Current Tobacco Product Use and Cessation Behaviors Among People Who Use Opioids: Implications for Integrated Harm Reduction Services

Abstract

Introduction

Tobacco use, particularly cigarette smoking, is disproportionately high among people who use opioids (PWUO). Although harm reduction programs provide trusted, low-barrier, and repeated contact with PWUO, tobacco cessation support is not routinely integrated into these settings. We assessed current use of different forms of tobacco products and smoking cessation behaviors among PWUO and considered implications for integrating tobacco cessation into harm reduction services.

Methods

We conducted a cross-sectional survey among PWUO attending a syringe service program (SSP) in New Haven, Connecticut (N=200) between November 2025 and March 2026. We used questionnaires adopted from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) to assess current tobacco product use (i.e., cigarettes, e-cigarettes, cigars, smokeless tobacco, and pipes). We used descriptive statistics to report current tobacco product use, cessation-related behaviors, and other participant characteristics.

Results

Participants had a mean age of 46.9 (± 10.9) years, 66.5% (n=133) were male, and 65.5% (n=131) were currently homeless. Most participants screened positive for opioid dependence (92.0%, n=184), and 65.0% (n=130) were currently receiving prescribed medication for opioid addiction. Nearly all participants [97.5% (n=195)] reported current use of any tobacco product. Prevalence of current use of each tobacco product was as follows: cigarettes (96.0%, n=192), e-cigarettes (73.5%, n=147), cigars (29.5%, n=59), smokeless tobacco (18.5%, n=37), and pipes (16.5%, n=33). Among current smokers, 87.5% (n=168/192) reported interest in quitting, and 37.5% (n=72/192) reported a past-year quit attempt.

Conclusions

This study demonstrated a high prevalence of tobacco use among PWUO, while most current smokers reported interest in quitting. Integrating tobacco cessation support into harm reduction programs, such as SSP and addiction treatment settings, represents a critical, yet underutilized, opportunity to address this unmet need and improve health outcomes in this vulnerable population.

Introduction

Tobacco use is the leading preventable cause of morbidity and mortality in the US, accounting for more than 480,000 deaths annually and affecting over 16 million Americans living with smoking-related diseases. ¹ While the smoking rate has declined among general US adults, ² it remains disproportionately high among people with substance use disorders (SUD),^3,4 including people who use opioids (PWUO). ⁵ Co-use of opioids and nicotine is common and may worsen health risks, increase craving, and complicate treatment, including opioid withdrawal symptoms and reduced treatment effectiveness. ⁶ It may double the risk of premature mortality compared to either substance use alone, ⁴ yet tobacco use control and cessation remain under-addressed in this population.

Prior research has documented high rates of tobacco smoking among PWUO and those receiving substance use treatment.^4-6 However, less is known about the current use of multiple tobacco and nicotine products, including e-cigarettes, cigars, smokeless tobacco, and pipes. Understanding patterns of tobacco product use is increasingly important because many individuals use multiple tobacco products, and e-cigarette use may reflect attempts to reduce smoking, quit smoking, or engage in dual use. ⁷ In addition, data on cessation behaviors are needed to identify gaps in tobacco cessation support for PWUO within existing harm reduction services.

Harm reduction services, such as syringe services programs (SSPs), are trusted, low-barrier points of care for PWUO. These programs often offer services such as syringe access, overdose education and naloxone distribution, infectious diseases testing and treatment, behavioral health services, care coordination, etc. ⁸ There is growing recognition that integrated harm reduction models can serve as platforms for delivering broader health services to populations that may otherwise face barriers to care. ⁸ Despite this opportunity, tobacco cessation support is not routinely integrated into harm reduction services, reflecting a missed opportunity to address a major contributor to preventable morbidity and mortality among PWUO.

This study assessed the current use of tobacco products and smoking cessation behaviors among PWUO. The findings from this study will help to identify unmet cessation needs and inform the integration of evidence-based tobacco cessation support into harm reduction and substance use treatment settings.

