Nicotine & Tobacco Research Advance Access published June 12, 2015 Nicotine & Tobacco Research, 2015, 1–7 doi:10.1093/ntr/ntv112 Original investigation
Original investigation
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Exploration of Incarcerated Men’s and Women’s Attitudes of Smoking in the Presence of Children and Pregnant Women: Is There a Disparity Between Smoking Attitudes and Smoking Behavior? Donna R. Parker ScD1,2, Mary B. Roberts MS2, Jacob J. van den Berg PhD3,4, Beth Bock PhD5, Lyn A. R. Stein PhD6, Rosemarie A. Martin PhD7, Jennifer G. Clarke MD, MPH2,8 Departments of Family Medicine and Epidemiology, Alpert Medical School of Brown University, Providence, RI; Brown University Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, RI; 3 Division of Infectious Diseases, Miriam Hospital, Providence, RI; 4Department of Medicine, Alpert Medical School of Brown University, Providence, RI; 5Center for Behavioral and Preventive Medicine, Department of Psychiatry, Brown University, Providence, RI; 6Department of Psychology, University of Rhode Island, Kingston, RI; 7Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI; 8Department of OB/ GYN, Alpert Medical School of Brown University, Providence, RI 1 2
Corresponding Author: Donna R. Parker, ScD, Brown University Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA. Telephone: 401-729-2531; Fax: 401-729-2494; E-mail: [email protected]
Abstract Introduction: A major health challenge facing persons who are incarcerated is tobacco smoking. Upon reentry to the community, concerns regarding smoking cessation may be less likely to receive needed attention. Many individuals have partners who are pregnant and/or reside in households where children and pregnant women live. We explored incarcerated adults’ attitudes of smoking in the presence of children and pregnant women and how post-release smoking behaviors are influenced by their attitudes. Methods: Two hundred forty-seven incarcerated adults participated in a smoking cessation randomized clinical trial in a tobacco-free prison. An instrument was developed to examine smoking attitudes and behaviors around children and pregnant women. Moderating effects of smoking factors on post-release abstinence were examined by evaluating interactions between smoking factors and treatment group. Results: Four factors were defined using factor analysis: smoking around children; impact of smoking on child’s health; awareness of environmental tobacco smoke (ETS) risk for pregnant women; and importance of smoking avoidance during pregnancy. We found moderation effects of smoking factors on smoking outcomes which included: treatment group by smoking behavior around children (β = 0.8085; standard error [SE] = 0.4002; P = .04); treatment group by impact of smoking on child’s health (β = 1.2390; SE = 0.5632; P = .03) and for those smoking 50% fewer cigarettes postrelease, treatment group by smoking impact on child’s health (β = 1.2356; SE = 0.4436; P < .01). Conclusions: Concern for smoking around children and pregnant women and awareness of ETS risk for pregnant women was not found to be significantly associated with smoking outcomes and requires additional investigation. Among individuals who continue to smoke post-release, effective ETS interventions are needed aimed at protecting children and pregnant women with whom they live. © The Author 2015. 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].
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Introduction
Methods Procedure and Sample The details on the full study design and methods have been described previously.14 Briefly, Project Working Inside for Smoking Elimination (WISE) was a randomized clinical trial to investigate an intervention aimed at increasing smoking abstinence rates among individuals following release from a tobacco-free prison. To be eligible, participants were required to be released within the next 8 weeks, were 18 years or older, smoked 10 or more cigarettes per day prior to incarceration, and spoke English. Outcome assessments took place in-person 3 weeks after release. Self-reported smoking status was confirmed by urine cotinine with current smoking defined as ≥200 ng/ml cotinine. 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. To further protect study
participants a Certificate of Confidentiality was obtained from the Department of Health and Human Services. Measurements Participant demographics collected at baseline included age, race, ethnicity, gender, and education level. Individual smoking history assessed years since smoked daily, age started smoking daily, and number of cigarettes smoked per day (smoking rate) prior to incarceration. “Plans for smoking after release” was evaluated using a single item with six responses. Responses included: (1) I plan to smoke when I get out of here and I will never plan to quit; (2) I plan to smoke when I get out of here but I might quit in the future; (3) I will probably smoke when I get out of here; (4) I probably won’t smoke when I get out of here; (5) I have made plans to not smoke when I get out of here; and (6) I have made plans to not smoke when I get out of here and I will never smoke again. Responses were recoded into the following: 1, 2, and 3 = plans to smoke upon release; 4, 5, and 6 = plans to NOT smoke upon release. Information regarding smoking within 24 hours of release was obtained by telephone and the Timeline Fallback.15 An indicator for smoking at least 50% less (“smoking 50% less”) at 3 weeks post-release was created by answering yes or no (coded as 1 or 0, respectively) to the calculated question: is the participant smoking at 3 weeks post-release no more than one-half the number of cigarettes reported at pre-incarceration. Participants were also asked 12 questions at baseline (Table 1) designed to explore their perceptions about the impact of smoking on children and pregnant women. Specifically, questions addressed smoking in the home, the impact of smoking on children’s health, the importance of smoking avoidance during pregnancy, and awareness of ETS risks to pregnant women/fetuses. These questions were developed based on interviews with incarcerated adults and the existing literature. Covariates Covariates were determined to be significant if P < .05. Significant covariates for the smoking outcomes were determined for the main results manuscript16 and these covariates are used in these analyses to be consistent. The association between smoking attitudes/behaviors and each of three individual smoking outcomes (“smoking status 3 weeks post-release,” “smoking status within 24 hours of release,” and “smoking 50% less 3 weeks after release”) were assessed in separate analyses. Data Analysis Descriptive statistics (means, standard deviations, frequencies, and percentages) were generated to characterize the data. For the smoking questions displayed in Table 1, a principal components analysis was conducted using varimax rotation. A factor was included if its eigenvalue was greater than one. Each factor was a summation of the questions regarding smoking in the presence of children and pregnant women with a factor loading greater than 0.40. Each of the developed factors characterized a smoking behavior/attitude around pregnant women or children. Each factor (smoking around children, impact of smoking on children’s health, importance of smoking avoidance during pregnancy, and awareness of ETS risks to pregnant women/fetuses) was examined by demographics and smoking outcomes. For associations with categorical variables, the behavior/attitude factors were examined using analysis of variance or nonparametric equivalent,
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Over 2 million individuals are incarcerated in the United States. Many of the individuals entering correctional facilities have a history of risky health behaviors and substance abuse.2,3 One of the major health challenges facing this population is tobacco smoking. The rate of tobacco smoking among persons who are incarcerated is disproportionately high compared to the general population with rates ranging from 70% to 80%.4–6 Once individuals are released from prison, they face numerous challenges including reestablishing relationships, finding housing and employment, and dealing with addictions including tobacco smoking.7 Yet, given major barriers and challenges of reentry of persons who are incarcerated to their families and the community, concerns regarding smoking cessation may be less likely to receive the attention that is needed. Indeed, over 97% of inmates will resume smoking upon release from a tobaccofree jail.8 The majority of persons who are incarcerated who return to the community have children. Overall, 52% of state and 63% of federal inmates report being parents to an estimated 1.7 million children.9 Many of these incarcerated individuals also have partners who are pregnant and/or reside in households where children and pregnant women live. Of concern is that environmental tobacco smoke (ETS) exposure poses serious health risks for all those who are exposed, especially children and pregnant women.10,11 The adverse effects associated with ETS include preterm birth, intrauterine growth retardation, perinatal mortality, respiratory illness, neurobehavioral problems, and decreased performance in school.12 Additionally, pregnant woman who smoke not only endanger their own health but also endanger the health of their unborn infants as well.13 Currently, there are no published studies using a qualitative approach to explore incarcerated smokers’ attitudes and behaviors regarding cigarette smoking in the presence of children and pregnant women. For this study, we developed a survey to explore factors associated with incarcerated adults’ attitudes of smoking in the presence of children and pregnant women and, given that this is a new instrument, we were interested in identifying the scale structure. The aims of this study are to: (1) identify the scale structure of the newly developed instrument using exploratory factor analysis; (2) examine the influence of these attitudes on post-release smoking cessation; and (3) examine the moderating effects of the smoking attitudes on smoking behavior post-release. 1
