With drug misuse of synthetic opioids and methamphetamines increasing in the USA,^1-5 research has shown potential transit operator exposure to drug residue in air and on surfaces resulting from drugs being smoked by riders.⁶ Transit systems are a vital component of a city’s infrastructure, playing a crucial role in moving people throughout communities. In 2023, transit systems in Washington (WA) and Oregon (OR) states served over 280 million passenger trips.⁷ As transit ridership increases and recovers to pre-pandemic rates,⁸ ensuring transit workers’ safety and health is crucial to maintain safe and effective service to communities.

Despite transit systems employing nearly 150,000 operators and drivers across the USA,⁹ the industry continues to experience workforce shortages due to challenges in worker retention,¹⁰ particularly among newer workers.¹¹ New operators are typically provided with brief trainings focusing on driving practices, company policies, and customer service¹²; however, it is unclear whether these trainings adequately prepare operators for other challenges such as drug misuse aboard their vehicle.

Transit systems in WA and OR employ an estimated combined 9,830 transit operators as of May 2024,^13,14 and research finding fentanyl and methamphetamine residue on transit vehicles suggests that misuse of these drugs occurs on transit vehicles,⁶ consistent with these illicit drugs being the most commonly misused nationally and in the Pacific Northwest specifically.^1,4 Additionally, states and cities have different local policies regarding drug use. For example, in OR, the introduction of Measure 110 in 2020 decriminalized drug use, and was subsequently repealed in 2024; however, it is unclear whether this impacted rates of drug use on transit vehicles.¹⁵ Both WA and OR have also decriminalized and legalized recreational and medical cannabis sale and consumption; however, public use remains illegal in both states.^16,17

Risk perception of secondhand drug exposure, particularly fentanyl, remains high,^18-22 despite research indicating low risk of toxicity associated with secondhand exposures.²³ Perceived risk refers to an individual’s beliefs about their vulnerability to a potential hazard, and is typically characterized by perceived risk severity (the believed magnitude of risk to health) and perceived risk susceptibility (the believed likelihood of exposure) to the hazard.²⁴ Front-line workers who respond to opioid overdose incidents remain concerned about fentanyl exposure despite low risks of toxicity.²³ This leads to a phenomenon where risk perceptions and expectations of negative health effects result in real health symptoms^21,25; however, in the case of fentanyl exposure, it is unclear if these symptoms are due to fentanyl toxicity.²⁶ Research of first responders indicated that there are misconceptions about the hazards associated with brief contact with fentanyl; in one study, nearly 80% believed touching fentanyl could be fatal.²⁷ Another study of first responders found that despite low frequency of exposure to fentanyl, first responders remained concerned about the potential for adverse health outcomes.²⁸ The psychosocial effects of these risk perceptions may be further exacerbated by increased job stress associated with witnessing or experiencing a traumatic opioid overdose event.²⁹

Research has yet to assess risk perceptions of drug exposures among transit operators; most occupational drug exposure research focuses on first responders. Unlike first responders, who are called to respond to emergencies and arrive on scene with information regarding the situation from their dispatch, transit operators are already present when emergencies occur on their vehicle, are not necessarily expected to respond, and are likely less prepared to do so. Therefore, it reasons that their experiences and risk perceptions related to drug exposures are different than first responders.

Individuals’ perceived risk is influenced by outrage factors (i.e., emotional aspects of risk that influence how people perceive risk).³⁰ In the context of transit operators, outrage factors such as voluntariness (whether the exposure is imposed or voluntary), fairness (whether the exposure is equally distributed, or unique to a given population), process (whether employer decision-making seems fair to the worker, and decisions address worker concerns), and morality may impact transit operators’ perceived risk of secondhand drug exposure.

Despite drug use occurring on transit, limited research has investigated how these incidents impact transit operators. Research in other occupations has suggested a positive relationship between perceived risk of a hazard and intent to leave the job^31,32; however, research has yet to investigate this relationship among transit operators with regard to secondhand drug exposures. Occupational research has shown that when workers feel dissatisfied with their jobs, they are more likely to want to leave.^33,34 Occupational stress is also related to intent to leave, but research has also shown that workers who have high occupational stress but high job satisfaction are less likely to want to leave.³⁴ Higher rates of intent to leave can result in increased attrition (through early departure or difficulty hiring for vacancies), leading to understaffing.³⁵ Understaffing can result in increased job demands and stress on remaining workers,^36,37 contributing to burnout.³⁸ Therefore, it is important to investigate factors (such as perceived risk of health outcomes associated with passenger drug misuse on transit vehicles) that may contribute to intent to leave among transit operators, as well as factors such as perceived occupational stress and job satisfaction that may impact these associations, and identify areas of intervention. Research has yet to investigate methods to change risk perceptions of drug exposures among transit operators, though one study among first responders indicated that providing brief trainings and educational resources regarding the risks of secondhand occupational exposure to drugs can be effective in changing risk perceptions and correcting misconceptions.²¹

