Implementation and impact of anti-smoking interventions in three prisons in the absence of appropriate legislation☆
Highlights
► In Europe in general, prisoners are not adequately protected against SHS. ► An extension of a smoking ban was feasible in only one of 3 prisons in this study. ► It decreased exposure to SHS and did not cause any serious discipline problems. ► Cohabitation between smokers and non-smokers remained difficult. ► In the absence of legal changes, ad hoc, local policy changes are insufficient.
Introduction
Smoking prevalence is much higher in prisoners than in the general population (Butler et al., 2007, Papadodima et al., 2009, Proescholdbell et al., 2008, Sieminska et al., 2006), particularly because many prisoners are affected by conditions that are correlated with smoking (substance abuse, psychiatric disorders, poor socio-economic background (Butler et al., 2006, Etter et al., 2004). The high smoking prevalence in prisons results in exposure to second-hand smoke (SHS), a recognized carcinogen (Boffetta et al., 1998). Concentrations of SHS may be very high in prison cells (Hammond and Emmons, 2005, Proescholdbell et al., 2008, Ritter et al., 2011) and overcrowding increases this problem, as it results in higher concentrations of smoke. In addition, because of the wide availability of tobacco and the social pressure to smoke in prisons, some non-smoking inmates may start to smoke or relapse to smoking (Belcher et al., 2006, Cropsey et al., 2008, Papadodima et al., 2009).
Smoking bans have been implemented in prisons for several reasons, including health effects, concerns about exposure to SHS, reduction of health care expenditure on prisoners, maintenance and cleaning costs, risk of fires, lower insurance rates, or fear of litigation (Eldridge and Cropsey, 2009, Falkin et al., 1998, Kauffman et al., 2008, Patrick and Marsh, 2001, Vaughn and Del Carmen, 1993). Smoking bans may also elicit smoking cessation among inmates (Cropsey and Kristeller, 2005), although only a minority of prisoners appear to remain abstinent following release from prison (Lincoln et al., 2009, Thibodeau et al., 2010).
By 2007, 87% of U.S. prisons had indoor smoking bans and 60% also banned smoking outdoors (Hammond and Emmons, 2005, Kauffman et al., 2008, Proescholdbell et al., 2008). In Europe, in contrast, even though smoking bans have been implemented in public places, workplaces and hospitals, including psychiatric hospitals (Etter et al., 2008), there are at best partial smoking bans in most prisons and very few prisons, if any, are totally smoke-free (Ritter et al., 2012), particularly because prison cells are considered private places and a right to smoke in privacy has been upheld (Swiss_Confederation, 2010). Reluctance to implement smoking bans in prisons may result from concerns about discipline problems. However, smoking bans in prisons have been relatively well accepted by prisoners and staff and have caused fewer disturbances than expected (Carpenter et al., 2001, Hammond and Emmons, 2005, Lawrence and Welfare, 2008, Skolnick, 1990).
The aims of this study were to assess the situation in three prisons, in order to implement anti-smoking interventions, and to assess the acceptability and impact of these interventions.
Section snippets
Settings
Switzerland has a relatively low prison population rate (81 per 100,000), in international comparison (USA: 714; UK: 142; Australia: 117) (Walmsley, 2007). The study was conducted in three prisons in Switzerland, two in Geneva and one in Berne. The first (prison A) houses 120 male sentenced prisoners in individual cells and has 120 staff members. Most prisoners benefit from an open regime and work outdoors in agriculture or in indoor workshops, and they have freedom of movement within the
Participants
In 2009, 417 participants (prisoners plus staff) responded and 228 in 2011 (Table 1). In prisons A and B, participation rates among prisoners (40-50%) were not significantly different in 2009 and 2011, whereas in prison C participation rates in prisoners were higher in 2009 (23%) than in 2011 (17%, p = 0.01). Staff participation rates in prisons A and B were 40-77%, with no significant change between 2009 and 2011 (Table 1).
In prison A, most prisoners were Swiss citizens and most foreigners had a
Discussion
The originality of this study lies in its comparison of smoking policies in three prisons: an open prison for sentenced prisoners, a closed prison for sentenced prisoners and an overcrowded prison for pretrial detainees. Before the interventions, the rules about smoking differed substantially across these prisons. Interventions that were deemed feasible and were implemented also differed across prisons, ranging from almost no additional action against SHS in prisons B and C to a partial smoking
Conclusions
Partial smoking bans were feasible but were loosely enforced, and medical advice to quit smoking was not implemented systematically. The partial smoking bans did not result in serious discipline problems, but cohabitation of smokers and non-smokers was difficult, conflicts about smoking were frequent, and most prisoners said they should be better protected against SHS. Thus, there is great need for improvement, but this study shows how difficult it is to protect prisoners and staff against SHS,
Conflict of interest
HW and AE are in charge of the medical services at the two prisons in Geneva included in this study. No other competing interests.
Funding
Swiss Federal Office of Public Health (Tobacco Prevention Fund). The funding source did not have any role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; nor in the decision to submit the article for publication.
Acknowledgments
The authors wish to thank the directors of the prisons in the cantons of Berne and Geneva, Switzerland, for their cooperation.
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Declaration of interests: HW and AE are in charge of the medical services at the two prisons in Geneva included in this study. No other competing interests.