Tobacco in prisons: a focus group study

Reimbursing incarcerated individuals for participation in research: A scoping review

BACKGROUND

Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices.

METHODS

We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided.

RESULTS

A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9).

CONCLUSIONS

The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Prisoners' experience of health self-management: A qualitative study

PURPOSE

Among the noninstitutionalized population, health care is increasingly shifting from a paternalistic model toward promoting patients' involvement in decision-making and in managing their condition. This paradigm shift toward health self-management is less applicable to individuals in prison whose health management choices are limited. The aim of this study was to explore prisoners' health self-management needs and the strategies used to maintain health self-management in a highly restrictive prison environment.

DESIGN

A qualitative phenomenological study design was selected for this research.

METHODS

An interpretive phenomenological analysis was chosen to present the narratives of prisoners regarding their health self-management. Semi-structured interviews were conducted with 15 male prisoners followed by content analysis.

RESULTS

The analysis of the participants' narratives revealed four major themes: (1) "I thrive on the anger so I can turn it into some more sit-ups:" Initiating sporting activities (2) "Food shouldn't be that white…:" Prisoners' quest for healthier eating (3) "I felt I want more out of life…:" Avoiding an unhealthy lifestyle (4) "I want to be taken care of:" The struggle for better health care.

CONCLUSIONS

The findings suggest that prisoners can overcome the challenges of maintaining health in prison and become committed to better health management. Prisoners who serve as health resources may help reduce the load on correctional facilities' health care systems and the public.

A Widening Divide: Cigarette Smoking Trends Among People With Substance Use Disorder And Criminal Legal Involvement

People with substance use disorder (SUD) smoke cigarettes at a rate more than twice that of the general population. Policies and programs have focused on promoting smoking cessation among people with SUD, yet it is unclear whether interventions have adequately reached the subgroup involved in the criminal legal system, who have among the highest smoking rates. Drawing on repeated cross-sections of the National Survey on Drug Use and Health, we found that smoking rates declined by 9.4 percentage points overall among people with SUD from 2010 to 2019, but rates remained virtually unchanged among the subgroup with criminal legal involvement. In regression analyses focused on people with SUD, three-quarters of the excess smoking burden for those with criminal legal involvement at baseline (2010-13) was accounted for by controlling for sociodemographics, substance use type, health insurance, and recent SUD treatment. However, even after we controlled for these same factors, the disparity in smoking prevalence among people with SUD between those with and without criminal legal involvement remained constant over time. These findings underscore the need for smoking cessation interventions focused on the criminal legal system, including correctional facilities and SUD treatment programs that serve people in this population.

Black Pepper (Piper nigrum) for Tobacco Withdrawal: A Case Report

Tobacco use continues to be one of humanity’s most significant public health concerns, causing more than 8-million deaths annually. Existing treatments for tobacco use disorder are limited in efficacy and there is a strong need for identifying effective novel treatments. Small clinical trials indicate that black pepper (Piper nigrum) essential oil may be helpful for treating nicotine withdrawal and craving. However, we are unaware of any cases reporting the use of black pepper for these purposes in nonresearch settings. Here we present the case of a patient who inhaled combusted black pepper to self-medicate nicotine withdrawal when lacking access to tobacco cigarettes while incarcerated. Based on our patient’s report, inhalation of combusted black pepper may have alleviated his tobacco withdrawal and cravings by reducing his automatic motor urge to smoke, quelling withdrawal-associated anxiety, and mimicking the sensorimotor experience of smoking tobacco cigarettes. Notably, our patient reported that inhalation of combusted black pepper for treatment of nicotine craving and withdrawal was common in his correctional facility. Though combusted black pepper is highly unlikely to be an appealing treatment outside of a correctional setting, this case suggests that further investigation of vaporized black pepper essential oil for tobacco cessation may be warranted.

Impact of smoking bans and other smoking cessation interventions in prisons, mental health and substance use treatment settings: A systematic review of the evidence

ISSUES

We conducted a systematic review to examine whether smoking bans alone are effective in achieving smoking cessation in people released from prison, and patients discharged from mental health or substance use settings.

APPROACH

We searched health, criminology and social science databases. Detailed search strings were used to combine terms related to smoking bans and cessation interventions in prison, mental health and substance use treatment settings. We used backward and forward snowballing and manual hand searching to find additional studies. Studies were included if they: were published between 1 January 2000 and 25 February 2022; included a complete smoking ban; measured people released from prison and/or mental health and/or substance use patients smoking post-release/discharge from a smoke-free facility; and reported smoking cessation intervention and/or smoking ban outcomes. Methodological quality was assessed using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies and reviewed by two authors.

KEY FINDINGS

People released from prison, mental health and substance use in-patients who experience a smoking ban while incarcerated or in in-patient settings often relapse to smoking shortly after release or discharge. We found that although smoking bans alone do not promote cessation, multi-component interventions in combination with smoking bans can significantly increase cessation rates post-release/discharge provided they support participants during this time.

CONCLUSIONS

There is limited evidence to suggest tobacco bans alone in prison, mental health and substance use treatment settings are effective in achieving long-term smoking cessation. This review suggests that combining smoking bans and cessation interventions including pre- and post-release/discharge support can be effective in achieving smoking cessation.

