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PubMed2003

The US tobacco control community's view of the future of tobacco harm reduction.

OBJECTIVE: Tobacco harm reduction (THR) has garnered recent attention due to the introduction of novel nicotine delivery products ostensibly intended to reduce risk for inveterate cigarette smokers. This study evaluates the grassroots tobacco control community's knowledge, opinions, and beliefs about THR. DESIGN: A web/mail survey conducted in October and November 2002, with a telephone survey of a sample of non-respondents. SUBJECTS: The 2833 US based registrants for the 2001 National Conference on Tobacco or Health. MAIN OUTCOME MEASURES: Respondents' awareness of THR, perception of its importance, support for regulation, and perception of which THR products should be recommended to inveterate cigarette smokers. RESULTS: 70% of respondents were aware of THR but respondents had low recognition of specific products at the forefront of the debate, such as Swedish snuff. Half believe THR will reduce smoking cessation and cause nicotine experimentation by children; 63% anticipate unintended adverse side effects. More expect THR to have a negative than a positive impact on health. Large majorities support government regulation of THR and conventional tobacco products, but fewer than 30% expect legislation regulating either. Most would recommend nicotine patches (76%) and gum (70%) to inveterate smokers, but no other product was supported by a majority. Scientists are more supportive of THR than activists, while respondents focusing on national/international issues are more supportive than those concentrating on local/state issues. CONCLUSIONS: Many members of the US tobacco control community are unaware of the THR "movement", while others possess only rudimentary familiarity with it. If and as THR achieves an increasingly prominent role on the tobacco-or-health scene, this community will have to become educated about THR, and be prepared to advocate for regulatory policies that will maximise the potential for positive outcomes. The potential for negative outcomes remains significant.

Adult↗
PubMed2006

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs.

Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.

Accidents, Traffic↗
PubMed1995

Harm reduction: what it is and is not.

The meaning of the term "harm reduction" has changed over the decades of its existence but it is now increasingly being aligned with public health approaches. An agreed meaning for the term would be helpful and should be sought. Antecedents are easy to find. Emphasis on small achievable steps is an important element; neither inherently supportive of prohibition nor of legalization, harm reduction is essentially pragmatic and tends to favour regulatory approaches. HIV has focused attention on harm reduction but even in the illicit drug field, a strong tradition of research and policy with an identical philosophical framework can be traced back well before the AIDS era. Harm reduction primary prevention educational approaches are more open, honest and respectful of responsible decision making processes. With current illicit drug users, harm reduction emphasizes the need to understand existing individual control mechanisms. The concept can be well understood if contrasted with prevailing approaches to drugs which generally emphasize punishment, lack of regulation and often augment harm.

Journal Article↗
PubMed1995

Harm reduction: Australia as a case study.

This paper explicates the term, "harm reduction"; demonstrates that harm reduction has a long tradition; and uses one country, Australia, as a case study. Harm reduction can be understood as "policies and programs which are designed to reduce the adverse consequences of mood altering substances without necessarily reducing their consumption"; it is consistent with the best traditions of both medicine and public health. Although it is difficult to interpret trends in mortality from alcohol, tobacco, and illicit drugs to determine whether harm reduction in Australia "worked", the effectiveness of harm-reduction policies and programs in controlling HIV among injecting drug users (IDUs) seems extremely strong and suggests that benefits of harm-reduction programs for other drugs will become apparent in time.

Alcoholism↗
PubMed2005

Developing an effective intervention for IDU women: a harm reduction approach to collaboration.

