Drug and Alcohol Review (November 2006), 25, 611 – 624

A review of the efficacy and effectiveness of harm reduction

strategies for alcohol, tobacco and illicit drugs

ALISON RITTER1,2 & JACQUI CAMERON1

1
Turning Point Alcohol and Drug Centre, Melbourne, Victoria, and 2Australian National University, Canberra,
Australian Capital Territory, Australia

Abstract
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. [Ritter A, Cameron J. A review of the efficacy and
effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev 2006;25:611 – 624]

Key words: alcohol, harm reduction, illicit drug, tobacco.

reduction policies and programmes through Asia, Latin

Introduction
Harm reduction is an important drug policy approach,
transcending health, law enforcement and prevention
endeavours through the unifying concept of reducing
harm. Relatively speaking, harm reduction is a new
paradigm in drugs (some authors refer to the UK
Rolleston Committee of the 1920s as the original
reference to harm reduction; methadone maintenance
has been available in some countries since the 1950s).
While there has been reference to minimising harm in the
alcohol and drug literature from the mid-1970s [1], it
only emerged as a significant paradigm in the early 1980s
and was focused largely on illicit drugs [2]. Australia,
Switzerland, the United Kingdom, the Netherlands and
Canada have been early adopters of the harm reduction
approach. There is now a focus on spreading harm
America and Central Eastern Europe.
Harm reduction is a very inclusive notion; it can readily
accommodate a vast array of drug interventions and drug
types. Harm reduction includes whole of population
interventions as well as those targeted at individuals, and
has considerable affinity with the new public health
movement. These features have been strengths of harm
reduction [3,4]. Despite this positive breadth, the
competing morass of definitions for harm reduction
means that it is hard to provide focus or boundary to the
concept. Part of the difficulty in defining harm reduction
is that it refers to both a philosophical approach and
specific types of programmes or interventions. There is
agreement that harm reduction refers to policies and
programmes that are aimed at reducing the harms from
drugs, but not drug use per se.

Alison Ritter, Turning Point Alcohol and Drug Centre, Melbourne, Australia and Australian National University, Jacqui Cameron, Turning Point
Alcohol and Drug Centre, Melbourne, Australia. Correspondence to Associate Professor Alison Ritter, Regulatory Institutions Network, Research
School of Social Sciences, Bldg #8, Australian National University, Canberra, ACT 0200, Australia. Tel: 02 6125 6033; Fax: 02 6125 1507;
E-mail: alison.ritter@anu.edu.au
Received 5 May 2006; accepted for publication 6 June 2006.

ISSN 0959-5236 print/ISSN 1465-3362 online/06/060611–14 ª Australasian Professional Society on Alcohol and Other Drugs
DOI: 10.1080/09595230600944529
612 Alison Ritter & Jacqui Cameron
The key features and principles of harm reduction
include:
. that the primary goal is reducing harm rather than
drug use per se;
. that there is acceptance that drugs are a part of
society and will never be eliminated;
. that harm reduction should provide a compre-
hensive public health framework;
. that priority is placed on immediate (and achiev-
able) goals; and
. that harm reduction is underpinned by values of
pragmatism and humanism [2 – 7].
A strict definition has been used in this review—as
above, interventions that reduce harms but do not aim
to or operate through use reduction. Therefore inter-
ventions that reduce harm primarily through use
reduction, such as methadone maintenance, are ex-
cluded from this review. The rationale for using a strict
definition is to assess the degree to which the most
stringent types of harm reduction interventions meet
efficacy (trial condition) and effectiveness (real world
condition) criteria. In these days of evidence-based
medicine (EBM) where policy is influenced by a
positivistic interpretation of evidence, it is helpful to
assess the extent to which harm reduction interventions
meet that standard.
Method
A comprehensive search strategy was employed to
identify the relevant literature. The following electronic
databases were searched: MEDLINE, EMBASE, PsycLIT,
Cochrane, CINAHL, Science Citation Index, Social Work
Abstracts, OVID and International Bibliography of the
Social Sciences. ‘Grey literature’ and the journals not
indexed in the above databases were searched compre-
hensively through specialist addiction libraries and
websites. In addition the reference lists of retrieved
studies, reviews and conference abstracts were hand-
searched.
The keywords used in the searches included: harm
reduction, alcohol, heroin, tobacco, cannabis, illicit
drug, drug use, dependence, abuse, needle and syringe
exchange/programme, supervised injecting, naloxone,
overdose, outreach, blood-borne virus and interven-
tion, brief intervention, HIV, HIV testing, counselling
and HCV.
