Jennifer Twyman is a big advocate for syringe service programs, or SSPs. She relied on harm reduction services herself when she was overcoming an opioid addiction, and later when she worked in a Louisville SSP for years.
But she said the programs have their limits.
“That’s only reaching one group of people that’s using in a particular way,” she said.
She’s now an organizer for VOCAL-KY, a social services and advocacy group. Among other things, the group operates a drop-in harm reduction site.
Kentucky, Tennessee and several other Appalachian states have passed laws legalizing needle services. But different forms of harm reduction supplies — like pipes and other smoking tools — haven’t gotten that treatment.
“People aren’t coming in to access the program because you only give out syringes,” she said. “There’re just lots of ways to connect with people through harm reduction programs, and the more supplies that you are allowed to give out, the better those responses are going to be.”
Pipes, foils and other smoking materials are essentially in the same legal position that fentanyl test strips were five or 10 years ago — before 45 states explicitly legalized them. Government agencies like county health departments aren’t allowed to pass them out. Grassroots organizations can, but it comes with some risks.
Public health experts recommend smoking supply kits for several reasons. The rate of absorption is lower with smoking than it is with injection, so overdoses are less likely. There is also a decreased risk of infectious disease spread. It opens the door for harm reduction services to people who smoke exclusively, too, creating more opportunities to connect people with treatment options, life-saving overdose reversal drugs and health care.
The law could change, but harm reduction supporters like Twyman say more states in the region adopting them probably isn’t likely in the current political climate.
“What I get told when I bring it up to people in the state is that it is such a touchy subject that people would be afraid that they would just, like, walk back everything, instead of allow for other supplies to be given out,” she said.
West Virginia and Tennessee have ranked first and second for overdose deaths among U.S. states for several years. Public health experts say smoking supply services can decrease deaths, but these states seem among the least likely to adopt the methods.
The West Virginia Legislature updated the syringe program law to add a ban on smoking supplies. Some of Tennessee’s top elected officials have railed against smoking supply programs on the Senate floor.
Potential benefits of smoking kits
As Twyman said, people who exclusively smoke likely won’t drop in to a safe syringe site.
That has been contributing to health disparities, said Shreeta Waldon, the executive director of the Kentucky Harm Reduction Coalition. Although people of all stripes use syringes, smoking is comparatively more common in communities of color.
“Well, that community is not walking up to a van parked out in the parking lot that’s providing syringes and wound care supplies, because that’s not what they need,” she said. “There has been a decrease in overdose fatalities every year over the last few years. That’s been notably in our white community because when you look at route of use, what demographic is using syringes? Well, we’re gonna talk about white men. That’s the highest rate of access when we’re talking about who comes to our syringe service programs.”
The overall drop in lethal overdoses has been heralded as a public health victory. But as The New York Times reported last year, not everyone is seeing that relief. Overdose deaths among Black Americans continued to increase. As of 2024, they were 1.4 times more likely to die this way than their white neighbors.
Smoking carries a lower infectious disease risk than injecting, but sharing equipment can lead to infections.
“If you have open wounds in your mouth … and you happen to be HIV positive, and you share a pipe with somebody that also has the open wound in their mouth, that can transmit HIV,” Waldon said. “Hep C is way easier to transmit than HIV is. It can’t live just out in the open on a surface, but Hep C can for up to two weeks. And so any tools that we can give people that cut down on any sharing … we are cutting down on the spread of both of those.”
Waldon said another way to enhance safety is to include candy with smoking kits, since it makes the mouth water.
“Saliva actually moisturizes our gums, our teeth, our mouth,” she said. “A lot of times when people are using drugs like meth, it ruins the teeth in the gum line. A lot of that has to do with once you’re drying it out, you got bacteria up in there, you’re not brushing your teeth properly, you get infections in your mouth. Now, you’re losing your teeth.”
Candy is the short-term solution, and the long-term solution includes connecting clients with dental services. This can head off even longer-term health problems associated with gum disease, which is tied to an increased risk of heart attack, other cardiovascular events and strokes.
Tough political climate
Tennessee Commissioner of Health Ralph Alvarado moderated a panel on smoking supplies at the Rx and Illicit Drug Conference, which took place in Nashville this spring. It involved a panel discussion with researchers at the National Association of City and County Health Departments. They presented success stories in harm reduction centers outside of the region.
“Some other states are in a different place than we would be,” Alvarado said in an interview after the panel. “I think it would be difficult to advocate for this in Tennessee.”
One of the most vocal opponents to these programs in Tennessee has been Republican U.S. Senator Marsha Blackburn.
In 2022, she raised concerns about a federal grant program for harm reduction providers. Its eligibility section said it could be used to procure safe smoking kits or supplies. She discussed the issue on the Senate floor.
“Just yesterday, I had to send a letter to Health and Human Services demanding to know why taxpayer dollars are funding fresh crack pipes for drug addicts,” she said. “That’s right. You know, every once in a while you think you’ve heard it all.”
The politics are even less welcoming in West Virginia. A bill banning smoking supplies from the state’s SSPs passed in 2024.
It says the sites “shall not distribute any smoking devices, including but not limited to hand pipes, bubblers, bongs, dab rings, hookahs, crack pipes, or disposable smoking devices.”
It passed unanimously off the Senate floor with no questions or discussion.
But supporters like Twyman in Kentucky haven’t given up hope.
“I have a survey that I have people fill out. ‘If these services were available at harm reduction programs in our city, would you use them? Yes or no?'” she said. “I mean, they’re really basic. But they’re also, ‘Have you ever gotten cut by using, you know, a used pipe? Or gotten an abscess, or an infection, or had to go to the doctor for anything related to all this?’ Because when we show the need … we can push the envelope a little bit.”
But that hope is tempered.
“In our current political state, I don’t feel fantastic about that right now,” she said.
This story was produced by the Appalachia + Mid-South Newsroom, a collaboration between West Virginia Public Broadcasting, WPLN and WUOT in Tennessee, LPM, WEKU, WKMS and WKU in Kentucky and NPR.
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