Over the past two decades, policy changes have led to increasing prison populations in countries around the globe.1 No country incarcerates more of its residents than the United States. With an incarceration rate of 737/100 000 residents, the United States far surpasses even Russia, the country with the next highest rate at 611/100 000 people.2 Though the practice of mass incarceration may be a source of social problems, it also presents a unique public health opportunity by creating a population of concentrated disadvantage to which health workers have easy access.3 4 As of 2006, more than 2.2 million people are being held in American jails and prisons on any given day.5 The poor and people of colour are over-represented in incarcerated populations and prisoners tend to be less educated and sicker than the general population, with high rates of mental illness and chronic and infectious diseases.4 6 Smoking is one of the behaviours contributing to these health disparities.

Tobacco is a leading cause of death in the United States; each year approximately 438 000 people die prematurely from smoking-related illnesses and exposure to secondhand tobacco smoke.7 Men and women held in prisons are disproportionately affected by tobacco use. Studies in multiple countries have found a high prevalence of smoking in incarcerated populations.8^–10 Among prison and jail inmates in the United States the estimated prevalence ranges from 60–80%, compared with only 21% in the US population as a whole.7 11 An abundance of tobacco users, crowded living quarters and long hours spent indoors combine to create an environment where there may be high levels of smoke exposure for smokers and non-smokers alike. Air samples from a prison with no indoor smoking restrictions showed the concentration of nicotine in one living area to be more than 12 times the average nicotine concentration in a random selection of smokers’ homes.12

Prisoners’ high prevalence of tobacco use can be explained, in part, by the important position tobacco has occupied in prison systems. In many American institutions free tobacco was distributed as a part of prisoner rations, a practice which was still prevalent in the mid-1980s.13 As a durable, replaceable good that is easily divided into natural units, cigarettes have often served as a currency for prisons’ underground economies.14

Surveys of American prison policies over the past two decades show a dramatic shift in the regulation of tobacco.11 13 15 Several factors have been behind a nationwide tightening of jail and prison tobacco policies.16 A growing awareness of the harmful effects of secondhand smoke has raised concerns about prisoner health and led to successful legal challenges by non-smoking prisoners.16 Additional benefits of smoke-free policies included reduced risk of fires, lower maintenance costs and lower insurance rates.16 Despite these advantages there is a continuing debate, even within the tobacco control community, as to whether the benefits of prison tobacco bans will outweigh unintended consequences.17

The last survey of American prison tobacco policies was published more than five years ago, and no survey to date has simultaneously examined tobacco policies and the availability of tobacco cessation programming. The current study provides an updated view of tobacco policy in American prisons and explores the potential impact of these policies on tobacco control efforts.

METHODS

Participants

In the United States the terms jail and prison are used to distinguish two separate types of facilities. Jails, which are the facilities where individuals are held when awaiting trial or for brief sentences (usually less than one year), are maintained at the local level.18 Prisons, those facilities holding individuals sentenced to longer terms, are overseen by departments of correction at the state level.18 To learn about current tobacco policies in American prisons, interviews were conducted with the 52 US departments of correction (50 state departments, the District of Columbia, and the Federal Bureau of Prisons) during the first half of 2007. Though a few states have combined jail and prison systems,5 the current survey focused solely on prison systems.

Initial contact was made by telephone with the chief administrator’s office using contact information obtained from the online directory of the American Correctional Association (http://www.aca.org/research/directory.asp). The interviewer explained the purpose of the study and requested to be connected with the person best equipped to answer questions about the department’s tobacco policies. Respondent roles included policy coordinators, medical staff, prison administrators and public relations officials. When a single person was unable to answer all questions, additional staff were contacted until complete survey data were obtained. The 10-minute to 15-minute interviews were completed over the phone. When requested or required by department policy, a copy of the questions was emailed to the contact so that written answers could be provided.

Survey instrument

The questionnaire was designed to allow comparison with previous surveys of prison tobacco policy,11 13 15 with questions about cessation assistance added to better understand the nature of tobacco control efforts in American prisons. The survey covered prison tobacco policies, the availability of tobacco and prisoner access to tobacco cessation and drug treatment programming.

The respondent was asked to classify the department’s policy as (1) a “total smoking ban”, indicating that no prisoner smoking was allowed anywhere within the facility; (2) “indoor smoking ban”, wherein tobacco use is allowed in specified outdoor areas but not inside of buildings; (3) “specified tobacco-free living areas”, whereby non-smoking inmates may live in separate areas from smokers; or (4) “no smoking policies are currently in place”. Information was also collected on when the policy was put in place and an open-ended question inquired about the reason for the policy’s implementation. The respondent was asked if the department had experienced any serious problems, “like increased violence or riots,” related to the policy, and if so, what kind of problems they were. Unprompted reports of problems other than violence were recorded when given.

Respondents were asked what types of tobacco were available for prisoners within their facilities, and if any tobacco was available to inmates free or at reduced rates. The respondents were also questioned about the types of tobacco cessation aids, if any, that were available to prisoners through institutional commissaries or medical services.

