Smoking cessation in male prisoners: a literature review Ashleigh Djachenko, Winsome St John and Creina Mitchell
Ashleigh Djachenko is an Honours Candidate, based at School of Nursing & Midwifery, Griffith University, Gold Coast, Australia. Dr Winsome St John is an Associate Professor and Creina Mitchell is a Lecturer, both are based at School of Nursing & Midwifery/Griffith Health Institute, Griffith University, Gold Coast, Australia.
Abstract 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. Keywords Offender health, Prisoners, Tobacco, Health promotion, Correctional health, Smoking Paper type Literature review
Background One of the most significant contemporary public health issues is that of tobacco smoking and the consequential burden of smoking-related illness. The links between smoking and poor health outcomes have been well-documented. The deaths of nearly six million people each year are attributed to smoking, making it the most significant behavioural risk factor for premature death (WHO, 2011). Between 1980 and 2012, the global prevalence of daily tobacco smoking has declined by an estimated 25 per cent for men and 42 per cent for women (Ng et al., 2014). This decline has been partly attributed to increased tobacco control measures as well as changing societal attitudes and a decreasing tolerance for cigarette smoking in the community. However, smoking rates remain high in certain groups such as people of lower socio-economic status, those with substance abuse problems, mental health clients and indigenous peoples (Zwar et al., 2011).
DOI 10.1108/IJPH-10-2014-0035
VOL. 11 NO. 1 2015, pp. 39-48, C Emerald Group Publishing Limited, ISSN 1744-9200
j INTERNATIONAL JOURNAL OF PRISONER HEALTH j PAGE 39
Prison populations, within which all the above groups are over-represented, have been identified as a priority group for strategies to promote smoking cessation (SC) (WHO, 2007). Prior to the emergence of the primary health care movement, prison health services were typically provided by custodial authorities as opposed to health agencies. Health care services were designed to respond to acute illness and failed to address the broader determinants that led to poorer health for prisoners in the first place (De Viggiani, 2006). The WHO Healthy Prisons movement emerged in the early 1990s and identified tobacco consumption as a significant contributor to poor prisoner health (WHO, 2007). Smoking prevalence has been reported at 70 per cent in US prisons (Chavez et al., 2005), 78 per cent in the Scottish Prison Service survey (Ritter et al., 2011) and as high as 83 per cent in Australian prisons (Australian Institute of Health and Welfare, 2010). Unlike the wider community, where effective social marketing and policy development has begun to diminish the social desirability of smoking, cigarettes remain entrenched in prison culture and are used as currency, to alleviate boredom and stress, and as a social lubricant (Richmond et al., 2012). Also, many key components of quitting strategies are inaccessible to prisoners, such as diversionary activities and social support. SC interventions need to be specifically tailored to this unique population. Prisons around the world are increasingly introducing tobacco bans, ranging from total bans on tobacco and related products, to partial bans restricting smoking to prisoners’ cells or dedicated smoking areas. Total bans have been implemented in prisons in Canada, Australia and New Zealand, and all US federal prisons (Ritter et al., 2011). Most European prisons have indoor smoking bans as do US state prisons. It has been argued that the drive for smoking bans in prisons comes primarily from fear of litigation from non-smoking staff and prisoners (Naylor, 2013). However, the World Health Organisation (WHO, 2011) advocates the imperative for protecting persons from exposure to environmental tobacco smoke in public areas, including those that are both homes and workplaces (such as prisons and nursing homes). Whatever the motivation, reducing smoking in the prison environment has become a priority for public health authorities worldwide. The role of the HCP with regard to SC interventions has been described in the literature. A 2009 Cochrane review of 42 studies found that nursing interventions significantly increase the likelihood of quitting, with a stronger effect found when interventions are provided by HCP whose primary role is in health promotion or SC (Rice and Stead, 2008). However, interventions were limited to counselling or advice-based strategies and patients receiving nicotine replacement therapy (NRT) were excluded from the analysis. The effect of HCP interventions in combination with NRT or pharmacological agents has been studied in population groups such as hospital inpatients (Gies et al., 2008; Meysman et al., 2010), general practice (Zwar et al., 2011), and patients with COPD (Tonnesen et al., 2006). However, to our knowledge, there are no studies which examine HCP approaches to SC for prisoners. We conducted a literature review to examine what is currently known about SC in prisons, with the aim of informing the health care professions and identifying implications for correctional health practice, education and research. Findings will be discussed with reference to the Ottawa Charter for Health Promotion and its application to the custodial environment.
Search strategy Databases PubMed, CINAHL and MEDLINE were searched for English language studies from 1990 to 2012. Foreign language papers were accepted if translated into English. We searched MeSH terms “smoking cessation”, “tobacco”, “nicotine” and “cigarette smoking” combined with “prison”, “prisoner”, “correctional” and descriptor terms “nursing” or “health promotion”. A Google search was also performed to identify “gray literature” such as conference proceedings and government reports. For this review, papers focusing on female prisoners were excluded. Females comprise less than 7 per cent of the global prison population (Walmsley, 2013) and it is recognised the barriers and motivations for smoking among female prisoners are unique (Eldridge and Cropsey, 2009) and arguably would be best represented in an analysis separate to the male majority. Prevalence studies which did not address the issue of SC were excluded. Studies focused on environmental
j
j
PAGE 40 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
issues such as air quality or policy issues such as the ethics of smoking ban enforcement were excluded, as were studies concerned with SC training and education for staff. A 2011 meta-analysis of SC in disadvantaged groups (Bryant et al., 2011) was excluded as it featured only one study of female prisoners. One study examined the role of a tobacco control coordinator in the criminal justice system (Eadie et al., 2012) – this was excluded as it was primarily an examination of the coordinator role and not of smoking cessation itself. Studies of released (former) prisoners were excluded, as the primary scope of this review is to inform practice and policy for people in custody. In total, 12 studies were identified which addressed SC in the male prisoner population (Table I). Four of these were from Australia, three from the USA and one each from Taiwan, Greece, Poland, Switzerland and the UK. Of these, four studies examined the effects of a partial or total smoking ban on smoking behaviour and SC (Chang et al., 2010; Cropsey and Kristeller, 2005; Kauffman et al., 2011; Thibodeau et al., 2012). The remaining studies looked at various combinations of NRT, pharmacological intervention, counselling and cognitive behavioural therapy (CBT).