Examining Attitudes, Expectations, and Tobacco Cessation Treatment Outcomes Among Incarcerated Tobacco Smokers

People who are incarcerated have limited resources to help them quit tobacco smoking. This study assessed the association between baseline attitudes and expectations of the program with final smoking status as the outcome. A 6-week group-based counseling with nicotine patches was provided to incarcerated individuals to quit smoking. A cross-sectional survey was given at the first session. Questions surrounding attitudes such as interest, confidence, motivation, and expectations were used to assess associations with smoking cessation. Exhaled carbon monoxide (CO) levels were taken at each sessions. Participants were categorized as nonsmoking or continued smoking at a 6.0 parts per million (ppm) CO at their final session attended. Overall, 123 participants had a CO higher than 6.0 ppm or missed more than two sessions at their final session, and 54 had a CO under 6.0 ppm. A total of 102 participants completed the 6-week program. Differences among the two groups in exhaled CO began at Session 3 and continued throughout the study.

Evaluating the impact of a prison smoking ban on the cardiovascular health of men in a UK prison

PURPOSE

Smoking rates are known to be higher amongst those committed to prison than the general population. Those in prison suffer from high rates of comorbidities that are likely to increase their risk of cardiovascular disease (CVD), making it more difficult to manage. In 2016, a tobacco ban began to be implemented across prisons in England and Wales, UK. This study aims to measure the effect of the tobacco ban on predicted cardiovascular risk for those quitting smoking on admission to prison.

DESIGN/METHODOLOGY/APPROACH

Using data from a prevalence study of CVD in prisons, the authors have assessed the effect of the tobacco ban on cardiovascular risk, using predicted age to CVD event, ten-year CVD risk and heart age, for those who previously smoked and gave up on admission to prison.

FINDINGS

The results demonstrate measurable health gains across all age groups with the greatest gains found in those aged 50 years and older and who had been heavy smokers. Quitting smoking on admission to prison led to a reduced heart age of between two and seven years for all participants.

ORIGINALITY/VALUE

The data supports tobacco bans in prisons as a public health measure to reduce risk of CVD. Interventions are needed to encourage maintenance of smoking cessation on release from prison for the full health benefits to be realised.

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.

Réduire le tabagisme dans les prisons : éléments théoriques et méthodologiques nécessaires à la co-construction d’une intervention en contexte pénitentiaire

Révélateur des inégalités sociales de santé, le tabagisme en établissement pénitentiaire exige des interventions visant sa réduction d’être adaptées aux spécificités du milieu carcéral. Dans le cadre de la recherche interventionnelle TABAPRI, nous avons mobilisé une première étude sociologique afin d’apporter des connaissances sur cette problématique. Une enquête a été réalisée au sein de trois établissements pénitentiaires, précédant les phases de construction, d’implémentation et d’évaluation de l’intervention. Cet article décrit d’une part la démarche méthodologique et d’autre part, la contribution de la sociologie, tant dans ses apports conceptuels que méthodologiques, à la construction d’une intervention. Notre travail a notamment souligné l’importance d’aménager des espaces d’échange permettant aux professionnels et aux personnes détenues de construire ensemble les modalités d'intervention qui participent à la réduction du tabagisme en détention.

Perspectives on smokefree prison policy among people in custody in Scotland

Purpose

This paper aims to explore smokefree prison policy, from the perspective of people in custody in Scotland.

Design/methodology/approach

In total, 77 people in custody in Scotland were interviewed in the period leading up to implementation of a nationwide prison smokefree policy. Data were thematically analysed to identify the diversity of views and experiences.

Findings

Participants described a widespread awareness in prisons of plans to implement a smokefree policy from 30 November 2018. Opinions about smokefree prisons varied among participants based on perceptions of the fairness, and anticipated positive and negative consequences of removing tobacco from prisons. At the time of the interviews, people in custody were responding to the impending smokefree policy, either by proactively preparing for the smokefree rule change or by deploying avoidance strategies. Participants described opportunities and challenges for implementing smokefree policy in prisons across three main themes: the role of smoking in prison, prison smoking cessation services and motivations for quitting smoking among people in custody.

Originality/value

This study exploring smokefree prisons from the perspectives of people in custody has several novel features which extend the evidence base. The findings highlight measures for jurisdictions to consider when planning to prohibit smoking in their prisons in the future. These include the need for evidence-based smoking cessation support in advance of smokefree policy, effective communication campaigns, consideration of broader structural determinants of health in prison and ongoing measures to reduce rates of return to smoking post release.