Harm reduction is fundamentally a movement intended to empower the patient and consumer of health services. This project applied harm reduction theory as a strategy to empower collaborating community partners and researchers to overcome their preconceptions about each other in order to create a successful HIV prevention intervention and evaluation study for injection drug using women. The Women's Options for Risk Reduction through Knowledge of Self (WORKS) intervention program offered a series of four HIV prevention workshops, in conjunction with sexually transmitted infection (STI) and HIV counseling and testing to female injection drug users (IDUs) or the partners of IDUs. This community collaboration was to integrate the strengths of researchers and service providers in a comprehensive approach to prevention evaluation. In this collaborative research context, capacity building meant developing the long-term goal, explicit commitment to and integration of evaluation into the overall operation of a HIV prevention service delivery organization. The WORKS Intervention collaboration's aim was to improve the capacity of community-based organizations (CBOs) to use research-based data on HIV risk taking behavior and prevention strategies to provide effective interventions and services and effectively evaluate their efforts. Barriers to successful planning, implementation, and evaluation are presented with the strategies used to overcome them. Intervention effectiveness results from the process evaluation are presented in the context of prevention and research capacity development in CBOs.

California↗
PubMed2004

Community tobacco control leaders' perceptions of harm reduction.

OBJECTIVE: To investigate community tobacco control leaders' attitudes toward harm reduction approaches to tobacco use, in order to assess benefits and risks associated with these strategies. DESIGN: Cross sectional design involving qualitative outcomes from nine structured focus groups. SUBJECTS: 47 community tobacco control leaders in Minnesota working in the areas of public policy, clinical treatment of nicotine dependence and youth development participated. OUTCOME MEASURES: Participants discussed definitions of harm reduction; benefits and risks of harm reduction methods; and how funds for tobacco control research and programmes should be allocated. RESULTS: Results indicated inconsistency about the definition of harm reduction: most groups included a broad range of strategies that extended beyond those typically referenced in the scientific literature. Many participants stated that harm reduction might be beneficial, particularly for smokers who could not or would not quit. However, most also expressed concern about a number of risks, including delivering a mixed message about tobacco, inadvertently benefiting the tobacco industry, and causing unanticipated negative health effects. Participants were inclined to suggest public policy measures (for example, smoking bans, increased taxes) as means for reducing harm. CONCLUSIONS: Results indicate that even among tobacco control leaders there is a need for common terminology to describe harm reduction approaches and that public policy approaches to harm reduction are considered more dependable than strategies that involve pharmaceutical treatment or rely on the tobacco industry, such as product modification.

Attitude of Health Personnel↗
PubMedDate not supplied

[Drug addiction: harm reduction policies in France and Spain].

INTRODUCTION: Harm reduction policies, such as needle exchange programs, injection centers, and substitution treatments, attempt to reduce the health and social damage associated with illegal drug use. Such policies were introduced in France and Spain in response to the urgent health threat that AIDS posed to injecting drug users. METHOD: This analysis of harm reduction policies as of 2003, in France and Spain, includes a review of the literature and relevant legal and administrative provisions; collection of indicators likely to illustrate the health effects of these policies; analysis of available information and information systems, to examine comparability; and finally, comparison of these indicators. RESULTS: Differences between France and Spain led to easier integration of harm reduction into global drug policy in Spain, while there was some resistance to its acceptance in France. Nonetheless, impact indicators follow the same trends in both cases. Implementation of harm reduction policies has been followed by a reduction in injection practices, HIV prevalence, and deaths from overdoses among injecting drug users. The prevalence of HIV among this population has fallen substantially more in France than in Spain. DISCUSSION: The impact of harm reduction policies in France and Spain appears very positive, although any effect on Hepatitis C virus remains unclear, probably because of the virus's inherent characteristics of resistance and infectiousness. The reasons for the more marked difference in HIV prevalence in France may be that sharing practices are more widespread in Spain than in France, that the proportion of injecting drug users with HIV at the beginning of the epidemic was higher in Spain, or that the impact of substitution treatments has been stronger in France because of different modes of management.

Drug Overdose↗
PubMed2005

Harm reduction--the cannabis paradox.