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Table 1. Factor Analysis for Items of Smoking in the Presence of Children and Pregnant Women: Items, Factor Loadings, and Reliability Items by factor
% yes
Factor loading
230 231 229 229
54.8 38.1 48.5 56.3
0.877 0.841 −0.818 0.475
228 232 233 232
92.1 94.8 86.3 90.5
0.858 0.858 0.613 0.436
242 243
92.6 90.1
0.914 0.838
236
90.7
0.887
239
87.0
0.876
Cronbach alpha
Eigenvalue (% variance)
Mean (SD)
0.770
3.139 (26.2)
2.01 (1.53)
0.670
2.231 (18.6)
3.64 (0.79)
0.789
1.464 (12.2)
7.36 (1.21)
0.840
1.221 (10.2)
1.78 (0.57)
Responded “Yes”. Important/very important. c ETS—environmental tobacco smoke. a
b
if warranted. For continuous variables, Spearman correlations were examined. Multiple variable logistic regressions were used to examine the associations between selected smoking outcomes and smoking behaviors/attitudes around pregnant women and children over and above significant predictive covariates for each smoking outcome. All analyses were conducted using IBM SPSS Version 20 (Released 2011, IBM Corp., Armonk, NY). For all analyses, a P value less than or equal to .05 is considered significant. Additionally, we wanted to examine the impact that any interaction between the smoking behavior/attitudes factors and treatment group would have on smoking outcomes. This moderation analysis treated the smoking attitudes/behavior factors as potential moderators of the treatment effect on the smoking outcomes. Moderation analyses followed a regression-based approach17 and utilized the SPSS PROCESS Macro (version 2.12.2, released August, 2014) developed by Hayes (www.Afhayes.com). Moderation models included covariates (gender, Hispanic ethnicity, participation in the drug treatment program, length of incarceration, smoking plans upon release), treatment group, a moderator (one of the smoking behaviors/attitudes factors), and a treatment by moderator interaction term. Significant moderator by treatment interactions were plotted using MS Excel with the visualization data obtained with the PROCESS Macro.
Results Study Population Of the 312 people screened for the study, 273 met eligibility criteria and 262 (95.9%) agreed to participate and completed the consent procedure. Of the 262 enrolled at baseline, nine were excluded from the analyses due to a technical error resulting in missing baseline data, and six participants were excluded because they were never released or were reincarcerated at the time of follow-up. The final sample of 247 participants included
161 men and 86 women. Two hundred twenty-eight participants (92.3%) completed the 3-week post-release follow-up assessment. Following the “intention-to-treat” approach,18 19 participants lost to follow-up were assumed to have returned to their preincarceration level of smoking, were included in the analyses and counted as smokers.
Exploratory Factor Analysis Table 1 presents the factor analysis for items of smoking in the presence of children and pregnant women. The factor analysis statistics indicated a good fit for a four-factor solution with Chronbach’s alphas ranging from 0.67 to 0.84. Individual item responses indicated that most of the participants (94.8%) believed that smoking around children is harmful and also believed (90.1%) that it is important/very important not to smoke around pregnant women. However, when participants were asked whether they smoked in the home where there is a pregnant woman, 54.8% responded that they did smoke in the home and 38.1% responded that they smoked in the same room.
Baseline Characteristics Baseline characteristics are presented in Table 2. Of the 247 participants, most were men (65.2%), had less than a high school education (63.6%), were primarily white (51.4%), and had a mean age of 35.6 years. Of their smoking history, participants began to smoke around 13 years of age (mean age; SD = 4.4) and had smoked an average of 19.4 years (SD = 10.0) prior to incarceration. Over half (51%) of the participants reported planning to resume smoking upon release from prison. Over half of all participants (52.6%) had at least two other members of their household who smoked, and 48.6% had a partner who smoked. Fifteen percent of the participants lived with children prior to incarceration. One hundred twenty-two participants (49.4%) were randomized into the intervention group and 125 (50.6%) were randomized into the control group.
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Smoking behavior around children Did you smoke in the home?a Did you smoke in the same room?a Did you only smoke outside?a Did you keep smoking the way you always had?a Impact of smoking on child health My smoking makes the kids around me less healthya My smoking hurts the health of kids that are near mea Smoking makes me worry about making kids sicka Kids around me are more likely to smoke because they see me smokea Importance of smoking avoidance during pregnancy How important do you think it is for a pregnant woman to stop smoking?b How important do you think it is not to smoke around a pregnant woman?b Awareness of ETSc risks to pregnant women/fetuses Were/are you aware that there are risks to a growing baby (fetus) from other people’s smoke?a Were/are you aware that there are risks to a pregnant woman from other people’s smoke?a
n
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Attitudes Regarding Smoking Around Children and Pregnant Women and Smoking Behavior Post-Release Unadjusted and adjusted odds ratios (ORs) of being abstinent for the first 24 hours after release and attitudes regarding smoking behavior around children and pregnant women are presented in Table 3. Prior to adjusting for covariates (gender, Hispanic ethnicity, participation in a drug treatment program, plans to quit smoking, length of incarceration and intervention status), participants whose attitudes Table 2. Participant Characteristics Characteristics (N = 247)
161 35.6
(65.2%) (9.2)
157 49 37
(63.6%) (19.8%) (15.0%)
43 127 49 28 13.1 15.7 19.4
(17.4%) (51.4%) (19.8%) (11.3%) (4.4) (4.5) (10.0)
120 120
(48.6%) (48.6%)
37 73 79 51 37
(15.0%) (29.6%) (32.0%) (20.6%) (15.0%)
119
(48.2%)
122 125
(49.4%) (50.6%)
40 105
(16.2%) (42.5%)
90
(36.4%)
Moderation Effects of Smoking Factors on Smoking Behavior Post-Release We next examined the moderation effects of smoking factors on smoking outcomes by evaluating the interaction between smoking factors and treatment group (Figure 1 and Supplementary Figure 1). Three interactions were significant: for smoking abstinence 3 weeks post-release, treatment group by smoking behavior around children (β = 0.8085; standard error (SE) = 0.4002; P = .04) and treatment group by attitudes regarding the impact of smoking on child health (β = 1.2390; SE = 0.5632; P = .03); and for smoking 50% fewer cigarettes after release, treatment group by attitudes regarding smoking impact on child’s health (β = 1.2356; SE = 0.4436; P < .01). In Figure 1, results suggest that the WISE intervention increases the probability of 3-week post-release abstinence over the control group by 11 percentage points for those less likely to smoke around children (20.0% vs. 9.0%, respectively). However, for those more likely to smoke around children, the intervention had a greater effect over the control group (21.0% vs. 1.0% respectively—an increase of
Table 3. Unadjusted and Adjusted Odds Ratios (ORs) of Abstinence for the First 24 Hours After Release and Attitudes Regarding Smoking Behavior Around Children and Pregnant Women Unadjusted
Adjusteda
Smoking behavior
OR
95% CI
P
OR
95% CI
P
Smoking behavior around children Impact of smoking on child health Awareness of ETS risks to pregnant women and fetuses Importance of smoking avoidance during pregnancy
0.82 1.35 1.64 1.40
0.69% to 0.98% 0.94% to 1.96% 0.99% to 2.73% 1.09% to 1.80%
.030 .108 .057 .008
0.83 1.26 1.56 1.19
0.67% to 1.02% 0.84% to 1.87% 0.86% to 2.84% 0.92% to 1.56%
.070 .267 .143 .192
CI = confidence interval; ETS = environmental tobacco smoke. Bold values are statistically significant. a Models were adjusted for: gender, Hispanic ethnicity, participation in a drug treatment program, plans to quit smoking, length of incarceration, and intervention status.