For inclusion in the harm reduction review, the goal
of the intervention needed to be concerned with
reducing harm, not reducing drug use per se. Only
English literature was included and there was no year
limit. Using inclusion criteria from evidence-based
medicine (EBM) studies were included with designs
that meet Level I (systematic reviews of RCTs), Level II
(single RCT), Level III (comparative studies) and Level
IV (case series with pre – post comparisons) [8].
Studies for possible inclusion were identified accord-
ing to the search strategy described, and abstracts
obtained. The authors evaluated independently each
abstract against inclusion criteria. A significant number
were excluded because they were descriptive only, had
no comparison condition or the design was otherwise
insufficient to meet the criteria for inclusion.
These eligibility criteria—the definition of harm
reduction and the focus on EBM levels of evidence
[8]—considerably shaped what was included in the
review. It limited the review to interventions that had
been systematically researched and as a result covered
interventions that are set up and implemented by
governments, non-governmental organisations (NGOs)
or other similar entities and excluded interventions
conducted at the grass roots by people at risk. Despite
the limitations placed on the review by the chosen
criteria and focus, the literature is still vast (more than
650 articles) and space limitations has meant that only a
cursory review of some interventions can be provided.
Alcohol
Harm reduction in relation to alcohol, as defined for
this review, concentrates upon interventions that do not
seek to alter the consumption levels of alcohol, but to
reduce the harms associated with consumption. Viewed
in this way, the harms that can be addressed through
harm reduction approaches are of three types: injury
and violence; road accidents (drink driving); and social
harms.
Interventions to reduce injury and violence
Alcohol outlet density has been shown to be strongly
associated with injury, violence and public disorder.
The relationship between consumption levels and outlet
density is complicated [9]. Here we are concerned only
with reducing harm from changes in alcohol outlet
density; however, no direct efficacy or effectiveness
research could be located that directly evaluated
reduced outlet density as a harm reduction strategy.
The drinking environment can be substantially
modified to reduce the harms arising from alcohol
consumption. Research has demonstrated a relation-
ship between approaches to closing time by staff
[10,11], management of aggression [12,13] and crowd-
ing [14]. While studies of the efficacy of interventions
are largely lacking, studies in Australia have accumu-
lated evidence of their acceptability, and changes in
behaviour (in the absence of a control group) [15,16].
This work also included the use of community mobi-
lisation strategies, contributing to the overall positive
outcomes [15,16].

In a powerful case example of the potential effective-
ness of harm reduction measures, a town in the
Netherlands banned full strength beer and the sale of
beer in bottles (which could be used as missiles) during
a 2000 soccer championship, resulting in less violence
and mayhem [9]. One evaluation of the use of
toughened glassware found increased injuries [17].
Provision of plastic glasses is regarded commonly as an
effective harm reduction measure. However, these
single reports do not create a body of solid evidence.
‘Given the limited current evidence of effectives of
. . . [harm reduction measures] they should not be
considered as substitutes for other alcohol policy
strategies that have well-documented evidence of
effectiveness’ [9: 152].
Interventions to reduce road accidents
No specific literature in relation to the effectiveness of
mass media campaigns on drink driving could be
located. The general evidence for mass media cam-
paigns to change risk behaviour is either poor or absent
[9]. Designated driver programmes have limited
evidentiary support [9]. Similarly, alternate transporta-
tion services are popular but appear to have little impact
on the number of alcohol-involved accidents.
Interventions for drink drivers—treatment pro-
grammes, punishment and prevention of driving—aim
to reduce offending, not necessarily to reduce alcohol
use and alcohol-related problems. Educational inter-
ventions have been the mainstay of drink driver
interventions. Overall, the results are somewhat pessi-
mistic. In two reviews the literature was summarised as
‘equivocal’ [18,19]. Wells-Parker et al. [20] completed
a meta-analysis of 215 programmes, of which 55% were
educational interventions. They reported an average
effect of ‘remediation’ of 7 – 9% reduction in recidivism
over and above licence sanctions. Mean effect sizes for
combined treatments exceeded those for education
alone. Wells-Parker et al. [20] found that multi-strategy
programmes were more effective (i.e. those involving
education, psychotherapy, counselling and follow-up
contact). Sanctions (notably alcohol interlock devices)
are likely to be much more effective than education and
treatment approaches but currently lack a strong
evidentiary basis [21].
The use of random breath testing increases the
deterrence effect (because of the importance of the
perceived risk of being detected). Overall, we have seen
reductions in alcohol-involved accidents across a
number of countries attributed to random breath
testing, but the combination of population measures
to deter people from drinking and driving, along with
sanctions and interventions programmes for drink
drivers and increased public concern about road
fatalities all contribute.