Findings Review of the studies revealed that forced abstinence (a total or partial smoking ban) had little impact on SC among prisoners. The percentage of prisoners continuing to smoke in banned areas ranged from around 24 (Thibodeau et al., 2012) to 76 per cent (Cropsey and Kristeller, 2005). In a prison with an indoor smoking ban, 51 per cent of prisoners reported smoking indoors (Kauffman et al., 2011). A qualitative Taiwan study identified that prisoners were willing to engage in black-market activity and pay inflated prices in order to continue smoking (Chang et al., 2010). Three studies (Etter et al., 2012; Makris et al., 2012; Richmond et al., 2009) identified that the co-habitation of non-smoking and smoking prisoners contributed to exposure to second-hand smoke (SHS) and to difficulties quitting. A recurring theme identified in this review was that local and national tobacco policies impacted on prisoners’ perceptions of smoking and forced abstinence. The Switzerland study (Etter et al., 2012) compared the effect of varying SC activities at three different prisons. Some extended non-smoking areas, one offered NRT for free and one offered NRT for purchase. It found a reduction in exposure to SHS and improved access to medical assistance to quit, but no reduction in quit attempts or smoking status. This study noted that inconsistent anti-smoking policies led to haphazard and generally poor implementation of SC initiatives. In Taiwan, the government’s dual role as managers of the tobacco industry and as anti-tobacco advocates was widely derided by prisoners as hypocritical (Chang et al., 2010). Two Australian studies by the same lead author examined various combinations of pharmacology, NRT and behavioural techniques (Richmond et al., 2006, 2012). The first was an uncontrolled study combining a pharmacological agent (buproprion) with NRT and CBT which achieved quit rates of 26 per cent at seven days and 22 per cent at six months. The second was the only randomised-controlled trial identified for this review. It compared the addition of the antidepressant nortryptiline to NRT and CBT against a control group receiving NRT and CBT alone. It found no significant difference between the two groups but reported quit rates of up to 23 per cent at three months and nearly 12 per cent at 12 months. A five-year review of an Australian prison-based SC programme (McCarthy and Brewster, 2009) achieved quit rates of 25 per cent at one month and 14 per cent at three months among prisoners receiving NRT and group education. However, this programme suffered a large loss to follow-up and on an intention-to-treat analysis the quit rates were 13 and 7 per cent, respectively. The highest reported quit rates were nearly 31 per cent at three months and 20 per cent at 12 months in a Greek prison with a dedicated SC Centre. Participants received a pharmacological agent (varenicline) with counselling (Makris et al., 2012). The relatively small study (n ¼ 114) was non-randomised and non-controlled; but viewed in light of the fact that
j
j
VOL. 11 NO. 1 2015 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 41
Table I Studies of smoking cessation in male prisoners Authors/year
Setting, sample, design
Findings applied to strategies for health promotion
Chang et al. (2010)
Qualitative focus group study of male prisoners in Taiwan under a total smoking ban n ¼ 77 Quantitative survey of male prisoners in USA under a total smoking ban n ¼ 188 Before-after intervention questionnaire of males in three Swiss prisons n ¼ 417 Pilot study of a quit programme for prisoners and staff in UK n ¼ 10
Build healthy public policy Forced abstinence has limited impact on cessation and is seen as hypocritical due to government taxation on cigarettes. Smoking bans must be accompanied by SC interventions Build healthy public policy Create supportive environments 76% continued to smoke. Smoking ban not properly enforced and may reflect low support of policy by staff Build healthy public policy Reorient health services Results varied between prisons due to variation in interventions. SC programmes require a systematic approach Reorient health services Develop personal skills Uncontrolled pilot study. Recommends SC programmes delivered by trained staff and potential for peer-led SC programmes Create supportive environments Indoor bans do not promote SC although may decrease the total number of cigarettes smoked
Cropsey and Kristeller (2005)
Etter et al. (2012)
Jenkins (2002)
Kauffman et al. (2011)
Makris et al. (2012)
Quantitative survey of male prisoners in USA under an indoor smoking ban n ¼ 200 Quantitative survey of male prisoners attending a Smoking Cessation Centre in Greece n ¼ 114
McCarthy and Brewster (2009)
Quantitative evaluation of prisonbased SC programme in Australia n ¼ 352
Richmond et al. (2006)
Quantitative pilot/feasibility study of multi-component intervention for male prisoners in Australia n ¼ 30 Qualitative focus group study of the impact of tobacco and the prison environment on male and female prisoners and ex-prisoners in Australia n ¼ 40 (28 male, 12 female)
Richmond et al. (2009).
Richmond et al. (2013)
Sieminska et al. (2006)
Thibodeau et al. (2012)
j
RCT of male prisoners in Australia: whether adding nortryptiline to CBT and NRT improves quitting rates n ¼ 425 Quantitative survey of male prisoners in Poland n ¼ 907 (current smokers n ¼ 736)
Qualitative interviews with male prisoners in USA under a total smoking ban n ¼ 49
j
PAGE 42 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
Build healthy public policy Create supportive environments Reorient health services A well-structured smoking cessation programme can help promote quitting. Segregation of smoking and non-smoking prisoners is recommended Strengthen community action Develop personal skills Reorient health services Recommends evaluation of peer-led SC programmes, teleconferencing and greater SC support in prisons Build healthy public policy Reorient health services Specialised smoking cessation interventions can be effective in prisons Build healthy public policy Strengthen community action Develop personal skills Reorient health services Recommends improved access to pharmacotherapies, a free telephone helpline, more non-smoking areas, more physical activity and continued SC help after release Reorient health services Addition of nortryptiline does not improve quitting rates. Quit rates were similar to the wider community. Recommends further research into SC interventions in prisons Develop personal skills Reorient health services Intrinsic motivation necessary for cessation. Prisoners suggest rewards system (40%), NRT (24%), individual counselling (21%), pharmacology (21%) and group counselling (19%) as potentially effective Strengthen community action Develop personal skills Contraband smokers (n ¼ 12) continued out of a sense of rebellion and exercising personal choice. Interventions should focus on providing a sense of control and a perception of choice
nearly 75 per cent of the prison’s inmates attempted to quit, compared with 23 per cent prior to the opening of the SC Clinic, holds promise for further research. One pilot study reported a 50 per cent quit rate at six weeks in prisoners using NRT and weekly group sessions (Jenkins, 2002), however this was a tiny study of just eight prisoners, included here only because it was the sole report of interventions delivered exclusively by nurses. In a study of Polish correctional centres, in which no SC interventions were provided, only 2 per cent of smokers successfully quit during their incarceration (Sieminska et al., 2006). These prisoners felt a rewards system and/or NRT would be the most helpful strategies. Details about which health professions delivered these interventions were not always clear. Some studies named “doctor”, “nurse” or “counsellor” as the provider, others named “clinic staff” and some involved external quit smoking educators or trained prison officers. No robust studies were identified which specifically examined the role of the HCP in promoting SC among prisoners. Several studies noted that the delivery of SC programmes was inconsistent due to under-resourcing or understaffing and that SC outcomes received lower priority than issues deemed more “important” such as drug misuse, infection control and mental health. Several studies identified that despite the high prevalence of smoking, prisoners hold paradoxically strong views about health and fitness. Makris et al. (2012) and Sieminska et al. (2006) found that health reasons were the primary reason given for wanting to quit, while Thibodeau et al. (2012) and Richmond et al. (2009) found that prisoners attempting to quit often turned to training and fitness as an alternative pastime. All 12 studies described the promotion of SC in the prison environment as unique and challenging. A central theme was the identification of a “pro-smoking” culture in prison and the entrenched role of tobacco in prison society.
Discussion The key findings from this review indicate that certain SC interventions can be successfully implemented in a prison setting. Various combinations of counselling, NRT and pharmacology have demonstrated quit rates comparable to those achieved in the wider community (Wu et al., 2006). Forced abstinence, such as a partial or total smoking ban, does not result in sustained cessation. All the reviewed studies identified the “pro-smoking” culture in prison as a significant contributor to smoking behaviour. SC strategies for prisoners must therefore move beyond individual approaches to address the broader determinants of health from a population perspective. The Ottawa Charter for Health Promotion outlines five major strategies: build healthy public policy; create supportive environments; strengthen community action; develop personal skills; and reorient health services. Each of these will be discussed in relation to the findings of this review and the implications for health practice. Build healthy public policy Tobacco control has been cited as a successful example of healthy public policy building in the wider community (Patterson, 2007). Warning labels, restrictions on advertising, more public smoke-free areas and increased tax on tobacco products have contributed to a reduction in smoking (Mercer et al., 2001). Unfortunately, the evidence shows these measures are not impacting the prisoner community. Forced abstinence may result in black-market activity and reluctance of prisoners to disclose their smoking status to health care providers, which could adversely impact on their health. While a prison smoking ban may still have desirable outcomes such as healthier air and improved quality of life for non-smokers, as well as protection from potential litigation from those unwillingly exposed to SHS (Awofeso, 2003), as a policy initiative it is not effective as a sole SC strategy. Correctional HCP must advocate for smoking bans to be combined with additional SC interventions.
