Should clients in substance use disorder rehabs for heroin or other opiate/opioid addiction be allowed to use methamphetamine or cocaine? Of course not, they are illegal, highly addictive, and detrimental to their health.

How about marijuana? That’s absurd. Not only is it still illegal at the federal level, but it may be addictive and detrimental to their health, although some research suggests it has many health benefits, it could replace opioids for some conditions, and maybe even help wean clients off of opioids.

What about alcohol? That is legal, after all, and many people drink without experiencing substance use disorder. Don’t be silly. Research shows that when a person with addiction is denied their drug or substance of choice—such as opioid addicts who have been given the opioid antagonist Vivitrol and cannot get high from opioids—they switch to other available substances.

So why allow smoking tobacco containing nicotine in recovery centers?

It doesn’t seem to make sense because:

• Nicotine is about as addictive as heroin (some say a little less, some say more).
• Clients of residential recovery centers denied all other intoxicants smoke like chimneys (it is available), which can slow down recovery.
• Tobacco definitely has detrimental health effects. It may not kill you as fast as opioid addiction, but most studies say it kills more people in a year.
• Research suggests that clients with addiction who stop smoking at the same time are more likely—a “25 percent better chance”, according to one study—to remain off drugs in the long term than those who continue to smoke.

So, why?

Well, according to the Centers for Disease Control and Prevention (CDC) and the Substance Use Disorder and Mental Health Services Administration (SAMHSA), 35 percent don’t. For the other two-thirds, the usual reason proffered is that social workers and others who favor increased access to addiction recovery services fear that if you ask addicts to give up smoking, too, they will not seek treatment for the more immediately serious addiction.

Is that true?

It’s not clear. In 2008, Newsweek reported that “New York became the first state in the country to ban smoking at all addiction recovery centers”. (The American Society of Addiction Medicine agreed with the decision.) A later analysis found that fewer than 5 percent refused to enter treatment with a tobacco ban.

Five percent is not nothing, and one life lost is one too many, but many who enter rehab relapse or drop out anyway. Based in part on New York’s experience, Philadelphia implemented its own ban on Jan. 1, with similar hand-wringing from opponents.

It seems needed. The Philadelphia Inquirer reported that “about 69 percent of Philadelphians with substance-use disorders smoke”, as opposed to only 22 percent of people who don’t abuse alcohol or drugs.

According to a National Institute on Alcohol Abuse and Alcoholism study, as many as 80 percent of people in drug rehab want to quit smoking.

If a smoking ban is a barrier to entering rehab, it doesn’t seem like much of one. Much higher barriers include the relative lack of available beds in residential rehabs, not being able to afford it (no insurance or not enough coverage), and the stigma of even needing rehab.

I wonder if part of the problem is that some substance use disorder providers don’t want to give up smoking themselves.

We’ve banned smoking in hospitals, mental health centers, federal prisons, restaurants, public housing, and most government buildings, to name a few. It may be time to extend that ban to rehabs.