Nicotine & Tobacco Research, Volume 16, Number 2 (February 2014) 238–242
Brief report
Cigarette Smoking as an Expression of Independence and Freedom Among Inmates in a Tobacco-Free Prison in the United States Jacob J. van den Berg PhD1,2,3, Beth Bock PhD1,3, Mary B. Roberts MS4, Lynda A. R. Stein PhD5,6,7,8, Peter D. Friedmann MD, MPH1,9, Stephen A. Martin MD, EdM10, Jennifer G. Clarke MD, MPH1,4 1Warren Alpert Medical School of Brown University, Providence, RI; 2Division of Infectious Diseases, Miriam Hospital, Providence, RI; 3Centers for Behavioral and Preventive Medicine, Miriam Hospital, Providence, RI; 4Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, RI; 5Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, RI; 6Department of Psychology, University of Rhode Island, Kingston, RI; 7Rhode Island Training School, Cranston, RI; 8Center for Prisoner Health and Human Rights, Miriam Hospital, Providence, RI; 9Division of General Internal Medicine, Rhode Island Hospital, Providence, RI; 10Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA
Received February 14, 2013; accepted September 3, 2013
Abstract Introduction: Most adults report initiation of cigarette smoking during adolescence, a time also marked by developmental striving for independence and freedom. Tobacco use may retain its association with independence and/or freedom into adulthood. This association may contribute to continued tobacco use and/or increased risk of relapse to smoking among some individuals. This study examines the relationship between cigarette smoking and perceptions of independence and freedom among inmates in a tobacco-free prison in the northeastern United States. Methods: Questionnaires administered to 247 male and female inmates 6 weeks prior to scheduled prison release assessed demographics, smoking history, nicotine dependence, attitudes toward smoking, and plans for tobacco use or abstinence after prison release. Perceptions of smoking as an expression of independence and freedom were measured using 2 items. Smoking was assessed 3 weeks postrelease. Results: Constructs of freedom and independence were correlated but did not overlap completely. Both constructs were negatively associated with plans for smoking abstinence after prison release, and with perceived costs of continued smoking. Number of cigarettes smoked postrelease and perception of the pros of smoking were associated with freedom, but not independence. Conclusions: Associations of smoking as an expression of freedom and independence may negatively influence plans for renewed smoking after a forced abstinence. Additional research is needed to determine the degree to which these 2 constructs predict smoking behavior and whether they can be used to improve interventions for incarcerated smokers.
Introduction In the United States, it has been estimated by the Centers for Disease Control and Prevention (CDC) that approximately 45.3 million adults are current cigarette smokers (CDC, 2011). Among U.S. incarcerated populations, tobacco use is higher than that of the general population (19% of adults), with estimates as high as 80% of incarcerated adults (National Commission on Correctional Health Care, 2001). Nearly 90% of all adult cigarette smokers in the United States report initiating smoking during adolescence (U.S. Department of Health and Human Services, 2012). Some adolescents use cigarette
smoking as a rebellion or a means to establish independence and freedom from their parents or other adult authorities (Jackson, 2002). The association between cigarette smoking and rebellion may be expressed as a sense of freedom or independence developed during adolescence and carried into adulthood (Moolchan, Ernst, & Henningfield, 2000). In American vernacular, the words “freedom” and “independence” tend to be used interchangeably; however, the current study conceptualizes these two constructs as separate and distinct as they may not operate identically. Freedom may be defined as “the absence of necessity, coercion, or constraint in choice of action (Freedom, n.d.),” whereas independence
doi:10.1093/ntr/ntt163 Advance Access publication October 22, 2013 © The Author 2013. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
238
Downloaded from http://ntr.oxfordjournals.org/ at Monash University on June 19, 2015
Corresponding Author: Jacob J. van den Berg, PhD, Centers for Behavioral and Preventive Medicine, Miriam Hospital, Coro West, Suite 309, 164 Summit Avenue, Providence, RI 02906, USA. Telephone: 401-793-8227; Fax: 401-793-8059; E-mail: [email protected]
Nicotine & Tobacco Research
Methods Participants and Procedures Data were collected from men and women inmates in a large correctional facility in the northeastern United States as part of a randomized controlled trial to evaluate the effectiveness of a six-session intervention using cognitive behavioral therapy enhanced with motivational interviewing (Clarke et al., 2011). All inmates who met study eligibility (18 years of age or older, smoked at least 10 cigarettes per day prior to incarceration, English speaking) and who were scheduled to be released within 8 weeks of study enrollment were invited to participate in the study. Trained research assistants explained the nature of the study, answered any questions or concerns, and reinforced that participation was completely voluntary and informed consent was obtained from individuals interested in participating. The study was approved by the Memorial Hospital of Rhode Island Institutional Review Board, the Office for Human Research Protections, and the Medical Research Advisory Group at the Rhode Island Department of Corrections. Measures After obtaining informed consent, an audio computer-assisted self-interview was used to administer the full assessment battery, which took participants approximately 60 min to complete. Questionnaires included demographic characteristics and cigarette smoking history. Nicotine dependence was measured using the Fagerström Test for Nicotine Dependence (FTND), with items modified to reflect back to when the participant was smoking (prior to incarceration). Scores on the FTND range from 0 to 10 with higher scores indicating a greater dependence (Heatherton, Kozlowski, Frecker, & Fagerström, 1991). We
