Implementing an indoor smoking ban in prison: enforcement issues and effects on tobacco use, exposure to second-hand smoke and health of inmates

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.

A Qualitative Study of the Implementation and Continued Delivery of Complete and Partial Smoke-Free Policies Across England's Prison Estate

INTRODUCTION

In the United Kingdom, smoking among prisoners is up to five times more prevalent than the national average. Between 2015 and 2018, HMPPS introduced a complete smoke-free policy in all closed prisons, and a partial policy permitting smoking only in smoking shelters in open prisons.

AIMS AND METHODS

This study aimed to explore the views of stakeholders regarding the implementation and continuation of smoke-free policies, including the management of nicotine addiction during imprisonment and after release. Individuals with key strategic and/or operational roles in delivering smoke-free prison policies across England were purposively sampled to complete a semi-structured interview. Twenty-eight interviews were analyzed thematically.

RESULTS

The smoke-free implementation across the closed prison estate was viewed as a success, though there were reports of reduced availability of smoking cessation support since the roll out. Participants thought the majority of tobacco smokers living in closed prison environments were now using an electronic cigarette, typically as a temporary means to manage nicotine addiction until release. In open prisons the partial policy has been less successful; high rates of smoking resumption on moving from closed to open conditions were reported, with many participants arguing that the open estate should also go completely smoke free. It was envisaged that most prisoners would resume smoking on community release.

CONCLUSIONS

The smoke-free policies provide a unique opportunity to promote lifelong cessation in this highly disadvantaged group. However more could be done to adopt a consistent smoke-free policy across all prisons, and to support prisoners in quitting smoking and nicotine use during and after imprisonment.

IMPLICATIONS

Our results identify the urgent need for more work to explore rates and reasons for relapse to smoking on transfer to the open estate and after release. With the majority of smokers in the closed prison estate now using e-cigarettes to manage their nicotine addiction, one way to support long-term tobacco abstinence could be to place greater emphasis on this switching behavior as a way of reducing tobacco-related harm within this population.

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 Arrest and Cigarette Smoking in Emerging Adulthood

Background:

Despite prior studies, transitions in smoking patterns are not fully understood. Getting arrested may alter an individual’s smoking pattern through processes proscribed by the criminological labeling theory. This study examined how arrest during emerging adulthood altered smoking behavior during subsequent years and whether there were differential effects by race/ethnicity and gender.

Methods:

We analyzed 15 waves of data from the National Longitudinal Survey of Youth 1997. Multinomial logistic regressions were performed using Stata software version 14.

Results:

For both genders, arrested black men and women had the most distinct smoking transitions (both increases and decreases) as compared with their non-arrested counterparts. Among men, particularly black males, arrest in early adulthood was associated with the men transitioning to both increased and decreased smoking. Patterns in smoking transitions for women were less clear, suggesting that women’s smoking may be influenced by factors not in the models. Women had a low probability of starting to smoke or increasing smoking if they were never arrested between 18 and 21 years of age.

Conclusions:

The results for transitioning into increased smoking offer some support for labeling theory processes. Other findings suggest that arrest may lead to some men reducing or quitting smoking. Early adulthood arrest may serve to “shock the system” and contribute to males altering their prior smoking behavior.

Implications:

Tobacco use over the life course, particularly across different racial and ethnic groups, remains understudied. This study contributes to the literature using a nationally representative sample to examine the effect of getting arrested in emerging adulthood on cigarette use during subsequent years. In conducting the study, investigators combined theories and methodological approaches from 2 complementary disciplines: public health and criminal justice. Because criminal justice policymakers tend to focus on issues like ex-offender unemployment, public health officials can provide guidance regarding the effect of justice system involvement on smoking, particularly given the adverse health outcomes of using cigarettes.