This article examines harm reduction from a novel perspective. Its central thesis is that harm reduction is not only a social concept, but also a biological one. More specifically, evolution does not make moral distinctions in the selection process, but utilizes a cannabis-based approach to harm reduction in order to promote survival of the fittest. Evidence will be provided from peer-reviewed scientific literature that supports the hypothesis that humans, and all animals, make and use internally produced cannabis-like products (endocannabinoids) as part of the evolutionary harm reduction program. More specifically, endocannabinoids homeostatically regulate all body systems (cardiovascular, digestive, endocrine, excretory, immune, nervous, musculo-skeletal, reproductive). Therefore, the health of each individual is dependent on this system working appropriately.

Journal Article↗
PubMed2005

Patterns of use and harm reduction practices of ecstasy users in Australia.

Harm reduction refers to the use of strategies to prevent or reduce harmful consequences associated with illicit drug use. There is a paucity of research concerning the harm reduction practices employed by ecstasy users. This study aimed to explore the prevalence, nature and factors associated with harm reduction practices employed by ecstasy users in Australia, with a specific focus on the practice of preloading and postloading--the use of pharmaceuticals and natural products prior and subsequent to ecstasy use. One hundred and sixteen Australian residents aged 18 years and over who had used ecstasy at least once in their lifetime were recruited via convenience sampling, 'snowballing' and via web-based advertisements and completed an anonymous questionnaire. Participants reported using a wide range of strategies for minimising ecstasy-associated harm. The most common strategies used for reducing negative side effects, 'comedown' or neurotoxicity were drinking water, limiting or reducing ecstasy use, taking breaks and taking vitamins or other natural substances. Forty percent of the sample had tested their ecstasy pills for the presence of MDMA. Forty-one percent and 47% of participants had engaged in pre- and postloading, respectively, with the most common pre- and postloading substances being multivitamins, 5-HTP, magnesium and fruit or fruit juice. Younger mean age and 'high' total occasions of ecstasy use was significantly associated with preloading, and 'high' total use and frequency of use was associated with postloading. The results indicate that ecstasy users are aware of the potential for harm associated with ecstasy use and attempt to minimise harm by actively employing strategies. By exploring the pattern of harm reduction practices among ecstasy users, this study has highlighted the need for further research into the efficacy and potential clinical drug interactions associated with such practices, as well as the need for investigation of how such practices may affect patterns of ecstasy use.

Adult↗
PubMedDate not supplied

Harm reduction: come as you are.

The purpose of this paper is to describe what harm reduction is, how it developed, how it works, and why it is becoming a major approach in the addictive behaviors field. Based on principles of public health, harm reduction offers a pragmatic yet compassionate set of strategies designed to reduce the harmful consequences of addictive behavior for both drug consumers and the communities in which they liver. To illustrate how harm reduction has been applied to both the prevention and treatment of addiction problems, highlights of a national conference on harm reduction are presented. The historical roots of harm reduction programs in Europe (Netherlands and the United Kingdom) are described. The paper concludes with a discussion of four basic assumptions central to harm reduction: (a) harm reduction is a public health alternative to the moral/criminal and disease models of drug use and addiction; (b) it recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm; (c) it has emerged primarily as a "bottom-up" approach based on addict advocacy, rather than a "top-down" policy established by addiction professionals; and (d) it promotes low threshold access to services as an alternative to traditional high threshold approaches.

Adaptation, Psychological↗
PubMed2001

Harm reduction - a historical view from the left.

The harm reduction movement formed during a period in which social movements of the working class and the excluded were weak, neo-liberalism ideologically triumphant, and potential opposition movements were viewed as offering "tinkering" with the system rather than a total social alternative. This climate shaped and limited the perspectives, strategies, and tactics of harm reductionists almost everywhere. In many countries, this period was also marked by a "political economy of scapegoating" that often targeted drug users as the cause of social woes. This scapegoating took the form of "divide and rule" political initiatives by business and political leaderships to prevent social unrest in a long period of worldwide economic trends toward lowered profit rates and toward increasing income inequality. However, times have changed. Mass strikes and other labor struggles, opposition to the World Trade Organisation and other agencies of neo-liberalism, community-based protests against belt-tightening, and other forms of social unrest have been increasing in many countries. This opens up the possibility of new allies for the harm reduction movement, but also poses difficult problems for which we need to develop answers. On-the-ground experience in alliance formation needs to be combined with careful discussion of and research about what approaches work to convince other movements to work for and with harm reduction, and which approaches do not. Class differences within the harm reduction movement are likely to become more salient in terms of (a) creating internal tensions, (b) increasingly, opening up new ways in which working class harm reductionists can organize within their own communities and workplaces, and (c) producing different strategic orientations that will need to be discussed and debated. As a movement, we will need to find ways to accommodate and discuss differing perspectives, needs, and assessments of opportunities and threats without paralyzing harm reduction activities.