The Preliminary Efficacy and Feasibility of Group-Based Smoking Cessation Treatment Program for Incarcerated Smokers

Group-based tobacco dependence treatment has been known to help smokers to quit in general adult populations, but the feasibility and efficacy of this type of smoking cessation treatment in correctional settings remain uncertain. A 6-week group-based smoking cessation treatment with nicotine replacement therapy (NRT) in the form of nicotine patches was implemented in seven male prison facilities, in the Northeast, among smokers who were born biologically as male. Exhaled breath carbon monoxide (CO) levels were collected from participants at each session to confirm smoking status. Participants were evaluated at the 1-month post-group treatment follow-up to determine abstinence. Those who were lost to follow-up were recorded as continued smoking and not using NRT nicotine patches. The goal of the study was to explore the feasibility and preliminary efficacy of conducting a smoking cessation treatment program for incarcerated smokers. A total of 350 inmates were screened, 177 inmates were enrolled across the prison sites for the 6-week program, and 102 inmates completed the program. A majority of those enrolled reported that they began smoking when they were between 15 and 19 years of age (44.9%) and were smoking on average for 26 years. Less than half (21.3%) reported ever using electronic cigarettes at baseline and in Session 1,116 individuals who attended reported a median CO level of 18.0 parts per million (ppm). At a 1-month follow-up, 43 individuals reported a median CO level of 5.00 ppm. The study demonstrated preliminary efficacy and feasibility of group-based smoking cessation treatment with NRT nicotine patches in incarcerated smokers.

Prison Staff and Prisoner Views on a Prison Smoking Ban: Evidence From the Tobacco in Prisons Study

Introduction

In jurisdictions permitting prisoner smoking, rates are high (c75%), with smoking embedded in prison culture, leading to secondhand smoke exposures among staff and prisoners and challenges for smoking cessation. Momentum is building to ban smoking in prisons, but research on staff and prisoner views is lacking. We address this gap, providing evidence on staff and prisoner views throughout all Scottish prisons.

Methods

Data were collected prior to the announcement of a (November 2018) prison smoking ban throughout Scotland. Mixed methods were used: surveys of staff (online, N = 1271, ~27%) and prisoners (questionnaire, N = 2512, ~34%); 17 focus groups and two paired interviews with staff in 14 prisons.

Results

Staff were more positive than prisoners about bans and increased smoking restrictions, although prisoner views were more favorable should e-cigarettes be permitted. Nonsmokers were more positive than smokers. Whilst 74% staff and 22% prisoners agreed bans were a good idea, both groups acknowledged implementation and enforcement challenges. Staff views were influenced by beliefs about: acceptability of the policy in principle and whether/how bans could be achieved. Although some voiced doubts about smoke-free policies, staff likened a ban to other operational challenges. Staff raised concerns around needs for appropriate measures, resources and support, adequate lead-in time, and effective communication prior to a ban.

Conclusion

We recommend that regular and open opportunities for dialogue within and between different stakeholder groups are created when preparing for prison smoking bans and that specific measures to address staff and prisoner concerns are incorporated into plans to create and maintain smoke-free environments.

Implications

To our knowledge, this study is the first to research staff and prisoner views across a whole prison system prior to implementation of smoke-free policies. The results highlight potential challenges and suggest measures, which might help to maximize the success of bans. Our results are relevant for prison service managers responsible for the forthcoming introduction of a ban in Scottish prisons (November 2018) and for other prison systems and comparable institutions planning smoke-free initiatives. Given that prison smoking bans may be contentious, we recommend creating regular and open opportunities for dialogue between stakeholders when preparing for and maintaining smoke-free environments.

A Pilot Study of Cancer 101 for Incarcerated Male Smokers

Incarcerated men in the United States, an understudied population, have not been the focus of cancer prevention research. This pilot study explored the impact of Cancer 101 for imprisoned male smokers to increase cancer knowledge and promote cancer prevention activities in the prison population. Cancer 101 was pilot tested for adoption with representatives from the target audience in three prison facilities located in the northeastern region of the United States, and based on their feedback, modifications were implemented. Pretest and posttest surveys were used to assess knowledge of attitudes regarding the benefits of cancer prevention activities at baseline and immediately after completing Cancer 101. Furthermore, a paired t test procedure was used to determine whether cancer knowledge improved after participating in the Cancer 101 program. A total of 161 men completed all of the modules, participated in pre/post assessments, and qualitatively described their behavioral intentions to participate in activities that could reduce cancer risk. The mean cancer knowledge scores differed before and after completing Cancer 101, t(163) = -14.67, p < .001. Regarding age, the older the respondent, the higher their cancer knowledge score, r = .29, p < .001. This study showed improvements in cancer knowledge scores and behavioral intentions to participate in activities to reduce cancer. Cancer 101 provides opportunities for inmates to increase cancer knowledge, as well as promote action for cancer control during incarceration.

Cigarette Smoke and Cancer Health Among Incarcerated Men in U.S. Northeastern Prison Facilities

Incarcerated men, an understudied population, have not been the focus of cancer prevention studies. The Cancer Risk in Incarcerated Men Study was developed to examine smoking behaviors and cancer health among 236 incarcerated men. The participants were between 19 and 86 years of age. Only 30.5% of the sample reported receiving a cancer screening test and less than 5% reported being diagnosed with cancer. In terms of the cancer screening test provided, 43.6% reported having had a prostate-specific antigen test, 19.2% a fecal occult blood test, and 11.4% a sigmoidoscopy or a colonoscopy. Age was the only significant predictor of having a cancer screening procedure (B = .10, p < .001). This study demonstrates the need to promote cancer prevention studies among incarcerated populations.

Offenders' perceptions of the UK prison smoking ban

PURPOSE

Despite overall reductions in levels of smoking in the UK, rates of offender smoking remain high. In 2016, it was announced that prisons in England and Wales would gradually introduce a smoking ban. The purpose of this paper is to explore offenders' perceptions around the upcoming smoking ban.