Efficacy and effectiveness of harm reduction strategies 613
Tobacco
Tobacco harm reduction is now regarded as a pressing
issue [22]. In one of the early papers on the issue,
Borland & Scollo [23] note that in fact harm reduction
strategies such as low tar content and low nicotine
content cigarettes have been around for some time (see
also [24]).
Put simply, harm reduction in the tobacco context is
making tobacco products safer and reducing the risks to
non-smokers [25]. In almost every single tobacco harm
reduction publication reference is made to the im-
portance of abstinence, and that harm reduction is
applicable only to those individuals unable or unwilling
to cease smoking. This contrasts with the alcohol and
illicit drug harm reduction literature where such
statements are not used.
Tobacco harm reduction has been controversial.
The issues raised are all identical to those for illicit
drugs, such as concern that it will promote drug use or
increase drug use, dilute the focus on effective
abstinence strategies, and potentially create new harms
(for example [24,26]). The ethical challenges for harm
reduction have also been discussed [27]. The only
additional critical issue in the tobacco area is the role of
industry. The tobacco industry has been seen by some
to lead the harm reduction push (through the develop-
ment of new nicotine delivery devices). Attitudes
towards tobacco harm reduction among tobacco con-
trol experts are mixed, but generally negative [22,28].
There is no consensus that harm reduction is appro-
priate. A number of commentators point to the need for
regulatory mechanisms around new nicotine delivery
devices and tobacco harm reduction appears to need
consideration of this in the context of any successful
overall harm reduction approach (for example [29,30]).
There is yet to develop a single schema or taxonomy
for tobacco harm reduction interventions (see [31]).
The Institute of Medicine (IOM) report uses the term
‘potential reduced exposure products’ (PREPs) to
encompass various potentially harm-reducing products
[25]. Here we identify five types of harm reduction
consistent with our definition: cigarettes with decreased
emission of toxicants; cigarette-like products; smoke-
less tobacco; protection from environmental tobacco
smoke; and other. The first three would be defined by
IOM as PREPs.
Consistent with the purpose of this review, we are
seeking efficacy and effectiveness data for these harm
reduction interventions. Cigarettes with decreased
emission of toxicants include products such as Advance
and Omni. The harm reduction goal is to preserve the
nicotine levels but reduce the toxic substances, such as
nitrosamines, while keeping to a smokeable drug.
These products have been developed by industry.
Preliminary research was located examining the
614 Alison Ritter & Jacqui Cameron
capacity for the product ‘Advance’ to reduce toxicants
[32] which demonstrated some positive results. The
study was framed as a test of the measurement issues,
rather than actual safety or efficacy per se. The situation
is similar for cigarette-like products such as Eclipse and
Accord. These devices are distinguished from the
reduced toxicants tobacco because they aim to deliver
nicotine without tobacco smoke or with much less
combustion. The effects of Eclipse have been studied
with positive results [33]. None the less, single studies
are insufficient to draw conclusions (industry research
was not sourced).
Smokeless tobacco (snuff, or Snus in Sweden)
appears to have a good evidence base for its reduced
harmfulness compared to cigarettes for some diseases,
but remains controversial and varies radically across
countries, with some being very hazardous. The
evidence appears insufficient regarding its impact on
heart disease, and commentators cannot agree on its
overall risk reduction effect [34 – 36].
The only area of tobacco harm reduction where there
is good evidence and agreement among the experts is in
relation to protection from environmental smoke.
There is a strong evidence-base that bans on smoking
in enclosed spaces reduces exposure to the harmful
effects of tobacco smoke. There are some other
examples of tobacco harm reduction, such as smokeless
ashtrays and self-extinguishing cigarettes, but no
evidence of efficacy or effectiveness could be located.
In summary, the tobacco field has identified harm
reduction as a new challenge. From one international
expert, ‘The control of toxicants is possible and is
needed urgently’ [37] but there does not appear to be
broad agreement about the necessity of such endeavours
and concerns about the industry and regulation of new
harm-reducing nicotine delivery devices abound.
Injecting drug use
Harm reduction interventions for illicit drugs focus on
the harms associated with injecting: blood-borne
viruses (HIV and hepatitis), overdose and other
injection-related harms. The most widely cited and
researched harm reduction intervention is needle
syringe programmes (NSP).
Needle syringe programmes (NSP)
The role of needle sharing in HIV and other infectious
diseases is well documented—sharing remains the
single most important risk factor for spread within
IDU populations. The goal of NSP is to reduce the
spread of infectious diseases (HIV, hepatitis), with
secondary goals to increase access to harm reduction
support services and treatment services; provide in-
formation and advice about safer injecting drug use
(and safer sexual practices); and make contact with
hidden populations.
