City officials sparked controversy late last year, extending the tobacco ban from mental health facilities (enacted in 2016) to include city-funded inpatient substance use disorder (SUD) programs. Citing overall health concerns and the risk to sustaining abstinence-based recovery, the bold move hopes to reduce negative impacts of concurrent tobacco and substance use, which include elevated risks of cancer, to cognitive functioning, and of all-cause mortality.
Critics of the ban expressed concerns related to individual help-seeking behavior, which deserves careful consideration.
Barriers to SUD treatment are plentiful in the United States, with less than 13 percent of those needing services in the past year actually getting treatment. However, the most common barriers involve stigma, a lack of insurance, or not being able to find a program — not the inability to smoke while in treatment.
Officials should look to our neighbors in New York for lessons on implementing a successful initiative. Following a similar ban, an analysis of treatment programs in New York found that less than 5 percent of referred individuals refused to enter treatment with a tobacco ban, suggesting that the barrier concern may be overstated.
When considered in light of other research — no adverse effects, but rather an enhancement effect of 25 percent greater likelihood for long-term abstinence when treating substance use disorders (alcohol and other substances) and nicotine use disorder concurrently — we must ask ourselves what is the real issue with the ban?
For a city reeling from the effects of the overdose crisis, more Philadelphians (including myself) have come to embrace and advocate staunchly for harm reduction programs and interventions. These programs include things like syringe service programs, overdose prevention sites, and fentanyl testing strips. It also includes a model of treatment — called low-threshold models — that do not have a requirement or primary focus on abstinence and seek to reduce seemingly arbitrary barriers (e.g., having an ID, engaging in counseling to receive medication, etc.) to receiving lifesaving medical care.
Does the city’s extending tobacco ban violate these same principles of harm reduction it is embracing in other areas? Maybe.
Currently, the ban extends only to inpatient programs, not to outpatient programs. (It does include city-funded recovery residences, according to one report.) This leaves several funded outpatient programs — both the more traditional abstinence-based and pharmacotherapy models of care — available to individuals in need of SUD treatment services. For almost half of individuals seeking treatment, quitting tobacco use is a priority; given the dire health risks and potential for improved outcomes, mandating tobacco cessation while providing medication and psychosocial supports to help quit while in inpatient settings seems like a great opportunity to improve the health of Philadelphians most in need.
The question remains though, does any level of coercion or mandate, despite the potential benefits at an individual and population health level, violate the principles many of us stand by on a daily basis? The devil is in the details in all things, as will be the case here.
The city will be well-placed to implement the policy with a recovery-informed perspective. This will mean ensuring that individuals aren’t discharged from programs when continuing to use nicotine products, that any person who refuses to engage in treatment that doesn’t allow smoking is not simply told “sorry, we can’t help you then,” but is referred appropriately, and that equitable access to nicotine cessation medications and psychosocial supports is available across all programs.
In the past, the city has failed to include the voices of those most impacted by its decisions, and this policy has the potential to be another failed effort in the same vein. While the ban extension is a public health opportunity, it can only be successful if the city does things a bit differently. If we are to be the city truly embracing harm reduction, there can be no other way.