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Gender: % male Age in years Education Less than high school High school Greater than high school Race/ethnicity Black White Hispanic/Latino Other/unknown Age (years) began smoking Age (years) began smoking regularly Years smoked Smoking plans Plans not to smoke upon release Spouse/partner smokes Household smoking (number of people) No one One person Two people Three or more people Lived with children prior to incarceration Participated in a drug treatment program while incarcerated Treatment group Intervention Control Smoking status Abstinent 3 weeks post-release Abstinent for first 24 hours post-release Smoked at least 50% less at 3 weeks post-release
Mean (SD) or n (%)
did not reflect concern about smoking around children were less likely to be abstinent for the first 24 hours after release (OR of 0.82; 95% confidence interval: 0.69% to 0.98%) compared with those whose attitudes did reflect concern about smoking around children (P = .03). The unadjusted OR was also significant for importance of smoking avoidance during pregnancy. Participants who placed high importance on avoiding smoking during pregnancy were more likely to be abstinent for the first 24 hours after release (OR = 1.40; 95% confidence interval: 1.09% to 1.80%) compared with those who placed less importance on avoiding smoking during pregnancy (P = .008). Results of remaining abstinent for the first 24 hours after release were not significant for participants’ attitudes related to smoking impact on children’s health nor awareness of smoking as a risk for pregnant women and the fetus. None of the adjusted ORs examining attitudes regarding smoking around children and pregnant women and smoking within 24 hours of release were significant. Similarly, models were run examining the unadjusted and adjusted ORs of smoking 50 less after release in relation to attitudes regarding smoking around children and pregnant women and were not significant (Table 4). Additionally, we examined the association between continued smoking abstinence 3 weeks post-release and attitudes regarding smoking around children and pregnant women but none of these results were significant (Table 5). Analyses were also examined for gender differences in regards to attitudes of smoking around children and pregnant women but none were noted nor were there any differences in the association of the attitudes to smoking abstinence.
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Table 4. Unadjusted and Adjusted Odds Ratios (ORs) of the Association Between Smoking At Least 50% Less After Release and Attitudes Regarding Smoking Around Children and Pregnant Women Unadjusted
Adjusteda
Smoking behavior
OR
95% CI
P
OR
95% CI
P
Smoking behavior around children Impact of smoking on child health Awareness of ETS risks to pregnant women and fetuses Importance of smoking avoidance during pregnancy
1.07 0.78 0.82 1.03
0.90% to 1.28% 0.56% to 1.09% 0.52% to 1.29% 0.83% to 1.29%
.456 .149 .385 .771
1.06 0.74 0.77 0.95
0.88% to 1.28% 0.52% to 1.05% 0.47% to 1.27% 0.75% to 1.19%
.554 .091 .305 .638
CI = confidence interval; ETS = environmental tobacco smoke. a Models were adjusted for: gender, Hispanic ethnicity, participation in a drug treatment program, plans to quit smoking, length of incarceration, and intervention status.
Unadjusted
Adjusteda
Smoking behavior
OR
95% CI
P
OR
95% CI
P
Smoking behavior around children Impact of smoking on child health Awareness of ETS risks to pregnant women and fetuses Importance of smoking avoidance during pregnancy
0.92 1.06 1.15 1.18
0.73% to 1.16% 0.67% to 1.66% 0.59% to 2.22% 0.85% to 1.64%
.456 .816 .682 .329
0.92 0.88 1.01 0.89
0.70% to 1.20% 0.53% to 1.44% 0.44% to 2.32% 0.62% to 1.28%
.527 .601 .973 .531
CI = confidence interval; ETS = environmental tobacco smoke. a Models were adjusted for: gender, Hispanic ethnicity, participation in a drug treatment program, plans to quit smoking, length of incarceration, and intervention status.
Figure 1. Moderation plot of smoking attitudes by treatment group for 3-week abstinence.
20 percentage points). In regards to the awareness of the impact of smoking on children’s health (Figure 1), the WISE intervention has an estimated increase in abstinence rates over the control group of 22 percentage points for those with a greater perceived awareness of the harm of ETS on children’s health (25.0% vs. 3.0%, respectively). For those less aware of this harm, this rate difference is approximately 9 percentage points (16.0% for intervention vs. 7.0% for the control). In Supplementary Figure 1, the effect of treatment group was moderated by the impact of smoking on child’s health for those smoking 50% less 3-weeks post-release. Among those who believed that ETS harms a child’s health, the WISE intervention group had a greater probability of smoking less than did the control group (43% vs. 24% respectively). The probability of smoking less was reversed
by treatment group for those who did not believe that smoking harms a child’s health (36% intervention group vs. 51% control group).
Discussion This study demonstrated that among individuals who were incarcerated, their attitudes toward smoking around children and pregnant women were not directly associated with their smoking behavior post-release. Of interest, however, was that we did find that there was a moderating effect of smoking attitudes on 3-week post-release abstinence by evaluating the interaction between smoking attitudes and treatment group. In fact, the WISE smoking cessation intervention increased abstinence rates (by 20%) in the intervention group
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Table 5. Unadjusted and Adjusted Odds Ratios (ORs) of the Association Between Continued Smoking Abstinence 3 Weeks After Release and Attitudes Regarding Smoking Around Children and Pregnant Women
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between attitudes and behaviors related to smoking around children and pregnant women and remaining tobacco free post-release. With respect to the original survey items, items were developed for this survey and item response options for nine of the questions were based on Yes/No responses. However, factor analyses indicated a good model fit for the four factors examined. In the WISE study, we found that our intervention, based on motivational interviewing and cognitive behavioral therapy, improved continued smoking abstinence 3 weeks post-release by 6.6 times over that of the control condition.16 In this study, we found that the WISE intervention increased the probability of 3-week postrelease abstinence among individuals who were more likely to smoke around children who were in the intervention group compared with the control group. Additionally, our intervention had a positive effect on abstinence rates 3 weeks post-release among participants who were less aware of the harm of ETS on children’s harm and were in the intervention group compared with those in the control group. In contrast, the intervention had a positive effect on the probability of smoking 50% less only among those who were aware of the harm of ETS on children’s health. Given that this is the first study to examine the moderation effects of attitudes and behaviors regarding smoking around children and pregnant among incarcerated individuals, further research is needed.
Conclusions Concern for smoking around children and pregnant women was not found to be significantly associated with smoking outcomes and requires additional investigation. Our results suggest that among individuals who continue to smoke post-release, effective interventions are needed that are aimed at protecting children and pregnant women with whom they live from ETS.
Supplementary Material Supplementary Figure 1 can be found online at http://www.ntr. oxfordjournals.org
Funding This study was funded by a grant from the National Institutes of Health (R01 DA 024093 to JGC). Registration of Clinical Trials: http://ClinicalTrials.gov Identifier: NCT01122589.
