Integration of safer smoking equipment in U.S. syringe services programs: Qualitative insights from program staff

BACKGROUND: Amidst population-level transitions from injecting to smoking unregulated drugs, US. syringe services programs (SSPs) are increasingly distributing safer smoking equipment. METHODS: We conducted qualitative interviews with representatives of 27 geographically diverse U.S. SSPs from May 2023-March 2024. Guided by the Consolidated Framework for Implementation Research, we explored programs' experiences distributing safer smoking equipment, including staff perceptions on challenges to implementation and sustainment. Thematic analysis identified key findings. RESULTS: We interviewed 41 SSP representatives, including leadership (63 %), frontline (22 %), and clinical and clinical support staff (15 %). Two critical incidents-fentanyl adulteration of unregulated drug supplies and the COVID-19 pandemic-drove the adoption of this intervention. Interviewees perceived that safer smoking equipment facilitated client engagement, expanded SSPs' reach into previously underserved communities, and promoted individual health by reducing the adverse consequences of injecting drugs. Barriers to implementation and sustainment included program staff and leadership concerns about limited evidence on the public health benefits of safer smoking equipment, stigma and negative local attitudes, funding restrictions, and cost (particularly for glass pipes). Strategies to support implementation included incrementally piloting safer smoking equipment, partnering with diverse funders, and adapting services to navigate resource constraints. Nevertheless, limited funding and legal support hindered broader adoption, reach and sustainability. CONCLUSIONS: Implementation of safer smoking equipment represents a critical evolution in harm reduction programming that may engage underserved communities in the range of evidence-based prevention services offered by SSPs. Flexible funding and supportive implementation climates are needed to support SSPs in providing this impactful service.