DESIGN/METHODOLOGY/APPROACH

A total of eight focus groups were conducted in four prisons across the North of England. Both smoking and non-smoking offenders participated in the focus groups, and thematic analysis was used to explore the findings.

FINDINGS

Themes generated from the data were "freedom and rights", "the prison environment" and "guiding support". Participants discussed how the smoking ban was viewed as a punishment and restricted their freedom, with perceptions as to why the ban was being implemented centring around others trying to control them. Participants expressed concerns around the financial implications of the smoking ban on already stretched prison resources. Participants also recommended improving the nicotine replacement therapy on offer, and increasing the range of leisure activities within the prison to prepare for the smoking ban.

ORIGINALITY/VALUE

Overall, it was apparent that participants' awareness of the smoking ban was generally poor. It is recommended that offenders need to be made more aware of the smoking cessation support they will receive and given the opportunity to ask questions about the smoking ban. Increasing offenders' awareness of the ban may reduce stress associated with a perceived lack of choice around their smoking behaviours.

Breaking Free from Smoking: A Novel Digital Smoking Cessation Intervention for Offenders in UK Prisons

Introduction: The level of smoking cessation support across UK prisons is variable, with most offering pharmacological support, such as nicotine replacement therapy. However, with a complete smoking ban in prisons in England now imminent, additional standardised behavioural support is necessary to help offenders go smoke-free.

Aims: This study used the Behaviour Change Wheel to aim to develop the content of an online smoking cessation intervention for offenders, with consideration of their capability, motivation and opportunity for behaviour change.

Methods: This was an intervention development study. The Behaviour Change Wheel was used to map cognitive, behavioural, physiological and social targets for the intervention, onto appropriate intervention techniques for inclusion in the smoking cessation programme for offenders.

Results: Psychological capability, social opportunity and reflective and automatic motivation were identified through deductive thematic analysis as areas of change required to achieve smoking cessation. A total of 27 behavioural change techniques were chosen for this smoking cessation intervention and were mapped onto the Lifestyle Balance Model which provided the theoretical basis on which the components of the programme are conceptualised. This included strategies around increasing motivation to quit, anticipating smoking triggers, modifying smoking-related thoughts, regulating emotions, managing cravings, replacing smoking and rewarding nicotine abstinence and adopting a healthier lifestyle.

Conclusions: Through the utilisation of the Behaviour Change Wheel, the development process of this digital smoking cessation intervention was achieved. Further research is planned to evaluate the clinical effectiveness of this intervention and to explore how the programme is implemented in practice within prison settings.

The Sociopharmacology of Tobacco Addiction: Implications for Understanding Health Disparities

Efforts to reduce the public health burden of tobacco use have not equally benefited all members of society, leading to disparities in tobacco use as a function of ethnicity/race, socioeconomic position, physical/behavioral comorbidity, and other factors. Although multilevel transdisciplinary models are needed to comprehensively understand sources of tobacco-related health disparities (TRHD), the incorporation of psychopharmacology into TRHD research is rare. Similarly, psychopharmacology researchers have often overlooked the societal context in which tobacco is consumed. In an effort to facilitate transdisciplinary research agendas for studying TRHD and the psychopharmacology of tobacco use, this article introduces a novel paradigm, called "sociopharmacology." Sociopharmacology is a platform for investigating how contextual factors amplify psychopharmacological determinants of smoking to disproportionately enhance vulnerability to smoking in populations subject to TRHD. The overall goal of sociopharmacology is to identify proximal person-level psychopharmacological mechanisms that channel distal societal-level influences on TRHD. In this article I describe: (1) sociopharmacology's overarching methodology and theoretical framework; (2) example models that apply sociopharmacology to understand mechanisms underlying TRHD; (3) how sociopharmacological approaches may enhance the public health impact of basic research on the psychopharmacology of tobacco use; and (4) how understanding sociopharmacological mechanisms of TRHD might ultimately translate into interventions that reduce TRHD.

Smoking cessation in male prisoners: a literature review

PURPOSE

The purpose of this paper is to review the available literature relating to smoking cessation (SC) for the male prisoner population.

DESIGN/METHODOLOGY/APPROACH

Databases PubMed, CINAHL and MEDLINE were searched for English language studies from 1990 to 2012. The authors identified 12 papers examining SC in male prisoners. Full-text articles were analysed for inclusion.

FINDINGS

A total of 12 studies were identified for inclusion. Four studies focused on forced abstinence (a smoking ban) while the remainder looked at various combinations of nicotine replacement, pharmacology and behavioural techniques. No robust studies were found that examined nursing approaches to SC for the prisoner population. The evidence shows a strong "pro-smoking" culture in prison and that many prisoners continue to smoke irrespective of an enforced ban. However, SC strategies can be successful if implemented systematically and supported by consistent policies.

RESEARCH LIMITATIONS/IMPLICATIONS

Female-only prisoner studies were excluded as females comprise just 7 per cent of the Australian prisoner population. The analysis does not differentiate between maximum- or minimum-security prisons, or length of prison sentence. Results cannot be generalised to other forms of detention such as police custody or immigration detention centres. Studies were not appraised for quality, as exclusion on that basis would render further exploration untenable. The analysis was presented in a narrative rather than meta-analytical format and may be subject to interpretation.