Questions were asked separately about the availability of smoking cessation programming and treatment programming for other drugs. For each category of programming, respondents were asked if such programming was available. If so, they were asked to classify the programmes as individual interventions, group sessions, medical cessation interventions or some other type of programming. They were also asked about entry criteria for these programmes.

This project was reviewed by the institutional review board of The Ohio State University and determined to be exempt research owing to its focus on institutional policies.

RESULTS

Complete responses were received from 51 correctional departments in the United States (49 state departments, the District of Columbia and the Federal Bureau of Prisons; see supplementary table on the Tobacco Control website giving a detailed summary of tobacco policies in US prisons). The one remaining state did not complete the full survey; however basic information on the Department of Correction’s tobacco policy was provided.

Of the 52 correctional departments, 31 (60%) reported that they had a total tobacco ban in place at the time of the survey, 14 (27%) had an indoor tobacco ban and seven (13%) had less restrictive policies in place. Only two of the departments reported having no type of statewide policy in place; one was exploring whether to implement a smoke-free policy in all its prisons while the other reported that attempts to implement a statewide tobacco policy had been blocked by employee unions. Figure 1 shows the geographical distribution of policies by state. Changes in US prison tobacco policy over time are presented in table 1 using data from previous surveys.11 13 15

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Figure 1 Geographical distribution of prison tobacco policies by state.

The 49 correctional departments with a statewide tobacco policy were asked to give the reasons for the policy’s implementation (table 2). The most commonly reported reason was the health and safety of prisoners and employees (69.4%). Other reasons frequently given were complaints and legal challenges to secondhand smoke exposure (36.7%), compliance with legislative action or executive order including one department which banned tobacco products as part of no-frills law that restricted prisoner access to amenities (34.7%), and reducing operating costs (26.5%). Several prisons also reported implementing tobacco policies to reduce contraband problems (10.2%).

No department reported violence or riots associated with their transition to a stricter tobacco policy; however, several departments with total tobacco bans reported that tobacco became the dominant contraband item following ban implementation. Though no specific question was asked about tobacco as contraband, 17 correctional departments explicitly mentioned the topic during the interview.

Nationwide, 27 (53%) of the 51 responding prison systems offered tobacco cessation programmes to their inmates. While most prison systems with an indoor tobacco ban (86%) and half of the systems with less restrictive policies reported having tobacco cessation programmes, few of those with total bans (39%) continued such programmes after the initial transition period. The availability of tobacco cessation aids, such as nicotine replacement therapy, followed a similar pattern. A total of 65% of correctional departments without a total tobacco ban offered cessation aids through their commissaries or medical facilities compared with only 35% of departments with a total ban in place.

DISCUSSION

An examination of prison tobacco policies over the past two decades shows a clear and consistent movement towards increasingly restrictive policies. Regarding tobacco policies, in a 1986 survey of 19 state prison systems, none reported offering prisoners smoke-free living areas.13 By 1993, 24% of state prison systems banned smoking in their dorms or cells, however there were no prisons with total smoking bans.11 A survey conducted in 1996 found that 44 (85%) of the 52 US prison systems had some kind of restriction on tobacco use, including seven systems that completely banned smoking in their facilities.15

The current survey shows a continued tightening of prison tobacco policies nationwide. Since 1996 there has been a more than threefold increase in the number of prison systems with total bans, while the number of departments with any kind of system-wide tobacco restriction has climbed to more than 96%. Recent years have seen the passage of an increasing number of public smoking restrictions for the general population.19 Given growing public support for tobacco restrictions it appears likely that the trend of increased tobacco restrictions in prisons will continue in the near future.

The increase in tobacco restrictions has coincided with a decline in the distribution of free tobacco to prisoners. In 1986, a survey of 19 prison systems found that 53% distributed free tobacco products to inmates.13 A survey of the 50 state prison systems published in 1993 reported that 26% provided free tobacco to indigent inmates and 8% provided free tobacco to all prisoners.11 In the current survey no prison systems reported offering free tobacco to prisoners.

Maintaining order is always the primary concern for prison administrators, and fear of unrest can be a major contributor to policy inertia. Both in the case of ending free tobacco and the current examination of tobacco bans, it appears that fears of violence due to a tightening of policy were unfounded. Previous studies have found no evidence that the tightening of tobacco restrictions resulted in behavioural problems, and no major violent events were reported in the current study by correctional departments implementing full or partial bans.13 15

There has, however, been consistent evidence that tobacco black markets quickly develop in prisons following implementation of a tobacco ban.14 15 With tobacco fetching high prices, this lucrative market may motivate inmate-on-inmate violence over control of tobacco sales.14 Furthermore, tobacco black markets may act as a corrupting force for staff; there is a strong motivation to smuggle when a single tobacco transaction may fetch a week’s pay for a staff member willing to violate prison policy.14 A potential benefit of the situation is that the tobacco market tends to overtake the markets for other products leading to a decrease in other contraband, including illicit drugs, within the prisons.15 Further study of the impact of these black markets on prisoner safety and institutional security is needed.

