Safer Solutions: Common Ground on Harm Reduction in Drugs and Tobacco

What do people who use drugs and people who smoke cigarettes have in common? The short answer: a lot.

Advocates for both groups know people have complex reasons for using substances, and agree that it doesn’t mean they don’t deserve better health or a better life. That’s why it’s a head-scratcher that there isn’t more collaboration across these issues. The overlap between people who use drugs and people who smoke is staggering—in fact, some data suggests that nicotine dependence may predict more frequent opioid use. And while only 12 percent of American adults smoke cigarettes, more than 75 percent of people with opioid use disorder smoke. People who use drugs face unique difficulties when trying to quit smoking, and tobacco smoking kills more people who use drugs than overdoses do, just on a different timescale.

Were these issues better integrated, we could create new opportunities to improve health holistically. Together, we could highlight their commonalities and build a powerful voice for comprehensive support of harm reduction in public policy.

Many similarities make a harm reduction approach important in both cases. Cigarettes can be addictive and hard to quit, and they are deadly on a massive scale. Opioids, too, can be extremely addictive, very hard to quit, and deadly. Both are highly stigmatized and hit some communities harder, including low-income individuals, minority communities, and veterans.

Many public health advocates support access to harm reduction tools for people who use drugs. These include syringe services programs, naloxone for overdose reversal, test strips to check for adulterants in drugs, and medications for opioid use disorder. These tools reflect the reality that drug use isn’t going to disappear and affirm that “any positive change” is good for individuals and society.

On the tobacco side, harm reduction tools can help people stay healthier even if they don’t quit nicotine altogether. There is growing scientific consensus that smokeless nicotine products like e-cigarettes and nicotine pouches present much lower health risk compared to combustible cigarettes. The Food and Drug Administration recently authorized marketing of several synthetic nicotine pouches, saying they “pose lower risk of cancer” than cigarettes and may help adults make the switch. This, too, is an “any positive change” mentality.

With so much in common, why would we tell people who use drugs and smoke cigarettes that they deserve harm reduction for one of these behaviors but must simply quit the other?

Perhaps political identity is a factor: While there is bipartisan support for some harm reduction policies, more conservative lawmakers have primarily supported harm reduction policies in tobacco, while more liberal lawmakers have primarily supported harm reduction policies in drugs.

Perhaps misinformation plays a role. False assertions about e-cigarettes persist, including the belief that nicotine vapes are as bad as or worse than cigarettes. We still see erroneous claims that vaping nicotine caused the rash of 2019 lung injuries known as EVALI, when we now know the culprit was an unregulated additive in illicit cannabis vapes called vitamin E acetate. We also hear claims that harm reduction strategies encourage drug use when the opposite is true—they can create strong pathways to recovery.

Perhaps the human issue of discomfort is at work. Harm reduction in drug use involves illegal substances, while harm reduction in nicotine involves products sold by companies that have been dishonest about the harms of smoking and continue to profit from selling deadly cigarettes in addition to reduced-risk products. These realities make some people uncomfortable—sometimes enough to hamper support for tools that can save people’s lives.

Whatever the reasons for these divides, thinking about people who use drugs and smoke cigarettes can help us see the contradictions inherent in treating smoking and drug use as if they require entirely different approaches.

The good news is that things are starting to change. In 2024, the National Harm Reduction Coalition (an organization with a long history of working in harm reduction in drug use) announced it would offer tobacco harm reduction support to its network of partners that serve people who use drugs. To help as many people as possible, both groups of harm reduction supporters must advocate for one another and for their shared interests. The recognition that these behaviors share quite a bit in common and show up together in many people’s lives could go a long way toward forging a coalition that cuts across traditional ideological lines.