also asked participants to report the number of cigarettes per day that they smoked in the month prior to incarceration. Plans to remain cigarette smoking abstinent versus resume smoking after release were measured by a single item using a modified version of the Ladder of Change (Biener & Abrams, 1991). Low scores indicate planning to resume smoking cigarettes after prison release, whereas high scores indicate planning to remain smoking abstinent. Decision making regarding cigarette smoking was assessed using the Decisional Balance Scale (short form), which includes six items on the pros and cons of smoking (Velicer, DiClemente, Prochaska, & Brandenburg, 1985). Independence and freedom associated with smoking were measured using two items (“Having that first cigarette when I get out is a way to express my independence” and “Having that first cigarette when I get out will make me feel like I’m really free or not in prison any more”), which were developed by the research team based upon clinical observations of comments made by participants in prior studies. These items were scored on a 4-point scale (1 = strongly disagree to 4 = strongly agree). Cigarette smoking outcomes were measured 3 weeks postrelease and included smoking status (smoking vs. quit) and smoking rate as the average number of cigarettes per day during the past 7 days. Data Analysis All analyses were performed using IBM SPSS Statistics for Windows, version 20.0. Descriptive statistics (e.g., means, SDs, frequencies) were used to describe sample characteristics including age, gender, race/ethnicity, and educational level, as well as plans to quit and smoking status at 3-week postrelease. Pearson correlation coefficients were calculated to examine the associations between independence, freedom, pros and cons of smoking, nicotine dependence, and plans to remain smoking abstinent. Spearman’s rank-order correlation was calculated to investigate the associations between length of incarceration, independence, and freedom.
Results Of the 312 inmates screened, 273 were eligible; 262 agreed to participate. Data were excluded from 15 participants (nine due to lost baseline survey data resulting from a computer glitch and six due to not being released from prison). Of the remaining 247 participants, 228 completed the follow-up assessment at 3 weeks. Approximately 65% of participants were men. Participants ranged in age from 19 to 56 years (M = 35.6; SD = 9.2). About 52% of participants self-identified as White, 20% as Hispanic, 18% as Black, non-Hispanic, and 10% as other or multiracial. Approximately 85% of participants had completed 12th grade or less, and 15% had education beyond 12th grade. The mean length of incarceration for the sample was 1.22 years (SD = 1.60 years, range =
Brief report
Cigarette Smoking as an Expression of Independence and Freedom Among Inmates in a Tobacco-Free Prison in the United States Jacob J. van den Berg PhD1,2,3, Beth Bock PhD1,3, Mary B. Roberts MS4, Lynda A. R. Stein PhD5,6,7,8, Peter D. Friedmann MD, MPH1,9, Stephen A. Martin MD, EdM10, Jennifer G. Clarke MD, MPH1,4 1Warren Alpert Medical School of Brown University, Providence, RI; 2Division of Infectious Diseases, Miriam Hospital, Providence, RI; 3Centers for Behavioral and Preventive Medicine, Miriam Hospital, Providence, RI; 4Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, RI; 5Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, RI; 6Department of Psychology, University of Rhode Island, Kingston, RI; 7Rhode Island Training School, Cranston, RI; 8Center for Prisoner Health and Human Rights, Miriam Hospital, Providence, RI; 9Division of General Internal Medicine, Rhode Island Hospital, Providence, RI; 10Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA
Received February 14, 2013; accepted September 3, 2013
Abstract Introduction: Most adults report initiation of cigarette smoking during adolescence, a time also marked by developmental striving for independence and freedom. Tobacco use may retain its association with independence and/or freedom into adulthood. This association may contribute to continued tobacco use and/or increased risk of relapse to smoking among some individuals. This study examines the relationship between cigarette smoking and perceptions of independence and freedom among inmates in a tobacco-free prison in the northeastern United States. Methods: Questionnaires administered to 247 male and female inmates 6 weeks prior to scheduled prison release assessed demographics, smoking history, nicotine dependence, attitudes toward smoking, and plans for tobacco use or abstinence after prison release. Perceptions of smoking as an expression of independence and freedom were measured using 2 items. Smoking was assessed 3 weeks postrelease. Results: Constructs of freedom and independence were correlated but did not overlap completely. Both constructs were negatively associated with plans for smoking abstinence after prison release, and with perceived costs of continued smoking. Number of cigarettes smoked postrelease and perception of the pros of smoking were associated with freedom, but not independence. Conclusions: Associations of smoking as an expression of freedom and independence may negatively influence plans for renewed smoking after a forced abstinence. Additional research is needed to determine the degree to which these 2 constructs predict smoking behavior and whether they can be used to improve interventions for incarcerated smokers.