Substance Use During Imprisonment in Low- and Middle-Income Countries

Substance use disorders are among the most common health problems of people involved with the criminal justice system. Scaling up addiction services in prisons is a global public health and human rights challenge, especially in poorly resourced countries. We systematically reviewed the prevalence of substance use in prison populations in low- and middle-income countries. We searched for studies reporting prevalence rates of nicotine, alcohol, illicit drug, and injection drug use during imprisonment in unselected samples of imprisoned people in low- and middle-income countries. Data meta-analysis was conducted and sources of heterogeneity were examined by meta-regression. Prevalence of nicotine use during imprisonment ranged from 5% to 87%, with a random-effects pooled estimate of 56% (95% confidence interval (CI): 45, 66) with significant geographical heterogeneity. Alcohol use varied from 1% to 76% (pooled prevalence, 16%, 95% CI: 9, 25). Approximately one-quarter of people (25%; 95% CI: 17, 33; range, 0–78) used illicit drugs during imprisonment. The prevalence of injection drug use varied from 0% to 26% (pooled estimate, 1.6%, 95% CI: 0.8, 3.0). Lifetime substance use was investigated in secondary analyses. The high prevalence of smoking in prison suggests that policies regarding smoking need careful review. Furthermore, the findings underscore the importance of timely, scalable, and available treatments for alcohol and illegal drug use by people involved with the criminal justice system.

Cervical Cancer Screening Access for Women Who Experience Imprisonment in Ontario, Canada

IMPORTANCE

Women who experience imprisonment have higher rates of cervical cancer. Lack of access to cervical cancer screening in the community or in prison may contribute to increased cervical cancer incidence.

OBJECTIVES

To determine cervical cancer screening rates for women in provincial prison in Ontario, Canada, and to compare these data with data for the general population.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used correctional and health administrative data from January 1, 2006, to December 31, 2013. Participants included Ontario women aged 21 to 69 years during the follow-up period with no history of cervical cancer or hysterectomy. Analyses were conducted between July 2017 and September 2018.

EXPOSURES

Women admitted to Ontario provincial prison in 2009 or 2010 and released in 2010 were considered exposed, and women in the general population of Ontario were considered unexposed.

MAIN OUTCOMES AND MEASURES

Whether women were overdue for cervical cancer screening at the time of admission to prison or on July 1, 2010, for the general population, defined as not having been screened in the previous 3 years, and whether women who were overdue were still overdue after 3 years.

RESULTS

There were 4553 women in the prison group and 3 647 936 women in the general population group. The median (interquartile range) age was 36 (29-43) years in the prison group and 43 (34-53) years in the general population. Women in the prison group had 2.20 times (95% CI, 2.08-2.33) the odds of being overdue for cervical cancer screening compared with women in the general population after adjusting for neighborhood income quintile, at 53.9% (95% CI, 51.8%-56.1%) compared with 32.9% (95% CI, 32.8%-33.0%) (P < .001). Women in the prison group also had nearly twice the odds of still being overdue at 3 years, with an odds ratio of 1.87 (95% CI, 1.76-1.99) after adjusting for neighborhood income quintile, and rates of still being overdue of 36.2% (95% CI, 34.5%-38.0%) compared with 21.9% (95% CI, 21.8%-21.9%) (P < .001).

CONCLUSIONS AND RELEVANCE

Women who experience imprisonment have worse cervical cancer screening access than women in the general population. Work should be done to promote cervical cancer screening awareness and to improve access to acceptable screening in prison and in the community after prison release.

Cancer prevalence, incidence and mortality in people who experience incarceration in Ontario, Canada: A population-based retrospective cohort study

Introduction

Evidence suggests that many risk factors for cancer are overrepresented in people who experience incarceration, and data on cancer epidemiology are limited for this population. We aimed to describe cancer prevalence, incidence and mortality in adults admitted to provincial custody in Ontario, Canada in 2000.

Methods

We linked data on 48,166 adults admitted to provincial custody in Ontario in 2000 with Ontario Cancer Registry data to 2012. We calculated cancer prevalence in the 10 years prior to admission to custody in 2000, incidence between 2000 and 2012 and mortality between 2000 and 2011. Standardized for age, we calculated incidence and mortality ratios by sex compared to the general population of Ontario.

