Syringe services programs (SSPs) play a unique role in our public health and health care systems, reaching people who use drugs (PWUD) with harm reduction supplies, building trust and connecting them to a broader range of health and social services. Many PWUD face significant barriers and deterrents to accessing health services in traditional settings, but the nonjudgemental environment and the availability of harm reduction supplies at SSPs can create a safe space for them to access health services. SSPs have historically focused on the distribution of syringes, enabling them to reach people who inject drugs, but many are now offering smoking supplies to better reach people who primarily smoke their drugs. A new report from the National Association of County and City Officials (NACCHO) explores national trends related to smoking and highlights the findings of a recent evaluation project of smoking supplies distribution. The report demonstrates the importance of offering smoking supplies as an outreach strategy to reach people who smoke, and ultimately to prevent overdose and infectious diseases.

National Trends

In recent years, smoking has increased while injection has decreased as a method for consuming opioids, stimulants, and other drugs.^{1, 2} Consequently, the proportion of smoking-involved overdoses has increased while the proportion of injection-involved overdoses has decreased.³ Given these trends, it is more important than ever for SSPs to reach people who smoke with overdose prevention and other health services—and offering the supplies they need is an effective way to reach this population. As of 2021, approximately half of SSPs distributed safer smoking supplies.⁴ These supplies include pipes or aluminum foil for smoking, mouthpieces to protect lips from burns, and tools like screens or push sticks for the handling of drugs.^5,6,7,8

Findings from a Multi-Site Evaluation of Smoking Supplies Distribution

In 2023, NACCHO funded six 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.

All six sites found that distributing smoking supplies enabled them to reach new and more diverse populations. All reported a substantial increase in participant encounters after initiating smoking supplies distribution, with one site reporting a 106% increase in annual visits. Most sites shared that they didn’t publicly promote their new offerings, but that the increase in clients occurred immediately, suggesting a significant, unmet need for smoking supplies, and the power of word-of-mouth among PWUD. Sites were able to confirm the increase in visits was directly linked to the availability of smoking supplies. At one site, 40% of clients reported that they initially came to the SSP for these supplies, and another found that 91% of new clients accessed smoking supplies exclusively. Sites also shared that offering smoking supplies allowed them to diversify their reach, reporting increased engagement with populations such as people who use crack/cocaine or Black, American Indian, and Transgender people.

Read Our Article in the May Issue of JPHMP

Five sites reported a reduction in syringe encounters since the inception of safer smoking supplies distribution—despite the overall increase in participant encounters. This suggests that participants may be transitioning from injection to smoking due to the availability of smoking supplies. Through interviews and focus groups, sites learned that participants wanted to switch to smoking due to the perception that it was safer in terms of HIV, hepatitis, and overdose risk and due to the perception that it is more convenient and less stigmatized. Notably, smoking poses lower risk for acquiring and transmitting HIV and hepatitis infections and limited but emerging evidence suggests that smoking might pose lower risk for overdose, although further research is needed to understand this relationship.^{9, 10, 11}  One site surveyed participants to assess health benefits and found that 78% of participants who had transitioned from injection to smoking reported fewer soft tissue injuries and 59% reported fewer non-fatal overdoses.

Conclusion

The findings of this project suggest that distributing smoking supplies allows SSPs to expand and diversify their reach, better reaching people who smoke which has become critically important as smoking and smoking-involved overdoses are on the rise. Distributing smoking supplies may also encourage or facilitate a transition from injection to smoking, which could combat the spread of HIV and viral hepatitis, and which may even reduce overdose risk. To learn more about these findings, check out the new report from NACCHO here.