PRACTICAL IMPLICATIONS

This paper provides a foundation on which to build further research evidence into the smoking behaviour of prisoners. This information can be used to advocate for healthier public policy for a vulnerable and marginalised population.

ORIGINALITY/VALUE

To the authors' knowledge, this is the first literature review into SC interventions in prisons. The authors apply the findings of this literature review to the five strategies for health promotion to propose a population approach to smoking cessation in male prisoners. Recommendations specific to the correctional environment are outlined for consideration by correctional health professionals.

Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need?

In Australia and New Zealand, population groups who experience social disadvantage smoke at much higher rates than the general population. As there are limited data specific to these groups regarding the success of nicotine replacement therapy for smoking cessation, this commentary will provide an overview of the relevant international literature supplemented with observational data relevant to the policy contexts in Australia and New Zealand. [Paul C, Wolfenden L, Tzelepis F, Yoong S, Bowman J, Wye P, Sherwood E, Rose S, Wiggers J. Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need? Drug Alcohol Rev 2016;35:785-789].

Comparing Motivational Interviewing-Based Treatment and its combination with Nicotine Replacement Therapy on smoking cessation in prisoners: a randomized controlled clinical trial

BACKGROUND

The prevalence of smoking is much higher in prisoners than it is in the general population. Prisoners who smoke cause many health problems for themselves and other prisoners. Therefore, we should help them stop smoking.

OBJECTIVE

To compare the effects of motivational interviewing-based (MI-based) treatment and its combination with nicotine replacement therapy (NRT) on smoking cessation in prisoners at Mashhad Central Prison.

METHODS

The study was designed as a double-blind, randomized, controlled clinical trial, and it began in February 2013 and ended in February 2014. Two hundred and thirteen prisoners met the inclusion criteria and were enrolled in the study. They were divided randomly into three groups, i.e., MI-based treatment, MI with NRT, and the control group, which didn't receive any therapy. The outcome measures were reported after intervention and at a 90-day follow-up, and changes in the CO levels in expired air and nicotine dependency were measured.

RESULTS

The average age of the subjects was 37.59 ± 8.76, and their mean duration of imprisonment was 3.3 ± 1.90 years. They smoked an average of 21.84 ± 8.72 cigarettes per day. Analysis of the concentration of CO in expired air in the pre-test, post-test, and at the follow-up for the three groups showed that the variations in the mean CO concentrations in the MI group and the MI with NRT group at the pre-test and at the post-test were statistically significant (p < 0.001), but no significant changes occurred between the post-test and the follow-up (p > 0.050). In addition, the results indicated that CO concentration in expired air in the MI with NRT group was statistically significant, with better efficacy of smoking cessation, compared with control group and the MI group after the follow-up (p = 0.02).

CONCLUSIONS

Motivational interviewing combined with NRT for smoking cessation is more effective than MI alone, and it resulted in a significant decrease in the CO concentration in expired air at the 90-day follow-up.

Intervention for Smokers through New Communication Technologies: What Perceptions Do Patients and Healthcare Professionals Have? A Qualitative Study

Background

The use of information and communication technologies (ICTs) in the health service is increasing. In spite of limitations, such as lack of time and experience, the deployment of ICTs in the healthcare system has advantages which include patient satisfaction with secure messaging, and time saving benefits and utility for patients and health professionals. ICTs may be helpful as either interventions on their own or as complementary tools to help patients stop smoking.

Objectives

To gather opinions from both medical professionals and smokers about an email-based application that had been designed by our research group to help smoking cessation, and identify the advantages and disadvantages associated with interventions based on the utilization of ICTs for this purpose.

Methods

A qualitative, descriptive–interpretative study with a phenomenological perspective was performed to identify and interpret the discourses of the participating smokers and primary healthcare professionals. Data were obtained through two techniques: semi-structured individual interviews and discussion groups, which were recorded and later systematically and literally transcribed together with the interviewer’s notes. Data were analyzed with the ATLAS TI 6.0 programme.

Results

Seven individual interviews and four focal groups were conducted. The advantages of the application based on the email intervention designed by our research group were said to be the saving of time in consultations and ease of access for patients who found work timetables and following a programme for smoking cessation incompatible. The disadvantages were thought to be a lack of personal contact with the healthcare professional, and the possibility of cheating/ self-deception, and a greater probability of relapse on the part of the smokers.

Conclusions

Both patients and healthcare professionals viewed the email-based application to help patients stop smoking as a complementary aid to face-to-face consultations. Nevertheless, ICTs could not substitute personal contact in the smoking cessation programme.

Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature

OBJECTIVES

To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth.

DESIGN

A systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups.

DATA SOURCES

MEDLINE, EMBASE, CINAHL and PsycInfo were searched using keywords and MeSH terms from each database's inception published prior to March 2014.

STUDY SELECTION

Studies that provided either qualitative or quantitative (ie, longitudinal, cross-sectional or cohort surveys) descriptions of self-reported perceived barriers to quitting smoking in one of the six aforementioned vulnerable groups were included.

DATA EXTRACTION

Two authors independently assessed studies for inclusion and extracted data.