Evaluation of NSP has used multiple methodologies,
including pre- and post-NSP comparisons; compar-
isons of NSP attendees versus non-attendees (on
variables such as BBV risk); longitudinal cohort studies;
case – control studies; regression of risk factors (ser-
opositive versus seronegative); population prevalence
and country comparisons; and dynamic epidemiologi-
cal and mathematical modelling. Iatrogenic effects have
also been studied.
On self-reported changes in risk behaviour, with
research designs that mainly used pre- and post- or
comparisons of attendees with non-attendees, there is a
good body of literature supporting reductions in risk
behaviour associated with NSP [38 – 49]. In the first
published meta-analysis, Cross et al. [50] found an
overall positive effect size. Ksobiech [51] has reported a
more recent meta-analyses of 47 NSP studies with
similarly positive results.
While changes in risk behaviour can be seen to be an
important outcome, more direct assessment of efficacy
can be found in research examining changes in HIV
and HCV infection rates. Research has demonstrated
the efficacy of NSP in reducing HIV seroconversion
[52 – 56]. Ecological studies, mathematical modelling
and other simulation approaches have all been under-
taken to assess the efficacy of NSP in reducing HIV
prevalence and incidence (for example [57,58 – 61]), all
of which demonstrated the significant positive effect of
NSP in reducing HIV.
The cost-effectiveness of NSP has been calculated
based upon estimates of the number of HIV and/or
HCV infections averted by the programme (programme
costs divided by averted infections). In all bar one of
these economic analyses (Pollack’s 2001 analysis of
cost-effectiveness of NSP for HCV prevention), NSP
are found to be cost-effective and cost-saving overall
[38,61 – 65].
There have been a number of issues raised about the
potential iatrogenic effects of NSP: that they may
increase drug use and injecting and, from a community
perspective, they may lower the perceived risks of
injecting resulting in greater numbers of new initiates to
injecting. The research evidence does not support these
conclusions [40,54,66 – 69]. The second area of con-
cern regarding NSP has been in relation to public
amenity included concerns regarding discarded syr-
inges and increased public disorder in areas proximal to
NSP, again not supported by the research evidence
[70 – 73]. The risk of a needlestick injury from a
publicly discarded syringe is very low [74]. There is
no evidence of increases in crime rates in areas where
NSP operate [75,76].
Not all the research on the impact of NSP on
HIV infection rates has been positive. In spite of

Vancouver’s NSP programme, an HIV epidemic broke
out among IDU approximately 5 years after implemen-
tation [77]. In Montreal, Bruneau et al. [78] found
higher rates of HIV in NSP attendees than in non-
attendees. Monterroso et al.’s [55] cohort study exami-
ning risk of acquiring HIV (seroconversion), found a
positive effect associated with use of a NSP. Part of this
can be explained by research design issues. NSP
attendees are at higher risk (and have greater injecting
risk behaviour) [78 – 82]. In the Gibson [83] review, all
the studies with mixed or negative findings were con-
ducted in settings which could not exclude the con-
found of access to syringes through pharmacies. None
the less, risk behaviours continue among IDU irrespec-
tive of their use of NSP (for example [84 – 89]), and as
demonstrated by the Vancouver experience, NSP are
likely to be only one among a number of harm reduc-
tion strategies that may be required to prevent HIV.
In summary, the most strongly identified harm
reduction programme is NSP and the body of evidence
is very strongly weighted towards their efficacy and
cost-effectiveness [54,61,83,90,91].
Outreach
Outreach is defined as contacting drug users in the
communities where they live [92,93]. The most
common interventions include provision of information
about risk behaviour and behavioural strategies to
reduce risk, provision of clean injecting equipment,
access to BBV testing and referral to relevant services
(health services, welfare services and drug treatment
services). Outreach can be provided by peers (current
drug users or former drug users), or by ‘traditional’
outreach workers (social workers or other health
professionals), with greater effectiveness of peer-based
models [94,95].
In relation to the evidence supporting the efficacy and
effectiveness of outreach, there are only observational
pre – post studies—there have been no controlled trials
of outreach. A comprehensive review was published in
1998 [96] that summarised the extant literature at that
time (36 studies). While acknowledging the limitations
of the evaluation designs, the authors concluded that
there is good evidence to support the effectiveness of
outreach in relation to: accessing a hard-to-reach
population; reduction in needle sharing; and increased
risk reduction behaviour [92,96]. Reduction in risk
behaviour (re-use of injection equipment) for those
receiving outreach services was in the order of 27%
[92,96]. More recent literature supports these findings
[97,98].
