Perspectives on smokefree prison policy among people in custody in Scotland

Implementation of a national smoke-free prison policy: an economic evaluation within the Tobacco in Prisons (TIPs) study

OBJECTIVE

To determine the cost-effectiveness of a smoke-free prison policy in Scotland, through assessments of the trade-offs between costs (healthcare and non-healthcare-related expenditure) and outcomes (health and non-health-related non-monetary consequences) of implementing the policy.

DESIGN

A health economic evaluation consisting of three analyses (cost-consequence, cost-effectiveness and cost-utility), from the perspectives of the healthcare payer, prison service, people in custody and operational staff, assessed the trade-offs between costs and outcomes. Costs associated with the implementation of the policy, healthcare resource use and personal spend on nicotine products were considered, alongside health and non-health outcomes. The cost-effectiveness of the policy was evaluated over 12-month and lifetime horizons (short term and long term).

SETTING

Scotland's national prison estate.

PARTICIPANTS

People in custody and operational prison staff.

INTERVENTION

Implementation of a comprehensive (indoor and outdoor) smoke-free policy.

MAIN OUTCOME MEASURES

Concentration of secondhand smoke, health-related quality of life (health utilities and quality-adjusted life-years (QALY)) and various non-health outcomes (eg, incidents of assaults and fires).

RESULTS

The short-term analyses suggest cost savings for people in custody and staff, improvements in concentration of secondhand smoke, with no consistent direction of change across other outcomes. The long-term analysis demonstrated that implementing smoke-free policy was cost-effective over a lifetime for people in custody and staff, with approximate cost savings of £28 000 and £450, respectively, and improvement in health-related quality of life of 0.971 QALYs and 0.262, respectively.

CONCLUSION

Implementing a smoke-free prison policy is cost-effective over the short term and long term for people in custody and staff.

Knowledge and cardiovascular disease risk perception from the perspectives of prisoners and staff in a Scottish prison: a qualitative study

PURPOSE

Prisoners have an increased risk of cardiovascular disease (CVD) compared to the general population. Knowledge and risk perception of CVD can influence engagement in preventative behaviours that lower an individual's CVD risk. This paper aims to explore prisoners' knowledge of CVD, and prisoners and staff's perceptions of prisoners' CVD risk.

DESIGN/METHODOLOGY/APPROACH

This was a qualitative study in which semi-structured interviews were conducted with 16 prisoners and 11 prison and National Health Services staff in a Scottish prison. Data were analysed thematically using the framework method.

FINDINGS

Most prisoners had limited knowledge of CVD as they could not describe it or could only identify one or two risk factors or cardiovascular events. Both prisoners and staff viewed prisoners' CVD risk as either pertaining to one individual, or pertaining to the general prisoner population. Unhealthy behaviours that were believed to increase CVD risk were linked to three perceived consequences of imprisonment: mental health problems, boredom and powerlessness.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first study to explore the CVD knowledge of prisoners, and perceptions of CVD risk from the perspectives of prisoners and prison staff. Findings from this study indicate that CVD education needs to be a priority for prisoners, addressing knowledge of CVD, its risk and risk perceptions. Additionally, the findings indicate that individual and socio-environmental factors linked to prisoners' CVD risk need to be targeted to reduce this risk. Future research should focus on socio-environmental interventions that can lead to reducing the CVD risk of prisoners.

Process and impact of implementing a smoke-free policy in prisons in Scotland: TIPs mixed-methods study

Background

Prisons had partial exemption from the UK’s 2006/7 smoking bans in enclosed public spaces. They became one of the few workplaces with continuing exposure to second-hand smoke, given the high levels of smoking among people in custody. Despite the introduction of smoke-free prisons elsewhere, evaluations of such ‘bans’ have been very limited to date.

Objective

The objective was to provide evidence on the process and impact of implementing a smoke-free policy across a national prison service.

Design

The Tobacco in Prisons study was a three-phase, multimethod study exploring the periods before policy formulation (phase 1: pre announcement), during preparation for implementation (phase 2: preparatory) and after implementation (phase 3: post implementation).

Setting

The study was set in Scotland’s prisons.

Participants

Participants were people in custody, prison staff and providers/users of prison smoking cessation services.

Intervention

Comprehensive smoke-free prison rules were implemented across all of Scotland’s prisons in November 2018.

Main outcome measures

The main outcome measures were second-hand smoke levels, health outcomes and perspectives/experiences, including facilitators of successful transitions to smoke-free prisons.

Data sources

The study utilised cross-sectional surveys of staff (total, n = 3522) and people in custody (total, n = 5956) in each phase; focus groups and/or one-to-one interviews with staff (n = 237 across 34 focus groups; n = 38 interviews), people in custody (n = 62 interviews), providers (n = 103 interviews) and users (n = 45 interviews) of prison smoking cessation services and stakeholders elsewhere (n = 19); measurements of second-hand smoke exposure (e.g. 369,208 minutes of static measures in residential areas at three time points); and routinely collected data (e.g. medications dispensed, inpatient/outpatient visits).

