Can switching from injecting to smoking drugs save a life? Or does it just encourage people to keep using harmful substances? This debate has played out in the media and legislatures across the United States in recent years, as harm reductionists advocated for permissions to distribute so-called safer smoking kits while opponents claimed the practice simply enables drug use without reducing risks. In some states, this latter group took steps to exclude smoking equipment—such as glass pipes—from the supplies that harm reduction programs were allowed to distribute. In others, lawmakers used harm reduction groups’ unauthorized distribution of smoking supplies to justify closing down syringe services programs (SSPs).

Nonetheless, evidence suggests that many people who use drugs want better access to these supplies and that many harm reductionists believe they are an important resource to offer their participants. The remainder of this article takes a closer look at why that is.

State Paraphernalia Laws Prior to 2024
In most states, drug paraphernalia—equipment used to prepare or consume illicit substances—is illegal. There are a handful of exceptions:

Mode of Administration and Health
Smoking substances reduces the risk of contracting many infectious diseases, including HIV. In addition, people who smoke rather than inject avoid soft-tissue wounds and infections at the injection site as well as associated endocarditis. Some research also suggests that people who smoke drugs are less likely to experience drug dependence and have a lower incidence of co-occurring physical and mental health issues, although the direction of this relationship is less clear.

However, while generally less risky than injection, smoking drugs does come with its own potential health consequences. For example, sharing a pipe can transmit some communicable diseases, including COVID-19, and smoking itself can increase risk for chronic obstructive pulmonary disease.

When it comes to overdose, it is not yet clear whether smoking reduces overdose risk in a drug environment dominated by fentanyl. Some research does suggest smoking reduces overdose risk in certain settings, perhaps because people tend to smoke small quantities at a time. For example, a recent study in California found that people who exclusively smoked fentanyl were 40 percent less likely than people who injected the drug to have experienced a nonfatal overdose in the past three months. Nonetheless, an analysis of population-level data across the country found that, as the number of people smoking fentanyl has increased (and the number injecting has decreased), overdose trends have shifted such that the majority of fatal overdoses may now be attributable to smoking opioids rather than  injecting them.

Safer Smoking Kits Are About Meeting People Where They Are
In addition to the fact that safer smoking kits have the potential to reduce certain health risks for people who use drugs, many harm reductionists have a philosophical justification for distributing them. Simply put, a central tenet of harm reduction is meeting program participants where they are in order to provide compassionate care and support aimed at empowering them to make any positive change. Data indicate that most people who use illicit drugs probably do not inject, and those who do inject drugs are disproportionately white, non-Hispanic men. Furthermore, a growing body of evidence suggests that many people are switching from injecting to smoking.

Making safer smoking kits available to their participants is one way harm reduction organizations can meet individuals who smoke drugs where they are. This service in turn connects them with an array of resources and services that go well beyond smoking equipment—from overdose reversal education and medications to referrals for substance use disorder treatment. 

What to Watch For
As an organization that supports limited, effective government, R Street discourages lawmakers from overregulating SSPs and other harm reduction organizations. These types of organizations are good at adapting quickly to real-world changes, such as novel drug supply adulterants or shifts in behaviors related to drug use, but only when given the flexibility to do so. Nonetheless, improving population health outcomes requires governments to identify health priorities and to prioritize those interventions that represent the most cost-effective use of taxpayer dollars. This means keeping up with the research. To make the smartest decisions around smoking versus injecting drug use, there is still more to learn about how smoking versus injecting fentanyl affects overdose risk; how polydrug use plays into this risk; what smoking- or injection-related risks may emerge alongside novel adulterants; and whether providing smoking or other noninjection supplies could help close racial and gender gaps in access to harm reduction and treatment services.