j
j
VOL. 11 NO. 1 2015 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 43
Create supportive environments The socio-ecological approach to health implies that it is easier to make healthy choices when one’s living environment is conducive to good health. Prisons troubled by over-crowding, poor sanitation, and poor air quality do not make for a supportive environment. The literature shows that non-smoking prisoners, or those wishing to quit, are often housed with smokers and are unwillingly exposed to SHS. The presence of SHS has been associated with increased nicotine dependence and lower intention to quit (Okoli et al., 2008). The provision of smoke-free accommodation for those prisoners who request it is desirable. This has proven difficult to implement, as the frequent transfer of prisoners, variations in security classification and other cultural and custodial factors must be prioritised ahead of smoking status when accommodation is determined (Etter et al., 2012). Where feasible, however, HCP should advocate for smoke-free accommodation to be available at the prisoner’s request. Strengthen community action Community development theory purports that a community requires insight into their own problems and involvement in solutions in order to initiate and sustain social change (Keleher, 2007). The challenge is that the philosophies which underpin health promotion – empowerment, autonomy and personal choice – are adversarial to the prison regime, which is based on a framework of security, control and disempowerment (Whitehead, 2006). Correctional HCP are often faced with dual and conflicting priorities when planning health care while functioning within the confines of a secure environment. One potential strategy is the development of peer-based SC programmes for prisoners. It is theorised that prisoners may identify more with fellow offenders than with a health professional, which may enhance their learning and uptake of desirable behaviours (Devilly et al., 2005). Peer-led intervention may be a cost-effective and human-resource-efficient response to under-staffing and under-resourcing of prison health education (Wright et al., 2011). Potentially, HCP could train appropriately chosen prisoners to act as “quit champions”, which would promote community involvement in the SC process. Further research into the feasibility of peer-led SC programmes in the correctional environment is recommended. Develop personal skills The development of personal skills would involve helping prisoners cultivate the intrinsic motivation and resilience necessary to successfully quit smoking. Psycho-social factors impacting on smoking behaviour include social isolation, stress, boredom, perceived loss of control and depression (Harwood et al., 2007), all of which are reasons given by prisoners for continuing to smoke, or for failing to quit (Richmond et al., 2009) Strategies to address these factors need to be incorporated into any SC teachings provided to prisoners. Four studies mentioned health and fitness as either a reason for quitting or a means of coping with the SC process. Men often exercise more in prison than they do in the community, as a diversion from the stress of prison life and an opportunity to socialise (Condon et al., 2008). Education about the impact of smoking on fitness, and the benefits of regular exercise, may help prisoners decide to quit and do so successfully. Fitness should be advocated to prisoners as a means of boosting self-esteem, relieving depression and creating social networks in the absence of smoking. Reorient health services There is no consensus in the literature as to which professional group, if any, should be primarily responsible for the delivery of SC programmes in prisons. However, as nurses comprise the single largest group of health care professionals working in corrections (Maroney, 2005), they are arguably the profession most likely to meet the human resource demands for such a service. SC programmes are more effective when delivered by a health professional trained specifically for that purpose (Rice and Stead, 2008). However, the role of
j
j
PAGE 44 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
the correctional nurse is poorly defined and often unrecognised outside of the prison system (Parrish, 2001; White and Larsson, 2012). In many countries there are no formal qualifications available in correctional nursing, despite the view that caring for prisoners requires specialised knowledge and skills not readily available in other health care settings (Haley et al., 2009). For the successful reorientation of prison health services, collaborative relationships are required between public health, tertiary education and corrective services providers to develop specialist courses in correctional nursing; with an SC component as part of the curriculum.
Limitations This literature review contains certain limitations. Due to the paucity of relevant research, the analysis does not account for differences between maximum- or minimum-security prisons, or prisoners serving longer or shorter sentences. Results cannot be generalised to other forms of detention such as police custody or immigration detention centres; and for reasons already given, female prisoner studies were excluded. Studies were not appraised for quality and several were methodologically flawed; although we suggest that research into this topic is limited to the extent that exclusion on the basis of quality would make any further exploration of the question untenable. Due to the combination of qualitative and quantitative literature, this analysis was presented in a narrative rather than meta-analytical format and may be subject to interpretation.
Conclusion This literature review identifies that SC interventions can be successfully implemented in prison settings provided that the underlying policies are clear and consistent. We recommend the following be considered in future evaluations of prison tobacco policy and health practice. First, that smoking bans alone have little impact on smoking behaviour and must be accompanied by other SC interventions. Second, that where possible, prisoners are accommodated according to smoking status. Third, that support be given to further research into the feasibility of peer-led SC programmes for prisoners. Fourth, that formal exercise and fitness programmes for prisoners be considered as a means of enhancing SC interventions. Finally, that correctional health providers partner with tertiary education services to develop specialist training for correctional HCP, particularly the nursing profession. While worldwide tobacco smoking prevalence appears to be decreasing, it remains a significant concern for people in custody. The current level of evidence is scant and further research is needed to determine the best approaches for SC in the prisoner population. Due to the strong “pro-smoking” culture in prisons, a health-promotion approach is necessary to address this issue at a population level.
References Australian Institute of Health and Welfare (2010), The Health of Australia’s Prisoners 2010 (Cat No PHE 149), Australian Institute of Health and Welfare, Canberra. Awofeso, N. (2003), “Implementing smoking cessation programmes in prison settings”, Addiction Research & Theory, Vol. 11 No. 2, pp. 119-30. Bryant, J., Bonevski, B., Paul, C., McElduff, P. and Attia, J. (2011), “A systematic review and meta-analysis of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups”, Addiction, Vol. 106 No. 9, pp. 1568-85. Chang, C., Huang, C. and Chen, C. (2010), “The impact of implementing smoking bans among incarcerated substance users: a qualitative study”, Evaluation and the Health Professions, Vol. 33 No. 4, pp. 473-9. Chavez, R., Oto-Kent, D., Porter, J., Brown, K., Quirk, L. and Lewis, S. (2005), Tobacco Policy, Cessation and Education in Correctional Centres, National Commission on Correctional Health Care and National Network on Tobacco Prevention and Poverty, Chicago, IL.
j
j
VOL. 11 NO. 1 2015 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 45
