Late last year, public health officials in Philadelphia—which ranks second among large cities hit hardest by the US overdose and drug poisoning death crisis—announced a ban on residents of publicly funded addiction treatment programs going outside to smoke cigarettes, effective January 1, 2019.
The policy has been rolled out across the city’s 80 publicly funded inpatient detox and addiction treatment facilities.
People in Philadelphia who are living with a substance use disorder and seeking publicly funded inpatient treatment now face an ultimatum: Either commit to going without smoking or do not enter treatment.
Asked why the city decided to implement this smoking ban at this time, David T. Jones, the commissioner of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services, told Filter in an email, “We are continuing to make a significant investment in the health outcomes for Philadelphians. We know that tobacco utilization is the #1 killer throughout the United States and we’re invested in saving lives.”
In addition to the general health risks of smoking, proponents of such smoking bans often cite a 2004 study that concluded, “Smoking cessation interventions provided during addictions treatment were associated with a 25 percent increased likelihood of long-term abstinence from alcohol and illicit drugs.”
Applying this study’s findings, however, to justify a smoking ban may be misguided. Dr. Brandon Bergman, an associate director and research scientist at the Recovery Research Institute, told Filter that the study “needs explication.”
“It’s really unlikely that it’s cigarette abstinence that produces the greater likelihood of substance use abstinence,” Dr. Bergman explained. “[Smoking] intervention participants almost always got more treatment–which typically involved some intensive behavioral intervention like cognitive behavioral therapy [CBT]. So they’re developing skills like learning to cope with cravings, finding alternative healthy rewarding activities, etc. Those skills overlap in many ways with CBT for substance use disorder.”
He added that the reported 25 percent difference “in real-world terms is pretty small–37 percent in the smoking cessation intervention compared to 31 percent in the control.” He also said that more recent studies, including a systematic review of smoking cessation policies in substance use disorder treatment settings, “aren’t very compelling” and that the “best policy is offering smoking cessation in each program–making it available, not mandating it.”
Unintended Harms for Vulnerable Populations
While Philadelphia’s decision to impose this ban is perhaps well-intentioned, it is likely to have several unintended negative consequences.
Most notably, it presents a treatment initiation barrier at a time when the illicit fentanyl-tainted street drug supply makes drug use in Philadelphia far riskier than ever before. At this time of unprecedented drug use-related deaths, the goal should be to eliminate all barriers to accessing treatment—not to erect new ones.
“It’s hard enough to go [into treatment] without using drugs,” one person who uses drugs told me. “Once you realize you have to go without smoking too, it’s even harder to go in.”
In addition to creating a new treatment initiation barrier, research has demonstrated smoking bans to negatively impact retention in treatment, with a significant increase in people leaving “against medical advice” prior to treatment completion. Bans therefore make it harder not only for people to enter treatment, but also to stay in treatment.
People with lower incomes, Native Americans and LGBTQ people are all disproportionately affected by this treatment barrier.
With the risk of overdose death at its highest after a period of abstinence, enacting a policy that positions people to be more likely to leave treatment prematurely is quite simply to place people at higher risk of death.
Of course, people with substance use disorders or other mental health diagnoses are far likelier than the general population to smoke, as proponents of smoking bans often point out. SAMHSA estimates that these populations account for 40 percent of all cigarettes smoked in the US. Yet this fact makes erecting a treatment barrier all the more damaging.
Philly’s smoking ban disproportionately punishes marginalized populations in general—including people with lower incomes, Native Americans and LGBTQ people. Higher smoking rates among these groups mean that they are all disproportionately affected by this treatment barrier.
What we see happening with policies like Philadelphia’s smoking ban—which of course only applies to publicly funded programs—is that wealthier people still have the right to smoke or quit smoking in a self-determined manner, while less privileged people are denied such rights. This is an outright injustice.
Breaking Harm Reduction Principles
Another problem with the blunt instrument of a smoking ban is that it contradicts the central principles of harm reduction—for all that Commissioner Jones told me that the ban “aligns well” and is “very consistent” with harm reduction.
The Harm Reduction Coalition includes among these principles: “the call for non-judgmental, non-coercive provision of services and resources to people who use drugs” and an affirmation of “drugs users themselves as the primary agents of reducing the harms of their drug use.”
Philadelphia public health officials moved closer to embracing a harm reduction approach with their early 2018 greenlighting of safer consumption spaces (a move that federal officials are now seeking to block, as Filter has reported).
Harm reduction means “meeting people where they’re at”—not resorting to coercion or prohibition.
But the implementation of this smoking ban, roughly one year later, represents a giant step backwards. Reducing the severe harms associated with smoking is a laudable, vital goal. But denying people the self-determination to go outside to smoke if they so choose is not what harm reduction looks like.
Harm reduction means “meeting people where they’re at” and respecting their agency in improving their lives—not resorting to coercion or prohibition.
Dr. Sheila Vakharia*, policy manager for the Office of Academic Engagement at the Drug Policy Alliance, emphasizes this. “Smoking bans create a higher threshold for engaging in treatment for some of the most vulnerable populations,” she told me. “Harm reduction is about lowering thresholds to start where people are at. This [ban] is just another illustration of how we expect change from people before they can get help.”
Blocking Use of Lifesaving Tools
There are a number of critically important ways to reduce the harms of smoking. And these do include some restrictions—such as age limits, and preventing indoor smoking that could harm others.
Yet unbelievably, Philadelphia’s ban covers not only combustible cigarettes, but also e-cigarettes and other vaping products. This is extremely troubling; any evidence-based, harm reduction approach to smoking has to include such tools.
There is no rational reason for a smoking ban to extend to vaping.
Research has shown vaping to be at least 95 percent less harmful than combustible tobacco, and vaping has helped millions of people quit smoking. Helen Redmond, LCSW has explained in Filter that because “e-cigarettes deliver nicotine rapidly and replicate the rituals of smoking, people are able to switch more easily.” And in a study recently published by the New England Journal of Medicine, researchers found that “E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support.”
When stigma and junk science are stripped away, there is no rational reason for a smoking ban to extend to vaping. A far more sensible and beneficial policy would be to make vaping more available to residents of addiction treatment programs than smoking. This might be achieved by allowing vaping in more areas than smoking, or by providing free vaping products to smokers (as has been done, for example, at a mental health hospital in England).
Even in private, 12-step-oriented addiction treatment facilities in the US, we see policies better aligned with harm reduction than is the case in Philadelphia. In Hazelden Betty Ford, for example, providers meet patients where they’re at with their smoking behaviors. They provide education about the risks and harms of cigarette smoking, as well as offering smoking cessation tools and support. They do not exclude people who do not wish to quit smoking from treatment.
If Philadelphia public health officials were truly serious about embracing a harm reduction approach to problematic substance use, they would not have imposed this smoking ban.
Harm reduction isn’t something to selectively apply in some places but then discard when it doesn’t fit neatly with a paternalistic public health attitude. Harm reduction principles apply to all people who use all drugs at all times.
*Dr. Vakharia is also a board member of The Influence Foundation, which operates Filter.