Promises and pitfalls of safer smoking supply distribution in the United States: a thematic analysis of open-ended survey questions from harm reduction organizations

With rising prevalence of smoking unregulated drugs across the United States, there is a need for more community-based distribution of safer smoking supplies (e.g., glass pipes) to reduce health harms for people who smoke drugs. While smoking supplies are increasingly offered through harm reduction organizations (HROs), which have predominantly focused on addressing injection-related harms, little is known about HROs’ experiences implementing this relatively novel service. Between November 2023–January 2024, we administered a survey with closed- and open-ended questions about safer smoking supplies to representatives of U.S. HROs. Thematic analysis of responses to open-ended survey questions identified themes related to organizations’ motivations and experiences implementing safer smoking supplies, including challenges with addressing smoking drug use in the communities they serve. Among 118 HROs responding to the survey, most were community-based organizations (74%) and had implemented safer smoking supplies (67%). From open-ended responses, the most common motivations for distributing safer smoking supplies included shifting local drug markets (e.g., from heroin to fentanyl) and increased community demand. Offering smoking supplies had positive implications for organizations, including improved engagement with previously underserved communities—such as people who primarily smoke drugs, and younger, unhoused, and racially and ethnically minoritized individuals. Funding restrictions presented a major challenge to implementing safer smoking supplies, and some respondents expressed concerns about potential negative health consequences of smoking drugs, including mouth and lung problems. Many U.S. HROs have implemented safer smoking supplies, resulting in improved engagement of previously underserved communities in their evidence-based prevention services. However, concerns remain regarding the feasibility, sustainability, and health implications of safer smoking supply distribution. In the context of rapid transitions from injecting to smoking unregulated drugs in communities across the U.S., support for HROs and research on shifting drug consumption patterns and impacts are urgently needed.