Limitations It is important to note that this study was a randomized clinical trial powered to investigate an intervention aimed at increasing smoking abstinence rates among individuals after release from a tobaccofree prison and was not powered to examine questions regarding attitudes about smoking around children and/or pregnant women. Additionally, it is unknown whether individuals who completed the questions regarding children were parents and what affect that might have on their responses or how many participants spent time with children who were not in their household (ie, divorced parents who did not have primary custody but spent time with their children). While the percent of individuals who lived with children prior to incarceration was small (15%) in this study, these results are similar to the Bureau of Justice statistics (22%).9 Also, there was limited power to examine differences in attitudes by child-inhousehold which requires further investigation. Finally, the limited power may have contributed to a lack of a significant association
Declaration of Interests None declared.
Acknowledgments We would like to thank the men and women who participated in this study and the Rhode Island Department of Corrections for supporting this research.
References 1. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Prisoners in 2012—Advance Counts. 2013. www.bjs.gov/content/pub/pdf/p12ac.pdf. Accessed April 29, 2015. 2. Wilson DJ. Drug use, testing, and treatment in local jails. 2000. www.bjs. gov/index.cfm?ty=pbdetail&iid=779. Accessed October 8, 2014.
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compared with the control group among individuals more likely to smoke around children. Our intervention increased abstinence by 9% among individuals less aware of the harm of ETS in the intervention group compared with the control group. Additionally, the intervention increased the probability of smoking 50% less by 11% among individuals who were aware of the harm of ETS on children’s health. These results highlight the importance of reviewing smoking attitudes and educating participants about risk during the WISE smoking cessation intervention. Several studies have examined the association of smoking exposure of children and smoking behavior in nonincarcerated populations. Liao and colleagues19 examined factors associated with smoking in the presence of children among 307 nonincarcerated parents who smoked. They reported that parents were more likely to smoke in the presence of children if there was a higher level of acceptance of smoking around children or they acknowledged fewer potential negative effects of their children’s exposure to ETS.19 In another study, 1352 nonincarcerated adults, 20–44 years of age, completed a mailed questionnaire examining whether parenthood affected smoking behavior. They reported that the smoking behavior (smoking outdoors or smoking near an open window) but not smoking prevalence was influenced by being a parent.20 Of interest was that although being a parent had an impact on attitudes toward protecting children from ETS, they found no differences in adult’s smoking patterns regardless of whether they had children or not.20 These studies suggest that there appears to be discordance between attitudes about smoking in the presence of children and actual smoking behaviors exhibited around children. However, our findings did not support these results. It may be that attitudes regarding smoking around children and pregnant women were not related to smoking outcomes 3-weeks post-release because the vast majority (86%–95%) endorsed negative attitudes hence we may be underpowered to detect these differences. Currently there is general public knowledge that smoking around children is undesirable although there is less understanding as to the potential harmful effects on children’s health.21 Yet there did not seem to be a relation between these attitudes and smoking outcomes. Attitudes surrounding pregnancy also had no impact on smoking behavior but this may be because few persons returned to situations in which they needed to be concerned about smoking around pregnant women.
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12. Hwang S-H, Hwang JH, Moon JS, Lee D-H. Environmental tobacco smoke and children’s health. Korean J Pediatr. 2012;55(2):35–41. http:// dx.doi.org/10.3345/kjp.2012.55.2.35. Accessed April 29, 2015. 13. Piquero AR, Gibson CL, Tibbetts SG, Turner MG, Katz SH. Maternal cigarette smoking and life-course-persistent offending. Int J Offender Ther Comp Criminol. 2002;46(2);231–248. doi:10.1177/0306624X02462008. 14. Clarke JG, Martin RA, Stein LAR, et al. Working inside for smoking elimination (Project W.I.S.E.) Study design and rationale to prevent return to smoking after release from a smoke free prison. BMC Public Health. 2011;11:767. doi:10.1186/1471-2458-11-767. 15. Shiffman S. How many cigarettes did you smoke? Assessing cigarette consumption by global report, time-line follow-back, and ecological momentary assessment. Health Psychol. 2009;28(5):519–526. doi:10.1037/a0015197. 16. Clarke JG, Stein LAR, Martin RA, et al. Forced smoking abstinence. Not enough for smoking cessation. JAMA Intern Med. 2013;179(9):789–794. doi:10.1001/jamainternmed.2013.197. 17. Hayes AF. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York, NY: Guilford Press; 2013. 18. West R, Hajek P, Stead L, Stapleton J. Outcome criteria in smoking cessation trials: proposal for a common standard. Addiction. 2005;100(8):299– 303. doi:10.1111/j.1360-0443.2004.00995.x. 19. Liao Y-M, Chen Y-T, Kuo L-C, Chen P-L. Factors associated with parental smoking in the presence of school-aged children: a cross-sectional study. BMC Public Health. 2013;13:819. doi:10.1186/1471-2458-13-819. 20. Johansson AK, Halling A; The LinQuest Study Group. Does having children affect adult smoking prevalence and behaviours at home? Tob Induc Dis. 2003;1(3):175–183. doi:10.1186/1617-9625-1-3-175. 21. Farber HJ, Knowles, SB, Brown NL, et al. Secondhand tobacco smoke in children with asthma: sources of and parental perceptions about exposure in children and parental readiness to change. Chest. 2008;133(6):1367– 1374. doi:10.1378/chest.07-2369.
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3. Conklin TJ, Lincoln T, Tuthill RW. Self-reported health and prior health behaviors of newly admitted correctional inmates. Am J Public Health. 2000;90(12):1939–1941. doi:10.2105/AJPH.90.12.1939. 4. Kaufman RM, Ferketch AK, Murray DM, Bellair PE, Wewers ME. Tobacco use by male prisoners under an indoor smoking ban. Nicotine Tob Res. 2011;13(6):449–456. doi:10.1093/ntr/ntr024. 5. Trosclair A, Caraballo R, Malarcher A, Husten C, Pechacek T; CDC. Cigarette smoking among adults—United States, 2003. MMWR. 2005;54(20):509– 513. www.cdc.gov/mmwr/preview/mmwrhtml/mm5420a3.htm. Accessed April 29, 2015. 6. Centers for Disease Control and Prevention (CDC). QuickStats: cigarette smoking prevalence among adults aged 18 years who have spent 24 hours on the streets, in a shelter, or in a jail or prison, by sex United States, 2004. 2006. 55(10):287. www.cdc.gov/mmwr/preview/mmwrhtml/mm5510a7. htm. Accessed October 8, 2014. 7. Petersilia J. When prisoners return to the community: political, economic, and social consequences. Correct Manag Q. 2001;5(3):1–11. 8. Lincoln T, Tuthill RW, Roberts CA, et al. Resumption of smoking after release from a tobacco-free correctional facility. J Correct Health Care. 2009;15(3):190–196. doi:10.1177/1078345809333388. 9. Glaze LE, Maruschak LM. Parents in Prison and Their Minor Children. Washington, DC: Bureau of Justice Statistics. Office of Justice Programs; 2008. www.bjs.gov/content/pub/pdf/pptmc.pdf Accessed April 29, 2015. 10. International Agency for Research on Cancer (IARC), Second-hand tobacco smoke. 2002. http://monographs.iarc.fr/ENG/Monographs/ vol100E/mono100E-7.pdf. Accessed May 11, 2015. 11. Jacobs M, Alonso AM, Sherin KM, Koh Y, Dhamija A, Lowe AL. Policies to restrict secondhand smoke exposure American College of Preventive Medicine Position Statement. Am J Prev Med. 2013;45(3):360–367. http://dx.doi.org/10.1016/j.amepre.2013.05.007. Accessed April 29, 2015.