Condon, L., Hek, G. and Harris, F. (2008), “Choosing health in prison: prisoners’ views on making healthy choices in English prisons”, Health Education Journal, Vol. 67 No. 3, pp. 155-66. Cropsey, K. and Kristeller, J. (2005), “The effects of a prison smoking ban on smoking behavior and withdrawal symptoms”, Addictive Behaviors, Vol. 30 No. 3, pp. 589-94. De Viggiani, N. (2006), “A new approach to prison public health? Challenging and advancing the agenda for prison health”, Critical Public Health, Vol. 16 No. 4, pp. 307-16. Devilly, G., Sorbello, L., Eccleston, L. and Ward, T. (2005), “Prison-based peer-education schemes”, Aggression and Violent Behavior: A Review Journal, Vol. 10 No. 2, pp. 219-40. Eadie, D., MacAskill, S., McKell, J. and Baybutt, M. (2012), “Barriers and facilitators to a criminal justice tobacco control coordinator: an innovative approach to supporting smoking cessation among offenders”, Addiction (Abingdon, England), Vol. 107 No. S2, pp. 26-38. Eldridge, G. and Cropsey, K. (2009), “Smoking bans and restrictions in US prisons and jails: consequences for incarcerated women”, American Journal of Preventive Medicine, Vol. 37 No. S2, p. S179. Etter, J., Ritter, C., Christie, D., Kunz, M., Rieder, J., Humair, J., Wollf, H., Eytan, A., Wahl, C., and Elger B. (2012), “Implementation and impact of anti-smoking interventions in three prisons in the absence of appropriate legislation”, Preventive Medicine, Vol. 55 No. 5, pp. 475-81. Gies, C., Buchman, D., Robinson, J. and Smolen, D. (2008), “Effect of an inpatient nurse-directed smoking cessation program”, Western Journal of Nursing Research, Vol. 30 No. 1, pp. 6-19. Haley, H., Ferguson, W., Brewer, A. and Hale, J. (2009), “Correctional health curriculum enhancement through focus groups”, Teaching and Learning in Medicine, Vol. 21 No. 4, pp. 310-7. Harwood, G., Salsberry, P., Ferketich, A. and Wewers, M. (2007), “Cigarette smoking, socioeconomic status, and psychosocial factors: examining a conceptual framework”, Public Health Nursing, Vol. 24 No. 4, pp. 361-71. Jenkins, L. (2002), “Quitting in prison: a pilot study in Worcestershire”, Practice Nurse, Vol. 23, p. 11. Kauffman, R., Ferketich, A., Murray, D., Bellair, P. and Wewers, M. (2011), “Tobacco use by male prisoners under an indoor smoking ban”, Nicotine & Tobacco Research, Vol. 13 No. 6, p. 449. Keleher, H. (2007), “Community development in health”, in St John, W. and Keleher, H. (Eds), Community Nursing Practice: Theory, Skills and Issues, Allen & Unwin, Crows Nest, p. 171. McCarthy, M. and Brewster, J. (2009), “Evaluation of the ‘Quitters are Winners’ course: a prison-based cessation program, 2002-2007”, available at: www.cancervic.org.au/about-our-research/behavioural/ research-papers/rps38_evaluation_of_prisons_co.html (accessed 13 May 2013). Makris, E., Gourgoulianis, K. and Hatzoglou, C. (2012), “Prisoners and cigarettes or ‘imprisoned in cigarettes’? What helps prisoners quit smoking?”, BMC Public Health, Vol. 12 No. 1, p. 508. Maroney, M. (2005), “Caring and custody: two faces of the same reality”, Journal of Correctional Health Care, Vol. 11 No. 2, pp. 157-69. Mercer, S., Green, L. and Nathan, R. (2001), “The health of health promotion in public policy: drawing inspiration from the tobacco control movement”, Health Promotion Journal of Australia, Vol. 12 No. 2, pp. 110-6. Meysman, M., Boudrez, H., Nackaerts, K., Dieriks, B., Indemans, R. and Vermeire, P. (2010), “Smoking cessation rates after a nurse-led inpatient smoking cessation intervention”, Journal of Smoking Cessation, Vol. 5 No. 1, pp. 69-76. Naylor, B. (2013), “Smoking in prisons: whose rights?”, available at: http://rightnow.org.au/topics/prisonersrights/smoking-in-prisons/ (accessed 23 October 2013). Ng, M., Freeman, M., Fleming, T., Robinson, M., Dwyer-Lindgren, L., Thomson, B., Wollum, A., Sanman, E., Wulf, S., Lopez, A., Murray, C., and Gakidou, E. (2014), “Smoking prevalence and cigarette consumption in 187 countries, 1980-2012”, JAMA, Vol. 311 No. 2, pp. 183-92. Okoli, C., Browning, S., Rayens, M. and Hahn, E. (2008), “Secondhand tobacco smoke exposure, nicotine dependence, and smoking cessation”, Public Health Nursing, Vol. 25 No. 1, pp. 46-56. Parrish, A. (2001), “Prison health care: who needs a nurse?”, Nursing Management, Vol. 8 No. 8, p. 6.
j
j
PAGE 46 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
Patterson, E. (2007), “Health promotion”, in St John, W. and Keleher, H. (Eds), Community Nursing Practice: Theory, Skills and Issues, Allen & Unwin, Crows Nest, p. 144. Rice, V. and Stead, L. (2008), “Nursing interventions for smoking cessation”, Cochrane Databse of Systematic Reviews, No. 5, p. CD00118874. Richmond, R., Butler, T., Belcher, J., Wodak, A., Wilhelm, K. and Baxter, E. (2006), “Promoting smoking cessation among prisoners: feasibility of a multi-component intervention”, Australian and New Zealand Journal of Public Health, Vol. 30 No. 5, pp. 474-8. Richmond, R., Butler, T., Indig, D., Wilhelm, K., Archer, V. and Wodak, A. (2012), “The challenges of reducing tobacco use among prisoners”, Drug and Alcohol Review, Vol. 31 No. 5, pp. 625-30. Richmond, R., Butler, T., Wilhelm, K., Wodak, A., Cunningham, M. and Anderson, I. (2009), “Tobacco in prisons: a focus group study”, Tobacco Control, Vol. 18 No. 3, pp. 176-82. Richmond, R., Indig, D., Butler, T., Wilhelm, K., Archer, V. and Wodak, A. (2013), “A randomised controlled trial of a smoking cessation intervention conducted among prisoners”, Addiction, Vol. 108 No. 5, pp. 966-74. Ritter, C., Sto¨ver, H., Levy, M., Etter, J. and Elger, B. (2011), “Smoking in prisons: the need for effective and acceptable interventions”, Journal of Public Health Policy, Vol. 32 No. 1, pp. 32-45. Sieminska, A., Jassem, E. and Konopa, K. (2006), “Prisoners’ attitudes towards cigarette smoking and smoking cessation: a questionnaire study in Poland”, BMC Public Health, Vol. 6 No. 1, p. 181. Thibodeau, L., Seal, D., Jorenby, D., Corcoran, K. and Sosman, J. (2012), “Perceptions and influences of a state prison smoking ban”, Journal of Correctional Health Care, Vol. 18 No. 4, pp. 293-301. Tonnesen, P., Mikkelsen, K. and Bremann, L. (2006), “Nurse-conducted smoking cessation in patients with COPD using nicotine sublingual tablets and behavioral support”, Chest, Vol. 130 No. 2, pp. 334-42. Walmsley, R. (2013), “Variation and growth in the levels of female imprisonment”, available at: www.prisonstudies.org/news/female-imprisonment (accessed 19 July 2014). White, A. and Larsson, L. (2012), “Exploring scope of practice issues for correctional facility nurses in Montana”, Journal of Correctional Health Care, Vol. 18 No. 1, pp. 70-6. Whitehead, D. (2006), “The health promoting prison (HPP) and its imperative for nursing”, International Journal of Nursing Studies, Vol. 43 No. 1, pp. 123-31. WHO (2007), “Health in prisons: a WHO guide to the essentials in prison health”, available at: www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174.pdf (accessed 12 May 2013). WHO (2011), WHO Report on the Global Tobacco Epidemic 2011, World Health Organisation, Geneva. Wright, N., Bleakley, A., Butt, C., Chadwick, O., Mahmood, K., Patel, K. and Salhi, A. (2011), “Peer health promotion in prisons: a systematic review”, International Journal of Prisoner Health, Vol. 7 No. 4, pp. 37-51. Wu, P., Wilson, K., Dimoulas, P. and Mills, E. (2006), “Effectiveness of smoking cessation therapies: a systematic review and meta-analysis”, BMC Public Health, Vol. 6 No. 1, p. 300. Zwar, N., Richmond, R., Forlonge, G. and Hasan, I. (2011), “Feasibility and effectiveness of nurse-delivered smoking cessation counselling combined with nicotine replacement in Australian general practice”, Drug and Alcohol Review, Vol. 30 No. 6, pp. 583-8. Zwar, N., Richmond, R., Borland, R., Peters, M., Litt, J., Bell, J., Ferretter, I. and Caldwell, B. (2011), Supporting Smoking Cessation: A Guide for Health Professionals, The Royal Australian College of General Practitioners, Melbourne, available at: www.racgp.org.au/download/documents/Guidelines/smokingcessation.pdf (accessed 9 May 2013).
About the authors Ashleigh Djachenko, RN, BN, G. Cert C Primary H Care is a Student and Honours Candidate at the Griffith University. She is the Nurse Educator for Prison Health Services, West Moreton Hospital & Health Service, Queensland. Ashleigh Djachenko is the corresponding author and can be contacted at: [email protected]
j
j
VOL. 11 NO. 1 2015 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 47
Dr Winsome St John, RN, RM, MCHN, BAppSc, GDipEd(HIE), MNS, PhD, FRNCA, is an Associate Professor at the Griffith University, Queensland. Her research expertise includes community health practice, community health, primary health care, health education, family, maternal and child health, fatherhood and continence care provision in the community. Creina Mitchell, DipAppSc(Ng), BAppSc(Ad Ng), GradDipComp, MPH, RN, RM, MCHN, MACN is a Lecturer at the Griffith University, Queenland. Her research expertise includes maternal and child health, community health, randomised trials, quantitative research and survey methods.
For instructions on how to order reprints of this article, please visit our website: www.emeraldgrouppublishing.com/licensing/reprints.htm Or contact us for further details: [email protected]
j
j
PAGE 48 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
Copyright of International Journal of Prisoner Health is the property of Emerald Group Publishing Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Ashleigh Djachenko is an Honours Candidate, based at School of Nursing & Midwifery, Griffith University, Gold Coast, Australia. Dr Winsome St John is an Associate Professor and Creina Mitchell is a Lecturer, both are based at School of Nursing & Midwifery/Griffith Health Institute, Griffith University, Gold Coast, Australia.
