Logo Medium Trans Bck.png__PID:9eb0ca9b-466f-464a-af9a-08321115a687
Increased Risk of
Overdose due to Smoking?

A response to: Routes of Drug Use Among Overdose Deaths

Written by Katie Ahern
Edited by Jim Duffy

"These findings do not indicate that smoking drugs increases risk of overdose, but that people's preferred route of administration is shifting."

Increased Risk of Overdose due to Smoking?

In February 2024, the CDC released “Routes of Drug Use Among Drug Overdose Deaths,” a report on drug overdose death trends related to routes of administration. Smoking overtook injecting in the period between July-December 2021, and the gulf has been increasing since.


Overdose deaths with evidence of smoking has risen from 13.3% of all deaths to 23.1% from in period 1* to period 2**, while overdose deaths attributed to injecting have fallen from 22.7% of all deaths to 16.1% respectively.

This trend is seen across different combinations of drugs; in deaths involving only “illegally manufactured fentanyl and fentanyl analogues” (IMFs), only stimulants, and both IMFs and stimulants. Deaths involving neither IMFs or stimulants (it is unclear which drugs exactly these are) saw no change in deaths from smoking.

The trend of increased deaths with evidence of smoking compared to injection is also consistent across all regions of the US. Below is a summary of changes in overdose deaths with evidence of injection versus smoking by drug type and region:

Where does this data come from?

The CDC gets this data from SUDORS, the State Unintentional Drug Overdose Reporting System. 49 states (and D.C.) participate, but this particular report looks at 28 states which had the information necessary for examining these trends for 75% or more of the overdose deaths in their state. State jurisdictions were determined by the census bureau. From January 2020-December 2022, 139,740 overdose deaths occurred in these states. The information comes from death certificates, postmortem toxicology tests, and medical examiner/coroner reports. The 28 states data for this report comes from includes: 

Screenshot 2024-05-24 at 11.54.22 AM.png__PID:f79f854f-6a1d-476c-965e-d035725e4799

*Period 1:   January 2020 - June 2020
**Period 2:   July 2022 - December 2022

This report also looks into trends relating to snorting and overdose, please see the full report for details.

Alaska, Arizona, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, and West Virginia. Illinois and Washington included data from counties that accounted for ≥75% of drug overdose deaths.

How do they know the route of administration?

They looked at four routes of administration: injecting, smoking, snorting and ingestion. Evidence relies on witness reports, drug paraphernalia found at the scene, or physical evidence on the deceased. For injecting, this would be observing recent injection points or injection supplies. For smoking, finding supplies like pipes, foils, and torches is considered evidence. Though imperfect, this data is likely the most comprehensive available.

So what?

These findings do not indicate that smoking drugs increases risk of overdose, but that people's preferred route of administration is shifting.

We don’t blame em!

There are a number of reasons why someone might choose to smoke rather than inject their drugs (fewer skin infections, more control over your use, etc). Some may believe that smoking lessens the risk of overdose, but the risk remains. Any route of administration carries this risk. Different routes of administration can:
(1) get the drug into your system faster and
(2) make more of that drug available in your system.

Safer Use Guides (Square).png__PID:e32a636f-7f55-492f-9d44-452edf2eb63e

Still, enough of any drug any way can result in an overdose. Each of these deaths, no matter the route of administration, are ultimately a result of systemic failure, and it is the responsibility of those systems to support efforts to respond to the needs of people who use drugs to keep us safe.

The CDC recommends expanding public health and harm reduction programs to include smoking and other injection alternatives. However, harm reductionists are limited in their ability to do this due to the criminalization of drug paraphernalia and restrictions on the use of federal funds to acquire safer smoking materials*.

The CDC points to syringe services as a successful model, and just like syringe distribution, pipe distribution is an effective risk reduction intervention. In response to the results of this CDC report, Smoke Works urges harm reduction advocates to push for (1) the decriminalization of possession and distribution of drug paraphernalia and (2) the allowance of federal funds to be used to purchase harm reduction tools for safer smoking supplies and other injection alternatives.

Harm Reduction Messaging & Misconceptions

These results indicate that harm reduction programs have been, and should continue adapting to meet preferences and needs. If you’ve had trouble advocating for the distribution of safer smoking materials in your area, this report demonstrates the increasing need to engage people who smoke drugs across the US. Though currently federal funding may not be used to purchase pipes, other funding sources and distributors can fill the gap. If you are having trouble securing funding for safer smoking supplies, please reach out to Smoke Works for help!


Doing your best to meet the needs of people who smoke by providing pipes and their trappings:

-alcohol wipes
-lip balm
-mouth pieces
-naloxone etc.


Just as with injecting, encourage people to start low, go slow when smoking. Only put some of your stuff in your pipe, you can always add more later. Take a beat between hits, distract yourself with something to kill time, let your first hit get into your system and see how you feel before taking the next- maybe that first one was enough after all.


Just as with injecting, smoking socially means safety in numbers. When not able to share the experience, overdose prevention hotlines, in the absence of supervised consumption, save lives.

Be prepared to have conversations addressing the rise in overdose deaths with evidence of smoking. Some may attempt to point to this data as an excuse to not provide safer smoking materials, the belief being that smoking drugs increases overdose risk. That is not what this report is saying.

This report indicates a need for increased support for those who want to smoke their drugs, which in practice looks like supplying pipes, naloxone, drug checking, and other harm reduction services. Halting safer smoking initiatives only alienates those who are demonstrably in need of overdose prevention services.