References

1. Kral AH, Lambdin BH, Browne EN, Wenger LD, Bluthenthal RN, Zibbell JE, Davidson PJ. Transition from injecting opioids to smoking fentanyl in San Francisco, California. Drug and Alcohol Dependence. 2021; 22:109003. https://doi.org/10.1016/j.drugalcdep.2021.109003
2. Karandinos G, Unick J, Ondocsin J, Holm N, Mars S, Montero F, Rosenblum D, Ciccarone D. Decrease in injection and rise in smoking and snorting of heroin and synthetic opioids, 2000-2021. Drug and Alcohol Dependence. 2024; 263:111419. https://doi.org/10.1016/j.drugalcdep.2024.111419
3. Tanz, L. J., Gladden, R. M., Dinwiddie, A. T., Miller, K. D., Broz, D., Spector, E., & O’Donnell, J. (2024). Routes of Drug Use Among Drug Overdose Deaths – United States, 2020-2022. MMWR. Morbidity and mortality weekly report, 73(6), 124–130. https://doi.org/10.15585/mmwr.mm7306a2
4. Centers for Disease Control and Prevention. Program and Operational Characteristics of Syringe Services Programs in the United States—2020 and 2021. National Syringes Services Programs Report 1. Published August 1, 2023. Accessed August 14, 2024.
5. California Department of Health. Issue Brief: Smoking Supplies for Harm Reduction. September, Published online 2020. Accessed October 30, 2024. https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/IssueBrief_SmokingSupplies_Web_ADA.pdf.
6. Singh S, Banta-Green C, Kingston S. Distribution of Safer Drug Smoking Supplies as a Public Health Strategy. Seattle, WA: Addictions, Drug & Alcohol Institute, University of Washington. Published online January 2022. Accessed October 30, 2024. https://adai.uw.edu/wordpress/wp-content/uploads/SaferSmokingBrief_2022.pdf
7. Reid MC, Oliphant-Wells T, Moreno C, Ketchum J, Fitzpatrick T, McMahan VM, Glick SN. High levels of interest in access to free safer smoking equipment to reduce injection frequency among people who inject drugs in Seattle, Washington. Drug Alcohol Depend Reports. 2023 May 2; 7:100163. https://doi.org/10.1016/j.dadr.2023.100163.
8. Edney, H, Martinez, JB, Armstrong, L, Rucker J, Santiago, P, Simkins MD, Wheeler, E, Asher, V, The Fentanyl Collective. Bevel Up. Published online 2022. Accessed October 30, 2024. https://www.bvlup.com/
9. Kral AH, Lambdin BH, Browne EN, Wenger LD, Bluthenthal RN, Zibbell JE, Davidson PJ. Transition from injecting opioids to smoking fentanyl in San Francisco, California. Drug and Alcohol Dependence. 2021; 227:109003. https://doi.org/10.1016/j.drugalcdep.2021.109003
10. Wang CW, Chuang HY, Chiang HC, Huang PC, Yu ML, Dai CY. Risk of hepatitis C virus infection in injecting and noninjecting drug users receiving opioid substitution therapy. J Chin Med Assoc. 2020; 83(5):454-460. https://doi.org/10.1097/JCMA.0000000000000312
11. Magerian CE, Bair L, Smith J, Browne EN, Wenger LD, Guzman L, Kral AH, Lambdin BH. Health risks associated with smoking versus injecting fentanyl among people who use drugs in California. Drug and Alcohol Dependence. 2024; 255:111053. https://doi:10.1016/j.drugalcdep.2023.111053

Acknowledgements

NACCHO staff Kat Kelley (Lead Analyst – Syndemics), Anjana Rao (Program Analyst – Harm Reduction), and Lisseth Guerra (Sr. Research and Evaluation Specialist) conducted this project and authored the referenced article, Distributing Smoking Supplies: A Strategy for Harm Reduction Programs to Reach New Communities with Overdose and Infectious Disease Prevention. NACCHO would also like to acknowledge the Centers for Disease Control and Prevention, who funded this work, and the evaluation sites who participated in this project: Being Alive LA, Chicago Recovery Alliance, Harlem United, Harm Reduction Sisters, Public Health Madison & Dane County, and Steady Collective.

Kat Kelley (she/her) is the Lead Analyst for Syndemics at the National Association of County and City Health Officials (NACCHO), where she works with local health departments to advance innovative solutions to the intersecting epidemics of HIV, STIs, hepatitis, and overdose.

Anjana Rao (she/they) is a Program Analyst on the Harm Reduction team at the National Association of County and City Health Officials (NACCHO). She supports projects related to capacity building for syringe service programs and local health departments and works across teams to serve NACCHO’s members.

Lisseth Guerra (she/her) is a Senior Research and Evaluation Specialist at the National Association of County and City Health Officials (NACCHO). She leads, designs, and manages evaluation activities for NACCHO programs.