Results

The 10-year cancer prevalence was 0.4% in men and 0.6% in women at admission to provincial custody in 2000. Between 2000 and 2012, 2.6% of men and 2.8% of women were diagnosed with new cancer. The standardized incidence ratio for cancer was 1.0 (95% CI 0.9–1.0) for men and 0.9 (95% CI 0.7–1.0) for women compared to the general population, and was significantly increased for cervical, head and neck, liver and lung cancers. The standardized mortality ratio was 1.6 (95% CI 1.4–1.7) in men and 1.4 (95% CI 1.0–1.9) in women, and was significantly increased for head and neck, liver, and lung cancers.

Conclusions

There is an excess burden of cancer in people who experience incarceration. Cancer prevention should include people who experience incarceration, and the period of incarceration may offer an opportunity for intervention.

Systematic review of health and behavioural outcomes of smoking cessation interventions in prisons

Objective

We conducted a systematic review to examine the impact of smoking cessation interventions, including smoking bans, on prisoners and prison staff.

Data sources

We systematically searched health and criminal justice databases for relevant studies. Search strings were used to combine terms related to smoking cessation interventions with terms related to incarceration. We used forward and backward snowballing to capture additional studies.

Study selection

Studies were included if: they were published between 1 January 1994 and 23 May 2016; the population was incarcerated adults and/or prison staff; they had a quantitative component; they were published in English; and they reported outcomes of a smoking cessation programme/ban with regard to reported change in smoking behaviour and/or behavioural outcomes.

Data extraction

Studies were reviewed for methodological rigour using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies. Data were independently reviewed for methodological quality by 1 author and a research assistant.

Data synthesis

Cessation programmes, including free nicotine replacement therapy and/or behavioural counselling can significantly increase the likelihood of quitting in prison and increase abstinence postrelease. Indoor bans have little impact on prisoner smoking behaviour. Prisoners who experience a complete smoking ban typically resume smoking shortly after release from prison. Bans may result in adverse behavioural outcomes, but these are generally minimal and short-lived.

Conclusions

While there is limited evidence to inform tobacco control policies in custodial settings, outcomes of this review suggest that cessation programmes/bans can be an effective mechanism to interrupt prisoner smoking behaviour when properly enforced.

Unexpected increase in indoor pollutants after the introduction of a smoke-free policy in a correctional center

Correctional centers (prisons) are one of the few non-residential indoor environments where smoking is still permitted. However, few studies have investigated indoor air quality (IAQ) in these locations. We quantified the level of inmate and staff exposure to secondhand smoke, including particle number (PN) count, and we assessed the impact of the smoking ban on IAQ. We performed measurements of indoor and outdoor PM2.5 and PN concentrations, personal PN exposure levels, volatile organic compounds (VOCs), and nicotine both before and after a complete indoor smoking ban in an Australian maximum security prison. Results show that the indoor 24-h average PM2.5 concentrations ranged from 6 (±1) μg/m(3) to 17 (±3) μg/m(3) pre-ban. The post-ban levels ranged from 7 (±2) μg/m(3) to 71 (±43) μg/m(3) . While PM2.5 concentrations decreased in one unit post-ban, they increased in the other two units. Similar post-ban increases were also observed in levels of PN and VOCs. We describe an unexpected increase of indoor pollutants following a total indoor smoking ban in a prison that was reflected across multiple pollutants that are markers of smoking. We hypothesise that clandestine post-ban smoking among inmates may have been the predominant cause.

Impact of institutional smoking bans on reducing harms and secondhand smoke exposure

BACKGROUND

Smoking bans or restrictions can assist in eliminating nonsmokers' exposure to the dangers of secondhand smoke and can reduce tobacco consumption amongst smokers themselves. Evidence exists identifying the impact of tobacco control regulations and interventions implemented in general workplaces and at an individual level. However, it is important that we also review the evidence for smoking bans at a meso- or organisational level, to identify their impact on reducing the burden of exposure to tobacco smoke. Our review assesses evidence for meso- or organisational-level tobacco control bans or policies in a number of specialist settings, including public healthcare facilities, higher education and correctional facilities.

