Distributing Smoking Supplies: A Strategy for Harm Reduction Programs to Reach New Communities With Overdose and Infectious Disease Prevention

The United States is experiencing a deadly drug overdose epidemic, resulting in over 100 000 deaths annually.1 Syringe services programs (SSPs) are uniquely positioned to address the overdose crisis by reaching people who use drugs (PWUD) with harm reduction supplies, building trust and connecting them to a broader range of health and social services. Distributing smoking supplies can help SSPs address substance use risks, reach a more diverse population of PWUD, enhance their ability to avoid infectious diseases such as HIV and viral hepatitis, and prevent overdose. Background In recent years, three notable shifts in overdose trends have occurred: an increase in smoking-involved overdose deaths, an increase in stimulant-involved overdose deaths, and worsening racial inequities.1-5 These trends reflect interconnected factors, such as shifts in the drug supply and drug use patterns, as well as social and political factors. For example, the increase in smoking-involved deaths is likely the result of an increase in smoking and decrease in injection as a method for consuming opioids, stimulants, and other drugs.6,7 The increase in stimulant-involved overdose deaths may reflect an increased presence of fentanyl in the cocaine and meth supplies.8 Worsening racial inequities may partially reflect reduced access to harm reduction supplies among Black, Indigenous, and other people of color.9 Ultimately, these trends suggest a need to better reach people who smoke, people who use stimulants, and PWUD of color with harm reduction services. SSPs were initially established to distribute sterile syringes and reduce the approximately 10% of HIV cases and over half of hepatitis C cases attributable to injection drug use.10,11 Over time, SSPs have adapted to meet the evolving needs of PWUD, serving as a bridge to health and social services for those facing barriers to accessing traditional healthcare systems.12 For instance, nearly all SSPs (96%) now offer naloxone, an opioid overdose reversal medication, and during the COVID-19 pandemic, over half (54%) provided COVID-19 vaccinations.13 As of 2021, approximately half of SSPs distributed safer smoking supplies.13 These supplies include pipes or aluminum foil for smoking, mouthpieces to protect lips from burns, and tools like screens or push sticks for handling drugs.14-17 Distributing these supplies can prevent the harms associated with sharing smoking equipment (eg, COVID-19 and other infectious diseases) or using makeshift or broken equipment (eg, cuts, burns, and other injuries).18-25 Smoking supplies can also serve as an outreach tool, helping SSPs engage and build trust with people who smoke. Smoking also poses lower risk for acquiring and transmitting HIV and hepatitis infections. In addition, limited but emerging evidence suggests that smoking might pose lower risk for overdose, although further research is needed to understand this relationship.6,26,27 Project Overview In March 2023, NACCHO conducted a survey to better understand the current landscape of safer smoking supplies distribution.28 The survey was completed by a convenience sample of 370 public health and harm reduction organizations from 44 states, plus DC and Puerto Rico—about half of whom distribute smoking supplies. The survey provided insight into current practices, factors that affect implementation, and outcomes. Respondents reported high demand for smoking supplies and shared that distributing smoking supplies could help harm reduction programs expand and diversify their reach and improve the health of their participants. Building on these findings, NACCHO funded 6 SSPs to evaluate the effects of their existing smoking supplies distribution programs. Sites used mixed methods, combining retrospective program data, surveys, focus groups, and interviews. While sites used different methods and indicators, several key themes emerged. All sites found that distributing smoking supplies enabled them to reach new and more diverse populations. Additionally, participants across all sites reported health and/or social benefits associated with transitioning from injecting to smoking. Project Findings All six sites reported a substantial increase in participant encounters after initiating smoking supplies distribution. At 1 site, analysis of administrative data revealed a 106% increase in average annual visits. Another site found a 50% increase in client encounters over an 11-month period when comparing data from before and after smoking supplies distribution. Sites reported that demand for smoking supplies was immediate, bringing in new participants as soon as they began distribution and remained consistent over time. Sites confirmed the increase in visits was directly linked to smoking supplies distribution. One site’s survey revealed 40% of participants began visiting the SSP specifically for smoking supplies. Another site found that 91% of new clients engaged after initiating smoking supplies received smoking supplies exclusively (ie, they did not pick up any syringes). For some sites, increases in encounters translated to opportunities to connect with new communities. One site’s analysis of participants’ interviews revealed that distributing smoking supplies allowed them to better reach people who use crack/cocaine. Other sites reported increased engagement with Black, American Indian, and transgender participants after initiating smoking supplies distribution. These findings suggest that by distributing smoking supplies, SSPs can expand and diversify their reach, most notably among people who smoke, but also among people who use stimulants and PWUD of color. Given recent increases in overdose deaths among these three overlapping populations, distributing smoking supplies is a promising strategy to reach people who are inequitably impacted by the overdose epidemic and connect them with overdose prevention and other services. Five sites reported a reduction in syringe encounters since the inception of safer smoking supplies distribution. Two sites explored this trend through interviews/focus groups with participants who shared the following: (1) participants are aware that smoking drugs decreased the risk of disease transmission, (2) participants appreciate that smoking does not leave track marks/scars, (3) participants perceive less stigma associated with smoking, (4) participants perceive a lower risk of overdose from smoking, and (5) smoking is perceived as more convenient. Sites explored participant interest in smoking in various ways. One site reported a 3.7% annual decrease in syringes distributed since smoking supplies were introduced, despite increased client encounters. Another site explored whether to expand their offerings to include hammer pipes (typically used for opioids) in addition to the stem/straight pipes (typically used for crack) they already offered. A survey conducted among people who access injection supplies revealed that half would be interested in trying a hammer pipe, with respondents noting a desire to try a safer option and avoid track marks. One site explored impacts on wound care and overdose among those who had made the transition from injecting to smoking. Seventy-eight percent of these participants indicated that soft tissue injuries decreased, and 59% indicated nonfatal overdoses decreased since switching to smoking. These findings suggest that PWUD are interested in transitioning from injecting to smoking due to perceived health and other benefits—although further research is needed to understand the impacts of transitioning from injecting to smoking drugs. Several sites found smoking patterns depended on the availability of smoking supplies. In 1 site’s survey, 72% of participants agreed with the statement “whether I smoke or inject depends on the supplies I have available.” In another site’s survey, 77% of participants reported that the number of syringes they picked up decreased due to the availability of smoking supplies at the SSP. All sites expressed challenges with keeping up with the demand for smoking supplies, and half reported that they had been forced to suspend distribution at times in the past (eg, due to budgetary constraints). SSPs need sustainable and flexible funding that enables them to consistently offer smoking supplies, respond to participants’ evolving needs, and support their participants in adopting and maintaining safer drug use behaviors. Sites identified promising practices that can help SSPs better engage and serve their participants. They emphasized the importance of being a safe, nonjudgmental, and stigma-free space for participants from varying backgrounds and experiences. SSPs should also work to maintain consistent supplies, expand hours, and provide the supplies that their participants want, which can be determined through engagement and evaluation. To foster strong relationships and support adoption of healthier drug use practices, peers with lived experience and who reflect the community served can assist incoming participants. Conclusion Distributing smoking supplies allows SSPs to reach a broader population of PWUD with a more comprehensive array of supplies and services. While further research and evaluation are needed to more fully understand the relationship between smoking and overdose, our program evaluation indicates that the distribution of smoking supplies allows SSPs to better reach populations that are inequitably impacted by overdose. The findings of this project also suggest that many PWUD are interested in smoking more in lieu of injecting. In short, distributing smoking supplies is paramount to reaching people who smoke and preventing overdose and infectious diseases.