Abstract 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. Keywords Offender health, Prisoners, Tobacco, Health promotion, Correctional health, Smoking Paper type Literature review
Background One of the most significant contemporary public health issues is that of tobacco smoking and the consequential burden of smoking-related illness. The links between smoking and poor health outcomes have been well-documented. The deaths of nearly six million people each year are attributed to smoking, making it the most significant behavioural risk factor for premature death (WHO, 2011). Between 1980 and 2012, the global prevalence of daily tobacco smoking has declined by an estimated 25 per cent for men and 42 per cent for women (Ng et al., 2014). This decline has been partly attributed to increased tobacco control measures as well as changing societal attitudes and a decreasing tolerance for cigarette smoking in the community. However, smoking rates remain high in certain groups such as people of lower socio-economic status, those with substance abuse problems, mental health clients and indigenous peoples (Zwar et al., 2011).
DOI 10.1108/IJPH-10-2014-0035
VOL. 11 NO. 1 2015, pp. 39-48, C Emerald Group Publishing Limited, ISSN 1744-9200
j INTERNATIONAL JOURNAL OF PRISONER HEALTH j PAGE 39
Prison populations, within which all the above groups are over-represented, have been identified as a priority group for strategies to promote smoking cessation (SC) (WHO, 2007). Prior to the emergence of the primary health care movement, prison health services were typically provided by custodial authorities as opposed to health agencies. Health care services were designed to respond to acute illness and failed to address the broader determinants that led to poorer health for prisoners in the first place (De Viggiani, 2006). The WHO Healthy Prisons movement emerged in the early 1990s and identified tobacco consumption as a significant contributor to poor prisoner health (WHO, 2007). Smoking prevalence has been reported at 70 per cent in US prisons (Chavez et al., 2005), 78 per cent in the Scottish Prison Service survey (Ritter et al., 2011) and as high as 83 per cent in Australian prisons (Australian Institute of Health and Welfare, 2010). Unlike the wider community, where effective social marketing and policy development has begun to diminish the social desirability of smoking, cigarettes remain entrenched in prison culture and are used as currency, to alleviate boredom and stress, and as a social lubricant (Richmond et al., 2012). Also, many key components of quitting strategies are inaccessible to prisoners, such as diversionary activities and social support. SC interventions need to be specifically tailored to this unique population. Prisons around the world are increasingly introducing tobacco bans, ranging from total bans on tobacco and related products, to partial bans restricting smoking to prisoners’ cells or dedicated smoking areas. Total bans have been implemented in prisons in Canada, Australia and New Zealand, and all US federal prisons (Ritter et al., 2011). Most European prisons have indoor smoking bans as do US state prisons. It has been argued that the drive for smoking bans in prisons comes primarily from fear of litigation from non-smoking staff and prisoners (Naylor, 2013). However, the World Health Organisation (WHO, 2011) advocates the imperative for protecting persons from exposure to environmental tobacco smoke in public areas, including those that are both homes and workplaces (such as prisons and nursing homes). Whatever the motivation, reducing smoking in the prison environment has become a priority for public health authorities worldwide. The role of the HCP with regard to SC interventions has been described in the literature. A 2009 Cochrane review of 42 studies found that nursing interventions significantly increase the likelihood of quitting, with a stronger effect found when interventions are provided by HCP whose primary role is in health promotion or SC (Rice and Stead, 2008). However, interventions were limited to counselling or advice-based strategies and patients receiving nicotine replacement therapy (NRT) were excluded from the analysis. The effect of HCP interventions in combination with NRT or pharmacological agents has been studied in population groups such as hospital inpatients (Gies et al., 2008; Meysman et al., 2010), general practice (Zwar et al., 2011), and patients with COPD (Tonnesen et al., 2006). However, to our knowledge, there are no studies which examine HCP approaches to SC for prisoners. We conducted a literature review to examine what is currently known about SC in prisons, with the aim of informing the health care professions and identifying implications for correctional health practice, education and research. Findings will be discussed with reference to the Ottawa Charter for Health Promotion and its application to the custodial environment.
Search strategy Databases PubMed, CINAHL and MEDLINE were searched for English language studies from 1990 to 2012. Foreign language papers were accepted if translated into English. We searched MeSH terms “smoking cessation”, “tobacco”, “nicotine” and “cigarette smoking” combined with “prison”, “prisoner”, “correctional” and descriptor terms “nursing” or “health promotion”. A Google search was also performed to identify “gray literature” such as conference proceedings and government reports. For this review, papers focusing on female prisoners were excluded. Females comprise less than 7 per cent of the global prison population (Walmsley, 2013) and it is recognised the barriers and motivations for smoking among female prisoners are unique (Eldridge and Cropsey, 2009) and arguably would be best represented in an analysis separate to the male majority. Prevalence studies which did not address the issue of SC were excluded. Studies focused on environmental
j
j
PAGE 40 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
issues such as air quality or policy issues such as the ethics of smoking ban enforcement were excluded, as were studies concerned with SC training and education for staff. A 2011 meta-analysis of SC in disadvantaged groups (Bryant et al., 2011) was excluded as it featured only one study of female prisoners. One study examined the role of a tobacco control coordinator in the criminal justice system (Eadie et al., 2012) – this was excluded as it was primarily an examination of the coordinator role and not of smoking cessation itself. Studies of released (former) prisoners were excluded, as the primary scope of this review is to inform practice and policy for people in custody. In total, 12 studies were identified which addressed SC in the male prisoner population (Table I). Four of these were from Australia, three from the USA and one each from Taiwan, Greece, Poland, Switzerland and the UK. Of these, four studies examined the effects of a partial or total smoking ban on smoking behaviour and SC (Chang et al., 2010; Cropsey and Kristeller, 2005; Kauffman et al., 2011; Thibodeau et al., 2012). The remaining studies looked at various combinations of NRT, pharmacological intervention, counselling and cognitive behavioural therapy (CBT).