RESULTS

65 eligible papers were identified: 24 with low socioeconomic groups, 16 with Indigenous groups, 18 involving people with a mental illness, 3 with homeless groups, 2 involving prisoners and 1 involving at-risk youth. One study identified was carried out with participants who were homeless and addicted to alcohol and/or other drugs. Barriers common to all vulnerable groups included: smoking for stress management, lack of support from health and other service providers, and the high prevalence and acceptability of smoking in vulnerable communities. Unique barriers were identified for people with a mental illness (eg, maintenance of mental health), Indigenous groups (eg, cultural and historical norms), prisoners (eg, living conditions), people who are homeless (eg, competing priorities) and at-risk youth (eg, high accessibility of tobacco).

CONCLUSIONS

Vulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social network-level interventions are priority areas for future smoking cessation interventions within vulnerable groups.

TRIAL REGISTRATION NUMBER

A protocol for this review has been registered with PROSPERO International Prospective Register of Systematic Reviews (Identifier: CRD42013005761).

Attitudes of detainees and prison staff towards tobacco control policy in Switzerland: a qualitative interview study

PURPOSE

To explore detainees and staff's attitudes towards tobacco use, in order to assist prison administrators to develop an ethically acceptable tobacco control policy based on stakeholders' opinion.

DESIGN

Qualitative study based on in-depth semi-structured interviews with 31 prisoners and 27 staff prior (T1) and after the implementation (T2) of a new smoke-free regulation (2009) in a Swiss male post-trial prison consisting of 120 detainees and 120 employees.

RESULTS

At T1, smoking was allowed in common indoor rooms and most working places. Both groups of participants expressed the need for a more uniform and stricter regulation, with general opposition towards a total smoking ban. Expressed fears and difficulties regarding a stricter regulation were increased stress on detainees and strain on staff, violence, riots, loss of control on detainees, and changes in social life. At T2, participants expressed predominantly satisfaction. They reported reduction in their own tobacco use and a better protection against second-hand smoke. However, enforcement was incomplete. The debate was felt as being concentrated on regulation only, leaving aside the subject of tobacco reduction or cessation support.

CONCLUSION

Besides an appropriate smoke-free regulation, further developments are necessary in order to have a comprehensive tobacco control policy in prisons.

Evaluation of a totally smoke-free forensic psychiatry in-patient facility: practice and policy implications

Objective To evaluate the impact of implementing a smoke-free policy in an Australian high-security forensic psychiatry in-patient hospital. Methods Focus groups (n = 21) and surveys with both patients (n = 45) and staff (n = 111; 53.2% nurses) elicited participants’ experience of and attitudes towards an introduced smoke-free policy. A follow-up survey elicited the impact of the policy on 15 patients’ smoking practice after discharge. Results Eighty-five per cent of patients stated it was easier to quit smoking when no one else smoked. Over half the discharged patients surveyed (58%) continued to not smoke after discharge, despite almost half the staff (41%) perceiving that patients were unlikely to quit long-term. Smoking staff were significantly more pessimistic than non-smoking staff. Many patients (69%) perceived that their health had improved as a result of not smoking. Most staff (80%) viewed nicotine dependence treatment as important, but fewer (66%) felt confident to support patients to stop smoking. Increased patient violence and management difficulties expected by staff were not realised. Conclusions A smoke-free policy can be successfully implemented in forensic psychiatry in-patient units. Nursing staff are a large and important group who need particular support to implement a smoke-free policy into practice effectively, particularly those who are smokers. Continuity of care as part of a coordinated policy and service response is needed. What is known about the topic? Healthcare settings are increasingly going totally smoke free, with mental health facilities the slowest to implement these policy changes. This is due, in part, to the fear of possible increases in violence and aggression among a patient population who have a high prevalence of smoking. What does this paper add? This paper adds to the evidence base that implementing a smoke-free policy in mental health in-patient hospitals is not only feasible, but also has substantial benefits for both staff and patients. In particular, it highlights the policy and practice implications that can assist mental health facilities to go smoke free. What are the implications for practitioners? A smoke-free policy can be successfully implemented in forensic psychiatry in-patient units; however, more support and education for staff is needed to increase their confidence and capacity to implement the policy consistently across service domains.

A randomized controlled trial of a smoking cessation intervention conducted among prisoners

AIM

To evaluate the efficacy of nortriptyline (NOR) added to a multi-component smoking cessation intervention, which included cognitive-behavioural therapy (CBT) and provision of nicotine replacement therapy (NRT).

DESIGN

Randomized controlled trial (RCT) comparing two study groups with blinded follow-up at 3, 6 and 12 months. Both groups received a multi-component smoking cessation intervention comprising two half-hour individual sessions of CBT and NRT with either active NOR or placebo.

SETTING

Prisons in New South Wales (17) and Queensland (one), Australia.

PARTICIPANTS

A total of 425 male prisoners met inclusion criteria and were allocated to either treatment (n = 206) or control group (n = 219).

MEASUREMENTS

Primary end-points at 3, 6 and 12 months were continuous abstinence, point prevalence abstinence and reporting a 50% reduction in smoking. Smoking status was confirmed by expired carbon monoxide, using a cut-point of ≤10 parts per million.

