Perceptions and influences of a state prison smoking ban

Diversion of medications to treat opioid use disorder: Qualitative findings from formerly incarcerated adults in Massachusetts

BACKGROUND

Carceral officials often cite diversion of medication for opioid use disorder (MOUD) (e.g., buprenorphine) as a reason for not offering MOUD treatment in jails and prisons with little understanding of patient perspectives. We aimed to understand patient perceptions of medication diversion from jail-based MOUD programs and the factors that contribute to and reduce diversion.

METHODS

We conducted thematic analyses of semi-structured interviews held in 2021-22 with 38 adults who received MOUD treatment and were released from eight Massachusetts jails that had implemented a MOUD program on or after September 2019.

RESULTS

Consistent with prior reports from carceral staff, patients perceived MOUD diversion to happen less frequently than expected, which they attributed to dosing protocols that have effectively reduced it. Patients reported that MOUD availability reduced the contraband buprenorphine market, although other contraband substances have entered jails (fentanyl, oxycodone, K2). Patients perceived Subutex to have greater misuse potential and added diversion risks. Patients valued graduated consequences and other efforts to reduce MOUD diversion and contraband for making jails safer and for enabling patients to receive treatment. Nearly all participants reported having heard about, witnessed, or been involved in actual or attempted diversion, with variation in reports by jail. Patients suggested that dispensing MOUD to all who need it immediately upon intake would be the most effective way to reduce MOUD diversion and contraband.

CONCLUSION

Formerly incarcerated patients perceived MOUD diversion within jail medication programs as occurring less often than expected and that it can be reduced with appropriate protocols. To help limit medication diversion, patients recommended provision of MOUD upon intake to all individuals with opioid use disorder who need it. Findings have implications for MOUD program adaptation, successful routinization, and diffusion in carceral settings.

Peer-Facilitated Tobacco Cessation in a Prison Setting: A Proof of Concept Study

Background

Despite the vast human and economic costs associated with tobacco use among U.S. inmates, smoking remains a largely ignored public health epidemic. Incarcerated individuals smoke at 3 to 4 times the rate of the general population and face tobacco-related health disparities.

Purpose

This paper reports results from a single arm, pre/post pilot study designed to test the feasibility and initial effectiveness of an inmate-administered group tobacco cessation intervention within a men’s pre-release program run by the Arizona Department of Corrections.

Methods

Corrections staff and inmate peer mentors were trained in the DIMENSIONS: Tobacco Free Program, a manualized 6-session tobacco cessation group curriculum. Group sessions used evidence-based interventions for assisting inmates develop skills to live tobacco and nicotine free. In 2019-2020, 39 men who reported tobacco use voluntarily participated in one of three cessation groups. Wilcoxen signed-rank tests evaluated changes across group sessions in frequency of tobacco use and attitudes about nicotine-free living post release.

Results

Most participants attended all six group sessions (79%) and made one or more quit attempts (78%). Overall, 24% of the sample reported quitting tobacco, and significant reductions in tobacco use were reported after only two sessions. Participants further reported significant positive changes in knowledge, plans, support, and confidence to live tobacco-free lives post-release.

Conclusions

To our knowledge, this is the first study to demonstrate that, with minimal investment, implementation of an evidence-based, peer-led tobacco free program is feasible and effective within an incarcerated population uniquely vulnerable to the burden of tobacco.

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.

Smoking Beyond Prison Bans: The Impact of Prison Tobacco Bans on Smoking Among Prison Entrants

This study aims to determine whether previous exposure to a total prison smoking ban is associated with a reduction in daily smoking postrelease and to identify the factors associated with daily tobacco use. Demographics, incarceration history, and substance use data were collected from the 2016 National Prisoner Entrants' Blood Borne Virus Survey for 389 Australian prison entrants. Predictors of daily smoking among those exposed to a smoking ban were illicit drug use and Indigenous status. No significant association was found between current daily smoking and recent exposure to a prison smoking ban, suggesting that the majority of Australian prisoners exposed to a tobacco ban while incarcerated will return to smoking once released. Complementary and culturally specific interventions supporting abstinence postrelease should be considered.

Post-implementation perspectives on smokefree prison policy: a qualitative study with staff and people in custody

Background

A comprehensive smokefree prison policy (SFPP) was introduced in Scottish prisons from November 2018, reflecting concern about inequalities in occupational exposures to second-hand smoke (SHS) and tobacco-related harms among people in custody (PiC). We aimed to address a gap, whereby few studies have sought to understand SFPP from the perspectives of people living and working in prisons.