Findings Review of the studies revealed that forced abstinence (a total or partial smoking ban) had little impact on SC among prisoners. The percentage of prisoners continuing to smoke in banned areas ranged from around 24 (Thibodeau et al., 2012) to 76 per cent (Cropsey and Kristeller, 2005). In a prison with an indoor smoking ban, 51 per cent of prisoners reported smoking indoors (Kauffman et al., 2011). A qualitative Taiwan study identified that prisoners were willing to engage in black-market activity and pay inflated prices in order to continue smoking (Chang et al., 2010). Three studies (Etter et al., 2012; Makris et al., 2012; Richmond et al., 2009) identified that the co-habitation of non-smoking and smoking prisoners contributed to exposure to second-hand smoke (SHS) and to difficulties quitting. A recurring theme identified in this review was that local and national tobacco policies impacted on prisoners’ perceptions of smoking and forced abstinence. The Switzerland study (Etter et al., 2012) compared the effect of varying SC activities at three different prisons. Some extended non-smoking areas, one offered NRT for free and one offered NRT for purchase. It found a reduction in exposure to SHS and improved access to medical assistance to quit, but no reduction in quit attempts or smoking status. This study noted that inconsistent anti-smoking policies led to haphazard and generally poor implementation of SC initiatives. In Taiwan, the government’s dual role as managers of the tobacco industry and as anti-tobacco advocates was widely derided by prisoners as hypocritical (Chang et al., 2010). Two Australian studies by the same lead author examined various combinations of pharmacology, NRT and behavioural techniques (Richmond et al., 2006, 2012). The first was an uncontrolled study combining a pharmacological agent (buproprion) with NRT and CBT which achieved quit rates of 26 per cent at seven days and 22 per cent at six months. The second was the only randomised-controlled trial identified for this review. It compared the addition of the antidepressant nortryptiline to NRT and CBT against a control group receiving NRT and CBT alone. It found no significant difference between the two groups but reported quit rates of up to 23 per cent at three months and nearly 12 per cent at 12 months. A five-year review of an Australian prison-based SC programme (McCarthy and Brewster, 2009) achieved quit rates of 25 per cent at one month and 14 per cent at three months among prisoners receiving NRT and group education. However, this programme suffered a large loss to follow-up and on an intention-to-treat analysis the quit rates were 13 and 7 per cent, respectively. The highest reported quit rates were nearly 31 per cent at three months and 20 per cent at 12 months in a Greek prison with a dedicated SC Centre. Participants received a pharmacological agent (varenicline) with counselling (Makris et al., 2012). The relatively small study (n ¼ 114) was non-randomised and non-controlled; but viewed in light of the fact that
j
j
VOL. 11 NO. 1 2015 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 41
Table I Studies of smoking cessation in male prisoners Authors/year
Setting, sample, design
Findings applied to strategies for health promotion
Chang et al. (2010)
Qualitative focus group study of male prisoners in Taiwan under a total smoking ban n ¼ 77 Quantitative survey of male prisoners in USA under a total smoking ban n ¼ 188 Before-after intervention questionnaire of males in three Swiss prisons n ¼ 417 Pilot study of a quit programme for prisoners and staff in UK n ¼ 10
Build healthy public policy Forced abstinence has limited impact on cessation and is seen as hypocritical due to government taxation on cigarettes. Smoking bans must be accompanied by SC interventions Build healthy public policy Create supportive environments 76% continued to smoke. Smoking ban not properly enforced and may reflect low support of policy by staff Build healthy public policy Reorient health services Results varied between prisons due to variation in interventions. SC programmes require a systematic approach Reorient health services Develop personal skills Uncontrolled pilot study. Recommends SC programmes delivered by trained staff and potential for peer-led SC programmes Create supportive environments Indoor bans do not promote SC although may decrease the total number of cigarettes smoked
Cropsey and Kristeller (2005)
Etter et al. (2012)
Jenkins (2002)
Kauffman et al. (2011)
Makris et al. (2012)
Quantitative survey of male prisoners in USA under an indoor smoking ban n ¼ 200 Quantitative survey of male prisoners attending a Smoking Cessation Centre in Greece n ¼ 114
McCarthy and Brewster (2009)
Quantitative evaluation of prisonbased SC programme in Australia n ¼ 352
Richmond et al. (2006)
Quantitative pilot/feasibility study of multi-component intervention for male prisoners in Australia n ¼ 30 Qualitative focus group study of the impact of tobacco and the prison environment on male and female prisoners and ex-prisoners in Australia n ¼ 40 (28 male, 12 female)
Richmond et al. (2009).
Richmond et al. (2013)
Sieminska et al. (2006)
Thibodeau et al. (2012)
j
RCT of male prisoners in Australia: whether adding nortryptiline to CBT and NRT improves quitting rates n ¼ 425 Quantitative survey of male prisoners in Poland n ¼ 907 (current smokers n ¼ 736)
Qualitative interviews with male prisoners in USA under a total smoking ban n ¼ 49
j
PAGE 42 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
Build healthy public policy Create supportive environments Reorient health services A well-structured smoking cessation programme can help promote quitting. Segregation of smoking and non-smoking prisoners is recommended Strengthen community action Develop personal skills Reorient health services Recommends evaluation of peer-led SC programmes, teleconferencing and greater SC support in prisons Build healthy public policy Reorient health services Specialised smoking cessation interventions can be effective in prisons Build healthy public policy Strengthen community action Develop personal skills Reorient health services Recommends improved access to pharmacotherapies, a free telephone helpline, more non-smoking areas, more physical activity and continued SC help after release Reorient health services Addition of nortryptiline does not improve quitting rates. Quit rates were similar to the wider community. Recommends further research into SC interventions in prisons Develop personal skills Reorient health services Intrinsic motivation necessary for cessation. Prisoners suggest rewards system (40%), NRT (24%), individual counselling (21%), pharmacology (21%) and group counselling (19%) as potentially effective Strengthen community action Develop personal skills Contraband smokers (n ¼ 12) continued out of a sense of rebellion and exercising personal choice. Interventions should focus on providing a sense of control and a perception of choice
nearly 75 per cent of the prison’s inmates attempted to quit, compared with 23 per cent prior to the opening of the SC Clinic, holds promise for further research. One pilot study reported a 50 per cent quit rate at six weeks in prisoners using NRT and weekly group sessions (Jenkins, 2002), however this was a tiny study of just eight prisoners, included here only because it was the sole report of interventions delivered exclusively by nurses. In a study of Polish correctional centres, in which no SC interventions were provided, only 2 per cent of smokers successfully quit during their incarceration (Sieminska et al., 2006). These prisoners felt a rewards system and/or NRT would be the most helpful strategies. Details about which health professions delivered these interventions were not always clear. Some studies named “doctor”, “nurse” or “counsellor” as the provider, others named “clinic staff” and some involved external quit smoking educators or trained prison officers. No robust studies were identified which specifically examined the role of the HCP in promoting SC among prisoners. Several studies noted that the delivery of SC programmes was inconsistent due to under-resourcing or understaffing and that SC outcomes received lower priority than issues deemed more “important” such as drug misuse, infection control and mental health. Several studies identified that despite the high prevalence of smoking, prisoners hold paradoxically strong views about health and fitness. Makris et al. (2012) and Sieminska et al. (2006) found that health reasons were the primary reason given for wanting to quit, while Thibodeau et al. (2012) and Richmond et al. (2009) found that prisoners attempting to quit often turned to training and fitness as an alternative pastime. All 12 studies described the promotion of SC in the prison environment as unique and challenging. A central theme was the identification of a “pro-smoking” culture in prison and the entrenched role of tobacco in prison society.
Discussion The key findings from this review indicate that certain SC interventions can be successfully implemented in a prison setting. Various combinations of counselling, NRT and pharmacology have demonstrated quit rates comparable to those achieved in the wider community (Wu et al., 2006). Forced abstinence, such as a partial or total smoking ban, does not result in sustained cessation. All the reviewed studies identified the “pro-smoking” culture in prison as a significant contributor to smoking behaviour. SC strategies for prisoners must therefore move beyond individual approaches to address the broader determinants of health from a population perspective. The Ottawa Charter for Health Promotion outlines five major strategies: build healthy public policy; create supportive environments; strengthen community action; develop personal skills; and reorient health services. Each of these will be discussed in relation to the findings of this review and the implications for health practice. Build healthy public policy Tobacco control has been cited as a successful example of healthy public policy building in the wider community (Patterson, 2007). Warning labels, restrictions on advertising, more public smoke-free areas and increased tax on tobacco products have contributed to a reduction in smoking (Mercer et al., 2001). Unfortunately, the evidence shows these measures are not impacting the prisoner community. Forced abstinence may result in black-market activity and reluctance of prisoners to disclose their smoking status to health care providers, which could adversely impact on their health. While a prison smoking ban may still have desirable outcomes such as healthier air and improved quality of life for non-smokers, as well as protection from potential litigation from those unwillingly exposed to SHS (Awofeso, 2003), as a policy initiative it is not effective as a sole SC strategy. Correctional HCP must advocate for smoking bans to be combined with additional SC interventions.