Methods

Study Design, Participants, and Procedure

We conducted a cross-sectional survey among PWUO in New Haven, Connecticut, between November 2025 and March 2026. Eligible individuals were: (i) adults aged 18+ years; (ii) those who had used any opioid drugs (e.g., heroin or fentanyl); in the last 12 months; and (iii) living in the Greater New Haven area. Individuals who were unable to provide informed consent or complete the survey in the English language were excluded.

Participants were recruited from the New Haven Syringe Services Program (NHSSP) in New Haven, Connecticut. ⁹ NHSSP provides a range of services, including primary and preventive health care (e.g., HIV/HCV/STI testing and treatment), harm reduction (e.g., syringe exchange, overdose education, naloxone distribution), substance use services (e.g., substance use disorder screening and treatment), behavioral health, and care coordination to stabilize those in crisis or in need. ⁸

Participants were recruited through study flyers, word of mouth, and referrals from staff at other organizations (e.g., APT Foundation, Inc.) providing services to people with SUDs. Interested individuals were invited to a private research room in the clinic for eligibility screening. Eligible participants who provided written informed consent completed an interviewer administered online survey through Qualtrics (Qualtrics LLC, Provo, UT). The interview took approximately 30 minutes to complete, and participants were compensated US$10 for their time. There were no missing data, as the interviewer-administered format ensured that all items were completed during the interview.

The study was approved by the Institutional Review Boards of Yale University (Protocol #HRP-503D) on 20^th July 2025 and the University of Connecticut (Protocol number #E25-0550-01) on 29^th October 2025.

Measures

Current Use of Tobacco Products

Participants who had smoked at least 100 cigarettes in their entire lifetime and reported smoking cigarettes ‘every day’ or ‘some days’ at the time of interview were considered current smokers. ¹⁰

Current use of e-cigarettes (e-cigarette or other electronic vaping product), cigars (regular cigar, cigarillo, or a little filtered cigar), smokeless tobacco products (chewing tobacco, snuff, dip snus, nicotine pouches, or dissolvable), and pipes was defined as use of each of these products ‘every day’ or ‘some days’ at the time of interview.^10,11 Any tobacco use was defined as current use of at least one tobacco product, including cigarettes, e-cigarettes, cigars, smokeless tobacco, or pipes. ¹⁰

Smoking Cessation-Related Behaviors

Interest in Quitting Smoking

Participants who smoked cigarettes ‘every day’ or ‘some days’ rated their interest in quitting smoking on a scale from 1 to 10, where 1 is ‘not at all interested,’ and 10 is ‘extremely interested’. Those with a score of ≥2 were considered to have an interest in quitting smoking. ¹⁰

Past Year Quit Attempt

Participants who currently smoked cigarettes reported whether they had stopped smoking for one day or longer during the last 12 months because they were trying to quit smoking (yes/no); those answering affirmatively were considered to have made a quit attempt in the last 12 months. ¹²

Past Year Use of Cessation Medication to Quit Smoking

Participants who made a quit attempt in the last 12 months were asked to select all the products or methods that they have used to try to quit smoking. Those who selected evidence-based medications (i.e., Nicotine replacement therapy and prescription medication) during their past-year quit attempt were considered as having used cessation medications. ¹⁰

Past-Year Receipt of Medical Advice to Quit Smoking

Participants who made a quit attempt in the last 12 months and had seen a doctor, nurse, or other health professional for any medical reasons were asked if they had received professional advice to stop smoking (yes/no). ¹⁰

Socio-Demographic, Substance Use, and Mental Health-Related Characteristics

Participants self-reported their age, sex, sexual orientation, ethnicity, education, employment, relationship status, and homelessness.

The Rapid Opioid Dependence Screen (RODS), an 8-item screening tool, was used to measure opioid dependence. ¹³ A score of 3 or more “yes” responses to items 2-8 on RODS indicates opioid dependence. ¹³

Participants currently receiving prescribed medication, such as pills, liquid medication, or injections, to help treat their drug addiction/dependence were asked to report for which addiction(s) they were receiving treatment (‘Opioids’, ‘Cocaine or crack’, ‘Tobacco/Nicotine’, ‘Alcohol’, ‘Cannabis’, or ‘Other’).