FINDINGS

Participants' demographics and baseline tobacco use were similar in treatment and control groups. Based on an intention-to-treat analysis, continuous abstinence between the treatment and control groups was not significantly different at 3 months (23.8 versus 16.4%), 6 months (17.5 versus 12.3%) and 12 months (11.7 versus 11.9%).

CONCLUSION

Adding nortriptyline to a smoking cessation treatment package consisting of behavioural support and nicotine replacement therapy does not appear to improve long-term abstinence rates in male prisoners.

Novel setting for addressing tobacco-related disparities: a survey of community welfare organization smoking policies, practices and attitudes

Research in the United States and Australia acknowledges the potential of non-government social and community service organizations (SCSOs) for reaching socially disadvantaged smokers. This study aimed to describe SCSO smoking policies and practices, and attitudes of senior staff towards smoking and cessation. It also investigated factors associated with positive tobacco control attitudes. In 2009, a cross-sectional telephone survey was undertaken of senior staff in Australian SCSOs, 149 respondents representing 93 organizations completed the survey (response rate=65%; 93/142). Most service clients (60%) remained in programs for 6 months plus, and 77% attended at least weekly. Although 93% of respondents indicated they had an organizational smoking policy, it often did not include the provision of smoking cessation support. Most respondents indicated that client smoking status was not recorded on case notes (78%). Attitudes were mostly positive towards tobacco control in SCSOs, with a mean (standard deviation) score of 8.3 (2.9) of a possible 13. The practice of assessing clients' interest in quitting was the only statistically significant factor associated with high tobacco control attitude scores. The results suggest that SCSOs are appropriate settings for reaching socially disadvantaged smokers with cessation support. Although generally receptive to tobacco control, organizations require further support to integrate smoking cessation support into usual care. In particular, education, training and support for staff to enable them to help their clients quit smoking is important.

Second-hand tobacco smoke in prison: tackling a public health matter through research

OBJECTIVES

This action-research study conducted in a Swiss male post-trial detention centre (120 detainees and 120 staff) explored the attitudes of detainees and staff towards tobacco smoking. Tackling public health matters through research involving stakeholders in prisons implies benefits and risks that need exploration.

STUDY DESIGN

The observational study involved multiple strands (quantitative and qualitative components, and air quality measurements). This article presents qualitative data on participants' attitudes and expectations about research in a prison setting.

METHODS

Semi-structured interviews were used to explore the attitudes of detainees and staff towards smoking before and after a smoke-free regulation change in the prison in 2009. Specific coding and thematic content analysis for research were performed with the support of ATLAS.ti.

RESULTS

In total, 77 interviews were conducted (38 before the regulation change and 39 after the regulation change) with 31 detainees (mean age 35 years, range 22-60 years) and 27 prison staff (mean age 46 years, range 29-65 years). Both detainees and staff expressed satisfaction regarding their involvement in the study, and wished to be informed about the results. They expected concrete changes in smoke-free regulation, and that the research would help to find ways to motivate detainees to quit smoking.

CONCLUSION

Active involvement of stakeholders promotes public health. Interviewing detainees and prison staff as part of an action-research study aimed at tackling a public health matter is a way of raising awareness and facilitating change in prisons. Research needs to be conducted independently from the prison administrators in order to increase trust and to avoid misunderstandings.

Smoking and other drug characteristics of aboriginal and non-aboriginal prisoners in australia

Introduction and Aim. Although tobacco and alcohol use have declined substantially in the Australian community, substance use among prisoners remains high. The aim was to compare the smoking, drug, and alcohol characteristics, sociodemographic profile, and general health of Aboriginal and non-Aboriginal male prisoners in a smoking cessation intervention. Design and Methods. This study was a descriptive cross-sectional analysis of data from 425 male prisoners who joined a quit smoking trial conducted at 18 correctional centres in NSW and Queensland using data collected by standardised self-report instruments. Results. Average age was 33 years with 15% from Aboriginal descent. Compared to non-Aboriginal prisoners, Aboriginal prisoners were significantly more likely to have left school with no qualifications, to have been institutionalised as a child, to be previously incarcerated, and commenced smoking at a younger age. The tobacco use profile of both groups was similar; most of them had a medium to high level of nicotine dependence, smoked roll your own tobacco, and were “serious” about quitting. Discussion and Conclusion. Despite differences in terms of sociodemographic characteristics and offending history, the smoking characteristics of Aboriginal and non- Aboriginal prisoners were similar. Incarceration offers an opportunity to encourage smoking cessation and reduction of drug use.

Health behaviors among short- and long- term ex-smokers: results from the Thai National Health Examination Survey IV, 2009

BACKGROUND

Although numerous studies have shown the health behaviors of ex-smokers to be better than those in regular smokers, the differences in health behaviors among ex-smokers at varying durations of cessation have not been investigated. This study aims to examine the relationship between different durations of smoking cessation and health behaviors.

METHODS

Data on dietary intake, alcohol consumption, physical activity, and smoking behavior from the Thai National Health Examination Survey IV for subjects aged 15-98 years (n=19 371) were included in the analysis. Trends between health behaviors among regular smokers, ex-smokers with different durations of smoking (<1 year, 1-10 years, >10 years), and never smokers were tested. Logistic regression models adjusted for sex, age, and economic status were used.

