Smoking still kills nearly half a million Americans each year. And while overdose deaths have come down from their peak, they still take nearly 70,000 lives annually. Behind those numbers are people—family, friends, neighbors—whose lives are cut short in ways that are often preventable. But there’s no switch we can flip to make cigarette or illicit drug use disappear overnight. In reality, harm reduction is more than an abstract policy idea—it’s a practical way to keep people alive and healthier as long as possible.
Backed by decades of evidence, harm reduction is an effective public health strategy with outcomes ranging from reduced infectious disease transmission and overdose to increased smoking cessation. At its core, harm reduction starts from a simple premise: People don’t have to be ready for abstinence to deserve protection. It meets people where they are and equips them with tools to make safer (though not risk-free) choices. In practice, this can mean switching from cigarettes to vaping or carrying naloxone when using opioids.
But what happens when the systems people rely on start to erode or fail?
About five years ago, the R Street Institute called for a comprehensive approach to harm reduction—supporting the health strategy across all behaviors—that built upon our earlier work around tobacco and opioids. Our ethos was simple: If you support harm reduction for one behavior, you should extend that logic to all of them. Then, ahead of the 2024 presidential election, the landscape began to change. Converging systemic crises in substance use, mental health, and homelessness took center stage in political debate, provoking bipartisan skepticism and even outright backlash against harm reduction. The shift marked an inflection point and begged the question: Is harm reduction enough?
This piece responds to that question and provides the reasoning behind our programmatic shift from Integrated Harm Reduction to Healthier Communities.
An Evolving Substance Landscape
The United States has been slowly (and unevenly) moving away from strict prohibition of certain substances. As demand for psychoactive substances persists, illicit markets endure despite bans or overregulation, introducing additional risks to both individual health and community well-being. Cannabis was placed on Schedule I—the Controlled Substances Act’s most restrictive level—in 1970. About a decade later, cannabis activist Richard C. Cowan coined “the Iron Law of Prohibition,” a theory that captures how stricter criminalization drives the production of more potent substances, as they are easier to conceal and transport in smaller quantities. Federal scheduling pressures contributed to rising cannabis potency in the decades that followed. Although many states have authorized medical and/or recreational use, the federal government has only moved to reschedule medicinal cannabis from Schedule I to Schedule III—a change that stops short of decriminalizing it for recreational use.
Opioids also illustrate this dynamic and underscore a further challenge: Not only do policies focused solely on supply increase the potency of existing illicit drugs, but they also drive the emergence of illegal substitutes when demand for less-accessible legal substances remains high. For example, in the early 2000s, the U.S. government tightened access to prescription opioids while simultaneously intensifying enforcement and interdiction targeting illicit heroin. Though well intentioned, these measures—implemented without sufficient expansion of prevention or treatment—contributed to the emergence and eventual dominance of illicitly manufactured fentanyl.
A similar dynamic appears in tobacco control. Federal regulation limited the availability of e-cigarettes because they were not “appropriate for the protection of public health,” which resulted in a constrained legal market. But because demand didn’t go away, illicit and unregulated products filled the gap. Retailers subsequently sold millions of unauthorized flavored vapes in the United States, often without meaningful quality or safety oversight.
Restricting supply without addressing demand drives innovation in unregulated, often riskier markets—and communities and families often pay the premium in terms of negative unintended consequences.
Systems Collision
As the landscape surrounding substance use has evolved, economic pressures have also increased. The housing shortage and record inflation have collided with the evolution of the illicit market and changing substance use patterns, playing a unique role in the rise of homelessness. Public disorder has become more visible across U.S. communities as these factors converge, prompting renewed questions about the limits of harm reduction as a standalone strategy.
Even before the COVID-19 pandemic, an estimated 51.5 million American adults were living with a mental illness—a crisis years in the making. The pandemic accelerated it, deepening rates of depression and anxiety across the population and leading to increased substance use among adults. The mental health system was ill equipped to respond, as chronic workforce shortages, decades of disinvestment, and persistently uneven access to care left it strained long before. This system collision has manifested in more visible signs of disorder (e.g., open-air drug use, encampments, loitering, public mental health crises) while contributing to heightened perceptions of crime.
Concerns about the appropriate scope of compassion in addressing substance use and homelessness— alongside increased attention to both voluntary and involuntary treatment approaches—have gained traction in communities facing these overlapping challenges. Yet the nation’s treatment infrastructure remains inadequate and at risk of further erosion in many places.
Leveraging Social Bonds and Infrastructure
The shift in public sentiment has unfolded against a backdrop of federal funding volatility for substance use and mental health treatment, including reductions to Medicaid, proposed cuts to treatment-focused agencies, and new investments in mental health care. Families and communities often absorb additional responsibility when public systems retrench or shift priorities. At the same time, broader economic pressures like increased living and health costs continue to strain many households. In response, states are advancing policy proposals aimed at expanding access to mental health treatment, increasing housing supply, and improving childcare affordability to help ease economic strain.
With resources constrained, addressing these intersecting challenges will require more coordinated, efficient, and less siloed approaches. It calls for policymaking that moves beyond single-issue frameworks to better align objectives across individual choice, market dynamics, public health systems, and social stability. Meeting this moment will depend on more pragmatic, integrated strategies that recognize the role of families in supporting prevention, stability, and recovery and, in turn, the connection between stronger families and healthier communities.
Our Work Moving Forward
Without this programmatic shift, public policy risks diminishing returns on health interventions where rising funding pressures lead to managing individual crises rather than preventing them, thereby blunting population-level improvements over time. Addressing both the causes and the symptoms of public disorder requires integrating harm reduction with clear pathways to treatment, expanding same-day or walk-in access, telehealth, and community-based care. This also requires addressing workforce shortages and ensuring ongoing recovery support—not just short-term stabilization.
To better respond to today’s complex environment, our programmatic rebrand to Healthier Communities reflects both a renewed focus and an expanded scope. We have consolidated research on tobacco and illicit opioids under a new Substance Regulation portfolio that now includes emerging substances. We remain committed to harm reduction while also broadening our work to encompass treatment and recovery in a new Behavioral Health portfolio that will include mental health. We have also introduced a policy portfolio focused on Thriving Families, where we address issues from economic mobility to family planning and maternal health.
Communities across the country are confronting these interconnected challenges, and this programmatic transition reflects a more holistic approach—one that recognizes the deep links between individual well-being, family stability, and community health.
Harm reduction is an essential part of the solution, but alone it is not enough.
Safer Solutions: Every two weeks we discuss a complicated harm reduction topic straight-forward terms and highlight policy solutions.