Journal Article↗
PubMed2001

Cross-cultural approaches to harm reduction research: some considerations on the Brazil experience.

Harm reduction initiatives for drug users comprise a range of approaches, including drug-user treatment, advocacy for changes in drug policy, needle exchange programs, bleach distribution, and broad-based interventions that focus on both safer drug use and less risky sexual behaviors. In many developing nations, harm reduction is a relatively new strategy, which focuses almost exclusively on the connections between drug use and the spread of HIV infection. In Brazil, harm reduction programs are few, and little has been documented about their scope, experience, and effectiveness. This paper reviews the status of Brazilian harm reduction initiatives in general, with a specific focus on lessons learned from the conduct of cross-national research in Rio de Janeiro. The study demonstrated the feasibility of implementing a community-based prevention program among an at-risk population of cocaine users in Brazil, and in other countries where there is little tradition of research with out-of-treatment drug users. Finally, the paper addresses aspects of the harm reduction movement that tend to hamper its progress in both developed and developing nations.

Adolescent↗
PubMed1996

Harm reduction and decriminalization in the United States: a personal perspective.

Harm reduction, an alternative to both drug legalization and drug prohibition, seeks to preserve prohibition by keeping the supply of drugs illegal while softening some of the harsh consequences of prohibition. Typical harm reduction proposals are needle exchanges for intravenous drug users to reduce the spread of HIV infection and the medical use of marijuana for a variety of illnesses including AIDS, glaucoma, multiple sclerosis, and cancer chemotherapy-induced nausea and vomiting. While attractive as a reasonable-sounding compromise, harm reduction carries a high price because it undermines the social signal of prohibition. This signal is a vital public health strategy, especially when it comes to primary prevention of use of alcohol and other drugs by youth. A personal experience with harm reduction, leading to rejection of this approach, is described. Harm reduction, enjoying a minor comeback in the United States, is a favored policy in much of Europe today. Harm reduction is not new, and it is a failure as a public health policy.

Adolescent↗
PubMed2004

A long-term view of harm reduction.

The concept of harm reduction is controversial, as it brings to mind the failures, public misconceptions, and undermining of prevention associated with the low-tar cigarette campaign. Modern cigarettes are, however, unnecessarily carcinogenic and toxic, a situation that could be improved by sensible and serious regulation of the contents of tobacco smoke. The risks potentially associated with reducing levels of known toxicants in cigarettes are tiny in comparison with the acceptance of the status quo, which is disastrous. Failure to act in these circumstances is negligence.

Harm Reduction↗
PubMedDate not supplied

Harm reduction approaches to alcohol use: health promotion, prevention, and treatment.

Harm reduction approaches to alcohol problems have endured a controversial history in both the research literature and the popular media. Although several studies have demonstrated that controlled drinking is possible and that moderation-based treatments may be preferred over abstinence-only approaches, the public and institutional views of alcohol treatment still support zero-tolerance. After describing the problems with zero-tolerance and the benefits of moderate drinking, the research literature describing prevention and intervention approaches consistent with a harm reduction philosophy are presented. Literature is reviewed on universal prevention programs for young adolescents, selective and indicated prevention for college students, moderation-based self-help approaches, prevention and interventions in primary care settings, pharmacological treatments, and psychosocial approaches with moderation goals. Overall, empirical studies have demonstrated that harm reduction approaches to alcohol problems are at least as effective as abstinence-oriented approaches at reducing alcohol consumption and alcohol-related consequences. Based on these findings, we discuss the importance of individualizing alcohol prevention and intervention to accommodate the preferences and needs of the targeted person or population. In recognizing the multifaceted nature of behavior change, harm reduction efforts seek to meet the individual where he or she is at and assist that person in the direction of positive behavior change, whether that change involves abstinence, moderate drinking, or the reduction of alcohol-related harm. The limitations of harm reduction and recommendations for future research are discussed.