To date, little has been done to evaluate the impact of extended exposure to prison tobacco restrictions on the long-term smoking behaviours of prisoners following their release; however two studies suggest that forced abstinence during incarceration does not lead to permanent cessation. A post-release survey of 123 individuals held in pretrial detention or serving sentences less than 30 months in a Massachusetts county correctional centre with a smoking ban found that only 37.3% of intake smokers refrained from smoking on their first day of freedom and only 2.4% remained abstinent six months later.20 Respondents to a 2003 survey of prison and jail medical directors estimated that 76% to 100% of prison inmates resumed their tobacco use upon release from a tobacco-free facility.21 Such high rates of relapse following release would be consistent with reports from psychiatric facilities with total tobacco bans.22 The same prison and jail medical directors reported that tobacco cessation programmes are viewed as low priority compared with other addiction and healthcare issues, with 80% of respondents reporting no tobacco cessation programming in their facility.21 Based on the current study, it does not appear that cessation programming has risen in priority during the intervening years. Given the low availability of cessation programmes in prisons with total tobacco bans, it seems likely that prisoner access to such programming may decline in coming years if trends do not change. While there have not been studies on the impact of terminating the already limited cessation assistance provided to prisoners, common sense would suggest that such a move would undermine efforts to achieve long-term cessation among prisoners and those formerly incarcerated.

According to current clinical guidelines, tobacco dependence should be regarded as a chronic disease.23 The average smoker will require multiple quit attempts before long-term cessation is achieved; effective treatment must be continued over an extended period of time rather than regarded as a single, acute event.23 Many prison systems have recognised the importance of treating other chronic conditions, creating clinics targeting specific diseases, and by doing so have reduced grievances and litigation.6 There is strong evidence of the clinical efficacy and cost-effectiveness of tobacco cessation both in the general population and among patients with schizophrenia who, like prisoners, represent a group of high-risk smokers23 24; yet it appears that opportunities to deliver such programmes to prisoners are being overlooked. In doing so, we miss a chance not only to improve prisoner health, but also to reduce the cost of prisoner health care by preventing future cases of heart and lung disease and cancer.

The re-entry movement provides a further impetus to take advantage of this public health opportunity. The vast majority of inmates will not spend the remainder of their life behind bars. As of 2004, some 1700 people return home from American prisons each day, while more than 7 million pass through US jails annually.4 25 A re-entry perspective recognises that these individuals do not simply disappear once they leave custody, but must reintegrate into home communities. Failure of former prisoners to reintegrate exacts a high toll on society because of increased recidivism and heavy reliance on social welfare measures. Health issues represent one potential barrier to successful reintegration. Given the well documented links between tobacco use and pulmonary disorders, cardiovascular disease, cancer and other negative health outcomes,26 tobacco cessation programming during incarceration and at the time of release could play an important part in removing health-related barriers to reintegration.

The current study does have limitations, which must be considered. Foremost, a statement of policy does not necessarily reflect realities on the ground. As noted above, contraband tobacco sales mean that most, if not all, “tobacco-free prison” are not truly tobacco free. Further data are needed on enforcement of and compliance with tobacco restrictions in prisons in order to understand the impact of these policies. The use of a telephone survey does allow for respondent misreporting due to error or intentional misreporting. Of particular concern is the potential for under-reporting of negative events; however the consistent lack of violence reported by other studies supports the current findings.13 15

The prison tobacco restrictions currently being implemented will have many effects, some intended and others not. The full impact of these policy changes will only become clear over time and with careful study; research is needed to explore the impact of these policies on prisoner tobacco use and health as well as the economic and social impact of these policies for correctional systems and society as a whole. Given current knowledge, however, there are a couple of recommendations that can be made. First, all prisons should, at minimum, ban smoking in indoor areas. Indoor tobacco bans have been found, as expected, to reduce the levels of secondhand smoke in enclosed areas.12 27 The results of the current survey indicate that indoor restrictions on tobacco are feasible, having been widely implemented in the United States without any reports of major violence. Second, forced abstinence is not equivalent to quitting; all prisoners should have access to cessation assistance, particularly during admission to the facility and in preparation for their release. Such programming should be made available regardless of the tobacco policy a correctional institution may have in place and should be offered at no cost to the participant. While additional work may be needed to create cessation programmes that appeal to prisoners, this effort is justified by evidence that a majority of incarcerated smokers wish to quit.9

The tightening of prison tobacco regulations may be regarded as a positive sign that administrators recognise the major role of tobacco in shaping prisoner health, but the low priority given to cessation programming is indicative of short-sightedness. Forcing prisoners to stop (or at least dramatically reduce) tobacco use while incarcerated should result in important health gains and decreased healthcare costs during incarceration. However in failing to assist prisoners in making a permanent change in their smoking behaviours we are missing an important public health opportunity to impact the health of the communities to which prisoners return after their release.