Results

Measures of second-hand smoke were substantially (≈ 90%) reduced post implementation, compared with baseline, largely confirming the views of staff and people in custody that illicit smoking is not a major issue post ban. Several factors that contributed to the successful implementation of the smoke-free policy, now accepted as the ‘new normal’, were identified. E-cigarette use has become common, was recognised (by both staff and people in custody) to have facilitated the transition and raises new issues in prisons. The health economic analysis (lifetime model) demonstrated that costs were lower and the number of quality-adjusted life-years was larger for people in custody and staff in the ‘with smoke-free’ policy period than in the ‘without’ policy period, confirming cost-effectiveness against a £20,000 willingness-to-pay threshold.

Limitations

The ability to triangulate between different data sources mitigated limitations with constituent data sets.

Conclusions

To our knowledge, this is the first study internationally to analyse the views of prison staff and people in custody; objective measurements of second-hand smoke exposure and routine health and other outcomes before, during and after the implementation of a smoke-free prison policy; and to assess cost-effectiveness. The results are relevant to jurisdictions considering similar legislation, whether or not e-cigarettes are permitted. The study provides a model for partnership working and, as a multidimensional study of a national prison system, adds to a previously sparse evidence base internationally.

Future work

Priorities are to understand how to support people in custody in remaining smoke free after release from prison, and whether or not interventions can extend benefits to their families; to evaluate new guidance supporting people wishing to reduce or quit vaping; and to understand how prison vaping practices/cultures may strengthen or weaken long-term reductions in smoking.

Study registration

This study is registered as Research Registry 4802.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information.

An Evaluation of the Impact of a Multicomponent Stop Smoking Intervention in an Irish Prison

The disproportionately high prevalence of tobacco use among prisoners remains an important public health issue. While Ireland has well-established legislative bans on smoking in public places, these do not apply in prisons. This study evaluates a multi-component tobacco control intervention in a medium security prison for adult males in Ireland. A stop-smoking intervention, targeting staff and prisoners, was designed, implemented, and evaluated with a before-and-after study. Analysis was conducted using McNemar’s test for paired binary data, Wilcoxon signed rank test for ordinal data, and paired T-tests for continuous normal data. Pre-intervention, 44.3% (n = 58) of the study population were current smokers, consisting of 60.7% of prisoners (n = 51) and 15.9% of staff (n = 7). Post-intervention, 45.1% of prisoners (n = 23/51) and 100% of staff (n = 7/7) who identified as current smokers pre-intervention reported abstinence from smoking. Among non-smokers, the proportion reporting being exposed to someone else’s cigarette smoke while being a resident or working in the unit decreased from 69.4% (n = 50/72) pre-intervention to 27.8% (n = 20/72) post-intervention (p < 0.001). This multicomponent intervention resulted in high abstinence rates, had high acceptability among both staff and prisoners, and was associated with wider health benefits across the prison setting.

E-cigarette Use in Prisons With Recently Established Smokefree Policies: A Qualitative Interview Study With People in Custody in Scotland

INTRODUCTION

E-cigarettes were one measure introduced to help people in custody (PiC) to prepare for and cope with implementation of comprehensive smokefree policies in Scottish prisons. Our earlier study explored experiences of vaping when e-cigarettes were first introduced and most participants were dual tobacco and e-cigarette users. Here we present findings of a subsequent study of vaping among a different sample of PiC when use of tobacco was prohibited in prison, and smokefree policy had become the norm.

METHODS

Twenty-eight qualitative interviews were conducted with PiC who were current or former users of e-cigarettes in prison, 6-10 months after implementation of a smokefree policy. Data were managed and analyzed using the framework approach.

RESULTS

PiC reported that vaping helped with mandated smoking abstinence. However, findings suggest that some PiC may be susceptible to heavy e-cigarette use potentially as a consequence of high nicotine dependence and situational factors such as e-cigarette product choice and availability in prisons; issues with nicotine delivery; prison regimes; and use of e-cigarettes for managing negative emotions. These factors may act as barriers to cutting down or stopping use of e-cigarettes by PiC who want to make changes due to dissatisfaction with vaping or lack of interest in continued use of nicotine, cost, and/or health concerns.

CONCLUSIONS

E-cigarettes helped PiC to cope with smokefree rules, although concerns about e-cigarette efficacy, cost, and safety were raised. PiC may desire or benefit both from conventional smoking cessation programs and from interventions to support reduction, or cessation, of vaping.

IMPLICATIONS

Findings highlight successes, challenges, and potential solutions in respect of use of e-cigarettes to cope with mandated smoking abstinence in populations with high smoking prevalence and heavy nicotine dependence. Experiences from prisons in Scotland may be of particular interest to health and/or justice services in other jurisdictions, with similar legislation on e-cigarettes to the United Kingdom, who are planning for institutional smokefree policies in their prisons or inpatient mental health settings in the future.