ROCHESTER, N.H. — Megan Merrill paused, mid-hike, as she surveyed the steep drop before her. She was standing on a five-foot snow drift, icy and brittle after 10 days of unrelenting New England cold, below which lay the railroad tracks that serve as a de facto border between the town behind her and the homeless encampment in front.
She took the downward slope at a gallop, using her oversized backpack as a counterweight. The bag was made heavy with a stockpile of harm reduction supplies meant to help vulnerable drug users stay healthy and avoid disease, including sterile syringes, condoms, emergency blankets, and hand warmers.
The items Merrill was most eager to distribute, however, were glass pipes. Her reasoning was simple: Injection can lead to infections, diseases, skin abscesses, and potentially higher rates of fatal overdose. To Merrill and harm reduction workers like her, pipes are health care.
“You’re going to see less vein damage, you’re not going to get abscesses on your arm or infections,” said Merrill, who works with a local community organization, SOS Recovery. “There’s less chance of you overdosing if you’re smoking than if you’re injecting. And infectious diseases: With injections, there are blood-borne illnesses, hepatitis C, HIV.”
In the last decade, U.S. drug consumption behavior has shifted rapidly away from injecting and toward smoking. Once largely limited to the West Coast, a preference for smoking opioids has spread east since the Covid-19 pandemic, becoming especially pronounced in hard-hit cities like Philadelphia.
The shift has taken place largely organically, making it a case study in how the U.S. health infrastructure has ignored the input of drug users — even when the outcomes they seek could reduce death, prevent disease, and save taxpayers millions of dollars.
Many users’ behavioral changes have followed shifts in the illicit opioid supply, which in the last decade has seen heroin largely disappear and fentanyl increasingly dominate. In many areas, the sheer toxicity of street drugs and the presence of xylazine, an animal tranquilizer associated with severe skin wounds that can require amputation, has led many users to avoid syringes at all costs.
In response, harm reduction organizations across the country have scrambled to ensure their offerings include foil, glass pipes, and mouthpieces in an effort to help people addicted to fentanyl or other substances smoke their drugs and avoid injection. Merrill, a former injection drug user who is in recovery, counts herself among the thousands of harm reduction workers nationwide evangelizing a shift away from needles and toward pipes.
The phenomenon was evident as Merrill made her rounds in the deep-forest encampment. The makeshift community’s dozen or so residents, who stay warm with the aid of campfires, propane tanks, and a portable generator, happily accepted the supplies she had on offer.
“When I was using three years ago, everyone was injecting their drugs,” she said. “You would have people smoking here or there, but now, people who inject drugs are switching to smoking them and sniffing them. We’re seeing a lot of people get foil and getting the glassware to smoke.”
Even as overdose rates have fallen substantially, more than 45,000 Americans still die of opioid overdose each year. Many experts view the shift from injecting to smoking as a promising development that could help extend the decline in deaths, on top of mitigating the harm and expense of the consequences that often accompany injection.
“One of the basic mottos of harm reduction is ‘any positive change,’” said Caty Simon, a leadership team member with the National Survivors Union, a nonprofit that advocates on behalf of people who use drugs. “It’s an example once again of the fact that people who use drugs value their health and are desperately trying to survive. Substituting injection for smoking is a self-protective gesture.”
Smoking is also not the only alternative to injecting: many harm reduction experts, particularly on the East Coast, reported that snorting or “sniffing” many drugs is another common route of administration that helps prevent syringe-related harms.
Still, as smoking rises in popularity, its benefits have become increasingly clear. Some limited research shows that people who smoke drugs might be as much as 30% less likely than those who inject to experience an overdose. Researchers and public health experts are confident, also, that smoking instead of injecting helps prevent diseases like HIV or hepatitis C, infections like endocarditis, or the serious skin lesions associated with injecting drugs that contain xylazine, often referred to as “tranq.”