There have been endeavours to quantify, in cost –
benefit terms, the impact of outreach as a harm
reduction intervention. Most of this work derives from
mathematical modelling. Wilson & Kahn [99] model
Efficacy and effectiveness of harm reduction strategies 615
the best investment allocations between methadone
maintenance and street outreach over the life of an HIV
epidemic. They report that outreach is the best
investment (in the epidemic stage of the cycle). An
analysis of the cost-effectiveness of the National AIDS
Demonstration Research programme [100] demon-
strated that the programme was cost-saving overall
(through averted HIV infections).
Supervised injecting facilities (SIF)
SIF were developed as a public health measure in
response to growing concern for the health of drug
users in relation to BBV transmission, access to
services, overdose and public order issues [101 – 104].
SIF first appeared in Amsterdam in the 1970s and were
later trialled in the Netherlands, Switzerland, Germany
and Spain [105]. Typically, SIF provide sterile equip-
ment, a safe place to inject and information services
with multi-function models also including access to
medical and welfare services.
There is emerging evidence of the impact of SIF on
BBV transmission [106,107]. Vancouver data demon-
strate a significant reduction in injecting risk behaviour
associated with the SIF [108].
In relation to overdose, researchers have noted the
number of non-fatal overdoses managed successfully
in SIF. The underlying assumption is that had these
overdoses occurred outside the SIF, some proportion
may have led to severe sequelae [107,109 – 111].
Another line of evidence used to support SIF has been
overall changes in overdose rates. Within cities
where SIF are operating, numbers of fatal overdoses
have fallen. For example in Frankfurt, Germany the
number of fatal overdoes has reduced from 147 in 1991
to 22 in 1997 and there has been no recorded fatal
overdose in SIF operating across Europe [101].
However, one cannot attribute this reduction to SIF,
or SIF alone.
Public nuisance is one of the most cited issues
around SIF in the literature and by communities raising
concerns. Research that has examined changes in
public injecting, discarded syringes and litter have all
reported positive results associated with SIF [106,
112 – 115].
In summary, SIF form part of a wider harm
reduction strategy designed to reduce drug-related
harm [116]. Research supports the effectiveness of
SIF in relation to reduced public nuisance and injecting
risk behaviour. Overdose deaths may be reduced by
SIF but the order of magnitude may be smaller
than claimed. There is some evidence that behaviour
change occurs and SIF users access treatment
[106,114,117,118], but without comparators to other
interventions it is difficult to estimate the direct effect of
SIF.
616 Alison Ritter & Jacqui Cameron
NIROA (non-injecting routes of administration)
Non-injecting routes of administration (NIROA), as it
is known in Australia, or route transition interventions
(RTIs). as it is known in the United Kingdom, is a
harm reduction intervention that has the goal of
reducing initiation into injecting and promoting transi-
tion away from injecting for those already injecting. The
only reported research on interventions for reducing
existing injectors’ injecting is work by Dolan et al.
[119]. The decrease in frequency of injecting and
decrease in sharing behaviour at 3 months suggests that
the intervention may have achieved the desired out-
comes, but in the absence of a no-treatment control
group interpretation of the data is difficult [119].
Interventions targeted at injectors to reduce their
initiation of others (rather than their own injecting
behaviour) is the focus of the ‘Break the Cycle’ cam-
paign [120]. Hunt [121] evaluated the single session
intervention (pre – post design), with positive results in
relation to reduction in injecting in front of non-
injectors and a decrease in the number of requests to
be initiated [121].
Work on at-risk non-injectors to prevent their
transition to injecting has reported positive results
[122,123]. Social marketing campaigns (see [124])
have potential for reducing initiation into injecting and
cessation of injecting, but have not been evaluated.
There does seem to be some promise in NIROA
interventions based on the limited research to date.
Education and information
In the context of harm reduction, education and
information are aimed at providing accurate and
credible information to promote behaviour that reduces
risk. The education/information can be delivered
through a variety of means: public awareness cam-
paigns, targeted campaigns, peer networks and out-
reach services; through health services and using
posters, leaflets, videos, booklets, and so on.
The evidence for the efficacy and effectiveness of
education and information is weak [125]. Most of the
published research examines the standard NIDA HIV
prevention intervention. A meta-analysis on the effec-
tiveness of educational programmes reported an overall
positive effective [50]. A number of studies have
compared the NIDA intervention with enhanced brief
interventions. Studies have found that the enhanced
interventions were more effective than the standard
educational interventions (for example see [126 – 128]).
However, there are also a number of studies that do not
find superior outcomes from enhanced interventions
compared to the standard educational intervention
(see for example [129,130]. More commonly, the
research findings suggest little difference between
education/information interventions and other experi-
mental conditions (for example [131]).