Methods

As part of a comprehensive evaluation, focus groups and interviews with staff (n = 99) and interviews with PiC (n = 23) were conducted 6–9 months post-implementation of SFPP in Scotland. Data were analysed using the framework approach.

Results

Our study found that new restrictions on smoking had been widely accepted by PiC, after a period of adjustment which was less troublesome than participants had anticipated. Benefits of the SFPP for the safety and comfort of staff and PiC who were no longer exposed to SHS, and additionally for the health of PiC who were now smoking-abstinent, were widely acknowledged. Drawbacks of the SFPP, such as difficulties managing without tobacco and use of alternatives (e.g. e-cigarettes and changes in use of illegal drugs), were also reported. Contraband tobacco was not reported to be a major problem following prisons becoming smokefree.

Conclusions

The findings strengthen evidence that SFPPs can be implemented without causing major disruption and highlight the need for removal of tobacco to be underpinned by careful planning, partnership working and ensuring the availability of support for smokers. Experiences from Scotland may be of interest and some comfort, internationally for jurisdictions considering smoke-free rules in prisons.

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.

Systematic Review of Factors Influencing Smoking Following Release From Smoke-Free Prisons

INTRODUCTION

Given the current proliferation of prison smoke-free policies internationally, and the multiple benefits of continued smoking abstinence for correctional populations, improved understanding of factors influencing postrelease smoking abstinence is required to inform support strategies aimed at individuals exiting smoke-free prisons.

METHODS

We systematically searched health, social science, and criminal justice databases for studies relating to smoking behaviors among people released from smoke-free prisons. Studies were included if: they were published between January 1, 2000 and July 26, 2017; they were published in English; the population was people who were incarcerated or formerly incarcerated in prisons with total smoke-free policies; and the reported outcomes included measures of: (1) prerelease intention to smoke or remain abstinent from smoking following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Both authors independently screened returned citations to assess eligibility and reviewed studies for methodological quality using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies.

RESULTS

Fifteen of 121 publications were included. The evidence base in this area is small, almost exclusively US-based, and is mostly methodologically weak. Interventions delivered both pre and postrelease, that strengthen intention to quit, integrate with other substance-use treatment, and facilitate social support for quitting may help maintain postrelease smoking abstinence.

CONCLUSIONS

There is an urgent need for high-quality research to inform interventions to reduce high smoking relapse rates upon release from smoke-free prisons, to extend the multiple benefits of continued smoking abstinence into the community.

IMPLICATIONS

Interventions designed to help people remain abstinent from tobacco following release from smoke-free prisons are an important opportunity to improve the health, finances, and well-being of this vulnerable population.

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.

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.

Barriers and facilitators of maintained smoking abstinence following release from smoke-free prisons: A qualitative enquiry

BACKGROUND

The prevalence of smoking among people entering prisons is high. Despite increasing adoption of prison smoke-free policies, relapse to smoking after release from prison is nearly universal, and policy to effectively mitigate this is largely absent. Informed by a risk environment framework, we aimed to identify key barriers and facilitators to maintaining smoking abstinence among former smokers released from smoke-free prisons.

METHOD

Twenty-one people released from smoke-free prisons in Queensland, Australia, were followed up from a larger survey of 114 former prisoners. Semi-structured interviews were used to explore the perceived barriers and facilitators of maintained smoking abstinence.

FINDINGS

Identified barriers to continued abstinence included pre-release intention to resume smoking; normalisation of smoking in home or social environments, resumption of smoking as a symbolic act of freedom and resistance from and to a restrictive environment; a perception that smoking provides stress relief to their difficult lives, and the use of tobacco/smoking to cope with cravings experienced on release for illicit substances. A number of interviewees were unable to provide clear reflective reasons for relapse. For those who did manage to remain abstinent for a period of time, identified facilitators included an awareness of the health and financial benefits of smoking abstinence, the use of intrinsic motivation, distraction from nicotine cravings using alternative activities, and social support from family and peers.

DISCUSSION

Interventions promoting continued smoking abstinence among people exiting smoke-free prisons should focus on targeting the perceived individual- and environmental-level barriers to maintained smoking abstinence while simultaneously promoting perceived facilitators, so as to reduce smoking-related health and economic disparities in this marginalised population.