This study characterized the perceived risk of secondhand drug exposures among transit operators and investigated whether operators with higher perceived risk are more likely to express an intent to leave. This study addressed the current literature gap regarding the impact of transit operators’ risk perceptions, and investigates their intent to leave. We hypothesized that operators who perceived a higher risk due to secondhand drug exposures were more likely to express an intent to leave. We also hypothesized that operators with increased occupational stress and decreased job satisfaction were more likely to express an intent to leave. Understanding factors that contribute to transit operators’ intent to leave and impact well-being can inform interventions that improve the work environment and experiences of these workers. This work also promotes worker voice, health self-advocacy, and workplace safety culture which are crucial components of worker well-being.^39,40 This study is also the first to explore transit operators’ experiences with drug misuse incidents and characterize the frequency of these incidents aboard transit vehicles.

We conducted a cross-sectional study from September 2023 to December 2023 designed to investigate the association between transit operators’ risk perceptions of secondhand drug exposure and their intent to leave their job. We partnered with Amalgamated Transit Union (ATU), who represents transit workers across the USA and Canada.⁴¹ In conjunction with ATU International and local ATU leadership, three ATU locals in WA (Seattle and Lynnwood) and OR (Portland) shared our survey with their membership. Transit operator perceived risk of secondhand drug exposure was assessed via survey. The survey also assessed perceived occupational stress, job satisfaction, intent to leave their job, workplace safety, and past experiences with passenger drug use on public transit.

Transit operators’ perceived risk of secondhand exposure to secondhand drugs was significantly positively associated with intent to leave in our base ordinal logistic regression model. Perceived risk scores of drug misuse among transit operators were on the higher range of scores per the Risk Perception Attitude framework²⁴; in particular, operators had high mean perceived susceptibility scores, indicating that operators felt they were highly susceptible to health effects due to drug misuse aboard their vehicles. In our base ordinal logistic regression model, we found that these perceived risk scores were significantly associated with intent to leave, suggesting that operators who felt they were at a greater risk due to drug use on their vehicles were more likely to consider leaving their job.

Consistent with literature in other occupational settings,^33,34 our regression analyses showed that transit operators with higher perceived occupational stress and lower job satisfaction were significantly more likely to express an intent to leave. In our full regression model, the inclusion of perceived occupational stress and job satisfaction attenuated the relationship between perceived risk and intent to leave, such that the relationship between perceived risk and intent to leave was no longer significant; this is likely due to the observed low to moderate correlation between these predictors. These findings may suggest a pathway where perceived occupational stress and job satisfaction mediate the relationship between perceived risk and intent to leave, such that higher perceived risks of health effects due to exposure to drug use are related to increased perceived occupational stress and decreased job satisfaction, which in turn are related to intent to leave. While the cross-sectional nature of this study prevented us from assessing this potential mediation, future research with longitudinal data should aim to elucidate these pathways, which can help better understand how perceived risk of secondhand exposure to drugs can impact transit operators. To our knowledge, this study was the first to investigate the association between risk perceptions related to passenger drug misuse and intent to leave among transit operators. These results build on previous literature that have identified possible relationships between perceived risks and intent to leave,^31,32 and between stress, job satisfaction, and intent to leave.^33,34

The findings of this study highlight the importance of perceived risk; however, it remains unclear what specific factors contribute to perceived risk. While this survey does not thoroughly capture all factors that may contribute to perceived risk, we did find that operators reported low self-efficacy scores. If operators feel that they cannot protect themselves from the health risks posed by secondhand exposure to drugs, this may increase outrage.⁴⁷ Research on perceived risk has postulated that perceived risk is influenced by the hazard itself, as well as outrage factors surrounding the hazard⁴⁷; therefore, increased outrage can increase perceived risk. While eliminating passenger drug misuse on transit would be the most effective solution to create a safer workplace,⁴⁸ interventions that target outrage factors may be beneficial in changing perceived risk, and possibly mental health, through improved job satisfaction and decreased stress and intent to leave.

