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Heroin Addiction and Related Clinical Problems: 2026, 28: 171-188

Smoking Harm Reduction in Opioid Use Disorder: From Neurobiology to Clinical Practice

Icro Maremmani, Peter Hajek, Angelo Giovanni Icro Maremmani, and Sharon Cox

Digital Object Identifier:
https://doi.org/10.62401/2531-4122-2026-20

Summary: People with opioid use disorder (OUD) smoke tobacco at rates far exceeding those of the general population. This makes cigarettes one of the leading causes of preventable morbidity and premature mortality in this population. Although contemporary addiction medicine has substantially reduced drug related deaths and improved long-term survival, smoking is still largely neglected within opioid treatment services, where clinical priorities understandably focus on opioid dependence and its immediate complications. Consequently, many people survive opioid addiction only to develop tobacco-related cardiovascular disease, chronic respiratory disease and cancer. This narrative review integrates current evidence from toxicology, clinical psychopathology and implementation science to examine the role of tobacco harm reduction in the management of OUD. Evidence consistently shows that most tobacco-related disease results from exposure to the products of tobacco combustion rather than nicotine itself. Electronic cigarettes and nicotine pouches markedly reduce exposure to carcinogens, carbon monoxide and other toxic combustion products while maintaining nicotine delivery, thereby offering substantially lower-risk alternatives to combustible cigarettes. The review also proposes that distinguishing physiological nicotine dependence from the broader behavioural syndrome of addiction may help clinicians individualise treatment strategies, particularly among people with psychiatric comorbidity, polysubstance use and recurrent relapse. This conceptual distinction should be regarded as a hypothesis to guide future clinical research rather than as an evidence-based treatment model. Clinical studies conducted in highly disadvantaged populations demonstrate that integrating tobacco harm reduction into addiction services is both feasible and acceptable. Even when cigarettes are replaced by lower risk products only gradually and complete abstinence is not achieved abruptly, or at all, substantial reductions in cigarette consumption, decreased exposure to tobacco smoke and greater patient engagement represent clinically meaningful indicators of therapeutic progress. Tobacco harm reduction should therefore be regarded as an essential component of comprehensive addiction medicine.

Keywords: Opioid Use Disorder; Tobacco Harm Reduction; Nicotine Addiction; Electronic Cigarettes; Nicotine Pouches