Occasional Paper no. 25 December 2015

Evidence on smoking and smoking restrictions in prisons. A scoping review for the Scottish Prison Service’s Tobacco Strategy Group.

Helen Sweeting & Kate Hunt

www.gla.ac.uk/sphsu

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

Table of Contents Page Table of Contents

i

1. Summary

1

2. Introduction

3

2.1 Background and rationale

3

2.2 Literature review strategy

3

3. Prevalence of Smoking in Prisons

6

3.1 Prevalence of smoking among prisoners and prison staff

6

3.2 Explanations for high smoking rates among prisoners

6

4. Health Impacts of Smoking in Prisons

8

4.1 Impacts on the health of smokers

8

4.2 Impact on the health of non-smokers

8

5. Prison Smoking Bans

10

5.1 History

10

5.2 Rationale for prison smoking bans

10

5.3 Impacts of prison smoking bans – second-hand smoke

11

5.4 Impacts of prison smoking bans - physical health

11

5.5 Anticipated and observed impacts of prison smoking bans – behavioural or unintended consequences 12 Violence or riots 12 Enforcement and smoking behaviour 12 Contraband 13 5.6 Impacts of prison smoking bans - longer-term cessation

14

5.7 Impacts of prison smoking bans – economic and environmental

14

5.8 Arguments against prison smoking bans

15

5.9 Individual case study experiences of partial and total bans in prisons and high security hospitals Partial smoking bans in prisons Victoria, Australia Quebec, Canada Total smoking bans in prisons Isle of Man New Zealand California, US Smoking bans in UK high-security psychiatric hospitals Carstairs Broadmoor Rampton Total bans in UK Young Offenders’ Institutions HMYOI Wetherby HMYOI Ashfield HMYOI Warren Hill

15 15 15 16 16 16 17 17 18 18 19 19 20 20 20 21

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5.10 Implications of detailed case studies

21

5.11 Conclusions in respect of prison smoking bans

21

6. Smoking Cessation Services in Prisons

22

6.1 Do prisoners want to quit?

22

6.2 Provision of cessation services

23

6.3 Evidence from prison smoking cessation interventions

23

6.4 Factors impacting on the success of prison smoking cessation interventions

26

7. Electronic Cigarettes

28

8. Summary

30

References

32

Appendices

45

Appendix 1 - Literature review strategy

45

Appendix Table A1 - Details of reviews and opinion pieces

47

Table A2 - Papers referred to in sections of review / opinion pieces relating to prevalence of smoking in prisons. 50 Table A3 - Papers referred to in sections of review / opinion pieces relating to the place of smoking in prison culture. 54 Table A4 - Papers referred to in sections of review / opinion pieces relating to health impacts of smoking in prisons. 56 Table A5 - Papers referred to in sections of review / opinion pieces relating to the experience of prison smoking bans. 57 Table A6 - Papers referred to in sections of review / opinion pieces relating to smoking cessation in prisons. 60

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1. Summary The findings of this review of evidence on smoking and smoking restrictions in prisons can be summarised as follows: Prevalence of smoking in prisons • Smoking rates among prisoners are very high, at around two to four times those of the general population, in all studies internationally. • Evidence of smoking rates among prison staff is scarce, but with some suggestions of higher rates than among the general population. • High prisoner smoking rates can be explained by both: prisoner characteristics (generally from population groups with high smoking rates and high resistance to cessation; and prison characteristics (smoking is a part of prison culture, historically permitted/encouraged, cigarettes/tobacco are used as currency and prisons are challenging settings for cessation services). Health impacts of smoking in prisons • The impact of tobacco on health is well-known, and some studies draw on this to suggest the impact of smoking on prisoner health. • The small number of studies to examine direct associations all show negative impacts of smoking on the health of prisoners who smoke. • Objective measurements show high levels of second-hand smoke (SHS) in prisons. • Evidence that SHS causes diseases and death has been used to make the point that prisoner smoking will impact on the health of all prisoners and prison staff, regardless of their own smoking status. Prison smoking bans • Prison smoking bans vary in respect of who (staff and/or prisoners) and where (all/some indoor/outdoor areas) they cover, and have been gradually introduced, in a number of countries, over the past 25 years. • Rationales for bans include health, economic costs, and concerns about litigation and safety. • The few studies to have taken objective measurements have generally found reductions in SHS following implementation of indoor bans. • There is evidence of positive impacts on prisoner health following the introduction of prison smoking bans. • Pre-ban concerns relating to violence or riots generally prove unfounded. • Tobacco black markets are the most frequently reported negative outcome following a ban. • Staff enforcement is key to the success of any ban. • The little available evidence suggests that simply banning smoking has no impact on longer-term cessation. • A series of detailed case studies suggests that: total bans are more effective both managerially and in terms of reducing SHS exposure; it is possible to identify processes associated with successful introduction of a smoking ban; there is no evidence that smoking bans significantly increase disorder; it has been established that there is no legal right to smoke (Rampton case); bans should be accompanied by cessation support.

