Effectiveness of responses to nicotine and opiate addiction (letter)

Rapid Response to: Alexander W Macara, Should doctors advocate snus and other nicotine replacements? BMJ 2008; 336: 359. Most authorities believe the harm reduction approach involving education and free availabilty of needles and syringes helped head off a potential epidemic of HIV infection amongst intravenous drug users in Australia from the mid-1980's. The evidence for harm reduction's effectiveness in reducing opiate overdose mortality is, however,much less clear cut. Until the advent of the "heroin drought" in Australia around Christmas 2000, heroin mortality rates had been increasing substantially and inexorably during the 1990's. At the same time, places on methadone maintenance programs had also been markedly increasing. Of course, it could be argued that heroin mortality may have been higher without methadone availability. Nonetheless, the evidence is clear that a sudden reduction in heroin supply had a more dramatic effect on heroin mortality in Australia than ever previously witnessed. On the Australian tobacco front, aggressive abstinence-orientated control efforts spear-headed by graphic television advertisements and smoke-free legislation have produced declines in smoking prevalence which have been the envy of many other countries. While nicotine replacement therapies are readily available, these have been promoted as a way of quitting not reducing smoking. Whether snus availability would increase the effectiveness of tobacco control efforts or serve as a distraction and perhaps also confuse the public message about tobacco is by no means clear.