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Abstract
Context: Regular alcohol use is a predominant risk factor for disease, injury, and social harm. While robust evidence is advocating for implementing interventions to reduce the harms of illegal substance use, less literature is dedicated to identifying and understanding interventions aiming at reducing the various harms associated with alcohol.
Objectives: This review describes how alcohol harm reduction (AHR) interventions are currently conducted and analyzes the facilitators and barriers identified by the studies on their efficacy.
Method: This scoping review with evidence appraisal included articles published between 2011 and 2022, addressing one or more AHR interventions for population of at least 18 years (including alcohol user who have an addiction but also alcohol user with harmful drinking), conducted in North industrialized countries (Europe, Nort America, Australia).
Results: Among the 61 articles selected, we identified several forms of support (face-to-face or remote, support in residential settings, structural interventions, and interventions created upon spontaneous initiatives), and strategies of intervention were also analyzed (the ones based upon learning and skill development, the ones based upon psychological support, the ones focusing upon socio-economic conditions, strategies focusing on the coordination and adaptation of the care system, and those strategies based on peer support). The facilitators linked to fundamental characteristics of the interventions were the promotion of empowerment and autonomy of beneficiaries, setting objectives tailored to individual needs, professionals harmonizing their values, evidence-based interventions taking into account cultural contexts, and comprehensive and holistic support. Practical facilitators from the intervention process consist of increasing the number of sessions, involvement, and formation of members of staff, disposing of the necessary resources, and using technological tools.
Discussion: The sheer variety of AHR interventions demonstrates that this is a fertile field in terms of intervention design and innovation. This work illustrates the importance of designing effective, adapted harm reduction interventions, prioritizing interventions that make support more accessible to more people. This also prompts us to consider the potential benefits of invoking proportionate universalism in the design of AHR interventions in order to operationalize alcohol harm reduction philosophy. accessible to more people.
Keywords: Addiction; Alcohol; Alcohol harm reduction; Harm reduction; Interventions; Public health; Scoping review.

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Abstract
Background: Internationally, strategies focusing on reducing alcohol-related harms in homeless populations with severe alcohol use disorder (AUD) continue to gain acceptance, especially when conventional modalities focused on alcohol abstinence have been unsuccessful. One such strategy is the managed alcohol program (MAP), an alcohol harm reduction program managing consumption by providing eligible individuals with regular doses of alcohol as a part of a structured program, and often providing resources such as housing and other social services. Evidence to the role of MAPs for individuals with AUD, including how MAPs are developed and implemented, is growing. Yet there has been limited collective review of literature findings.
Methods: We conducted a scoping review to answer, "What is being evaluated in studies of MAPs? What factors are associated with a successful MAP, from the perspective of client outcomes? What are the factors perceived as making them a good fit for clients and for communities?" We first conducted a systematic search in PubMed, Embase, PsycINFO, CINAHL, Sociological Abstracts, Social Services Abstracts, and Google Scholar. Next, we searched the gray literature (through focused Google and Ecosia searches) and references of included articles to identify additional studies. We also contacted experts to ensure relevant studies were not missed. All articles were independently screened and extracted.
Results: We included 32 studies with four categories of findings related to: (1) client outcomes resulting from MAP participation, (2) client experience within a MAP; (3) feasibility and fit considerations in MAP development within a community; and (4) recommendations for implementation and evaluation. There were 38 established MAPs found, of which 9 were featured in the literature. The majority were located in Canada; additional research works out of Australia, Poland, the USA, and the UK evaluate potential feasibility and fit of a MAP.
Conclusions: The growing literature showcases several outcomes of interest, with increasing efforts aimed at systematic measures by which to determine the effectiveness and potential risks of MAP. Based on a harm reduction approach, MAPs offer a promising, targeted intervention for individuals with severe AUD and experiencing homelessness. Research designs that allow for longitudinal follow-up and evaluation of health- and housing-sensitive outcomes are recommended.
Keywords: Alcohol use disorder; Harm reduction; Homelessness; Managed alcohol program; Scoping review.

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Abstract
Background: Worldwide, alcohol-related road traffic accidents represent a major avoidable health risk. The aim of this study was to evaluate the accuracy of self-estimating the degree of acute alcohol intoxication regarding the legal driving limit, and to identify risk factors for misjudgement.
Methods: In this prospective randomised controlled crossover trial, 90 social drinkers (mean age 23.9 ± 3.5 years, 50% female) consumed either beer or wine. Study group subjects were made aware when exceeding the legal driving limit (BrAC = 0.05%). Controls received no information about their BrAC. For crossover, beer or wine were consumed in the opposite order.
Results: 39-53% of all participants exceeded the legal driving limit whilst under the impression to be still permitted to drive. Self-estimation was significantly more accurate on study day 2 (p = 0.009). Increasing BrAC positively correlated with self-estimation inaccuracy, which was reproducible during crossover. Multiple regression analysis revealed fast drinking and higher alcohol levels as independent risk factors for inaccurate self-estimation.
Conclusions: Social drinkers are commonly unaware of exceeding the legal driving limit when consuming alcohol. Self-estimating alcohol intoxication can be improved through awareness. Dedicated awareness programs, social media campaigns and government advice communications should be utilised to address this avoidable hazard. Trial registration The trial was registered prospectively at the Witten/Herdecke University Ethics Committee (trial registration number 140/2016 on 04/11/2016) and at the DRKS-German Clinical Trials Register (trial registration number DRKS00015285 on 08/22/2018-Retrospectively registered). Trial protocol can be accessed online.
Keywords: Alcohol-related road traffic accident; DUI; Drink-driving; Driving under the influence; Perceived alcohol intoxication; Public health concern; Road safety.