While injecting remains the norm, other factors have allowed smoking to proliferate in some cities: mainly, that many users have grown tired of injecting and weary of some street drugs’ flesh-destroying capabilities. And critically, fentanyl’s composition allows it to be smoked more easily than most heroin.
“The drug is cheap enough, and what’s more, it’s bioavailable enough,” said Dan Ciccarone, a University of California San Francisco physician-researcher and addiction medicine professor who has tracked the shift in drug use behavior. “People are also avoiding the negative aspects of injection, and then they tell their friends. They say, ‘Listen, man, you got a bad abscess there. You should just smoke your dope.’ And people get convinced pretty quickly.”
‘Not everybody wanted to inject’
The shift toward smoking underscores the extent to which behavior, even in the context of using dangerous substances, can significantly change health outcomes. It shows, too, the extent to which public opinion and government policy is often out of step with basic cause-and-effect principles in drug use epidemiology.
Syringe exchanges, for instance, are widely accepted in many states. But some efforts to distribute pipes have faced blowback. The Biden administration’s support in 2021 for the distribution of “safer smoking kits,” which often included pipes meant to help drug users safely consume drugs they intended to smoke or to switch over from injecting, became a major controversy among Republicans.
Still, other groups have bought into the idea of smoking, saying American public health officials have failed to embrace strategies that recognize the reality on the ground.
Smoke Works, a Massachusetts-based group that distributes pipes that it bills as “injection alternatives,” was born out of a program embedded within an existing syringe exchange. But when it won a private grant in 2019 for a pilot program to distribute pipes, it found that within months, fully half of its participants were showing up only for smoking supplies, with no needles changing hands at all.
“It really illustrates what questions we weren’t asking,” said Jim Duffy, the organization’s executive director. “Not everybody wanted to inject. We’d put some syringes in someone’s hands and say, ‘Hey, do you need a pipe, too?’ They’d hand us the syringes back.”
Smoke Works, in particular, has scaled up its pipe-distribution efforts even against a backdrop of hostility from the Trump administration and a hawkish drug policy climate. The organization now has nine full-time employees, and has needed to expand its space in a nondescript warehouse compound in Braintree, Mass., approximately once a year for the last five years, Duffy said.
Smoke Works has shipped over 5 million units total and 1.9 million pipes in 2025 alone, Duffy said, conducting unit-by-unit quality control on each one to guard against cracks, chips, or sharp edges. Roughly 10% of the pipes distributed last year were given away free of charge.
But amid frustration with homelessness and public drug use, other areas have wound down their pipe-distribution programs. Even San Francisco, long known for its tolerant drug laws, recently rolled back a program that distributed foils and pipes in an effort to encourage smoking over injection.
Pipes, in particular, have drawn even stronger public opposition than other treatment and harm reduction services, like the opening of new methadone clinics or even supervised consumption sites.
Duffy cast the backlash as a relic of the crack cocaine epidemic, during which smoking was the main route of administration. As a result, he said, many who oppose harm reduction can still use the symbolism of glass pipes to stoke images and often-racist media depictions of largely Black communities ravaged by a prior drug epidemic.
“When you look at headlines about pipe distribution, nine out of ten are going to say ‘crack pipe,’” he said. “It just plays right into the crack epidemic fear — it’s an easier way to frame it as evil and scary.”
‘This is an intervention’
Drug consumption methods vary greatly by age and geography, with smoking most concentrated among younger drug users and first emerging in the Pacific Northwest, California, and Arizona, where large majorities of fentanyl users smoke rather than inject.
In East Coast cities, said Ciccarone, the UCSF researcher, rates are far lower — often in the range of 5% to 15% — but growing fast.
These patterns began to take shape roughly a decade ago, thanks to a rare silver lining of the fentanyl era. In the 2010s, as prescription opioids became more scarce, thousands of Americans switched to heroin, some forms of which are less bioavailable when smoked. Fentanyl, by contrast, can be smoked easily and efficiently by users who are often cash-strapped and concerned with cost-effectiveness.