7
Original investigation
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Exploration of Incarcerated Men’s and Women’s Attitudes of Smoking in the Presence of Children and Pregnant Women: Is There a Disparity Between Smoking Attitudes and Smoking Behavior? Donna R. Parker ScD1,2, Mary B. Roberts MS2, Jacob J. van den Berg PhD3,4, Beth Bock PhD5, Lyn A. R. Stein PhD6, Rosemarie A. Martin PhD7, Jennifer G. Clarke MD, MPH2,8 Departments of Family Medicine and Epidemiology, Alpert Medical School of Brown University, Providence, RI; Brown University Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, RI; 3 Division of Infectious Diseases, Miriam Hospital, Providence, RI; 4Department of Medicine, Alpert Medical School of Brown University, Providence, RI; 5Center for Behavioral and Preventive Medicine, Department of Psychiatry, Brown University, Providence, RI; 6Department of Psychology, University of Rhode Island, Kingston, RI; 7Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI; 8Department of OB/ GYN, Alpert Medical School of Brown University, Providence, RI 1 2
Corresponding Author: Donna R. Parker, ScD, Brown University Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA. Telephone: 401-729-2531; Fax: 401-729-2494; E-mail: [email protected]
Abstract Introduction: A major health challenge facing persons who are incarcerated is tobacco smoking. Upon reentry to the community, concerns regarding smoking cessation may be less likely to receive needed attention. Many individuals have partners who are pregnant and/or reside in households where children and pregnant women live. We explored incarcerated adults’ attitudes of smoking in the presence of children and pregnant women and how post-release smoking behaviors are influenced by their attitudes. Methods: Two hundred forty-seven incarcerated adults participated in a smoking cessation randomized clinical trial in a tobacco-free prison. An instrument was developed to examine smoking attitudes and behaviors around children and pregnant women. Moderating effects of smoking factors on post-release abstinence were examined by evaluating interactions between smoking factors and treatment group. Results: Four factors were defined using factor analysis: smoking around children; impact of smoking on child’s health; awareness of environmental tobacco smoke (ETS) risk for pregnant women; and importance of smoking avoidance during pregnancy. We found moderation effects of smoking factors on smoking outcomes which included: treatment group by smoking behavior around children (β = 0.8085; standard error [SE] = 0.4002; P = .04); treatment group by impact of smoking on child’s health (β = 1.2390; SE = 0.5632; P = .03) and for those smoking 50% fewer cigarettes postrelease, treatment group by smoking impact on child’s health (β = 1.2356; SE = 0.4436; P < .01). Conclusions: Concern for smoking around children and pregnant women and awareness of ETS risk for pregnant women was not found to be significantly associated with smoking outcomes and requires additional investigation. Among individuals who continue to smoke post-release, effective ETS interventions are needed aimed at protecting children and pregnant women with whom they live. © The Author 2015. 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].
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Introduction
Methods Procedure and Sample The details on the full study design and methods have been described previously.14 Briefly, Project Working Inside for Smoking Elimination (WISE) was a randomized clinical trial to investigate an intervention aimed at increasing smoking abstinence rates among individuals following release from a tobacco-free prison. To be eligible, participants were required to be released within the next 8 weeks, were 18 years or older, smoked 10 or more cigarettes per day prior to incarceration, and spoke English. Outcome assessments took place in-person 3 weeks after release. Self-reported smoking status was confirmed by urine cotinine with current smoking defined as ≥200 ng/ml cotinine. 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. To further protect study
participants a Certificate of Confidentiality was obtained from the Department of Health and Human Services. Measurements Participant demographics collected at baseline included age, race, ethnicity, gender, and education level. Individual smoking history assessed years since smoked daily, age started smoking daily, and number of cigarettes smoked per day (smoking rate) prior to incarceration. “Plans for smoking after release” was evaluated using a single item with six responses. Responses included: (1) I plan to smoke when I get out of here and I will never plan to quit; (2) I plan to smoke when I get out of here but I might quit in the future; (3) I will probably smoke when I get out of here; (4) I probably won’t smoke when I get out of here; (5) I have made plans to not smoke when I get out of here; and (6) I have made plans to not smoke when I get out of here and I will never smoke again. Responses were recoded into the following: 1, 2, and 3 = plans to smoke upon release; 4, 5, and 6 = plans to NOT smoke upon release. Information regarding smoking within 24 hours of release was obtained by telephone and the Timeline Fallback.15 An indicator for smoking at least 50% less (“smoking 50% less”) at 3 weeks post-release was created by answering yes or no (coded as 1 or 0, respectively) to the calculated question: is the participant smoking at 3 weeks post-release no more than one-half the number of cigarettes reported at pre-incarceration. Participants were also asked 12 questions at baseline (Table 1) designed to explore their perceptions about the impact of smoking on children and pregnant women. Specifically, questions addressed smoking in the home, the impact of smoking on children’s health, the importance of smoking avoidance during pregnancy, and awareness of ETS risks to pregnant women/fetuses. These questions were developed based on interviews with incarcerated adults and the existing literature. Covariates Covariates were determined to be significant if P < .05. Significant covariates for the smoking outcomes were determined for the main results manuscript16 and these covariates are used in these analyses to be consistent. The association between smoking attitudes/behaviors and each of three individual smoking outcomes (“smoking status 3 weeks post-release,” “smoking status within 24 hours of release,” and “smoking 50% less 3 weeks after release”) were assessed in separate analyses. Data Analysis Descriptive statistics (means, standard deviations, frequencies, and percentages) were generated to characterize the data. For the smoking questions displayed in Table 1, a principal components analysis was conducted using varimax rotation. A factor was included if its eigenvalue was greater than one. Each factor was a summation of the questions regarding smoking in the presence of children and pregnant women with a factor loading greater than 0.40. Each of the developed factors characterized a smoking behavior/attitude around pregnant women or children. Each factor (smoking around children, impact of smoking on children’s health, importance of smoking avoidance during pregnancy, and awareness of ETS risks to pregnant women/fetuses) was examined by demographics and smoking outcomes. For associations with categorical variables, the behavior/attitude factors were examined using analysis of variance or nonparametric equivalent,
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Over 2 million individuals are incarcerated in the United States. Many of the individuals entering correctional facilities have a history of risky health behaviors and substance abuse.2,3 One of the major health challenges facing this population is tobacco smoking. The rate of tobacco smoking among persons who are incarcerated is disproportionately high compared to the general population with rates ranging from 70% to 80%.4–6 Once individuals are released from prison, they face numerous challenges including reestablishing relationships, finding housing and employment, and dealing with addictions including tobacco smoking.7 Yet, given major barriers and challenges of reentry of persons who are incarcerated to their families and the community, concerns regarding smoking cessation may be less likely to receive the attention that is needed. Indeed, over 97% of inmates will resume smoking upon release from a tobaccofree jail.8 The majority of persons who are incarcerated who return to the community have children. Overall, 52% of state and 63% of federal inmates report being parents to an estimated 1.7 million children.9 Many of these incarcerated individuals also have partners who are pregnant and/or reside in households where children and pregnant women live. Of concern is that environmental tobacco smoke (ETS) exposure poses serious health risks for all those who are exposed, especially children and pregnant women.10,11 The adverse effects associated with ETS include preterm birth, intrauterine growth retardation, perinatal mortality, respiratory illness, neurobehavioral problems, and decreased performance in school.12 Additionally, pregnant woman who smoke not only endanger their own health but also endanger the health of their unborn infants as well.13 Currently, there are no published studies using a qualitative approach to explore incarcerated smokers’ attitudes and behaviors regarding cigarette smoking in the presence of children and pregnant women. For this study, we developed a survey to explore factors associated with incarcerated adults’ attitudes of smoking in the presence of children and pregnant women and, given that this is a new instrument, we were interested in identifying the scale structure. The aims of this study are to: (1) identify the scale structure of the newly developed instrument using exploratory factor analysis; (2) examine the influence of these attitudes on post-release smoking cessation; and (3) examine the moderating effects of the smoking attitudes on smoking behavior post-release. 1