RESULTS

The prevalences of regular smoking, ex-smoking, and never smoking were 22.3%, 12% , and 65.7%, respectively. A trend was found for consumption of fruit, beans and meats, dairy and soy milk, whole-grain products, nutritional supplements, and eating habits. Average daily alcohol consumption (g) was lowest among ex-smokers who had quit for>10 years ex-smokers (16.4) followed by 1-10 years ex-smokers (27.2), and <1 year ex-smokers (33.7).

CONCLUSION

A longer duration of smoking cessation correlated with better health behaviors.

The challenges of reducing tobacco use among prisoners

ISSUE

The prevalence of smoking among prisoners is exceptionally high and is often comorbid with alcohol and drug problems, mental illness and other health problems. This review paper summarises the literature and available research related to smoking prevalence and smoking cessation initiatives among prisoners and identifies areas of need for further research and intervention.

APPROACH

This paper highlights three studies conducted in the New South Wales prison system which attempt to address these high rates of smoking including a feasibility study, a focus group study and a randomised controlled trial.

KEY FINDINGS

The challenges of making systems-level changes to address these high rates of smoking are discussed including a recent National Summit on Tobacco Smoking in Prisons.

IMPLICATIONS

Dissemination of research findings has assisted in highlighting the importance of tobacco smoking among prisoners and the need to develop culturally and setting appropriate smoking cessation initiatives for prisoners.

CONCLUSIONS

As one of the most marginalised and socially disadvantaged populations in Australia, prisoners represent an important population to target for smoking cessation programs and interventions. This paper highlights a number of initiatives undertaken to address this problem and suggests directions for the future.

Cardiovascular risk among Aboriginal and non-Aboriginal smoking male prisoners: inequalities compared to the wider community

Background

Cardiovascular risk factors (CVRF) were collected as part of a randomised controlled trial of a multi-component intervention to reduce smoking among male prisoners. Cross-sectional baseline data on CVRF were compared among smoking male prisoners and males of similar age in the general population.

Methods

425 smoking prisoners were recruited (n = 407 in New South Wales; 18 in Queensland), including 15% of Aboriginal descent (mean age 33 years; median sentence length 3.6 years). We measured CVRF such as smoking, physical activity, blood pressure, risky alcohol use, symptoms of depression, and low socioeconomic status.

Results

We found that 39% of prisoners had 3+ CVRF, compared to 10% in a general community sample of most disadvantaged men of a similar age. Significantly more Aboriginal prisoners had 3+ CVRF than non-Aboriginal prisoners (55% vs 36%, p < 0.01) and were twice as likely to have 4+ CVRF (27% vs 12%). In addition to all prisoners in this study being a current smoker (with 70% smoking 20+ cigarettes per day), the prevalence of other CVRF was very high: insufficient physical activity (23%); hypertension (4%), risky drinking (52%), symptoms of depression (14%) and low socioeconomic status (SES) (44%). Aboriginal prisoners had higher levels of risky alcohol use, symptoms of depression, and were more likely to be of low SES.

Conclusion

Prisoners are at high risk for developing cardiovascular disease compared to even the most disadvantaged in their community and should be the focus of specific public health interventions.

Trial Registration

This trial is registered with the Australian New Zealand Clinical Trials Registry ACTRN#12606000229572.

Psychiatric symptoms, psychological distress and somatic comorbidity among remand prisoners in Switzerland

OBJECTIVE

The aims of this study were to determine the prevalence of psychiatric symptoms and complaints among remand prisoners in Switzerland and to analyze the relationships between psychiatric symptoms, physical health and substance abuse problems in this population.

METHOD

The medical files of all detainees attending the prison health service in 2007 were reviewed. Identified health problems were coded using the International Classification of Primary Care (ICPC-2). Descriptive statistics and measures of association were computed.

RESULTS

A total of 1510 files were analyzed. Several associations between psychological symptoms (anxiety and insomnia) and physical health problems (skin, respiratory and circulatory) were observed. Substance abuse was also frequently associated with somatic health problems.

CONCLUSIONS

These data provide the first comprehensive description of the mental health of detainees in Switzerland's largest remand prison. Our findings emphasize the need for coordinated health care services in detention settings.

Smoking in prisons: the need for effective and acceptable interventions

Tobacco-smoking prevalence has been decreasing in many high-income countries, but not in prison. We provide a summary of recent data on smoking in prison (United States, Australia, and Europe), and discuss examples of implemented policies for responding to environmental tobacco smoke (ETS), their health, humanitarian, and ethical aspects. We gathered data through a systematic literature review, and added the authors' ongoing experience in the implementation of smoking policies outside and inside prisons in Australia and Europe. Detainees' smoking prevalence varies between 64 per cent and 91.8 per cent, and can be more than three times as high as in the general population. Few data are available on the prevalence of smoking in women detainees and staff. Policies vary greatly. Bans may either be 'total' or 'partial' (smoking allowed in cells or designated places). A comprehensive policy strategy to reduce ETS needs a harm minimization philosophy, and should include environmental restrictions, information, and support to detainees and staff for smoking cessation, and health staff training in smoking cessation.