The Alcohol Use Disorders Identification Test (AUDIT-C) was used to assess the degree of alcohol abuse or dependence. ¹⁴ Scores of ≥ 4 for males and ≥ 3 for females were considered positive for alcohol use disorders.

Depressive symptoms and anxiety symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9; range: 0-27, ≥10 indicates depressive symptoms) ¹⁵ and Generalized Anxiety Disorder-2 scale (GAD-2; range: 0-6, ≥3 indicates anxiety symptoms). ¹⁶ A single-item Sleep Quality Scale (SQS) was used to assess sleep quality (range: 0-10; 0 = terrible, 10 = excellent). ¹⁷

Statistical Analysis

Statistical analyses were conducted using R software, version 4.6.0. We used frequencies and percentages to describe categorical variables and means and standard deviations to describe continuous variables.

Results

Participants Characteristics

We screened 205 individuals; 4 were ineligible (had not used opioids in the last 12 months), and 1 declined to participate, resulting in 200 participants who use opioids in New Haven, Connecticut.

Participants were on average 46.9 (± 10.9) years of age; 66.5% (n=133) were male, 86.0% (n=172) were heterosexual, 52.5% (n=105) were non-Hispanic White, 51.0% (n=102) had completed high school or GED, 66.5% (n=133) were single, and 65.5% (n=131) were currently homeless (Table 1).

Table 1.

Participants Characteristics (N=200)

Participants characteristics	n (%)
Socio-demographic characteristics
Age (years), mean ± SD	46.9 ± 10.9
Sex
Male	133 (66.5)
Female	67 (33.5)
Sexual orientation
Heterosexual	172 (86.0)
Homosexual (lesbian/gay)	7 (3.5)
Bisexual	20 (10.0)
Others	1 (0.5)
Race/ethnicity
Non-Hispanic White	105 (52.5)
Other race/ethnicity	95 (47.5)
Education
Less than high school	35 (17.5)
High school graduate/GED	102 (51.0)
Some college or associate’s degree	55 (27.5)
College graduate or above	8 (4.0)
Relationship status
Partnered	67 (33.5)
Not partnered	133 (66.5)
Currently homeless
Yes	131 (65.5)
No	69 (34.5)
Substance use-related characteristics
Screened positive for opioid dependence	184 (92.0)
Currently receiving prescribed medication for their drug dependence	135 (67.5)
Currently receiving treatment for opioid addiction	130 (65.0)
Screened positive for alcohol use disorders	69 (34.5)
Mental health-related characteristics
Depressive symptoms (score: 10-27)	91 (45.5)
Anxiety symptoms (score: 3-6)	62 (31.0)
Poor sleep quality (score: 1-3)	64 (32.0)

Most of the participants (92%, n=184) were opioid dependent, 67.5% (n=135) were currently receiving prescribed medication for their drug dependence, and 65% (n=130) were currently receiving treatment for opioid addiction. More than one-third (34.5%, n=69) were screened positive for alcohol use disorders (Table 1).

Among the participants, 45.5% (n=91) and 31.0% (n=62) reported depressive symptoms and anxiety symptoms, respectively. Thirty-two percent (n=62) reported poor sleep quality (Table 1).

Current Use of Tobacco Products

Among participants, 97.5% (n=195) currently used any tobacco product. Similarly, 77% (n=154) and 37.5% (n=75) were currently using two or more and three or more tobacco products, respectively. Cigarettes were the most used tobacco product (96.0%, n=192). Prevalence of current use of other tobacco products was as follows: e-cigarettes (73.5%, n=147), cigars (29.5%, n=59), smokeless tobacco (18.5%, n=37), and pipes (16.5%, n=33). (Figure 1).

Figure 1.

Current use of tobacco products among people who use opioids (N=200)

Smoking Cessation-Related Behaviors

Among participants who currently smoke cigarettes, 87.5% (n=168/192) were interested in quitting smoking, and 37.5% (n=72/192) reported past-year quit attempts. Similarly, among those who made past-year quit attempts, 58.3% (n=42/72) reported using cessation medications and 59.7% (n=43/72) received quit advice from a doctor, nurse, or other health professionals.