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Smoking cessation services in prisons • A majority of prisoners report that they want to quit smoking. • Although prison represents an ideal opportunity to quit, cessation service provision tends to be patchy and inconsistent. • Studies of prison-based smoking cessation interventions suggest that it is possible to identify operational, staff-related and cessation service/support-related factors which impact on their success. Electronic cigarettes • Although relatively new phenomena, rates of e-cigarette use have increased rapidly in the general population. • E-cigarette use is associated with both smoking and with quit-smoking attempts. • There is evidence of e-cigarette use within criminal justice settings internationally (US) and in England and Wales. • While one recent opinion piece suggests prisoners who smoke should have access to ecigarettes, another urges caution; this disagreement reflecting divided opinion among public health researchers and advocates about e-cigarettes more generally.

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2. Introduction 2.1 Background and rationale In Scotland, at the time of writing (late 2015), prisoners are permitted to smoke only in cells indoors and specified areas outdoors. The latter vary between prisons, e.g. exercise yards, but not football pitches; exercise yards away from doors and windows. Governors can designate cells as ‘smoking’/’non-smoking’, and designations may change in accordance with prisoner wishes 1. The Scottish Government has described “creating a smoke-free prison service” as “a key step on our journey to creating a smoke-free Scotland” and made a commitment to working “in partnership with the Scottish Prison Service and local NHS Boards to have plans in place by 2015 that set out how indoor smoke-free prison facilities will be delivered” 2. In September 2015, the Westminster Government announced that a smoke-free policy will be implemented in all prisons in Wales from January 2016, and in four English prisons from March 2016, with the eventual intention of banning smoking in all English and Welsh prisons. Media reports of this also noted the Scottish Prison Service’s intention to have plans in place by December 2015 on how indoor smoke-free prison facilities would be delivered 3. This literature review was written in response to acknowledgement by the Scottish Prison Service Tobacco Strategy Group that any action plan on smoke-free prison facilities should be based on evidence in respect of: • Rationale for restrictions on prisoner smoking: health; safety; economic/legal. • Current position: culture (meaning of tobacco, pricing strategies, alternative currencies, New Psychoactive Substances), examples of other cultural changes; provision of cessation support. • Types of restriction; implementation process; stakeholder engagement, consultation and communication; cessation services; benefits and risks (health, behavioural, financial, legal, etc) and their mitigation/management. • Evidence/measurement of change or success (performance, outcome, qualitative) from jurisdictions which have introduced bans. 2.2 Literature review strategy Papers were identified via two literature searches conducted in July-August 2015 (one by NHS Scotland’s Health Management Library and Information Service, the other by the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow) using search terms relating to prisons, smoking, smoke-free and health. (See Appendix 1 for further details.) These searches identified 24 reviews and opinion pieces based on or including brief reviews (summarised in Table 1 and in more detail in Appendix Table A1). Next, literature included in these reviews was identified. (Appendix Tables A2 to A5 detail this in respect of empirical sources related to the various sections of this review, thus providing a more extensive list of references to those who are interested).