j
j
VOL. 11 NO. 1 2015 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 43
Create supportive environments The socio-ecological approach to health implies that it is easier to make healthy choices when one’s living environment is conducive to good health. Prisons troubled by over-crowding, poor sanitation, and poor air quality do not make for a supportive environment. The literature shows that non-smoking prisoners, or those wishing to quit, are often housed with smokers and are unwillingly exposed to SHS. The presence of SHS has been associated with increased nicotine dependence and lower intention to quit (Okoli et al., 2008). The provision of smoke-free accommodation for those prisoners who request it is desirable. This has proven difficult to implement, as the frequent transfer of prisoners, variations in security classification and other cultural and custodial factors must be prioritised ahead of smoking status when accommodation is determined (Etter et al., 2012). Where feasible, however, HCP should advocate for smoke-free accommodation to be available at the prisoner’s request. Strengthen community action Community development theory purports that a community requires insight into their own problems and involvement in solutions in order to initiate and sustain social change (Keleher, 2007). The challenge is that the philosophies which underpin health promotion – empowerment, autonomy and personal choice – are adversarial to the prison regime, which is based on a framework of security, control and disempowerment (Whitehead, 2006). Correctional HCP are often faced with dual and conflicting priorities when planning health care while functioning within the confines of a secure environment. One potential strategy is the development of peer-based SC programmes for prisoners. It is theorised that prisoners may identify more with fellow offenders than with a health professional, which may enhance their learning and uptake of desirable behaviours (Devilly et al., 2005). Peer-led intervention may be a cost-effective and human-resource-efficient response to under-staffing and under-resourcing of prison health education (Wright et al., 2011). Potentially, HCP could train appropriately chosen prisoners to act as “quit champions”, which would promote community involvement in the SC process. Further research into the feasibility of peer-led SC programmes in the correctional environment is recommended. Develop personal skills The development of personal skills would involve helping prisoners cultivate the intrinsic motivation and resilience necessary to successfully quit smoking. Psycho-social factors impacting on smoking behaviour include social isolation, stress, boredom, perceived loss of control and depression (Harwood et al., 2007), all of which are reasons given by prisoners for continuing to smoke, or for failing to quit (Richmond et al., 2009) Strategies to address these factors need to be incorporated into any SC teachings provided to prisoners. Four studies mentioned health and fitness as either a reason for quitting or a means of coping with the SC process. Men often exercise more in prison than they do in the community, as a diversion from the stress of prison life and an opportunity to socialise (Condon et al., 2008). Education about the impact of smoking on fitness, and the benefits of regular exercise, may help prisoners decide to quit and do so successfully. Fitness should be advocated to prisoners as a means of boosting self-esteem, relieving depression and creating social networks in the absence of smoking. Reorient health services There is no consensus in the literature as to which professional group, if any, should be primarily responsible for the delivery of SC programmes in prisons. However, as nurses comprise the single largest group of health care professionals working in corrections (Maroney, 2005), they are arguably the profession most likely to meet the human resource demands for such a service. SC programmes are more effective when delivered by a health professional trained specifically for that purpose (Rice and Stead, 2008). However, the role of
j
j
PAGE 44 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
the correctional nurse is poorly defined and often unrecognised outside of the prison system (Parrish, 2001; White and Larsson, 2012). In many countries there are no formal qualifications available in correctional nursing, despite the view that caring for prisoners requires specialised knowledge and skills not readily available in other health care settings (Haley et al., 2009). For the successful reorientation of prison health services, collaborative relationships are required between public health, tertiary education and corrective services providers to develop specialist courses in correctional nursing; with an SC component as part of the curriculum.
Limitations This literature review contains certain limitations. Due to the paucity of relevant research, the analysis does not account for differences between maximum- or minimum-security prisons, or prisoners serving longer or shorter sentences. Results cannot be generalised to other forms of detention such as police custody or immigration detention centres; and for reasons already given, female prisoner studies were excluded. Studies were not appraised for quality and several were methodologically flawed; although we suggest that research into this topic is limited to the extent that exclusion on the basis of quality would make any further exploration of the question untenable. Due to the combination of qualitative and quantitative literature, this analysis was presented in a narrative rather than meta-analytical format and may be subject to interpretation.
Conclusion This literature review identifies that SC interventions can be successfully implemented in prison settings provided that the underlying policies are clear and consistent. We recommend the following be considered in future evaluations of prison tobacco policy and health practice. First, that smoking bans alone have little impact on smoking behaviour and must be accompanied by other SC interventions. Second, that where possible, prisoners are accommodated according to smoking status. Third, that support be given to further research into the feasibility of peer-led SC programmes for prisoners. Fourth, that formal exercise and fitness programmes for prisoners be considered as a means of enhancing SC interventions. Finally, that correctional health providers partner with tertiary education services to develop specialist training for correctional HCP, particularly the nursing profession. While worldwide tobacco smoking prevalence appears to be decreasing, it remains a significant concern for people in custody. The current level of evidence is scant and further research is needed to determine the best approaches for SC in the prisoner population. Due to the strong “pro-smoking” culture in prisons, a health-promotion approach is necessary to address this issue at a population level.
References Australian Institute of Health and Welfare (2010), The Health of Australia’s Prisoners 2010 (Cat No PHE 149), Australian Institute of Health and Welfare, Canberra. Awofeso, N. (2003), “Implementing smoking cessation programmes in prison settings”, Addiction Research & Theory, Vol. 11 No. 2, pp. 119-30. Bryant, J., Bonevski, B., Paul, C., McElduff, P. and Attia, J. (2011), “A systematic review and meta-analysis of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups”, Addiction, Vol. 106 No. 9, pp. 1568-85. Chang, C., Huang, C. and Chen, C. (2010), “The impact of implementing smoking bans among incarcerated substance users: a qualitative study”, Evaluation and the Health Professions, Vol. 33 No. 4, pp. 473-9. Chavez, R., Oto-Kent, D., Porter, J., Brown, K., Quirk, L. and Lewis, S. (2005), Tobacco Policy, Cessation and Education in Correctional Centres, National Commission on Correctional Health Care and National Network on Tobacco Prevention and Poverty, Chicago, IL.
j
j
VOL. 11 NO. 1 2015 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 45
Condon, L., Hek, G. and Harris, F. (2008), “Choosing health in prison: prisoners’ views on making healthy choices in English prisons”, Health Education Journal, Vol. 67 No. 3, pp. 155-66. Cropsey, K. and Kristeller, J. (2005), “The effects of a prison smoking ban on smoking behavior and withdrawal symptoms”, Addictive Behaviors, Vol. 30 No. 3, pp. 589-94. De Viggiani, N. (2006), “A new approach to prison public health? Challenging and advancing the agenda for prison health”, Critical Public Health, Vol. 16 No. 4, pp. 307-16. Devilly, G., Sorbello, L., Eccleston, L. and Ward, T. (2005), “Prison-based peer-education schemes”, Aggression and Violent Behavior: A Review Journal, Vol. 10 No. 2, pp. 219-40. Eadie, D., MacAskill, S., McKell, J. and Baybutt, M. (2012), “Barriers and facilitators to a criminal justice tobacco control coordinator: an innovative approach to supporting smoking cessation among offenders”, Addiction (Abingdon, England), Vol. 107 No. S2, pp. 26-38. Eldridge, G. and Cropsey, K. (2009), “Smoking bans and restrictions in US prisons and jails: consequences for incarcerated women”, American Journal of Preventive Medicine, Vol. 37 No. S2, p. S179. Etter, J., Ritter, C., Christie, D., Kunz, M., Rieder, J., Humair, J., Wollf, H., Eytan, A., Wahl, C., and Elger B. (2012), “Implementation and impact of anti-smoking interventions in three prisons in the absence of appropriate legislation”, Preventive Medicine, Vol. 55 No. 5, pp. 475-81. Gies, C., Buchman, D., Robinson, J. and Smolen, D. (2008), “Effect of an inpatient nurse-directed smoking cessation program”, Western Journal of Nursing Research, Vol. 30 No. 1, pp. 6-19. Haley, H., Ferguson, W., Brewer, A. and Hale, J. (2009), “Correctional health curriculum enhancement through focus groups”, Teaching and Learning in Medicine, Vol. 21 No. 4, pp. 310-7. Harwood, G., Salsberry, P., Ferketich, A. and Wewers, M. (2007), “Cigarette smoking, socioeconomic status, and psychosocial factors: examining a conceptual framework”, Public Health Nursing, Vol. 24 No. 4, pp. 361-71. Jenkins, L. (2002), “Quitting in prison: a pilot study in Worcestershire”, Practice Nurse, Vol. 23, p. 11. Kauffman, R., Ferketich, A., Murray, D., Bellair, P. and Wewers, M. (2011), “Tobacco use by male prisoners under an indoor smoking ban”, Nicotine & Tobacco Research, Vol. 13 No. 6, p. 449. Keleher, H. (2007), “Community development in health”, in St John, W. and Keleher, H. (Eds), Community Nursing Practice: Theory, Skills and Issues, Allen & Unwin, Crows Nest, p. 171. McCarthy, M. and Brewster, J. (2009), “Evaluation of the ‘Quitters are Winners’ course: a prison-based cessation program, 2002-2007”, available at: www.cancervic.org.au/about-our-research/behavioural/ research-papers/rps38_evaluation_of_prisons_co.html (accessed 13 May 2013). Makris, E., Gourgoulianis, K. and Hatzoglou, C. (2012), “Prisoners and cigarettes or ‘imprisoned in cigarettes’? What helps prisoners quit smoking?”, BMC Public Health, Vol. 12 No. 1, p. 508. Maroney, M. (2005), “Caring and custody: two faces of the same reality”, Journal of Correctional Health Care, Vol. 11 No. 2, pp. 157-69. Mercer, S., Green, L. and Nathan, R. (2001), “The health of health promotion in public policy: drawing inspiration from the tobacco control movement”, Health Promotion Journal of Australia, Vol. 12 No. 2, pp. 110-6. Meysman, M., Boudrez, H., Nackaerts, K., Dieriks, B., Indemans, R. and Vermeire, P. (2010), “Smoking cessation rates after a nurse-led inpatient smoking cessation intervention”, Journal of Smoking Cessation, Vol. 5 No. 1, pp. 69-76. Naylor, B. (2013), “Smoking in prisons: whose rights?”, available at: http://rightnow.org.au/topics/prisonersrights/smoking-in-prisons/ (accessed 23 October 2013). Ng, M., Freeman, M., Fleming, T., Robinson, M., Dwyer-Lindgren, L., Thomson, B., Wollum, A., Sanman, E., Wulf, S., Lopez, A., Murray, C., and Gakidou, E. (2014), “Smoking prevalence and cigarette consumption in 187 countries, 1980-2012”, JAMA, Vol. 311 No. 2, pp. 183-92. Okoli, C., Browning, S., Rayens, M. and Hahn, E. (2008), “Secondhand tobacco smoke exposure, nicotine dependence, and smoking cessation”, Public Health Nursing, Vol. 25 No. 1, pp. 46-56. Parrish, A. (2001), “Prison health care: who needs a nurse?”, Nursing Management, Vol. 8 No. 8, p. 6.