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Table 1. Factor Analysis for Items of Smoking in the Presence of Children and Pregnant Women: Items, Factor Loadings, and Reliability Items by factor
% yes
Factor loading
230 231 229 229
54.8 38.1 48.5 56.3
0.877 0.841 −0.818 0.475
228 232 233 232
92.1 94.8 86.3 90.5
0.858 0.858 0.613 0.436
242 243
92.6 90.1
0.914 0.838
236
90.7
0.887
239
87.0
0.876
Cronbach alpha
Eigenvalue (% variance)
Mean (SD)
0.770
3.139 (26.2)
2.01 (1.53)
0.670
2.231 (18.6)
3.64 (0.79)
0.789
1.464 (12.2)
7.36 (1.21)
0.840
1.221 (10.2)
1.78 (0.57)
Responded “Yes”. Important/very important. c ETS—environmental tobacco smoke. a
b
if warranted. For continuous variables, Spearman correlations were examined. Multiple variable logistic regressions were used to examine the associations between selected smoking outcomes and smoking behaviors/attitudes around pregnant women and children over and above significant predictive covariates for each smoking outcome. All analyses were conducted using IBM SPSS Version 20 (Released 2011, IBM Corp., Armonk, NY). For all analyses, a P value less than or equal to .05 is considered significant. Additionally, we wanted to examine the impact that any interaction between the smoking behavior/attitudes factors and treatment group would have on smoking outcomes. This moderation analysis treated the smoking attitudes/behavior factors as potential moderators of the treatment effect on the smoking outcomes. Moderation analyses followed a regression-based approach17 and utilized the SPSS PROCESS Macro (version 2.12.2, released August, 2014) developed by Hayes (www.Afhayes.com). Moderation models included covariates (gender, Hispanic ethnicity, participation in the drug treatment program, length of incarceration, smoking plans upon release), treatment group, a moderator (one of the smoking behaviors/attitudes factors), and a treatment by moderator interaction term. Significant moderator by treatment interactions were plotted using MS Excel with the visualization data obtained with the PROCESS Macro.
Results Study Population Of the 312 people screened for the study, 273 met eligibility criteria and 262 (95.9%) agreed to participate and completed the consent procedure. Of the 262 enrolled at baseline, nine were excluded from the analyses due to a technical error resulting in missing baseline data, and six participants were excluded because they were never released or were reincarcerated at the time of follow-up. The final sample of 247 participants included
161 men and 86 women. Two hundred twenty-eight participants (92.3%) completed the 3-week post-release follow-up assessment. Following the “intention-to-treat” approach,18 19 participants lost to follow-up were assumed to have returned to their preincarceration level of smoking, were included in the analyses and counted as smokers.
Exploratory Factor Analysis Table 1 presents the factor analysis for items of smoking in the presence of children and pregnant women. The factor analysis statistics indicated a good fit for a four-factor solution with Chronbach’s alphas ranging from 0.67 to 0.84. Individual item responses indicated that most of the participants (94.8%) believed that smoking around children is harmful and also believed (90.1%) that it is important/very important not to smoke around pregnant women. However, when participants were asked whether they smoked in the home where there is a pregnant woman, 54.8% responded that they did smoke in the home and 38.1% responded that they smoked in the same room.
Baseline Characteristics Baseline characteristics are presented in Table 2. Of the 247 participants, most were men (65.2%), had less than a high school education (63.6%), were primarily white (51.4%), and had a mean age of 35.6 years. Of their smoking history, participants began to smoke around 13 years of age (mean age; SD = 4.4) and had smoked an average of 19.4 years (SD = 10.0) prior to incarceration. Over half (51%) of the participants reported planning to resume smoking upon release from prison. Over half of all participants (52.6%) had at least two other members of their household who smoked, and 48.6% had a partner who smoked. Fifteen percent of the participants lived with children prior to incarceration. One hundred twenty-two participants (49.4%) were randomized into the intervention group and 125 (50.6%) were randomized into the control group.
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Smoking behavior around children Did you smoke in the home?a Did you smoke in the same room?a Did you only smoke outside?a Did you keep smoking the way you always had?a Impact of smoking on child health My smoking makes the kids around me less healthya My smoking hurts the health of kids that are near mea Smoking makes me worry about making kids sicka Kids around me are more likely to smoke because they see me smokea Importance of smoking avoidance during pregnancy How important do you think it is for a pregnant woman to stop smoking?b How important do you think it is not to smoke around a pregnant woman?b Awareness of ETSc risks to pregnant women/fetuses Were/are you aware that there are risks to a growing baby (fetus) from other people’s smoke?a Were/are you aware that there are risks to a pregnant woman from other people’s smoke?a
n
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Attitudes Regarding Smoking Around Children and Pregnant Women and Smoking Behavior Post-Release Unadjusted and adjusted odds ratios (ORs) of being abstinent for the first 24 hours after release and attitudes regarding smoking behavior around children and pregnant women are presented in Table 3. Prior to adjusting for covariates (gender, Hispanic ethnicity, participation in a drug treatment program, plans to quit smoking, length of incarceration and intervention status), participants whose attitudes Table 2. Participant Characteristics Characteristics (N = 247)
161 35.6
(65.2%) (9.2)
157 49 37
(63.6%) (19.8%) (15.0%)
43 127 49 28 13.1 15.7 19.4
(17.4%) (51.4%) (19.8%) (11.3%) (4.4) (4.5) (10.0)
120 120
(48.6%) (48.6%)
37 73 79 51 37
(15.0%) (29.6%) (32.0%) (20.6%) (15.0%)
119
(48.2%)
122 125
(49.4%) (50.6%)
40 105
(16.2%) (42.5%)
90
(36.4%)
Moderation Effects of Smoking Factors on Smoking Behavior Post-Release We next examined the moderation effects of smoking factors on smoking outcomes by evaluating the interaction between smoking factors and treatment group (Figure 1 and Supplementary Figure 1). Three interactions were significant: for smoking abstinence 3 weeks post-release, treatment group by smoking behavior around children (β = 0.8085; standard error (SE) = 0.4002; P = .04) and treatment group by attitudes regarding the impact of smoking on child health (β = 1.2390; SE = 0.5632; P = .03); and for smoking 50% fewer cigarettes after release, treatment group by attitudes regarding smoking impact on child’s health (β = 1.2356; SE = 0.4436; P < .01). In Figure 1, results suggest that the WISE intervention increases the probability of 3-week post-release abstinence over the control group by 11 percentage points for those less likely to smoke around children (20.0% vs. 9.0%, respectively). However, for those more likely to smoke around children, the intervention had a greater effect over the control group (21.0% vs. 1.0% respectively—an increase of
Table 3. Unadjusted and Adjusted Odds Ratios (ORs) of Abstinence for the First 24 Hours After Release and Attitudes Regarding Smoking Behavior Around Children and Pregnant Women Unadjusted
Adjusteda
Smoking behavior
OR
95% CI
P
OR
95% CI
P
Smoking behavior around children Impact of smoking on child health Awareness of ETS risks to pregnant women and fetuses Importance of smoking avoidance during pregnancy
0.82 1.35 1.64 1.40
0.69% to 0.98% 0.94% to 1.96% 0.99% to 2.73% 1.09% to 1.80%
.030 .108 .057 .008
0.83 1.26 1.56 1.19
0.67% to 1.02% 0.84% to 1.87% 0.86% to 2.84% 0.92% to 1.56%
.070 .267 .143 .192
CI = confidence interval; ETS = environmental tobacco smoke. Bold values are statistically significant. a Models were adjusted for: gender, Hispanic ethnicity, participation in a drug treatment program, plans to quit smoking, length of incarceration, and intervention status.
