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Harm Reduction Approach Should Extend to Patient Smoking

December 31, 2019

The addiction treatment and recovery system in the United States is massive. The industry comprises approximately 15,000 public and private service units with more than 1.3 million persons in care at any point in time. Some 24 million people are in long-term recovery, having benefited from treatment, recovery support and/or a variety of mutual aid organizations. Considerable innovation occurs regularly in the system, including motivational/cognitive-behavioral approaches, recovery community organizations, and harm reduction strategies such as needle exchange and naloxone distribution.

The addiction and recovery field can justifiably point to the success of its evolution and the important outcomes that benefit so many Americans. Notwithstanding the above, however, there is a problem at the core of this enterprise that has long been avoided and now requires systematic and focused attention.

Unaddressed addiction to cigarette smoking among treatment and recovery populations is responsible for disease and premature death among a substantial number of Americans who achieve long-term recovery from their substance use disorder (SUD).

Inaction, despite the data

The Substance Abuse and Mental Health Services Administration (SAMHSA) in 2013 issued a report, based on National Survey on Drug Use and Health data, titled Adults with Mental Health Illness or Substance Use Disorder Account for 40 Percent of All Cigarettes Smoked. The Centers for Disease Control and Prevention (CDC) also endorses the proposition that adults with mental illness or substance use disorders smoke cigarettes more than adults without these disorders. National Comorbidity Survey data published in Nicotine & Tobacco Research report a smoking prevalence of 56.1% among persons with past-month alcohol use disorders and 67.9% among those with SUDs. Current literature cites smoking prevalence among treatment clients as ranging between 49% and 98%.

The Nicotine & Tobacco Research report concluded: “The very high smoking rates reported in addiction treatment samples warrant significant, organized, and systemic response from addiction treatment systems, from agencies that fund and regulate those systems, and from agencies concerned with tobacco control.”

Despite calls for action, treatment and recovery programs continue to avoid robustly confronting the smoking behavior of clients and members. While the majority of privately and publicly funded treatment programs maintain a nominal “smoke-free” environment, provisions are rarely available beyond referrals to smoking cessation programs.

In most cases, safer alternatives to conventional cigarettes, such as electronic cigarettes or Swedish snus, are never components of a treatment program’s tobacco policies. Those programs that do incorporate tobacco as an addiction to be addressed almost universally adopt the total abstinence model adapted from traditional 12-Step recovery practices.

Within the United States the SUD treatment sector continues to embrace total abstinence as the gold standard for measuring success. While drug harm reduction approaches are no longer demonized by drug war ideology, the mainstream treatment and recovery communities only grudgingly accept that a harm minimization approach has some merit for some people.

A recent well-intentioned systemwide ban on smoking in Philadelphia’s 80-unit public SUD treatment system generated criticism for creating an additional barrier to treatment engagement and retention, at a time when there is an increased need for access to care due to the current opioid epidemic. The policy also prohibited any use of electronic cigarettes, which have been shown to be considerably less harmful than smoking combustible tobacco.

Strong evidence exists that many smokers are able to reduce or quit cigarette smoking by switching to vaping. A British study published in the New England Journal of Medicine and reported last January in The New York Times found that in a yearlong trial of 886 smokers assigned randomly to use either e-cigarettes or traditional nicotine replacement therapies, e-cigarettes were nearly twice as effective as conventional nicotine replacement products (patches, nasal spray and gum) for quitting smoking.

Despite reports about the health benefits of switching from combustible tobacco to e-cigarettes, addiction treatment and recovery programs for the most part ban their use. A recent survey of 259 residential SUD programs in California found that 98% prohibited use of these products.

A useful alternative

Rather than total bans, the concept of risk proportionality offers policy-makers a useful alternative that weighs the relative risks and benefits of various courses of action. For example, addiction treatment programs in the United Kingdom encourage clients to use e-cigarettes while in treatment. Similarly, policies that accommodate smokers while offering less harmful alternatives should be in place both for client retention and health education purposes.

Efforts such as these should not be avoided by conflating current concerns about youth vaping with the need to improve care for adults in treatment and recovery populations. E-cigarettes have been in widespread use for more than 10 years and are enjoyed by millions worldwide. Many of these users are former smokers who have significantly improved their health by ending smoking of combustible tobacco.

Our collective tendency to “let the perfect be the enemy of the good” delayed the adoption of drug harm reduction practices for many years, at the cost of many lives. We should not be content to travel this same path again when it comes to the health of treatment and recovery populations.

John de Miranda is an independent consultant who has worked in the alcohol and drug problem field for most of the 45 years that he has been in recovery. He is recipient of a 2019 Tobacco Harm Reduction scholarship from Knowledge Action Change. He can be reached at (650) 218-6181 or


Submitted byFr. Jack Kearney on June 26, 2020


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