1

Scottish Prison Rules Smoking Direction 2014. Scottish Prison Service (February 2014). See http://www.sps.gov.uk/Corporate/Information/PrisonRulesandDirections.aspx 2 Scottish Government (2013) Creating a Tobacco-Free Generation: A Tobacco Control Strategy for Scotland (P26). Edinburgh: The Scottish Government. See http://www.gov.scot/resource/0041/00417331.pdf 3 BBC News (29 September 2015) Prison smoking ban to begin in 2016. See http://www.bbc.co.uk/news/uk-34395034 Page 3 - Occasional Paper Number 25

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Table 1: Details of reviews and opinion pieces. Ref [1] [2]

Author ASH Awofeso

Date (2014) (2002)

[3]

Baybutt et al

(2014)

[4] [5] [6]

Bonita Butler et al Butler et al

(2013) (2007) (2011)

[7] [8]

Collier Collinson et al

(2013) (2012)

[9]

Cork

(2012)

[10] [11]

Djachenko et al Donahue

(2015) (2009)

[12]

Eldridge et al

(2009)

[13]

Gautam et al

(2011)

[14]

(2009)

[15] [16]

Globalsmokefree Partnership Hartwig et al Jakeman et al

[17]

Kennedy et al

(2015)

[18]

MacDonald et al

(2010)

[19]

(2015)

[20]

Public Health England Ritter et al

[21]

Ritter

(2012)

[22]

Ritter

(2014)

[23] [24]

Sullivan Taylor et al

(2014) (2012)

(2008) (2014)

(2011)

Title Smokefree prisons Reducing smoking prevalence in Australian prisons; a review of policy options Tobacco use in prison settings: a need for policy implementation. New Zealand leads the way in banning smoking in prisons Should smoking be banned in prisons National summit on tobacco smoking in prisons: report on the summit Prison smoking bans: clearing the air New Zealand’s smokefree prison policy appears to be working well: one year on Tobacco behind bars: policy options for the adult correctional population Smoking cessation in male prisoners: a literature review Tobacco smoking among incarcerated individuals: a review of the nature of the problem and what is being done in response Smoking bans and restrictions in US prisons and jails: consequences for incarcerated women Smoke-free prisons in New Zealand: maximising the health gain Reducing tobacco smoke exposure in prisons

Author country UK Australia

Report on tobacco smoking in prison Smoking in prisons in England and Wales: an examination of the case for public health policy change Smoke-free policies in US prisons and jails: a review of the literature Rapid literature review of smoking cessation and tobacco control issues across criminal justice system settings Reducing smoking in prisons: management of tobacco use and nicotine withdrawal Smoking in prisons: the need for effective and acceptable interventions. Tobacco use and control in detention facilities: a literature review Tobacco use in prisons: none is best, but a complete ban is not the answer Smoking bans in secure psychiatric hospitals and prisons Tobacco smoking and incarceration - expanding the ‘lost poor smoker thesis’: an essay in honour of Dr David Ford

Germany UK

UK New Zealand Australia Australia Canada New Zealand US Australia US US New Zealand Switzerland

US UK UK Germany Germany Germany Australia UK

A small number of sub-sections in this review draw mainly from the 24 review or opinion pieces. These 4 cover areas where great detail was not thought necessary. All other sections are more detailed, and include individual empirical studies, including some published too recently to have been picked up by the other reviews. These cover areas where it was thought that more in-depth information might be of use to the Scottish Prison Service as it formulates plans on how indoor smoke-free prison facilities will be delivered. In the text which follows: 4

Sub-sections include: explanations for high smoking rates among prisoners; history of prisons smoking bans; rationale for prison smoking bans. Page 4 - Occasional Paper Number 25

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• The reviews/opinion pieces are consistently referred to as reviews and the original empirical papers as studies. • Study descriptions include date of publication and country, given the impact that social context and attitudes towards tobacco control might have had on the results (e.g. adult smoking rates in Scotland were 23% in 1999[25] and 22% in 2014[26]; it might be hypothesised that lower population smoking rates might mean lower prisoner smoking and higher desire to quit rates among prisoners). • Numbered referencing is used, with reference numbers 1-24 referring to the reviews, so allowing them to be easily distinguished from the studies.

