Invited commentary:
As cigarette smoking in the Unites States has declined overall, it has also become more concentrated into high-risk populations, namely among those who are less educated, have fewer resources, and have comorbid psychiatric disorders (both substance-related and non–substance-related). A stark reminder of this health disparity is the extraordinarily high rate of current cigarette smoking found in the sample of rural individuals who inject drugs included in the study by Akhtar and colleagues. While opioid misuse is a critical problem that the country has been mobilized to address, populations that experience opioid use disorder (and other severe addictive disorders) also experience multiple other comorbidities. Addiction to tobacco is one of these important comorbidities, and Akhtar and colleagues document current tobacco smoking among more than 90% of their sample of 986 rural individuals who inject drugs. Akhtar et al also documented very high rates of recent experiences of homelessness (62.5%) and low overall rates of contact with health care (ie, 42.0% of the study population had received any primary care within the previous 6 months), providing clear evidence for the extreme nature of adversity that these individuals experience and the overall lack of engagement with health care systems.