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Background British Columbia (BC) is in the midst of an opioid overdose crisis. Since 2017, smoking illicit drugs has been the leading mode of drug administration causing overdose death. Yet, little is known about people who smoke opioids, and factors underlying choice of mode of administration. The study objectives are to identify the prevalence and correlates associated with smoking opioids. Methods The Harm Reduction Client Survey is a monitoring tool used by the BC Centre for Disease Control since 2012. This survey is disseminated to harm reduction sites across BC to understand drug use trends and drug-related harms. We examined data from the survey administered October–December 2019 and performed descriptive, univariate, and multivariate analyses to better understand factors associated with smoking opioids. Results A total of 369 people who used opioids in the past 3 days were included, of whom 251 (68.0%) reported smoking opioids. A total of 109 (29.5%) respondents experienced an overdose in the past 6 months; of these 79 (72.5%) smoked opioids. Factors significantly associated with smoking opioids were: living in a small community (AOR =2.41, CI =1.27–4.58), being a woman (AOR = 1.84, CI = 1.03–3.30), age under 30 (AOR = 5.41, CI = 2.19–13.40) or 30–39 (AOR = 2.77, CI = 1.33–5.78) compared to age ≥ 50, using drugs alone (AOR = 2.98, CI = 1.30–6.83), and owning a take-home naloxone kit (AOR = 2.01, CI = 1.08–3.72). Reported use of methamphetamines within the past 3 days was strongly associated with smoking opioids (AOR = 6.48, CI = 3.51–11.96). Conclusions Our findings highlight important correlates associated with smoking opioids, particularly the recent use of methamphetamines. These findings identify actions to better respond to the overdose crisis, such as targeted harm reduction approaches, educating on safer smoking, advocating for consumption sites where people can smoke drugs, and providing a regulated supply of opioids that can be smoked.