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Gender: % male Age in years Education Less than high school High school Greater than high school Race/ethnicity Black White Hispanic/Latino Other/unknown Age (years) began smoking Age (years) began smoking regularly Years smoked Smoking plans Plans not to smoke upon release Spouse/partner smokes Household smoking (number of people) No one One person Two people Three or more people Lived with children prior to incarceration Participated in a drug treatment program while incarcerated Treatment group Intervention Control Smoking status Abstinent 3 weeks post-release Abstinent for first 24 hours post-release Smoked at least 50% less at 3 weeks post-release
Mean (SD) or n (%)
did not reflect concern about smoking around children were less likely to be abstinent for the first 24 hours after release (OR of 0.82; 95% confidence interval: 0.69% to 0.98%) compared with those whose attitudes did reflect concern about smoking around children (P = .03). The unadjusted OR was also significant for importance of smoking avoidance during pregnancy. Participants who placed high importance on avoiding smoking during pregnancy were more likely to be abstinent for the first 24 hours after release (OR = 1.40; 95% confidence interval: 1.09% to 1.80%) compared with those who placed less importance on avoiding smoking during pregnancy (P = .008). Results of remaining abstinent for the first 24 hours after release were not significant for participants’ attitudes related to smoking impact on children’s health nor awareness of smoking as a risk for pregnant women and the fetus. None of the adjusted ORs examining attitudes regarding smoking around children and pregnant women and smoking within 24 hours of release were significant. Similarly, models were run examining the unadjusted and adjusted ORs of smoking 50 less after release in relation to attitudes regarding smoking around children and pregnant women and were not significant (Table 4). Additionally, we examined the association between continued smoking abstinence 3 weeks post-release and attitudes regarding smoking around children and pregnant women but none of these results were significant (Table 5). Analyses were also examined for gender differences in regards to attitudes of smoking around children and pregnant women but none were noted nor were there any differences in the association of the attitudes to smoking abstinence.
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Table 4. Unadjusted and Adjusted Odds Ratios (ORs) of the Association Between Smoking At Least 50% Less After Release and Attitudes Regarding Smoking Around Children and Pregnant Women Unadjusted
Adjusteda
Smoking behavior
OR
95% CI
P
OR
95% CI
P
Smoking behavior around children Impact of smoking on child health Awareness of ETS risks to pregnant women and fetuses Importance of smoking avoidance during pregnancy
1.07 0.78 0.82 1.03
0.90% to 1.28% 0.56% to 1.09% 0.52% to 1.29% 0.83% to 1.29%
.456 .149 .385 .771
1.06 0.74 0.77 0.95
0.88% to 1.28% 0.52% to 1.05% 0.47% to 1.27% 0.75% to 1.19%
.554 .091 .305 .638
CI = confidence interval; ETS = environmental tobacco smoke. a Models were adjusted for: gender, Hispanic ethnicity, participation in a drug treatment program, plans to quit smoking, length of incarceration, and intervention status.
Unadjusted
Adjusteda
Smoking behavior
OR
95% CI
P
OR
95% CI
P
Smoking behavior around children Impact of smoking on child health Awareness of ETS risks to pregnant women and fetuses Importance of smoking avoidance during pregnancy
0.92 1.06 1.15 1.18
0.73% to 1.16% 0.67% to 1.66% 0.59% to 2.22% 0.85% to 1.64%
.456 .816 .682 .329
0.92 0.88 1.01 0.89
0.70% to 1.20% 0.53% to 1.44% 0.44% to 2.32% 0.62% to 1.28%
.527 .601 .973 .531
CI = confidence interval; ETS = environmental tobacco smoke. a Models were adjusted for: gender, Hispanic ethnicity, participation in a drug treatment program, plans to quit smoking, length of incarceration, and intervention status.
Figure 1. Moderation plot of smoking attitudes by treatment group for 3-week abstinence.
20 percentage points). In regards to the awareness of the impact of smoking on children’s health (Figure 1), the WISE intervention has an estimated increase in abstinence rates over the control group of 22 percentage points for those with a greater perceived awareness of the harm of ETS on children’s health (25.0% vs. 3.0%, respectively). For those less aware of this harm, this rate difference is approximately 9 percentage points (16.0% for intervention vs. 7.0% for the control). In Supplementary Figure 1, the effect of treatment group was moderated by the impact of smoking on child’s health for those smoking 50% less 3-weeks post-release. Among those who believed that ETS harms a child’s health, the WISE intervention group had a greater probability of smoking less than did the control group (43% vs. 24% respectively). The probability of smoking less was reversed
by treatment group for those who did not believe that smoking harms a child’s health (36% intervention group vs. 51% control group).
Discussion This study demonstrated that among individuals who were incarcerated, their attitudes toward smoking around children and pregnant women were not directly associated with their smoking behavior post-release. Of interest, however, was that we did find that there was a moderating effect of smoking attitudes on 3-week post-release abstinence by evaluating the interaction between smoking attitudes and treatment group. In fact, the WISE smoking cessation intervention increased abstinence rates (by 20%) in the intervention group
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Table 5. Unadjusted and Adjusted Odds Ratios (ORs) of the Association Between Continued Smoking Abstinence 3 Weeks After Release and Attitudes Regarding Smoking Around Children and Pregnant Women
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between attitudes and behaviors related to smoking around children and pregnant women and remaining tobacco free post-release. With respect to the original survey items, items were developed for this survey and item response options for nine of the questions were based on Yes/No responses. However, factor analyses indicated a good model fit for the four factors examined. In the WISE study, we found that our intervention, based on motivational interviewing and cognitive behavioral therapy, improved continued smoking abstinence 3 weeks post-release by 6.6 times over that of the control condition.16 In this study, we found that the WISE intervention increased the probability of 3-week postrelease abstinence among individuals who were more likely to smoke around children who were in the intervention group compared with the control group. Additionally, our intervention had a positive effect on abstinence rates 3 weeks post-release among participants who were less aware of the harm of ETS on children’s harm and were in the intervention group compared with those in the control group. In contrast, the intervention had a positive effect on the probability of smoking 50% less only among those who were aware of the harm of ETS on children’s health. Given that this is the first study to examine the moderation effects of attitudes and behaviors regarding smoking around children and pregnant among incarcerated individuals, further research is needed.
Conclusions Concern for smoking around children and pregnant women was not found to be significantly associated with smoking outcomes and requires additional investigation. Our results suggest that among individuals who continue to smoke post-release, effective interventions are needed that are aimed at protecting children and pregnant women with whom they live from ETS.
Supplementary Material Supplementary Figure 1 can be found online at http://www.ntr. oxfordjournals.org
Funding This study was funded by a grant from the National Institutes of Health (R01 DA 024093 to JGC). Registration of Clinical Trials: http://ClinicalTrials.gov Identifier: NCT01122589.