Smoking cessation in smoke-free prisons: a grounded theory study

Purpose

Prisoners are vulnerable to tobacco addiction and have a smoking prevalence significantly higher than that of the general community. The context of this study was the implementation of a “smoke-free prisons” policy, which imposed forced smoking cessation onto the Queensland, Australian prison population. The study asked the question: “What are the psychosocial processes in which male prisoners engage during smoking cessation in a smoke-free environment?”

Design/methodology/approach

Qualitative interviews were conducted with 15 prisoners in South-east Queensland smoke-free correctional centres. Grounded theory methodology was applied to construct a theory of the processes of smoking cessation.

Findings

The constructed theory was named Engaging with Quitting. In this model, prisoners proceed through a cycle of evaluations, adjustments and reflections on their reality as related to the smoke-free prison. The study gives first-hand accounts of the prisoners’ use (and abuse) of nicotine replacement therapy. Three personality typologies emerged from the data: The Angry Smoker, the Shifting Opportunist and the Optimistic Quitter.

Research limitations/implications

This qualitative study makes no claim of generalisability and cannot be taken to represent all prisoners. Females, youths and culturally diverse prisoners were not represented in the sample.

Practical implications

Smoking cessation in prisons must be recognised as an ongoing process, rather than a discrete event. A coordinated approach between custodial and health authorities is required to minimise maladaptive coping strategies.

Originality/value

This study provides a descriptive account of the processes prisoners undertake during involuntary smoking cessation and has described the manner in which prisoners manufacture home-made tobacco from nicotine patches. The study has produced an original theory named Engaging with Quitting.

Cigarette Smoking Among Inmates by Race/Ethnicity: Impact of Excluding African American Young Adult Men From National Prevalence Estimates

INTRODUCTION

Cigarette smoking prevalence is more than two times greater among incarcerated adults, a population usually excluded from national health surveys. African American young adult (18-25) men are less likely to smoke cigarettes than their white counterparts. However, they are two and a-half-times more likely to be incarcerated. This study estimated smoking prevalence with noninstitutionalized and incarcerated samples combined to determine if excluding incarcerated adults impacts smoking prevalence for certain populations.

METHODS

The Bureau of Justice Statistics last fielded the Survey of Inmates in State and Federal Correction Facilities in 2003-2004. We combined data from Survey of Inmates in State and Federal Correction Facilities (n = 17 910) and the 2003 and 2004 National Health Interview Survey (n = 61 470) to calculate combined cigarette smoking estimates by race/ethnicity, sex, and age.

RESULTS

Inmates represented the greatest proportion of smokers among African American men. Among African American young adult men, inmates represented 15.2% of all smokers in the combined population, compared to 2.0% among white young adult men. Cigarette smoking prevalence was 17.6% in the noninstitutionalized population of young adult African American men and 19.7% in the combined population. Among white young adult men, cigarette smoking prevalence was 29.8% in the noninstitutionalized population, and 30.2% in the combined population. There was little difference in estimates among women.

CONCLUSIONS

The exclusion of incarcerated African American young adult men may result in a small underestimation of cigarette smoking prevalence in this population. Increasing access to smoking cessation support among inmates may reduce smoking prevalence in disproportionately incarcerated segments of the US population.

IMPLICATIONS

The exclusion of incarcerated adults from national survey data should be considered when examining differences in cigarette smoking prevalence estimates between African American and white young adult men. Approximately one in six African American young adult men who smoke were incarcerated. Increasing access to smoking cessation support among inmates may reduce smoking prevalence among disproportionately incarcerated segments of the population.

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.

Prevalence and factors associated with smoking tobacco among men recently released from prison in California: A cross-sectional study

BACKGROUND

Over 1.5 million people are incarcerated in state and federal correctional facilities in the United States. Formerly incarcerated men have significantly higher rates of mortality and morbidity than the general population, disparities that have been partially attributed to higher rates of tobacco smoking-related illnesses such as cardiovascular disease, pulmonary disease and cancer.

METHODS

We compared the prevalence of smoking tobacco in a sample of 172 men who were released from California state prisons to Oakland and San Francisco between 2009 and 2011 to sub-populations of respondents to the 2009 California Health Interview Survey (CHIS). Using logistic regression, we analyzed the association between lifetime history of incarceration and self-reported smoking status.