OBJECTIVES

To assess the extent to which institutional smoking bans may reduce passive smoke exposure and active smoking, and affect other health-related outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE, EMBASE, and the reference lists of identified studies. We contacted authors to identify completed or ongoing studies eligible for inclusion in this review. We also checked websites of state agencies and organisations, such as trial registries. Date of latest searches was 22nd June 2015.

SELECTION CRITERIA

We considered studies that reported the effects of tobacco bans or policies, whether complete or partial, on reducing secondhand smoke exposure, tobacco consumption, smoking prevalence and other health outcomes, in public healthcare, higher educational and correctional facilities, from 2005 onwards.The minimum standard for inclusion was having a settings-level policy or ban implemented in the study, and a minimum of six months follow-up for measures of smoking behaviour. We included quasi-experimental studies (i.e. controlled before-and-after studies), interrupted time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently assessed studies for inclusion in the review. Due to variation in the measurement of outcomes we did not conduct a meta-analysis for all of the studies included in this review, but carried out a Mantel-Haenszel fixed-effect meta-analysis, pooling 11 of the included studies. We evaluated all studies using a qualitative narrative synthesis.

MAIN RESULTS

We included 17 observational studies in this review. We found no randomized controlled trials. Twelve studies are based in hospitals, three in prisons and two in universities. Three studies used a controlled before-and-after design, with another site used for comparison. The remaining 14 studies used an uncontrolled before-and-after study design. Five studies reported evidence from two participant groups, including staff and either patients or prisoners (depending on specialist setting), with the 12 remaining studies investigating only one participant group.The four studies (two in prisons, two in hospitals) providing health outcomes data reported an effect of reduced secondhand smoke exposure and reduced mortality associated with smoking-related illnesses. No studies included in the review measured cotinine levels to validate secondhand smoke exposure. Eleven studies reporting active smoking rates with 12,485 participants available for pooling, but with substantial evidence of statistical heterogeneity (I² = 72%). Heterogeneity was lower in subgroups defined by setting, and provided evidence for an effect of tobacco bans on reducing active smoking rates. An analysis exploring heterogeneity within hospital settings showed evidence of an effect on reducing active smoking rates in both staff (risk ratio (RR) 0.71, 95% confidence interval ( CI) 0.64 to 0.78) and patients (RR 0.86, 95% CI 0.76 to 0.98), but heterogeneity remained in the staff subgroup (I² = 76%). In prisons, despite evidence of reduced mortality associated with smoking-related illnesses in two studies, there was no evidence of effect on active smoking rates (1 study, RR 0.99, 95% CI 0.84 to 1.16).We judged the quality of the evidence to be low, using the GRADE approach, as the included studies are all observational.

AUTHORS' CONCLUSIONS

We found evidence of an effect of settings-based smoking policies on reducing smoking rates in hospitals and universities. In prisons, reduced mortality rates and reduced exposure to secondhand smoke were reported. However, we rated the evidence base as low quality. We therefore need more robust studies assessing the evidence for smoking bans and policies in these important specialist settings.

Health status of prisoners in Canada: Narrative review

OBJECTIVE

To review the literature for quantitative research on the health status of persons in custody in provincial, territorial, and federal correctional facilities in Canada, and summarize recent evidence.

QUALITY OF EVIDENCE

A search was performed in research databases and the websites of relevant Canadian governmental and non-governmental organizations for quantitative studies of health conducted between 1993 and 2014. Studies were included that provided quantitative data on health status for youth or adults who had been detained or incarcerated in a jail or prison in Canada.

MAIN MESSAGE

The health status of this population is poor compared with the general Canadian population, as indicated by data on social determinants of health, mortality in custody, mental health, substance use, communicable diseases, and sexual and reproductive health. Little is known about mortality after release, chronic diseases, injury, reproductive health, and health care access and quality.

CONCLUSION

Health status data should be used to improve health care and to intervene to improve health for persons while in custody and after release, with potential benefits for all Canadians.