Although not a primary aim, it was notable that this study captured transit operators’ experiences with passenger drug misuse. The majority of operators indicated that they observed passengers using drugs more than once a week, highlighting the prevalence of this issue across public transit in the Pacific Northwest; however, our survey did not gather information on specific drugs that operators observed passengers using, as we do not expect operators to be able to accurately identify drug types, especially while focusing on driving. Previous research has found that operators in the Pacific Northwest are at risk of exposure to secondhand drug residue from passenger drug use of fentanyl and methamphetamine,⁶ aligning with data showing a national increase in the misuse of these drugs in the past 2 years.⁴ Per the hierarchy of controls,⁴⁸ eliminating a hazard is the most effective method to protect workers from its health effects; therefore, it is of public health importance to reduce passenger drug use on transit vehicles. Doing so not only protects operators from secondhand exposure to drug residue, but also reduces workplace stress, as observing drug use incidents at work can be distressing.⁴⁹

It was also notable that 34.8% of operators reported experiencing passengers on their vehicle requiring medical attention from EMS; these situations may be particularly distressing and can have adverse mental health effects.^50-52 Therefore, while reducing the frequency of such distressing incidents should be prioritized, providing mental health supports for operators who experience such events not only promotes the well-being of operators, but may also reduce the impact that such incidents have on operators, which can in turn reduce intent to leave. Providing operators with naloxone and appropriate training for how and when to use it may empower operators during drug overdose incidents and allow them, if they are comfortable, to intervene during high risk drug use incidents. However, this intervention may be practically limited as operators may not be able or comfortable intervening. Systematic changes to reduce the frequency of these incidents and reduce the impact on operators are higher on the hierarchy of controls,⁴⁸ and should therefore be prioritized, rather than relying on the operator to intervene in high risk situations.

The majority of operators in our study reported receiving no guidance on how to handle passenger drug use incidents, and our regression results indicated that receiving trainings did not significantly impact intent to leave. It is possible that the context of increasing fentanyl misuse since 2021^1,4 and the misconceptions that exist about the hazard of fentanyl exposure^27,28 can impact risk perceptions among transit operators. Research has shown that brief trainings regarding the risks of secondhand occupational exposure to drugs can be effective in increasing knowledge and changing risk perceptions about secondhand drug exposures.²¹ Future research should investigate the types of guidance and trainings currently provided to transit operators, and how these trainings can be changed to better address operators’ needs.

Open and transparent risk communication to workers,⁵³ from sources of information that workers trust (e.g., their unions or physicians, as was also found in our survey),⁵⁴ can be effective in changing risk perceptions. Additionally, communication from leadership on how concerns about passenger drug use are being addressed, and worker engagement in this process, can help workers feel validated and reduce outrage.⁴⁷ Future research should seek a deeper understanding of operators’ risk perceptions of exposure to drug use and their unfulfilled workplace support needs (for example, via focus groups and qualitative interviews), which can inform further interventions that change these risk perceptions and reduce its impacts.

This study only surveyed transit operators, and not other types of transit workers (e.g., maintenance, security), who may have different work experiences. The majority of respondents in this study were bus drivers, who often have more passenger interactions than other types of transit operators; therefore, the attitudes reflected by this study may not be generalizable to other transit operators with different levels of passenger interaction. This study was also estimated to have a low response rate (2.8%), which could further impact generalizability. Survey respondents were recruited via their union and only within the Pacific Northwest; therefore, the findings of this study may not be generalizable to operators affiliated with different unions or in different regions. The majority of respondents in this study reported they were affiliated with the Seattle ATU local, with lower representation from the Portland ATU local and Lynnwood ATU Local, limiting comparison between cities that have different policies or practices regarding the use of drugs in public. Despite these concerns with generalizability, our sample was demographically consistent with national trends in gender and age of transit operators.^9,55 Additionally, 37.0% of respondents indicated experiencing a family or friend overdose due to drugs in the past, which is only a slightly higher rate than in the general U.S. population (32%).⁵⁶ This consistency with the larger population improved the generalizability of this study.

This survey was cross-sectional, and therefore only reflects attitudes at the time of the survey. Due to the cross-sectional nature of this survey, it is unable to identify causal relationships. This survey relies on self-report and is therefore prone to reporting bias, as respondents may not accurately recall or report past events or experiences. This reliance on self-report also limited the identification of specific drugs being used on transit vehicles, as operators cannot be expected to accurately identify drugs, especially while focusing on driving.

Given the importance of transit operators to the communities they serve, investigating the impacts of transit operators’ experiences with passenger drug use incidents is crucial to promote their workplace safety and health, especially as increasing drug misuse on transit in the Pacific Northwest^1-5 creates potential for operators’ secondhand exposure.⁶ We found that perceived risk of drug exposures, perceived occupational stress, and job satisfaction have an impact on operator intent to leave. Operator turnover can potentially be reduced by increasing supports that target risk perceptions of drugs. Furthermore, operators routinely experience drug use incidents on their vehicles, which can be distressing. Reducing the occurrence of drug use on transit and providing supports such as mental health resources can further benefit operators by reducing stress and improving job satisfaction.