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Abstract
Harm-reduction programs, first developed in an attempt to mitigate the adverse consequences of illicit drug use, can be applied to alcohol-prevention programs as well. In fact, the movement toward harm reduction in illicit drug prevention may be closely paralleled by a similar trend in the alcohol-prevention field. Harm-reduction approaches to alcohol aim to diminish the negative consequences of intoxication (e.g., by using special glassware that breaks into fine particles instead of sharp pieces, thus reducing the chance of injury during pub fights). Such measures may receive increased attention as public support declines for restrictions on alcohol availability and new evidence emerges on the potential benefits of moderate alcohol consumption. In addition, analyses suggest that harm reduction may be an efficient approach, because it often focuses on minimizing heavy-drinking occasions, which predict drinking problems more strongly than level of consumption.
Keywords: harm reduction policy, prevention strategy, prevention goals, prevention of AOD associated consequences, illicit drug, alcoholic beverage, public health, legal regulation, AOD education, AOD availability, AODR (alcohol and other drug related) injury prevention, bar, moderate AOD use, heavy AOD use.

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Background
People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings.
Methods
A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature.
Findings
The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives.
Conclusion
This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.

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Background
ETHER (“Education THEérapeutique pour la Réduction des dommages en alcoologie” or Therapeutic education for alcohol-related harm reduction) is a multicentre community-based mixed-methods study, which aims to evaluate the effectiveness of the innovative therapeutic patient education (TPE) programme ‘Choizitaconso’ in a sample of French people with alcohol use disorder (people with AUD). Choizitaconso teaches people with AUD psychosocial skills to help them (re)establish controlled drinking and reduce alcohol-related harms. Recruitment started in October 2019. We present here the protocol of the ETHER study.
Methods
ETHER’s quantitative component involves a 6-month controlled intervention study which evaluates Choizitaconso’s effectiveness by comparing 30 people with AUD following the programme with a control group of 60 people with AUD not enrolled in it, using a questionnaire co-constructed by the research team and members of the people with AUD community. Thirty-four alcohol-related harms are assessed and summed to provide an individual measure of the ‘harm burden’ from consuming alcohol (primary outcome). Secondary outcomes are anticipated and internalized stigma, alcohol consumption measures, craving for alcohol, coping strategies, health-related quality of life, self-confidence to control or abstain from drinking, treatment self-regulation, anxiety and depressive symptoms, alcohol-related neuropsychological impairments, and capabilities (a measure of wellbeing in adults). Data will be collected in face-to-face and phone-based interviews at enrolment and 6 months later. Linear regression models will be used to assess the impact of the TPE programme on changes in the primary and secondary outcomes, while adjusting for other correlates and confounders. The study’s qualitative component comprises semi-structured interviews with 16 people with AUD who have already completed the TPE programme at least 6 months before the interview. Qualitative interviews will be analysed using thematic analysis.
Results and conclusions
ETHER is the first evaluation study of an innovative TPE programme specifically designed to reduce alcohol-related harms and reach controlled drinking in France. The involvement of the people with AUD community in selecting which experienced and perceived alcohol-related harms to measure ensures that ETHER will provide healthcare staff and researchers with a relevant set of harm reduction criteria for use in future research. Finally, ETHER will provide scientific justification for implementing novel alcohol-related harm reduction approaches and champion controlled drinking as a therapeutic goal.

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Background: The 2010 World Health Organization Global Strategy to Reduce the Harmful Use of Alcohol recommends countries adopt evidence-based interventions.
Aim: To update, summarize, and appraise the methodological rigour of systematic reviews of selected alcohol control interventions in the Strategy.
Methods: We searched for systematic reviews across PUBMED, EMBase and The Cochrane Library in 2016 and updated in 2017 with no language limits. Two investigators independently in duplicate conducted screening, eligibility, data extraction, and quality assessment using the ROBIS tool. We categorized interventions according to the WHO recommendations, and rated reviews as at high, low or unclear risk of bias. We applied a hierarchical approach to summarizing review results. Where overlap existed, we report results of high quality reviews and if none existed, by most recent date of publication. We integrated the ROBIS rating with the results to produce a benefit indication.
Results: We identified 42 systematic reviews from 5,282 records. Almost all eligible reviews were published in English, one in German and one in Portuguese. Most reviews identified only observational studies (74%; 31/42) with no studies from low or lower-middle income (LMIC) countries. Ten reviews were rated as low risk of bias. Methodological deficiencies included publication and language limits, no duplicate assessment, no assessment of study quality, and no integration of quality into result interpretation. We evaluated the following control measures as possibly beneficial: 1) community mobilization; 2) multi-component interventions in the drinking environment; 3) restricting alcohol advertising; 4) restricting on- and off-premises outlet density; 5) police patrols and ignition locks to reduce drink driving; and 6) increased price and taxation including minimum unit pricing.
Conclusions: Robust and well-reported research synthesis is deficient in the alcohol control field despite the availability of clear methodological guidance. The lack of primary and synthesis research arising from LMIC should be prioritized globally.