j
j
PAGE 46 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
Patterson, E. (2007), “Health promotion”, in St John, W. and Keleher, H. (Eds), Community Nursing Practice: Theory, Skills and Issues, Allen & Unwin, Crows Nest, p. 144. Rice, V. and Stead, L. (2008), “Nursing interventions for smoking cessation”, Cochrane Databse of Systematic Reviews, No. 5, p. CD00118874. Richmond, R., Butler, T., Belcher, J., Wodak, A., Wilhelm, K. and Baxter, E. (2006), “Promoting smoking cessation among prisoners: feasibility of a multi-component intervention”, Australian and New Zealand Journal of Public Health, Vol. 30 No. 5, pp. 474-8. Richmond, R., Butler, T., Indig, D., Wilhelm, K., Archer, V. and Wodak, A. (2012), “The challenges of reducing tobacco use among prisoners”, Drug and Alcohol Review, Vol. 31 No. 5, pp. 625-30. Richmond, R., Butler, T., Wilhelm, K., Wodak, A., Cunningham, M. and Anderson, I. (2009), “Tobacco in prisons: a focus group study”, Tobacco Control, Vol. 18 No. 3, pp. 176-82. Richmond, R., Indig, D., Butler, T., Wilhelm, K., Archer, V. and Wodak, A. (2013), “A randomised controlled trial of a smoking cessation intervention conducted among prisoners”, Addiction, Vol. 108 No. 5, pp. 966-74. Ritter, C., Sto¨ver, H., Levy, M., Etter, J. and Elger, B. (2011), “Smoking in prisons: the need for effective and acceptable interventions”, Journal of Public Health Policy, Vol. 32 No. 1, pp. 32-45. Sieminska, A., Jassem, E. and Konopa, K. (2006), “Prisoners’ attitudes towards cigarette smoking and smoking cessation: a questionnaire study in Poland”, BMC Public Health, Vol. 6 No. 1, p. 181. Thibodeau, L., Seal, D., Jorenby, D., Corcoran, K. and Sosman, J. (2012), “Perceptions and influences of a state prison smoking ban”, Journal of Correctional Health Care, Vol. 18 No. 4, pp. 293-301. Tonnesen, P., Mikkelsen, K. and Bremann, L. (2006), “Nurse-conducted smoking cessation in patients with COPD using nicotine sublingual tablets and behavioral support”, Chest, Vol. 130 No. 2, pp. 334-42. Walmsley, R. (2013), “Variation and growth in the levels of female imprisonment”, available at: www.prisonstudies.org/news/female-imprisonment (accessed 19 July 2014). White, A. and Larsson, L. (2012), “Exploring scope of practice issues for correctional facility nurses in Montana”, Journal of Correctional Health Care, Vol. 18 No. 1, pp. 70-6. Whitehead, D. (2006), “The health promoting prison (HPP) and its imperative for nursing”, International Journal of Nursing Studies, Vol. 43 No. 1, pp. 123-31. WHO (2007), “Health in prisons: a WHO guide to the essentials in prison health”, available at: www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174.pdf (accessed 12 May 2013). WHO (2011), WHO Report on the Global Tobacco Epidemic 2011, World Health Organisation, Geneva. Wright, N., Bleakley, A., Butt, C., Chadwick, O., Mahmood, K., Patel, K. and Salhi, A. (2011), “Peer health promotion in prisons: a systematic review”, International Journal of Prisoner Health, Vol. 7 No. 4, pp. 37-51. Wu, P., Wilson, K., Dimoulas, P. and Mills, E. (2006), “Effectiveness of smoking cessation therapies: a systematic review and meta-analysis”, BMC Public Health, Vol. 6 No. 1, p. 300. Zwar, N., Richmond, R., Forlonge, G. and Hasan, I. (2011), “Feasibility and effectiveness of nurse-delivered smoking cessation counselling combined with nicotine replacement in Australian general practice”, Drug and Alcohol Review, Vol. 30 No. 6, pp. 583-8. Zwar, N., Richmond, R., Borland, R., Peters, M., Litt, J., Bell, J., Ferretter, I. and Caldwell, B. (2011), Supporting Smoking Cessation: A Guide for Health Professionals, The Royal Australian College of General Practitioners, Melbourne, available at: www.racgp.org.au/download/documents/Guidelines/smokingcessation.pdf (accessed 9 May 2013).
About the authors Ashleigh Djachenko, RN, BN, G. Cert C Primary H Care is a Student and Honours Candidate at the Griffith University. She is the Nurse Educator for Prison Health Services, West Moreton Hospital & Health Service, Queensland. Ashleigh Djachenko is the corresponding author and can be contacted at: [email protected]
j
j
VOL. 11 NO. 1 2015 INTERNATIONAL JOURNAL OF PRISONER HEALTH PAGE 47
Dr Winsome St John, RN, RM, MCHN, BAppSc, GDipEd(HIE), MNS, PhD, FRNCA, is an Associate Professor at the Griffith University, Queensland. Her research expertise includes community health practice, community health, primary health care, health education, family, maternal and child health, fatherhood and continence care provision in the community. Creina Mitchell, DipAppSc(Ng), BAppSc(Ad Ng), GradDipComp, MPH, RN, RM, MCHN, MACN is a Lecturer at the Griffith University, Queenland. Her research expertise includes maternal and child health, community health, randomised trials, quantitative research and survey methods.
For instructions on how to order reprints of this article, please visit our website: www.emeraldgrouppublishing.com/licensing/reprints.htm Or contact us for further details: [email protected]
j
j
PAGE 48 INTERNATIONAL JOURNAL OF PRISONER HEALTH VOL. 11 NO. 1 2015
Copyright of International Journal of Prisoner Health is the property of Emerald Group Publishing Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