Others speculated about even simpler factors. In an interview, Alex Kral, a researcher with RTI International focused on drug use epidemiology, theorized that use trends could be partly linked to climate. The warmer West Coast climate, he said, means drug users might put a premium on avoiding syringes because they are less likely than their East Coast counterparts to wear coats or long sleeves that could cover up potential injection site scarring, often known as “track marks.”
Regardless of why, the transition to smoking is welcomed by most experts.
“If you’re smoking rather than injecting, you’re not going to be transmitting viral infections like HIV and hepatitis,” Kral said. “That’s pretty clear. The bigger question mark that we’re all trying to learn more about is overdoses.”
Kral’s early research, like Ciccarone’s, suggests that overdose rates are lower among smokers than injectors. But the reasons remain fuzzy, too. One possible explanation: smokers can consume the drug more slowly and control their intake more precisely. Another: Smoking is often a collective activity, the researchers said, while injecting is often done alone or in pairs, meaning more people are present to administer naloxone and reverse an overdose, or to call 911.
While the early evidence on smoking instead of injecting is promising, harm reduction advocates also stressed that it is not an all-or-nothing proposition. Shifting some use to smoking, even for people who continue to inject, can still meaningfully improve a person’s health.
Experts did point to one potential concern: that people who use drugs often share equipment. Meth users, for instance, typically smoke the drug, and commingling pipes with people who use fentanyl risks meth users overdosing after unwittingly smoking leftover fentanyl residue.
But for now, Ciccarone, the UCSF researcher, argued that the more pressing concern is selling local leaders on the benefits of actively marketing smoking as a safer alternative to injecting.
“I tell any public health or harm reduction people that want to listen that this is an intervention,” he said, adding that the benefit of distributing pipes instead of syringes “needs to be sold” to government officials wary of the optics. One strategy, he said, is simply pointing to the savings likely to result from reduced rates of overdose or hospitalization.
“Most overdoses are not fatal. Most overdoses wind up in an ambulance or hospital, and that costs a lot of money,” he said. “I sound a bit conservative or crass when I talk about money, but this is what politicians want to hear.”
‘The lesser of evils’
Upon leaving the encampment, Merrill, the New Hampshire harm reduction worker, still carried hundreds of sterile syringes in her backpack. But she had distributed every one of the glass pipes she brought with her — a reality she said would have been unthinkable just a few years ago.
Smoking, in fact, has become so common that it now causes more overdose deaths overall, even as experts and harm reductionists maintain that the actual likelihood of overdosing from an individual instance of smoking is far lower than from injecting.
George Karandinos, a Harvard physician-researcher who has worked alongside Ciccarone to track the shift, concurred, taking the optimistic view that smoking reduces death though it remains highly risky.
“These are all pieces of data that agree with each other and suggest that there may be a lower risk of overdose” from smoking, Karandinos said. “However, a lot of people are dying from opioid smoking. It is not safe by any means. It is still very risky and still has resulted in many, many deaths.”
But for those unable to reduce their opioid use or abstain altogether, harm reduction services and supplies like those offered by Merrill are a key component of preventing wounds, disease, and even death.
As a onetime client of SOS Recovery’s harm-reduction services, Merrill’s primary guideposts as she distributes supplies are the wishes of her clients. Those requesting syringes get syringes; those requesting pipes get pipes; and so on.
But she does not shy away from sharing a conclusion drawn from years of personal and professional experience: Smoking is safer than injecting.
Clearly, her message has resonated. As Merrill left the encampment, she regretfully told a resident who had emerged from her tent that she was out of foil used for smoking — but that she’d bring more tomorrow.
As she again crossed the railroad tracks and climbed back up the embankment, Merrill was rewarded not just with a sense of pride, but with a backpack no longer weighed down by dozens of glass pipes. Even going uphill, she barely needed a running start.
“I will always offer the lesser of evils,” Merrill said. “We call it safer because you’re not always going to be 100% safe in everything you do, but we can make it safer.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