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Background: People experiencing homelessness are disproportionately affected by harms related to alcohol use. Indeed, their alcohol dependence is associated with numerous physical and mental health problems along with strikingly high rates of alcohol-related mortality. Recent research has extensively examined alcohol use patterns among people experiencing homelessness in an effort to develop interventions and treatments for this problem. However, only a few studies have incorporated the perspectives of the individuals under study about their drinking or examined the ways in which they manage the associated harms. To bridge this gap, we conducted a qualitative study exploring the relation between the drinking motives, risky drinking patterns and harm reduction practices of a group of people (n = 34) experiencing homelessness in Montreal, Canada.
Methods: The qualitative methods we used consisted of semi-structured interviews (n = 12) and focus groups (n = 2, with a total of 22 participants). The content of the collected data was then analyzed.
Results: Participants identified their various motives for alcohol use (coping with painful memories, dealing with harsh living conditions, socializing/seeking a sense of belonging, enjoying themselves/having fun); their risky drinking patterns (binge drinking, mixing alcohol with drugs, non-beverage alcohol drinking, failing to keep sufficient alcohol on hand to prevent acute withdrawal, drinking in public settings); their harm reduction practices (planning how much to drink, keeping a supply of alcohol to prevent acute withdrawal, hiding to drink, concealing alcohol, drinking alone, drinking/hanging out with others, drinking non-beverage alcohol, and taking benzodiazepines, cocaine or other stimulant drugs); and the rationales underpinning their alcohol use and harm reduction practices.
Conclusion: Associating the drinking motives of a group of study participants with their risky drinking patterns and harm reduction practices shed light on their rationales for alcohol use, yielding insights that could be used to better tailor policies and interventions to their needs.
Keywords: Alcohol dependence; Harm reduction; Motives for alcohol use; Patterns of alcohol use; People who experience homelessness; Risk management.

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Background: The World Health Organization global strategy on alcohol called for  municipal policies to reduce the harmful use of alcohol. Yet, there is limited evidence that documents the impact of city-level alcohol policies.
Methods: Review of reviews for all years to July 2017. Searches on OVID Medline Healthstar, Embase, PsycINFO, AMED, Social Work Abstracts, CAB Abstracts, Mental Yearbook, Health and Psychosocial Instruments, International Pharmaceutica Abstracts, International Political Science Abstracts, NASW Clinical Register, and Epu Ahead of Print databases. All reviews that address adults, without language or dat restrictions resulting from combining the terms (“review” or “literature review” or “review literature” or “data pooling” or “comparative study” or “systematic review” o “metaanalysis” or “pooled analysis”), and “alcohol”, and “intervention” and (“municipal” or “city” or “community”).
Results: Five relevant reviews were identified. Studies in the reviews were all fro hig income countries and focussed on the acute consequences of drinking, usually wit on target intervention, commonly bars, media, or drink-driving. No studies in the review reported the impact of comprehensive city-based action. One community cluste randomized controlled trial in Australia, published after the reviews, failed to fin convincing evidence of an impact of community-based interventions in reducing adult harmful use of alcohol.
Keywords Cities; Municipalities; communities; harmful use of alcohol. 

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The evidence for the efficacy of harm reduction approaches to harmful alcohol use has accumulated over the past 30 years. Self-determination theory (SDT; Ryan and Deci 2017) offers a useful framework for understanding why people engage in alcohol harm reduction behaviors, as well as for delineating active ingredients of harm reduction interventions and individual characteristics that influence response to intervention. In the current paper, we sought to advance a research agenda for applying SDT to alcohol harm reduction behaviors. Specifically, we provide specific examples of the utility of SDT in advancing research on alcohol harm reduction behaviors and provide recommendations for future studies to address issues related to measurement, generalizability, temporal directionality, and causal relationships in examining the constructs of SDT and alcohol harm reduction behaviors. We also suggest that future research apply SDT to advance the understanding of how, why, and for whom harm reduction interventions are most effective. Finally, we provide recommendations for how SDT could potentially be applied to develop novel alcohol interventions.
Keywords: self-determination theory, alcohol use, harm reduction behaviors, motivation

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