [Translations are provided in the International Abstracts Section of this issue.]

Canada↗

PubMed2001

Manipulations of the features of standard video lottery terminal (VLT) games: effects in pathological and non-pathological gamblers.

The present study was conducted to identify game parameters that would reduce the risk of abuse of video lottery terminals (VLTs) by pathological gamblers, while exerting minimal effects on the behavior of non-pathological gamblers. Three manipulations of standard VLT game features were explored. Participants were exposed to: a counter which displayed a running total of money spent; a VLT spinning reels game where participants could no longer "stop" the reels by touching the screen; and sensory feature manipulations. In control conditions, participants were exposed to standard settings for either a spinning reels or a video poker game. Dependent variables were self-ratings of reactions to each set of parameters. A set of 2(3) x 2 x 2 (game manipulation [experimental condition(s) vs. control condition] x game [spinning reels vs. video poker] x gambler status [pathological vs. non-pathological]) repeated measures ANOVAs were conducted on all dependent variables. The findings suggest that the sensory manipulations (i.e., fast speed/sound or slow speed/no sound manipulations) produced the most robust reaction differences. Before advocating harm reduction policies such as lowering sensory features of VLT games to reduce potential harm to pathological gamblers, it is important to replicate findings in a more naturalistic setting, such as a real bar.

Adult↗

PubMed2005

Effect of smoking reduction on lung cancer risk.

CONTEXT: Many smokers are unable or unwilling to completely quit smoking. A proposed means of harm reduction is to reduce the number of cigarettes smoked per day. However, it is not clear whether this strategy decreases the risk for tobacco-related diseases. OBJECTIVE: To assess the effects of smoking reduction on lung cancer incidence. DESIGN, SETTING, AND PARTICIPANTS: Observational population-based cohort study with up to 31 years of follow-up from the Copenhagen Centre for Prospective Population Studies, which administrates data from 3 longitudinal studies conducted in Copenhagen and suburbs, the Copenhagen City Heart Study, the Copenhagen Male Study, and the Glostrup Population Studies, Denmark. Participants were 11,151 men and 8563 women (N = 19,714) aged 20 to 93 years, who attended 2 consecutive examinations with a 5- to 10-year interval between 1964 and 1988. Participants underwent a physical examination and completed self-filled questionnaires about lifestyle habits. The study population was divided into 6 groups according to smoking habits: continued heavy smokers (> or =15 cigarettes/d), reducers (reduced from > or =15 cigarettes/d by minimum of 50% without quitting), continued light smokers (1-14 cigarettes/d), quitters (stopped between first and second examination), stable ex-smokers, and never smokers. MAIN OUTCOME MEASURE: Incident primary lung cancer cases assessed by record linkage with the National Cancer Registry until December 31, 2003. RESULTS: There were 864 incident lung cancers during follow-up. Using Cox regression, the adjusted hazard ratio (HR) for lung cancer in reducers was 0.73 (95% confidence interval [CI], 0.54-0.98) compared with persistent heavy smokers. The HR for light smokers was 0.44 (95% CI, 0.35-0.56); for quitters, HR 0.50 (95% CI, 0.36-0.69), for stable ex-smokers, HR 0.17 (95% CI, 0.13-0.23), and for never smokers, HR 0.09 (95% CI, 0.06-0.13). CONCLUSION: Among individuals who smoke 15 or more cigarettes per day, smoking reduction by 50% significantly reduces the risk of lung cancer.

Adult↗

PubMed1996

Occasional condom use and HIV risk reduction.

Model-based estimates indicate that even occasional condom use can substantially reduce the probability of human immunodeficiency virus transmission. For many realistic parameter values, an essentially linear relationship exists between the proportion of sexual contacts in which a condom is used and the resultant reduction in the risk of infection. Thus, in many cases, the use of condoms for half of all sexual contacts reduces the probability of transmission by about half the maximum possible reduction obtained through consistent use. These results suggest that occasional condom use should be reconceptualized within a harm-reduction paradigm in which increased use is stressed for those individuals who are either unable or unwilling to use condoms consistently.

Condoms↗

PubMed2003

Where to for tobacco regulation: time for new approaches?

From a public health perspective, tobacco remains the number one drug problem facing most countries, even countries such as Australia, which has made considerable headway in reducing tobacco use and associated harm. Clearly more needs to be done, but is it the case that more of the same will be sufficient? In this Harm Reduction Digest based in part on a presentation at the 'International Research Symposium Preventing Substance Use, Risky Use and Harm: What is Evidence-Based Policy?' held in Fremantle, Western Australia in February 2003, the author proposes a new regulatory framework through which to further reduce tobacco-related harm. The paper challenges whether the current profit motive is an appropriate driver of the tobacco industry and suggests a new model of tobacco regulation.

Evidence-Based Medicine↗

PubMed1996

Needle exchange use among a cohort of injecting drug users.