Limitations It is important to note that this study was a randomized clinical trial powered to investigate an intervention aimed at increasing smoking abstinence rates among individuals after release from a tobaccofree prison and was not powered to examine questions regarding attitudes about smoking around children and/or pregnant women. Additionally, it is unknown whether individuals who completed the questions regarding children were parents and what affect that might have on their responses or how many participants spent time with children who were not in their household (ie, divorced parents who did not have primary custody but spent time with their children). While the percent of individuals who lived with children prior to incarceration was small (15%) in this study, these results are similar to the Bureau of Justice statistics (22%).9 Also, there was limited power to examine differences in attitudes by child-inhousehold which requires further investigation. Finally, the limited power may have contributed to a lack of a significant association
Declaration of Interests None declared.
Acknowledgments We would like to thank the men and women who participated in this study and the Rhode Island Department of Corrections for supporting this research.
References 1. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Prisoners in 2012—Advance Counts. 2013. www.bjs.gov/content/pub/pdf/p12ac.pdf. Accessed April 29, 2015. 2. Wilson DJ. Drug use, testing, and treatment in local jails. 2000. www.bjs. gov/index.cfm?ty=pbdetail&iid=779. Accessed October 8, 2014.
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compared with the control group among individuals more likely to smoke around children. Our intervention increased abstinence by 9% among individuals less aware of the harm of ETS in the intervention group compared with the control group. Additionally, the intervention increased the probability of smoking 50% less by 11% among individuals who were aware of the harm of ETS on children’s health. These results highlight the importance of reviewing smoking attitudes and educating participants about risk during the WISE smoking cessation intervention. Several studies have examined the association of smoking exposure of children and smoking behavior in nonincarcerated populations. Liao and colleagues19 examined factors associated with smoking in the presence of children among 307 nonincarcerated parents who smoked. They reported that parents were more likely to smoke in the presence of children if there was a higher level of acceptance of smoking around children or they acknowledged fewer potential negative effects of their children’s exposure to ETS.19 In another study, 1352 nonincarcerated adults, 20–44 years of age, completed a mailed questionnaire examining whether parenthood affected smoking behavior. They reported that the smoking behavior (smoking outdoors or smoking near an open window) but not smoking prevalence was influenced by being a parent.20 Of interest was that although being a parent had an impact on attitudes toward protecting children from ETS, they found no differences in adult’s smoking patterns regardless of whether they had children or not.20 These studies suggest that there appears to be discordance between attitudes about smoking in the presence of children and actual smoking behaviors exhibited around children. However, our findings did not support these results. It may be that attitudes regarding smoking around children and pregnant women were not related to smoking outcomes 3-weeks post-release because the vast majority (86%–95%) endorsed negative attitudes hence we may be underpowered to detect these differences. Currently there is general public knowledge that smoking around children is undesirable although there is less understanding as to the potential harmful effects on children’s health.21 Yet there did not seem to be a relation between these attitudes and smoking outcomes. Attitudes surrounding pregnancy also had no impact on smoking behavior but this may be because few persons returned to situations in which they needed to be concerned about smoking around pregnant women.
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12. Hwang S-H, Hwang JH, Moon JS, Lee D-H. Environmental tobacco smoke and children’s health. Korean J Pediatr. 2012;55(2):35–41. http:// dx.doi.org/10.3345/kjp.2012.55.2.35. Accessed April 29, 2015. 13. Piquero AR, Gibson CL, Tibbetts SG, Turner MG, Katz SH. Maternal cigarette smoking and life-course-persistent offending. Int J Offender Ther Comp Criminol. 2002;46(2);231–248. doi:10.1177/0306624X02462008. 14. Clarke JG, Martin RA, Stein LAR, et al. Working inside for smoking elimination (Project W.I.S.E.) Study design and rationale to prevent return to smoking after release from a smoke free prison. BMC Public Health. 2011;11:767. doi:10.1186/1471-2458-11-767. 15. Shiffman S. How many cigarettes did you smoke? Assessing cigarette consumption by global report, time-line follow-back, and ecological momentary assessment. Health Psychol. 2009;28(5):519–526. doi:10.1037/a0015197. 16. Clarke JG, Stein LAR, Martin RA, et al. Forced smoking abstinence. Not enough for smoking cessation. JAMA Intern Med. 2013;179(9):789–794. doi:10.1001/jamainternmed.2013.197. 17. Hayes AF. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York, NY: Guilford Press; 2013. 18. West R, Hajek P, Stead L, Stapleton J. Outcome criteria in smoking cessation trials: proposal for a common standard. Addiction. 2005;100(8):299– 303. doi:10.1111/j.1360-0443.2004.00995.x. 19. Liao Y-M, Chen Y-T, Kuo L-C, Chen P-L. Factors associated with parental smoking in the presence of school-aged children: a cross-sectional study. BMC Public Health. 2013;13:819. doi:10.1186/1471-2458-13-819. 20. Johansson AK, Halling A; The LinQuest Study Group. Does having children affect adult smoking prevalence and behaviours at home? Tob Induc Dis. 2003;1(3):175–183. doi:10.1186/1617-9625-1-3-175. 21. Farber HJ, Knowles, SB, Brown NL, et al. Secondhand tobacco smoke in children with asthma: sources of and parental perceptions about exposure in children and parental readiness to change. Chest. 2008;133(6):1367– 1374. doi:10.1378/chest.07-2369.
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3. Conklin TJ, Lincoln T, Tuthill RW. Self-reported health and prior health behaviors of newly admitted correctional inmates. Am J Public Health. 2000;90(12):1939–1941. doi:10.2105/AJPH.90.12.1939. 4. Kaufman RM, Ferketch AK, Murray DM, Bellair PE, Wewers ME. Tobacco use by male prisoners under an indoor smoking ban. Nicotine Tob Res. 2011;13(6):449–456. doi:10.1093/ntr/ntr024. 5. Trosclair A, Caraballo R, Malarcher A, Husten C, Pechacek T; CDC. Cigarette smoking among adults—United States, 2003. MMWR. 2005;54(20):509– 513. www.cdc.gov/mmwr/preview/mmwrhtml/mm5420a3.htm. Accessed April 29, 2015. 6. Centers for Disease Control and Prevention (CDC). QuickStats: cigarette smoking prevalence among adults aged 18 years who have spent 24 hours on the streets, in a shelter, or in a jail or prison, by sex United States, 2004. 2006. 55(10):287. www.cdc.gov/mmwr/preview/mmwrhtml/mm5510a7. htm. Accessed October 8, 2014. 7. Petersilia J. When prisoners return to the community: political, economic, and social consequences. Correct Manag Q. 2001;5(3):1–11. 8. Lincoln T, Tuthill RW, Roberts CA, et al. Resumption of smoking after release from a tobacco-free correctional facility. J Correct Health Care. 2009;15(3):190–196. doi:10.1177/1078345809333388. 9. Glaze LE, Maruschak LM. Parents in Prison and Their Minor Children. Washington, DC: Bureau of Justice Statistics. Office of Justice Programs; 2008. www.bjs.gov/content/pub/pdf/pptmc.pdf Accessed April 29, 2015. 10. International Agency for Research on Cancer (IARC), Second-hand tobacco smoke. 2002. http://monographs.iarc.fr/ENG/Monographs/ vol100E/mono100E-7.pdf. Accessed May 11, 2015. 11. Jacobs M, Alonso AM, Sherin KM, Koh Y, Dhamija A, Lowe AL. Policies to restrict secondhand smoke exposure American College of Preventive Medicine Position Statement. Am J Prev Med. 2013;45(3):360–367. http://dx.doi.org/10.1016/j.amepre.2013.05.007. Accessed April 29, 2015.
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