There is also a literature on delivery of HIV
education and information in the context of drug
treatment programmes. Prendergast et al.’s [132] meta-
analysis revealed an overall positive effect for such
interventions, although interventions were heteroge-
neous, such that the pooled effect size may have less
meaning when different types of interventions are
extracted.
Given equivocal findings for the effectiveness of
education and information, more recent research has
examined ways of attempting to enhance outcomes,
such as through the use of computer-delivered HIV
education and information intervention. This may be a
highly cost-effective method [133]. There is also an
emerging literature on the use of educational interven-
tion in the context of HIV antiretroviral treatment
adherence (for example) [134,135]. The results to date
are not particularly positive.
Brief interventions
Brief interventions, in the context of this harm
reduction review, are those interventions that are aimed
at changing risk behaviour (including risk for blood-
borne viruses, risk for overdose and risk for other harms
associated with injecting drug use) without focusing on
use reduction. They include motivational interviewing,
brief solution-focused therapy, single-session therapy
and cognitive – behavioural therapy. The length of a
brief intervention can range from a single 15-minute
intervention to a four-session intervention.
Given the wealth of literature in relation to brief
interventions and use reduction, it was expected that
there would be a reasonable literature on brief inter-
ventions for risk reduction. This is not the case. Only a
handful of studies could be located that examine brief
interventions to reduce harms associated with injecting
drug use. Des Jarlais et al. [122] reported positive
findings from a brief behavioural intervention to prevent
transition from sniffing to injecting. Stein et al. [136]
found some limited support for motivational interview-
ing to reduce risk behaviour in NSP participants who
were also heavy drinkers. In a systematic review, Dunn
et al. [137] reviewed motivational interviewing as a brief
intervention to impact upon HIV risk behaviour,
locating four studies. Two of the four studies had
significant positive effects, although both of these
measured sexual risk behaviour as the outcome. (The
two studies measuring changes in injecting risk beha-
viour [138,139] did not produce significant effects).
As with educational interventions, there is a literature
in relation to brief harm reduction interventions in the
context of drug treatment. Examples of this work are
Sorensen et al. [140] and MacMahon et al. [141] both

of whom conclude that the brief intervention showed
little additional effect on risk behaviour (see also [142]).
Naloxone distribution and other overdose prevention
interventions
A significant harm arising from injecting drug use is
overdose. Overdose prevention interventions are con-
cerned with reducing the risk of an overdose and
improving the likelihood of a positive medical response
to an overdose.
One overdose prevention intervention is the provi-
sion of information. Known risk factors for overdose
can be used to tailor appropriate educational and
informational materials that are distributed to injecting
drug users through existing services (such as NSP) or
through targeted campaigns. Training of peers in first
aid and CPR are also important strategies. There have
been no direct evaluations or trials of the effectiveness
of CPR/resuscitation training for peers. The two other
strategies that have been reported in the literature are:
support services delivered to recent victims of overdose;
and collaborations between user groups, police and
emergency services to increase the likelihood that users
will call an ambulance. While there has been broad
support for these approaches and some positive process
evaluations (for example [143 – 145]) the research
evidence regarding their effectiveness is limited [146].
Naloxone is a short-acting opioid antagonist that
reverses the immediate effects of heroin. It is available
to be administered by emergency medical personnel
(and is administered via injection). One promising but
controversial strategy has been to provide naloxone to
drug users and/or their family and friends [147 – 151].
As at 2003, there were only three countries where
naloxone was legally available to drug users [152],
although this is a good place to point out that in harm
reduction circles, legal availability of an intervention is
less critical because of frequent policies of tolerated
availability and distribution, as with the history of
needle exchange programmes. There has been much
exploratory research on peer-administered naloxone
(for example [147 – 149,153 – 155]), but there have
been no trials or evaluations to date. As such it remains
a scientifically untested but practical and theoretically
promising harm reduction intervention.
Drug users groups and peer networks
A significant harm reduction intervention is grass-roots
activism by injecting drug users. As Friedman et al.
note, the harm reduction movement has been oriented
‘upward’ and user groups have not be seen by all as an
important mainstay of harm reduction efforts [156].
The establishment of drug user organisations has
occurred in a number of countries and is a widespread
Efficacy and effectiveness of harm reduction strategies 617
modality for the delivery of harm reduction [156].
These organisations provide advocacy, empowerment
and harm reduction services [157,158].
No published evaluations of user groups that
included a comparator could be located. Using a case
study methodology, evaluation of the Vancouver Area
Network of Drug Users pointed towards reduced harm
and decreased marginalisation of drug users [158]. In
support of such initiatives, three rigorous research
projects have demonstrated greater effectiveness of
peer-driven outreach interventions in reducing HIV
risk behaviour [94,95,128].