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3. Prevalence of Smoking in Prisons 3.1 Prevalence of smoking among prisoners and prison staff The 2013 Scottish Prisoner Survey found 74% prisoners reported being a smoker [27]. This is consistent with the vast literature on prevalence drawn on by previous reviews (see Table 1). Broadly, this highlights very high smoking rates among prisoners, at around two to four times that of the general population, in all studies internationally. The two most detailed reviews provide figures of 77-97% [3] and 50-97% [21] in studies of male prisoners across Canada, the US, Australia, Asia and Europe and, although based on fewer studies, of around 40-90% among female prisoners across a similar spread of countries. The UK studies on prevalence included in the reviews include: a Royal College of Physicians and Psychiatrists report of studies conducted 2005-10 which found smoking rates of over 80% in both male and female prisoners [28]; a 2007 study of oral health in male remand prisoners which reported 78% smoked [29]; 89% smokers in a 2009 study of smoking cessation among English and Welsh male prisoners [30]; rates of 85% among male sentenced and 78% among male remand prisoners and of 83% (sentenced) and 81% (remand) among females in the 1997 ONS survey of psychiatric morbidity among prisoners in England and Wales [31]; a rate of 85% among prisoners in NHS Information Centre 2011 Statistics on Smoking [32]; 60-80% of male and 34-99% of female prisoners in a 2007 UK Department of Health South West Region report (now unavailable) [33]; 85% in a 2009 study of cardiovascular disease factors among women prisoners [34]; and 66% in a 2005 study of imprisoned pregnant women [35]. There is also some evidence of high rates in other areas of the UK Criminal Justice Service (CJS) system: a 2008 study found that 83% of offenders on probation caseloads in two English counties were smokers [36] and 63% of London police custody offenders in a 2010 study reported dependence on cigarettes [37]. In addition to high rates, prisoners who smoke have been shown to have high levels of nicotine dependence [5, 21, 23]. Scottish Prisoner Survey data are drawn on by some reviews to show no change in rates between 2004 (80%), 2006 (78%) and 2008 (79%) [38, 39] at a time when rates continued to fall in the general population. The 2013 Scottish Prisoner Survey report (not included in any of the reviews) includes the rates found in 2009 (76%), 2011 (76%) and 2013 (74%) [27], suggesting only a slight reduction over the total period. Evidence of smoking rates among prison staff is scarce. One review cites a survey conducted in HMP Bowhouse in 2002 (report now unavailable) which found rates of 75% among staff [40], while two reviews note a 2007 UK Department of Health South West Region report (now unavailable) which found rates of only 17% among staff [33]. The few studies available from other countries tend to report somewhat higher rates among prison staff than among the general population [3, 21] 3.2 Explanations for high smoking rates among prisoners In attempting to explain very high rates, the reviews draw on characteristics of both prisoners and prisons. Prisoner characteristics The prison population contains many (overlapping) vulnerable groups. Prisoners are drawn disproportionately from those who are from more deprived backgrounds, are poorer and have less Page 6 - Occasional Paper Number 25

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education; rates of both mental health problems and substance abuse are also high. All these characteristics are associated not only with smoking, but also with resistance to cessation [1-3, 5, 9, 17, 19-21, 23]. The 2015 Public Health England (PHE) review also points out that associations between smoking, deprivation and use of cheaper illicit tobacco, increase the likelihood of getting drawn into criminal groups and so, possibly, (re)offending [19]. Prison characteristics Several reviews describe the impact of the prison setting on prisoner smoking and discuss reasons for this in either more [3, 11, 21, 24] or less detail [2, 9, 10, 12, 14, 16-20, 23] (see Table 2). The reviews note that although some prisoners reduce or quit smoking on prison entry due to limited access to, or high cost of tobacco, increased smoking is more likely. Increases occur both in terms of rates (due to relapse of ex-smokers and initiation of never-smokers) and, among current smokers, frequency and heaviness of smoking [3, 11, 14, 18, 19, 21]. The expense of obtaining cigarettes mean many prisoners switch to much cheaper roll-you-own, often unfiltered cigarettes, resulting in higher tar and nicotine intake [12, 21]. Historically, two reviews note that until the 1980s, many prison systems actually issued free tobacco as rations to both prisoners and staff (although there is no evidence from the literature that this ever occurred in UK prisons). This was viewed as a way of managing prisoner behaviour, providing them with a reward, and to help staff cope with work-related stress [9, 17, 21]. Smoking is a strong part of prison culture, and high rates mean that prisoner smoking is a social norm, unlike the contemporary world outside, where, particularly following bans on smoking in public places, smoking has become increasingly marginalised and/or stigmatised [3, 11, 16, 21]. In prison, the opposite may be the case: cigarettes may provide a sense of group membership, and act as a social lubricant, while being a non-smoker may be socially isolating [10, 19-21]. Smoking is described by prisoners as a way of dealing with boredom, lengthy periods locked in cells without purposeful – or indeed any – activity, and isolation from family and friends [3, 10, 12, 18-21, 23, 24]. Smoking may be almost the only pleasure experienced by some prisoners, outbalancing any concerns for health [24]. There is also a strong belief by both prisoners and staff that smoking helps prisoners cope with stress (e.g. in relation to court appearances, transfers or bad news from home) [2, 3, 10, 12, 18-21]. Some staff may also have believed that permitting smoking (or, in the past, smoking together), improved their relationship with prisoners [23]. Cigarettes have been described as both property, in a context where this is sparse, and privilege [24]. Both cigarettes and tobacco are used as currency within prison black market economies. They may simply be used for barter, or as a gambling stake, or as protection from violence, bullying or trouble with other prisoners, with some evidence that this may lead to trading, including in the form of sexual favours, for cigarettes [3, 10, 11, 13, 19-21, 23, 24]. Finally, smoking rates are high in prisons because they are a challenging setting for cessation services. Smoking cessation has tended to be given low priority over other health issues, such as illicit drug use, mental illness and violent behaviours; one review describes how smoking is perceived as a lesser evil [3, 9, 14, 15, 21, 22]. Some prisoners may have low motivation to quit due to social and interpersonal difficulties, lack of access to or understanding of health education materials [3, 21], and the transient nature of prison stays for many means the opportunity for consistent, supportive cessation input is significantly reduced [3, 21].

