Six months into a ban on smoking in all city-funded inpatient drug treatment centers, Philadelphia officials say the prohibition hasn’t impacted the number of people seeking or staying in addiction treatment — in fact, they say, more people are entering rehab.

But advocates, who on Tuesday protested the ban by marching to City Hall, call the ban an unnecessary barrier to treatment in the middle of an overdose crisis. They say they’ve been fielding stories for months of people who are reluctant to seek treatment because of the ban — and of patients who were removed from treatment because they’ve been caught smoking, or simply aren’t ready to quit cigarettes.

The ban took effect in January of this year, and at that time, the Inquirer Opinion section solicited varying viewpoints on the smoking ban to help readers better understand the issue.

Protesters pause on Market Street to share their misgivings about the Philadelphia's ban on smoking in city-funded, in-patient drug treatment centers.
Protesters pause on Market Street to share their misgivings about the Philadelphia's ban on smoking in city-funded, in-patient drug treatment centers.

Confusing message: City shouldn’t add barriers to treatment.

Having spent many years working in the behavioral health field and many years prior to that living as a person actively using drugs, I know firsthand the significant struggles people must overcome to begin the journey of recovery.

Among other things, there must first be an internal acknowledgment that their substance use is problematic and something they want to change. Then action steps must be taken, whether that is to enter into a treatment center, take medications, or even cutting back — everyone’s road to wellness is different. Everyone deserves the right the choose that path.

Advocates across the county and in Philadelphia have been fighting for people to have a choice in recovery. That’s why I was disappointed to learn that the 80 inpatient drug treatment programs that receive city funds will ban smoking at their facilities. Patients will be offered smoking cessation classes and medications, but will be not allowed to smoke while in treatment. I don’t think it’s fair that people don’t get to make a choice about whether or not to smoke.

Since overdose rates have reached epidemic levels, Pennsylvania has made leaps and bounds in removing barriers to treatment. Gov. Tom Wolf expanded Medicaid, in turn giving hundreds of thousands of people access to health care. The state declared a disaster around opioids, paving the way for some of the most troublesome barriers to be removed. These include removing prior insurance authorization for medications used to treat people with opioid use disorders and waving the fee for people seeking to obtain a birth certificate. The city of Philadelphia also waived another troublesome barrier in 2018 by eliminating the need for photo identification to enter treatment. With our city and state having made much progress over the past couple of years, adding a new barrier for people seeking treatment in 2019 seems counterproductive.

In recent years, Philly officials have embraced the concept of harm reduction, practical strategies aimed at reducing negative consequences associated with drug use. Harm reduction embraces a “meeting a person where they are at but not leaving them there” attitude. Under this thinking, in Philadelphia, we have rightly told people who use drugs that if they don’t want to stop using drugs, that’s OK — but we have given them clean needles to help prevent the spread of such diseases as hepatitis C. The most clear example of Philly’s harm reduction mentality came last January when Mayor Jim Kenney and other city officials announced that they’d be open to allowing a safe injection site, where addicted people can go to safely consume drugs in a supervised manner.

If the city is willing to OK overdose prevention sites, why are cigarettes a problem? Isn’t it all about the drug user’s right to choose?

I think the city is making great progress in addressing the opioid epidemic. It was an honor to serve on the Mayor’s Task Force to Combat the Opioid Epidemic, but I oppose the ban on cigarettes in city-funded rehab facilities. It strips people of choice and there is a great chance people will be harmed by this policy.

Is cigarette smoking an issue we should address? Absolutely, yes. But this should be done in addiction treatment through engaging people and offering education, nicotine replacement therapy options, smoking cessation resources, and support around individuals goals for quitting — not forcing people to stop smoking or else be barred from inpatient treatment. During a time of declared disaster and unprecedented overdose deaths, the city should be looking to continue removing barriers to treatment — not adding to them.

Devin Reaves, MSW, is executive director of the Pennsylvania Harm Reduction Coalition.@Devin_Reaves

Bold move: Sensitivity needed if Philadelphia wants positive results.

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.

Robert Ashford is a recovery scientist at the Substance Use Disorders Institute at the University of Sciences in Philadelphia. He was an appointee to the mayor’s task force to combat the opioid epidemic and is a person in long-term recovery himself. @RDashford