Safer Solutions: Rethinking Smoking Cessation for People Who Use Drugs

From sterile syringes to naloxone for overdose reversal, harm reduction has long been part of saving lives and creating pathways to wellness for people who use drugs. While the public health community largely supports harm reduction for opioids and other drugs, there’s a curious disconnect when it comes to similarly evidence-backed harm reduction for another substance: tobacco. In fact, many public health leaders and healthcare providers remain highly resistant to tobacco harm reduction.

That’s a problem, because people who use drugs are more likely to die from smoking tobacco than from an opioid overdose. The reality is that traditional cessation methods don’t work for many people in this population: In the United States, more than 75 percent of people who use drugs also smoke cigarettes (compared to less than 10 percent of all U.S. adults). That makes harm reduction—in this case, switching from cigarettes to lower-risk alternatives like vapes and nicotine pouches—an especially important approach to have available on the menu of options for cessation.

We recently sat down with Gaby Zabala Alemán of National Harm Reduction Coalition (NHRC) and three individuals who work with people who use drugs to talk about the challenges and opportunities in integrating tobacco harm reduction into traditional harm reduction spaces:

• Kevin Garcia, Substance Use Specialist, Points West Syringe Services Program (Lakewood, Colorado)
• Cyndee Clay, Executive Director, HIPS (a Washington, D.C.-based harm reduction organization)
• Annie Kleykamp, Director of Research and Evaluation, Maryland Addiction Consultation Service

Here’s what we learned.

1. Our panelists’ personal journeys led them to tobacco harm reduction.

Clay was a lifelong smoker who “rolled [her] eyes at the tobacco harm reduction conversation” because she was focused on people dying from overdose in the short term. She changed her mind when she realized she could quit smoking herself by switching to vaping. Garcia started vaping nicotine while in outpatient care for substance use disorder. Kleykamp’s father struggled with drug use and smoking for decades—an experience that informs her research.

2. Accurate information is sorely lacking.

Despite stemming from the same principles of person-centered care and “any positive change,” many healthcare professionals don’t consider harm reduction for tobacco and harm reduction for drug use as equally valid. Kleykamp noted that many providers still believe nicotine causes cancer (it doesn’t; it’s the combustion and smoke that deliver carcinogenic toxins into the body) and that vaping is as dangerous to health as smoking (also untrue). Similarly, Garcia regularly hears program participants say that vapes are worse for health than smoking.

3. Tobacco harm reduction can meet unique needs.

For many people, it’s not just physical dependence on nicotine that makes it difficult to quit smoking. Garcia said that some people who smoke depend on “rituals” like the hand-to-mouth action of smoking a cigarette. He said that switching to vaping can help replicate those rituals with fewer health risks. Clay shared another potential benefit: People who smoke tobacco face a lot of stigma—including in healthcare and housing—and “going into a healthcare appointment smelling like smoke” can trigger worse treatment and negatively affect patients’ willingness to seek future care. Switching to vapes or nicotine pouches (which don’t carry a lingering scent) could have the added benefit of reducing that stigma.

4. Quitting smoking is possible for people who use drugs—and harm reduction helps.

Quitting smoking and addressing problematic drug use can happen at the same time, especially when a harm reduction mindset is applied to both. Kleykamp shared early findings from her recent study on older adults at a Baltimore methadone clinic, where participants have smoked for 44 years on average. She offered nicotine vapes and basic tobacco harm reduction education to a group of individuals with no interest in quitting smoking. Eight weeks later, although Kleykamp had given participants no explicit instructions to try quitting their tobacco use, most had achieved a significant reduction in cigarettes smoked per day, with six of the 17 individuals stopping smoking entirely (compared to zero in a control group).

Other panelists said that sharing their personal experiences with tobacco harm reduction helped spread the word about its potential. Zabala Alemán said of her community drug use harm reduction work in Puerto Rico, “[P]art of the way I connected with the people I was serving was by giving them a cigarette … it builds trust.” When she switched to vaping herself, she spread the message of tobacco harm reduction in a peer-to-peer manner by talking about the health benefits she felt. Clay said that she and other HIPS staff have switched to vaping and that program participants have started to notice.

What’s next?

Tobacco harm reduction is a growing topic of interest within the drug harm reduction community, but there is more work to do. Kleykamp is focused on reminding people that smoking is concentrated in forgotten populations that deserve our attention—something Safer Solutions has addressed before. Clay told us she intends to continue engaging in peer-to-peer education, a strategy that goes back to the earliest days of harm reduction for intravenous drug users. Garcia said he would like to offer tobacco harm reduction support to the people he serves; however, a lack of dedicated funding is a barrier. He hopes harm reduction programs will embrace harm reduction in tobacco the way they have in drug use so that frontline workers like himself are empowered to integrate this important approach into their work.