Adolescent↗
PubMed2001

The medicalization of female "circumcision": harm reduction or promotion of a dangerous practice?

In recent decades the practice of female "circumcision" has come under intense international scrutiny, often conceptualized as a violation of women's basic right to health. Although the adverse health consequences of female "circumcision" form the basis of opposition to the practice, anti-circumcision activists, as well as many international medical associations, largely oppose measures to improve its safety. The debate over medicalization of female "circumcision" has, up until now, been cast as a moral dilemma: to protect women's health at the expense of legitimating a destructive practice? Or to hasten the elimination of a dangerous practice while allowing women to die from preventable conditions? This paper seeks to re-examine this debate by conceptualizing medicalization of female "circumcision" as a harm-reduction strategy. Harm reduction is a new paradigm in the field of public health that aims to minimize the health hazards associated with risky behaviors, such as intravenous drug use and high-risk sexual behavior, by encouraging safer alternatives, including, but not limited to abstinence. Harm reduction considers a wide range of alternatives, and promotes the alternative that is culturally acceptable and bears the least amount of harm. This paper evaluates the applicability of harm reduction principles to medical interventions for female "circumcision," and draws parallels to other harm reduction programs. In this light, arguments for opposing medicalization of female "circumcision", including the assertion that it counteracts efforts to eliminate the practice, are critically evaluated, revealing that there is not sufficient evidence to support staunch opposition to medicalization. Rather, it appears that medicalization, if implemented as a harm-reduction strategy, may be a sound and compassionate approach to improving women's health in settings where abandonment of the practice of "circumcision" is not immediately attainable.

Circumcision, Female↗
PubMed2002

Tobacco harm reduction: a call to address the ethical dilemmas.

The 2001 Institute of Medicine report Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction has helped to focus attention on the scientific basis for assessing tobacco harm reduction products. As the tobacco research and policy communities tackle the challenges of evaluating harm reduction, there are ethical issues that must also be addressed. There has, however, been very little writing on the ethics of this field. In an effort to spur research into answering these ethical questions, we present two complementary approaches. First we outline three overarching topics in tobacco harm reduction that would particularly lend themselves to study: (a) Is the pursuit of tobacco harm reduction an ethical goal? (b) What are the ethical considerations of tobacco harm reduction vis-à-vis pharmaceutical companies? and (c) What are the ethical considerations for harm reduction vis-à-vis tobacco companies? We then present one possible framework for analyzing the ethical issues that accompany particular tobacco harm reduction strategies. By considering the ethical dilemmas attendant to tobacco harm reduction in a prospective and thoughtful manner, we will be better prepared to handle the challenges that face us individually as researchers and collectively as a tobacco control community.

Drug Industry↗
PubMed2003

SACHR: an example of an integrated, harm reduction drug treatment program.

In this article, we report on our work at St. Ann's Corner of Harm Reduction, a multi-service agency committed to implementing effective public health strategies in disenfranchised communities from a harm reduction perspective. Based on our experiences, we hope to contribute to the ongoing dialogue about the definition of harm reduction, while proposing to integrate harm reduction and abstinence-oriented treatment modalities into a model of comprehensive drug prevention and care. The five components of our harm reduction service provision are discussed, and a vignette is provided. We conclude with a plea for close collaborations between innovative researchers and harm reduction agencies, and a call for the full integration of harm reduction approaches into the substance abuse field at large.

Adult↗