People in Drug Treatment Smoke at 4x the General Rate. It’s Been an Afterthought for Decades.

In the harm reduction community, the principle is consistent: you meet people where they are. You prioritize the most acute risks. You don’t demand lifestyle perfection as the price of receiving support. And yet the field has, for decades, maintained a remarkable blind spot about tobacco — a substance that kills roughly a quarter of the people who use drugs before they ever die of their primary addiction.

A panel at the Global Forum on Nicotine in Warsaw earlier this month put that paradox directly. Filter Magazine reported on June 18 that addiction medicine specialists and drug-user advocates made a case that substance use treatment programs have been systematically ignoring a comorbidity hiding in plain sight.

The numbers are not subtle. Smoking rates among people who use drugs — or people actively enrolled in substance use treatment — are two to four times higher than the general population. In a 2021 cohort study of 100,000 UK heroin users, 63% were projected to die before age 70, compared with 16% of the general population. Of that excess mortality, tobacco accounted for 23.6% of premature deaths — nearly equal to the 27.6% attributed to drug use itself. And up to 80% of people in substance use treatment report wanting to quit smoking.

Gerry Stimson, an emeritus professor at Imperial College London and a founding figure of the harm reduction movement, made the argument that the field’s current model is logically incoherent: “We can’t talk about harm reduction without tobacco harm reduction.” If the goal is to reduce the total burden of harm to people who use drugs, tobacco is not an afterthought. It is a primary cause of death that the field has been culturally uncomfortable addressing — partly because many staff in drug treatment programs smoke, partly because smoking has long served as a bonding ritual and a stress management tool within treatment settings, and partly because the history of tobacco cessation has been dominated by abstinence-based framing that sits uneasily in a harm reduction context.

The proposal from Warsaw is not to harangue people in treatment into quitting. It is to offer information about safer nicotine alternatives — nicotine pouches, patches, heated tobacco products — through the same low-judgment framework that the field applies to every other substance. Drug treatment programs already counsel people on safer injection practices, naloxone use, and fentanyl testing. Adding evidence-based safer nicotine options to that menu is a matter of consistency, not imposition.

Marianna Iwulska, a drug-user activist and board chair of EuroNPUD, framed it more directly: “Cigarettes are an important part of people’s lives, a way of coping with stress.” Denying that reality — or treating tobacco cessation as a secondary concern for after recovery is “complete” — is a version of the same hierarchical thinking harm reduction has always argued against.

For providers building recovery navigation tools and facility networks: integrated tobacco harm reduction is not on most facility quality scorecards. It should be.