Other
There are a number of other harm reduction interven-
tions which have received some attention more
recently. One example is the provision of pill-testing
kits, which may reduce harm at both individual and
population levels [159 – 164]. Another is tolerance
areas/zones. These are not described widely in the
literature, and no efficacy data exist.
A meta-analysis on HIV testing and counselling
concluded that HIV testing and counselling was
effective in altering sexual risk practices among those
who were already infected, but not effective in altering
sexual risk practices in those uninfected [165]. There
have been a number of non-significant findings in
relation to the impact of HIV testing and counselling on
risk reduction behaviour [166 – 168]. There are also
some positive findings reported in the literature
[169,170]. A Cochrane review of the effectiveness of
mass media campaigns to promote HIV testing
concluded that there were short-term effects (in relation
to increased testing) but no long-term effects were
found [171]. Certainly there is an important role for the
provision of voluntary HIV and hepatitis testing and
associated counselling for the purposes of screening
and early access to treatments. Whether such services
actually reduce risk behaviour seems equivocal.
There has been much recent focus on harm reduc-
tion programmes in prison settings. The harm reduc-
tion interventions that have been trialled or established
in prisons include provision of voluntary HIV testing,
education and counselling; provision of bleach; needle
exchange programmes, provision of condoms and
provision of opioid replacement pharmacotherapies.
There have been a limited number of evaluations of
these interventions, but all with positive results in
relation to reducing risk behaviour and no evidence of
iatrogenic effects (see [172 – 177].
Legal and regulatory frameworks—all drugs
There is a set of harms arising from the illegal status of
drugs. These harms are accrued largely by the drug user
618 Alison Ritter & Jacqui Cameron
and include imprisonment and loss of liberty, a criminal
record (which leads to difficulties with employment
etc.), developing criminal experience and associating
with criminal networks. In addition corruption and the
presence of black markets are harms borne by the
community. The potential for blood-borne virus trans-
mission is also associated with the illegal status of drug
use (hurried, inadequate injecting practices for fear of
detection; and illegality of injecting equipment in some
countries/states). Indeed, Friedman et al. have demon-
strated a positive association between legal repressive-
ness and HIV prevalence among injectors [178].
Thus, one way of reducing the harm associated with
injecting drug use is to change the legal frameworks.
Consistent with our definition of harm reduction, these
interventions are not designed to reduce the amount of
drug use (and indeed some argue they have the
potential to increase drug use) but to reduce the harms
arising from drug use.
There is a spectrum of legislative and regulatory
strategies. At one end is full legalisation and at the other
is prohibition. In between these two extremes there are
a number of other possibilities: prescribed availability
(such as for registered drug users), licensed availability
(such as occurs with alcohol); and various versions of
decriminalisation of drug use (dejure and defacto
depenalisation, partial prohibition, cautioning and
diversion schemes).
MacCoun & Reuter [179] have published a compre-
hensive analysis of these different drug control regimes
and the likely impact on use and harms of the different
models. They concluded that use and dependency
would increase under a legalisation model; that for
heroin, providing prescribed heroin to registered users
posed little risk and may significantly reduce harms;
and that for cannabis there was no evidence that
depenalisation would create more harms [179].
The vast majority of the literature in the area of
legalisation and regulation is concerned with cannabis.
There is an emerging literature on the impact of
legislative change in relation to cannabis that demon-
strates that removing the criminal sanctions surround-
ing cannabis use reduces the harms to the users, and
does not produce increases in cannabis use. ‘Taken as a
whole, this research finds that removing criminal
penalties for cannabis possession and use does not
result in higher rates of cannabis use in the general
community’ [5: 24] (see also [152]).
Evaluation of harm reduction as a policy
approach
The assessment of whether harm reduction is a useful
and cost-effective policy resides largely in evaluating
individual programmes, as detailed above. However, at
a more general level harm reduction describes an
overarching policy approach, and is amenable to
evaluation.
One intuitively appealing way of assessing the effec-
tiveness of harm reduction is to examine and compare
countries, regions or states where harm reduction
predominates as the policy platform with those areas
where it does not. For example, Wodak & Lurie [180]
compared Australia with the United States in relation to
HIV prevalence and concluded that Australia’s harm
reduction policies and interventions are the most
plausible explanation for the striking differences in
HIV rates between the two countries. In a similar
analysis Stimson [181] finds that the United Kingdom’s
harm reduction public health response has most
probably averted an HIV epidemic (see also [182]).