Introduction In the United States, it has been estimated by the Centers for Disease Control and Prevention (CDC) that approximately 45.3 million adults are current cigarette smokers (CDC, 2011). Among U.S. incarcerated populations, tobacco use is higher than that of the general population (19% of adults), with estimates as high as 80% of incarcerated adults (National Commission on Correctional Health Care, 2001). Nearly 90% of all adult cigarette smokers in the United States report initiating smoking during adolescence (U.S. Department of Health and Human Services, 2012). Some adolescents use cigarette
smoking as a rebellion or a means to establish independence and freedom from their parents or other adult authorities (Jackson, 2002). The association between cigarette smoking and rebellion may be expressed as a sense of freedom or independence developed during adolescence and carried into adulthood (Moolchan, Ernst, & Henningfield, 2000). In American vernacular, the words “freedom” and “independence” tend to be used interchangeably; however, the current study conceptualizes these two constructs as separate and distinct as they may not operate identically. Freedom may be defined as “the absence of necessity, coercion, or constraint in choice of action (Freedom, n.d.),” whereas independence
doi:10.1093/ntr/ntt163 Advance Access publication October 22, 2013 © The Author 2013. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
238
Downloaded from http://ntr.oxfordjournals.org/ at Monash University on June 19, 2015
Corresponding Author: Jacob J. van den Berg, PhD, Centers for Behavioral and Preventive Medicine, Miriam Hospital, Coro West, Suite 309, 164 Summit Avenue, Providence, RI 02906, USA. Telephone: 401-793-8227; Fax: 401-793-8059; E-mail: [email protected]
Nicotine & Tobacco Research
Methods Participants and Procedures Data were collected from men and women inmates in a large correctional facility in the northeastern United States as part of a randomized controlled trial to evaluate the effectiveness of a six-session intervention using cognitive behavioral therapy enhanced with motivational interviewing (Clarke et al., 2011). All inmates who met study eligibility (18 years of age or older, smoked at least 10 cigarettes per day prior to incarceration, English speaking) and who were scheduled to be released within 8 weeks of study enrollment were invited to participate in the study. Trained research assistants explained the nature of the study, answered any questions or concerns, and reinforced that participation was completely voluntary and informed consent was obtained from individuals interested in participating. The study was approved by the Memorial Hospital of Rhode Island Institutional Review Board, the Office for Human Research Protections, and the Medical Research Advisory Group at the Rhode Island Department of Corrections. Measures After obtaining informed consent, an audio computer-assisted self-interview was used to administer the full assessment battery, which took participants approximately 60 min to complete. Questionnaires included demographic characteristics and cigarette smoking history. Nicotine dependence was measured using the Fagerström Test for Nicotine Dependence (FTND), with items modified to reflect back to when the participant was smoking (prior to incarceration). Scores on the FTND range from 0 to 10 with higher scores indicating a greater dependence (Heatherton, Kozlowski, Frecker, & Fagerström, 1991). We
also asked participants to report the number of cigarettes per day that they smoked in the month prior to incarceration. Plans to remain cigarette smoking abstinent versus resume smoking after release were measured by a single item using a modified version of the Ladder of Change (Biener & Abrams, 1991). Low scores indicate planning to resume smoking cigarettes after prison release, whereas high scores indicate planning to remain smoking abstinent. Decision making regarding cigarette smoking was assessed using the Decisional Balance Scale (short form), which includes six items on the pros and cons of smoking (Velicer, DiClemente, Prochaska, & Brandenburg, 1985). Independence and freedom associated with smoking were measured using two items (“Having that first cigarette when I get out is a way to express my independence” and “Having that first cigarette when I get out will make me feel like I’m really free or not in prison any more”), which were developed by the research team based upon clinical observations of comments made by participants in prior studies. These items were scored on a 4-point scale (1 = strongly disagree to 4 = strongly agree). Cigarette smoking outcomes were measured 3 weeks postrelease and included smoking status (smoking vs. quit) and smoking rate as the average number of cigarettes per day during the past 7 days. Data Analysis All analyses were performed using IBM SPSS Statistics for Windows, version 20.0. Descriptive statistics (e.g., means, SDs, frequencies) were used to describe sample characteristics including age, gender, race/ethnicity, and educational level, as well as plans to quit and smoking status at 3-week postrelease. Pearson correlation coefficients were calculated to examine the associations between independence, freedom, pros and cons of smoking, nicotine dependence, and plans to remain smoking abstinent. Spearman’s rank-order correlation was calculated to investigate the associations between length of incarceration, independence, and freedom.
Results Of the 312 inmates screened, 273 were eligible; 262 agreed to participate. Data were excluded from 15 participants (nine due to lost baseline survey data resulting from a computer glitch and six due to not being released from prison). Of the remaining 247 participants, 228 completed the follow-up assessment at 3 weeks. Approximately 65% of participants were men. Participants ranged in age from 19 to 56 years (M = 35.6; SD = 9.2). About 52% of participants self-identified as White, 20% as Hispanic, 18% as Black, non-Hispanic, and 10% as other or multiracial. Approximately 85% of participants had completed 12th grade or less, and 15% had education beyond 12th grade. The mean length of incarceration for the sample was 1.22 years (SD = 1.60 years, range =