RESULTS

Seventy-four percent of men recently released from prison reported being current tobacco smokers. The prevalence of smoking in a demographically similar group of men in the CHIS was 24%. We found in bivariate analysis that each additional five years of history of incarceration was associated with 1.32 times greater odds of smoking (95% CI 1.02 to 1.71). Illicit substance use was associated with a 2.47 higher adjusted odds of smoking (95% CI 1.29 to 5.39). In the multivariate model adjusting for age, income, substance use and mental health, every five years of incarceration was associated with 1.23 greater odds of smoking (95% CI 0.94 to 1.63) which was not statistically significant.

CONCLUSIONS

Given the high prevalence of smoking tobacco among former prisoners and the underlying high tobacco-related mortality rates, these findings suggest that a history of incarceration may be an important determinant of smoking. Prison and parole systems may be important potential settings for smoking-cessation interventions.

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.

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.

Forced smoking abstinence: not enough for smoking cessation

IMPORTANCE

Millions of Americans are forced to quit smoking as they enter tobacco-free prisons and jails, but most return to smoking within days of release. Interventions are needed to sustain tobacco abstinence after release from incarceration.

OBJECTIVE

To evaluate the extent to which the WISE intervention (Working Inside for Smoking Elimination), based on motivational interviewing (MI) and cognitive behavioral therapy (CBT), decreases relapse to smoking after release from a smoke-free prison.

DESIGN

Participants were recruited approximately 8 weeks prior to their release from a smoke-free prison and randomized to 6 weekly sessions of either education videos (control) or the WISE intervention.

SETTING

A tobacco-free prison in the United States.

PARTICIPANTS

A total of 262 inmates (35% female).

MAIN OUTCOME MEASURE

Continued smoking abstinence was defined as 7-day point-prevalence abstinence validated by urine cotinine measurement.

RESULTS

At the 3-week follow-up, 25% of participants in the WISE intervention (31 of 122) and 7% of the control participants (9 of 125) continued to be tobacco abstinent (odds ratio [OR], 4.4; 95% CI, 2.0-9.7). In addition to the intervention, Hispanic ethnicity, a plan to remain abstinent, and being incarcerated for more than 6 months were all associated with increased likelihood of remaining abstinent. In the logistic regression analysis, participants randomized to the WISE intervention were 6.6 times more likely to remain tobacco abstinent at the 3-week follow up than those randomized to the control condition (95% CI, 2.5-17.0). Nonsmokers at the 3-week follow-up had an additional follow-up 3 months after release, and overall 12% of the participants in the WISE intervention (14 of 122) and 2% of the control participants (3 of 125) were tobacco free at 3 months, as confirmed by urine cotinine measurement (OR, 5.3; 95% CI, 1.4-23.8).

CONCLUSIONS AND RELEVANCE

Forced tobacco abstinence alone during incarceration has little impact on postrelease smoking status. A behavioral intervention provided prior to release greatly improves cotinine-confirmed smoking cessation in the community.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01122589.

Health effects of the Federal Bureau of Prisons tobacco ban

BACKGROUND

Tobacco smoking remains the leading cause of preventable death in America, claiming 450,000 lives annually. Chronic Obstructive Pulmonary Disease, caused by smoking in the vast majority of cases, became the third leading cause of death in the U.S. in 2008. The burden of asthma, often exacerbated by tobacco exposure, has widespread clinical and public health impact. Despite this considerable harm, we know relatively little about the natural history of lung disease and respiratory impairment in adults, especially after smoking cessation.

METHODS/DESIGN

Our paper describes the design and rationale for using the 2004 Federal Bureau of Prisons tobacco ban to obtain insights into the natural history of respiratory diseases in adult men and women of different races/ethnicities who are imprisoned in federal medical facilities. We have developed a longitudinal study of new prison arrivals, with data to be collected from each participant over the course of several years, through the use of standardized questionnaires, medical chart reviews, lung function tests, six-minute walk tests, and stored serum for the analysis of present and future biomarkers. Our endpoints include illness exacerbations, medication and health services utilization, lung function, serum biomarkers, and participants' experience with their health and nicotine addiction.

DISCUSSION

We believe the proposed longitudinal study will make a substantial contribution to the understanding and treatment of respiratory disease and tobacco addiction.