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4. Health Impacts of Smoking in Prisons Smoking impacts not only on the personal health of individual smokers but also on the health of both non-smokers and smokers exposed to second-hand smoke (SHS)’. 4.1 Impacts on the health of smokers Tobacco is the world’s leading cause of avoidable poor health and premature death [41]. It has been estimated that around half those who smoke will die as a result [42]. Within the UK, smoking causes 19% of all new cancer cases [43]; in 2010 27% of UK cancer deaths and 22% of all deaths were attributable to smoking [44]. Several reviews cite general references such as these on the personal health impacts of smoking. In some others, personal health impacts are simply assumed rather than referred to. Although a few reviews [5, 9, 11, 17, 20, 23] also cite studies of smoking and prisoner health, examination of the original papers drawn on by these reviews, shows not all make explicit reference to smoking. For example, a 2009 US study reported that around 40% of prisoners had at least one chronic medical condition, however this study did not separate out smoking-related conditions [45]. Some original studies suggest the importance of smoking. For example, a 2001 UK study of the health of older male prisoners found higher rates of cardiovascular and respiratory disease (for both of which smoking is a contributory factor) than in a community sample of older men [46], and analysis of 2001-4 US state prisoner deaths found 27% were due to heart diseases and 23% to cancer, with lung cancer alone accounting for 8% of all deaths [47]. A 2014 US survey (not included in the reviews) found 38% prisoners reported an illness that had been worsened by smoking and 53% had smoking-related health concerns [48]. However, a small number of studies (none from the UK) make direct links between a prisoner’s health and their smoking. A 2006 US study found high rates of oral disease among a large, randomly selected prisoner sample, with smokers having the worst dental outcomes [49]. In 2007, a large Australian study found the standardised mortality ratios for smoking-related cancers were 1.7 among men and 2.4 among women who had served time in prison compared with the expected local population rates [50] and, importantly, a 2009 US study found these higher rates of all-cause cancer among prisoners than the general population could be accounted for by smoking status [51]. 4.2 Impact on the health of non-smokers Breathing in SHS also causes diseases and death [52]. It has been estimated that second-hand smoke exposure causes around 1% of total worldwide mortality [53]; it also significantly increases the risk for cardiovascular disease [54]. Following introduction of smoke-free legislation in Scotland there was evidence of reduced hospital admissions for both acute coronary syndrome (among both non-smokers and smokers) [55] and childhood asthma [56]. Similar legislation in England was also associated with an immediate drop in adult emergency admissions for asthma [57] and a small but significant drop in the number of emergency admission for myocardial infarction [58]. As with the personal health impacts of smoking, several reviews cite general references on the health impacts of SHS exposure and others cite none; some simply make the point that SHS risks are particularly high in prisons because of the high smoking prevalence, combined with overcrowding and the impossibility of going elsewhere to avoid exposure. However, a few [1, 8, 12, 14, 16, 18, 21] include prison-related SHS studies.