Discussion

The findings of this study show very high rates of current tobacco product use among PWUO using SSP services, compared to the general US adult population.^11,18 Cigarettes were the most commonly used tobacco product, but e-cigarette use was also found to be considerably high, consistent with the findings reported in other studies among people with SUDs. ³ The high prevalence of e-cigarette and multiple tobacco product use may reflect several coexisting patterns, including attempts to reduce or quit smoking, or dual use patterns, or substitution between products in the belief that some are safer form of tobacco use which have been increasingly reported as a concern in recent years. ⁷ Consistent with this, recent evidence suggests that people often use newer tobacco products through social influence and the belief that they are safer, rather than as a true attempt to quit. ¹⁹ These findings reinforce the high burden of tobacco use among PWUO and suggest that tobacco-related morbidity and mortality remain important but under-addressed health concerns in this population, despite tobacco being a leading cause of preventable death among people with SUDs. ²⁰

In addition, our results indicated substantial social and clinical vulnerability, including high levels of opioid dependence, alcohol use disorder, homelessness, mental health symptoms (like depressive and anxiety symptoms), and poor sleep quality. These factors may influence tobacco use and cessation behaviors by increasing stress, limiting access to preventive care, and complicating sustained quit attempts. ²¹ Although most current smokers in our study reported at least some interest in quitting, fewer than four in ten reported a past-year quit attempt. This significant gap between interest in quitting and actual quit attempts suggests an important unmet need for accessible, tailored cessation support.

The findings from this study have important implications for developing tobacco cessation programs tailored to PWUO. Integrating such services within existing harm reduction settings, such as SSPs, may offer a strategic platform to address this need, as these settings often provide trusted, low-barrier, and frequent contact for PWUO. ⁸ Integrating tobacco cessation into harm reduction and drug treatment services could allow providers to routinely assess tobacco product use, deliver brief counseling, offer FDA-approved cessation medications (i.e., nicotine replacement therapy or non-nicotine-based medicines), and connect participants to ongoing support.

This study has several limitations that should be considered when interpreting the findings. First, the study participants were recruited from a single syringe service program in urban New Haven, Connecticut, which may limit generalizability to PWUO in other settings. Other rural and non-urban areas often face limited availability of harm reduction services, longer travel distances to providers, less access to transportation, and higher levels of stigma. Future work in geographically and structurally diverse settings, including the samples recruited outside of syringe services programs is needed to establish the external validity of result. Second, it was cross-sectional design which means we cannot determine causality or the direction of the observed associations. Third, measures related to the use of harm reduction services were not collected, limiting our ability to examine how engagement with specific services relates to tobacco use or cessation behaviors. Fourth, tobacco use was self-reported and not confirmed by biochemical testing, which may have led to misclassification, and self-report also raises the possibility of recall and social desirability bias. In addition, sample size or power calculation was not performed. Instead, the sample size was determined based on study conducted among PWUO, ²² whose sample size we used as a reference. Therefore, the study may have been underpowered to determine associations, and findings should be interpreted with this constraint in mind.

Conclusions

Tobacco product use, particularly cigarette smoking, was highly prevalent among PWUO, while most current smokers reported at least some interest in quitting. These findings highlight a substantial need for accessible, evidence-based tobacco cessation support for this vulnerable population. Because syringe services offer trusted, low barriers, and repeated contact with population who often face barriers to traditional health care, they may represent promising settings to deliver such support. Future research should evaluate the feasibility, effectiveness and cost effectiveness of integrating tobacco cessation services into these settings to determine how best to address this burden.

ORCID iDs

Sandesh Bhusal https://orcid.org/0000-0002-3060-5823

Reyusha Chalise https://orcid.org/0009-0005-3636-2788

Ethical Considerations

The study was approved by the Institutional Review Boards of Yale University (Protocol #HRP-503D) and the University of Connecticut.

Consent to Participate

Informed consent was obtained from all participants before enrollment.

Data Availability Statement

The data supporting this study are available from the corresponding author upon reasonable request.*