Substance use in incarcerated male offenders: Predictive validity of a personality typology of substance misusers

INTRODUCTION

Substance use and misuse is highly prevalent in offenders, and a significant proportion of convicted offenders continue to use controlled substances during incarceration. Few studies have focused on the identification of variables, especially personality characteristics, that may be predictive of institutional substance use. The purpose of this study is to assess the validity of the Substance Use Risk Profile (SURP) personality typology in a sample of male offenders and to determine whether it may have utility in identifying offenders at risk for substance use during incarceration.

METHODS

A total of 118 offenders across all provincial and federal institutions in New Brunswick, Canada completed questionnaires assessing personality, mental health symptoms, substance use motives, and substance use.

RESULTS

Latent class cluster analysis revealed the presence of three distinct clusters of offenders based on severity of substance use, personality, and mental health symptoms. Survival analysis indicated a significant effect of levels of sensation seeking, a trend of cluster membership, and anxiety sensitivity on days until first institutional substance use.

CONCLUSION

High levels of sensation seeking and low anxiety sensitivity appear to indicate increased risk for substance misuse in this population.

Smoke-free policies in U.S. Prisons and jails: A review of the literature

INTRODUCTION

Despite progress in limiting exposure to secondhand smoke (SHS) in the United States, little is known about the impact of smoke-free polices in prisons and jails. SHS exposure in this setting may be great, as smoking prevalence among inmates is more than three times higher than among non-incarcerated adults. To inform the implementation of smoke-free policies, this article reviews the literature on the extent, nature, and impact of smoke-free policies in U.S. prisons and jails.

METHODS

We systematically searched PubMed, Embase, EconLit, and Social Services Abstracts databases. We examined studies published prior to January 2014 that described policies prohibiting smoking tobacco in adult U.S. correctional facilities.

RESULTS

Twenty-seven studies met inclusion criteria. Smoke-free policies in prisons were rare in the 1980s but, by 2007, 87% prohibited smoking indoors. Policies reduced SHS exposure and a small body of evidence suggests they are associated with health benefits. We did not identify any studies documenting economic outcomes. Non-compliance with policies was documented in a small number of prisons and jails, with 20%-76% of inmates reporting smoking in violation of a policy. Despite barriers, policies were implemented successfully when access to contraband tobacco was limited and penalties were enforced.

CONCLUSION

Smoke-free policies have become increasingly common in prisons and jails, but evidence suggests they are not consistently implemented. Future studies should examine the health and economic outcomes of smoke-free policies in prisons and jails. By implementing smoke-free policies, prisons and jails have an opportunity to improve the health of staff and inmates.

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.

Indoor air pollution levels were halved as a result of a national tobacco ban in a New Zealand prison

INTRODUCTION

Few studies have measured the effect of tobacco bans on secondhand smoke (SHS) exposure in prisons. From June 1, 2011, the sale of tobacco was prohibited in New Zealand prisons. One month later, the possession of tobacco was banned. We studied the indoor air quality before and after this policy was enforced.

METHODS

We measured indoor-fine-particulate (PM(2.5)) concentrations using a TSI SidePak photometer. The instrument was placed in a staff base of a New Zealand maximum-security prison, adjacent to four 12-cell wings. Measurements were made before the sales restriction, during this period, and after the ban. Data were summarized using daily geometric means and generalized least squares regression.

RESULTS

A total of 7,107 observations were recorded at 5-min intervals, on 14 days before and 15 days after implementation, between 24 May and 5 August. Before the policy was implemented, the geometric mean was 6.58 μg/m(3) (95% CI = 6.29-6.58), which declined to 5.17 μg/m(3) (95% CI = 4.93-5.41) during the sales ban, and fell to 2.44 μg/m(3) (95% CI = 2.37-2.52) after the smoking ban. Regression analyses revealed an average 57% (95% CI = 42-68) decline in PM(2.5) concentrations, comparing the before and after periods.

CONCLUSIONS

Our study showed a rapid and substantial improvement in indoor air quality after tobacco was banned at a prison. We conclude that prisoners have reduced their smoking in line with the ban, and that a significant health hazard has been reduced for staff and prisoners alike.