OBJECTIVE: To study prospectively injection behavior of injecting drug users (IDU) who did and did not utilize a local needle exchange in the Bronx, New York City. DESIGN: Since 1985, IDU attending a methadone maintenance program have been enrolled in a prospective study of HIV-related risk behaviors. Since 1989, when a needle exchange opened near the methadone program, data have been collected from study participants regarding utilization of the exchange. PARTICIPANTS: Study participants (n = 904) who injected between 1985 and 1993. RESULTS: Of 904 IDU, 21.9% used the needle exchange. Male gender [adjusted odds ratio (AOR), 1.57], HIV seropositivity (AOR, 1.39) and younger age (AOR per 10 years of age, 1.66) were independently associated with needle exchange attendance. The percentage injecting declined each year, preceding the opening of the needle exchange and concurrent with its operation (from 64.6% in 1985 to 43.6% in 1993). Among the 329 participants who injected in the year before the exchange opened, 1988, 53 out of 124 (42.7%) needle exchange users and 168 out of 205 (81.9%) non-users reduced or stopped injecting by 1993 (P < 0.001). Exchange users shared needles less than non-users (P < 0.05 in 1993). HIV infection was unrelated to these reductions in injection. CONCLUSIONS: Methadone-treated IDU with access to a needle exchange reduced injecting and needle-sharing. This pattern of harm reduction, which began at least 4 years before the needle exchange opened, occurred in both those who did and did not utilize the needle exchange. Needle exchange, as a strategy to reduce injection-related harm, should not be viewed as discordant with methadone treatment.

Adolescent↗

PubMed2004

The ethics of policies for the prevention of tobacco disease.

Public Health policy is widely assumed to be ethical. However, the field of tobacco control is extremely complex and opportunities to reduce the disastrous amount of harm caused by tobacco smoking involve taking calculated risks. These risks are avoided by doing nothing. However, doing nothing means accepting the status quo. More effective application of policies aimed at attaining abstinence from tobacco via prevention of initiation and promotion of cessation is needed. The development of other opportunities for harm reduction pose ethical challenges because they involve taking risks and thus may breach the basic ethics principle of doing no harm. These opportunities include consideration of regulating the smoke of tobacco products, of accepting more widespread use of Snus, the use of nicotine replacement therapy (NRT) in continual smokers, the acceptance of the concept of recreational addictive 'clean' nicotine, the regulation and acceptance of potential reduced exposure products (PREPs) and more widespread use of existing NRT. The experience with low tar cigarettes is presented as a cautionary tale.

Adolescent↗

PubMed1996

Secondary prevention of excessive alcohol use: assessing the prospects of implementation.

BACKGROUND: Alcohol risk and harm reduction is a public health approach that goes beyond specialized treatments for alcoholism. The greatest potential for reducing alcohol risk and harm in a population depends on the extent to which health care practitioners use secondary prevention programmes. OBJECTIVE: We aim to assess the factors that affect the prospects of disseminating comprehensive, secondary prevention programmes into mainstream practice. METHOD: A decision balance was used to assess the prospects of practitioners implementing comprehensive programmes systematically. The stages-of-change model provides perspectives about behaviour change with regard to patients, practitioners and practice settings. RESULTS AND CONCLUSIONS: Programme implementation is extremely unlikely given the current organization of health care settings. To maintain the use of such programmes, we need to change the "unit of leverage" in the system: from the clinical encounter--that is, practitioners working with individual patients in a case-finding manner--to an organizational level--that is, the appropriate use of managerial and information systems supporting health care settings to identify at-risk patients systematically as they enter primary care and hospital settings. With appropriate infrastructure support, practitioners will be able to fulfil the potential for as well as maintain the use of comprehensive, secondary prevention programmes to reduce alcohol risk and harm in the population.

Alcoholism↗

PubMed2001

Smoking during pregnancy and intention to quit: a profile of methadone-maintained women.

The present study characterized cigarette smoking patterns (self-report, carbon monoxide, and cotinine), health-risk perceptions, attitudes, and quitting intentions among pregnant methadone-maintained women (n = 50) enrolled in comprehensive perinatal drug treatment. At baseline, women expressed only moderate motivation and self-efficacy for smoking cessation, and 60% were in the precontemplation stage of change for quitting. Follow-up assessment during pregnancy (n = 40) showed no change in self-reported cigarettes per day or cotinine values. Despite recognition of the personal and fetal health risks of smoking and high social support for quitting, none of the women stopped smoking and few demonstrated reduction. Compared to other pregnant smokers, this sample is characterized by many of the factors associated with difficulty in quitting. Innovative harm-reduction strategies and nicotine replacement medications deserve scientific attention in this high-risk group of tenacious smokers.

Adult↗

PubMed1996

Should prisons ease drug prohibition to help reduce disease spread?

A session at this summer's international AIDS conference in Vancouver focused on the use of harm-reduction policies to reduce the spread of disease caused by injection drug use. The concept, which is gaining popularity, focuses on the need to limit the harm caused by drug use, not on elimination of the problem.

Acquired Immunodeficiency Syndrome↗

PubMed2003

Cognitive and behavioral change in health care professionals after training in the treatment of injection drug users.

A training program was implemented for 56 health care professionals who work with injection drug users (IDUs) in Spain. The aims were to change health care professionals' concepts of drug treatment for IDUs and increase the knowledge required to implement effective drug treatment programs and train professionals who would in turn train other professionals, thus creating a network. Follow-up was carried out at 8 months. All of the professionals had little prior experience in designing and implementing risk reduction programs. At the end of the training program, all thought that they had increased their knowledge; had gained the skills required to design, implement, and evaluate harm reduction programs for IDUs; and felt qualified to train colleagues from other treatment centers. After 1 year, they had trained 676 health care professionals. The program is appropriate with regard to the aims sought and the target population for which it was designed. The effectiveness of a network-building strategy was also validated.

Adult↗