In an ecological study comparing cities with and
without NSP on both HIV and HCV infection rates,
those cities with NSP had a mean annual decrease of
18.6% in HIV seroprevalence, compared to a mean
annual increase of 8.1% for those cities without NSP
[61]. The results were less striking for HCV (because of
the high underlying prevalence) but still revealed
favourable results for NSP (60% HCV prevalence for
cities with NSP compared to 75% for those without
NSP) [61].
There have been publications evaluating harm
reduction policies within countries. While these studies
do not directly test the effectiveness of the harm
reduction policy approach, they do lend data to the
problem. In Australia, an early review by Hawks &
Lenton [183 summarised the changes in drug use and
harms over a 10-year period in Australian history, from
when harm minimisation was introduced as the
national policy approach. They concluded that there
is evidence for reductions in tobacco and alcohol
consumption, reductions in risk behaviour among
injecting drug users, low prevalence of HIV and low
numbers of AIDS cases [183].
In Germany, Fischer [184] assessed the impact of
harm reduction through changes in drug use, activities
of law enforcement personnel, criminal activities and
drug-related hospital presentations—all of which were
reduced in association with the new harm reduction
programmes. Somaini et al. [185] reported an 80%
reduction for HIV, HCV and HBV in injectors who had
commenced injecting since the introduction of harm
reduction measures in Switzerland. There are also
optimistic reports from New York, a city that experi-
enced one of the largest HIV epidemics in the
developed world. Des Jarlais et al. [186] report a
‘substantial and consistent’ decline in the HIV infection
in those entering detoxification in conjunction with
increases in the use of HIV prevention services,
particularly NSP and HIV testing and counselling.
Kumaranayake et al. [187 modelled the cost-
effectiveness of a harm reduction programme in

Eastern Europe (Belarus) using simulations that
estimated the number of HIV cases averted, demon-
strating high cost-effectiveness [187]. In another
example of mathematical modelling, an analysis of the
cost-effectiveness of the National AIDS Demonstration
Research Program demonstrated that the programme
was cost-saving overall (through averted HIV infec-
tions) [100].
Not all the reports have been positive. Continued
high prevalence and incidence of HCV has occurred in
spite of good coverage of harm reduction interventions
[188 – 190]. Typical of this work is the study by Patrick
et al. [191], who conclude that the ‘harm reduction
initiatives deployed in Vancouver during the study
period proved insufficient to eliminate hepatitis C
transmission in this population’ [191].
There are a number of difficulties in interpreting the
evidence for harm reduction as a policy approach.
Issues include the potential differences between actual
programmes versus the overall policy stance; a myriad
of background factors (underlying prevalence, history
of policies); cultural differences in implementation; and
counting differences for key statistics and variables.
Notwithstanding these points, the data point to the
effectiveness of harm reduction as a policy approach.
Summary and conclusions
The strict definition of harm reduction employed
here—reducing harm, not use—has meant that some
programmes, such as pharmacotherapy maintenance or
controlled drinking, have been excluded from this
review. In addition, the formal definition of efficacy and
effectiveness, as tested through experimental studies,
has been used. This excludes much process evaluation
research, anecdotal and case study reports. However,
this approach gives clarity to the degree of ‘scientific’
evidence for the selected harm reduction interventions.
For alcohol, current harm reduction efforts of known
efficacy and effectiveness are those that reduce drink
driving (RBT and interventions for drink drive offen-
ders). The evidence in relation to interventions that
reduce injury and violence is growing but not yet
strong. For tobacco, new products that reduce the
emission of toxicants and low combustion cigarette-like
products are being developed and tested. However,
there is scepticism and reluctance among the tobacco
control community to embrace such harm reduction
strategies. Injecting drug use has seen the strongest
growth of harm reduction interventions complemented
by strong evidence to support efficacy and effectiveness
and cost-savings for NSP and outreach. There are
equivocal findings for brief interventions, education
and HIV testing. NIROA, naloxone distribution and
SIF are interventions for which there is emerging
positive evidence.
Efficacy and effectiveness of harm reduction strategies 619
Harm reduction provides an overarching framework
for global drug policies. Analysis of the processes by
which countries choose and adopt drug policies is
beyond the scope of this review. None the less, recent
publications have highlighted a degree of convergence
across European countries in relation to harm reduc-
tion approaches [192,193]. We require more research
at this broad framework level, especially in light of the
failure by many policy makers to adopt cost-effective
harm reduction interventions.
Acknowledgements
This work was completed in association with the Drug
Policy Modelling Project, funded by the Colonial
Foundation Trust. There are no conflicts of interest
to declare. The authors thank Anna Guthrie for her
assistance in sourcing reference materials. The paper
was completed while Alison Ritter was a Visiting Fellow
at the Regulatory Institutions Network, ANU. We
appreciate the thoughtful input from the anonymous
reviewers.
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