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In respect of indoor air quality, a 2005 US study in two prisons prior to the introduction of an indoor ban found airborne nicotine levels in living and sleeping areas were around 3-4 times higher than those found in most smokers’ homes; levels in a gym being used as a bunkroom were over 10 times higher [59]. A 2008 US study also found high levels of respirable suspended particulates (PM2.5 - a marker for SHS) in the indoor areas of several prisons before introduction of a smoking ban [60]. One review [21] cites a 2010 study ([61], original in French) which found 65-92% of prison staff reported SHS exposure at work, around 3-4 times general population levels. The review also notes this study as suggesting that prisons were considered to be the places with the highest SHS risk in the US in 2006. Consistent with this, a 2012 Irish study found that 44% of nonsmoking prison officers had carbon monoxide levels similar to those of light to heavy smokers in their exhaled breath [62]. A recent (2015) study of English and Welsh prisons found evidence of SHS in smoking (and occasional non-smoking) cells and all prison wing samples measured, with higher levels during meal-times, periods of association and weekends. Personal monitors showed staff exposure to SHS across the work-shift, with around one-sixth of work-time spent in excess of the World Health Organisation (WHO) guidance value for PM2.5, and short-term peaks associated with entering smoking cells [63]. In respect of the health impacts of prison SHS, a 2007 US study estimated that over twice as many prisoners died annually from SHS (N=115) as had been legally executed the preceding year (N=53) [64] and a 2011 US study found high levels of awareness among prisoners that SHS could cause lung cancer (83%) and heart disease (48%) [65].

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5. Prison Smoking Bans Bans on smoking in prison vary in respect of: whether they apply to prisoners only or also include staff; and whether they are ‘total’ (all indoor and outdoor areas) or ‘partial’ (which may mean smoking is: only allowed in designated indoor areas, typically, but not exclusively, cells; only outdoors; only in designated outdoor areas; or any combination of these). It is important to bear this in mind when drawing conclusions on the basis of research on the impact of bans, particularly since some studies include prison samples with different types of bans but do not report the results separately. 5.1 History Several reviews cite a 2007 survey of tobacco policies in US prisons which includes historical data showing that in 1986, 58% provided free tobacco to prisoners, 5% offered smoke-free living areas and none had a total ban. Ten years later, considerable changes were already apparent: in 1996 only 27% provided free tobacco, while 85% had smoke-free living areas and 14% a total ban. These changes had solidified further by 2007 when none provided free tobacco, 96% had smoke-free living areas and 60% a total ban [66]. The greatest impetus within the US for introduction of prison smoking bans was fear of litigation from non-smoking prisoners and staff following a 1993 Supreme Court ruling describing exposure of prisoners to second-hand smoke as a “cruel and unusual punishment” and so violating a prisoner’s Eighth Amendment rights (“‘Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted”); counter-claims that banning smoking also violated rights, were not upheld [5, 9, 10]. In 2005, the WHO Framework Convention on Tobacco Control (FCTC), which aimed to ensure protection from tobacco consumption and exposure, came into force. The UK was one of the first group of countries to accept the convention, and so is legally bound by its provisions. Several reviews [3, 14, 15, 21] cite FCTC Article 8: “Careful consideration should be given to workplaces that are also individuals’ homes or dwelling places, for example, prisons, mental health institutions or nursing homes. These places also constitute workplaces for others, who should be protected from exposure to tobacco smoke”. One of these reviews [21] notes related recommendations made by WHO in 2007 that: there should be a 100% smoke-free environment (not ventilation); legislation requiring all indoor workplaces to be 100% smoke-free was needed (ensuring protection for all); legislation must be properly implemented and adequately enforced; and educational strategies should be provided. In March 2006 legislation banning smoking in public places was implemented in Scotland. Although prisons did not fall within the scope of the legislation, Prison Rules were changed to support its principles, restricting smoking to prisoners’ cells and during outdoor recreation. This meant Scotland became only the second European country to introduce any smoking ban in prisons (the Netherlands had introduced a partial ban (smoking for prisoners only in their cells and special rooms; smoke free cells for non-smoking prisoners) two months earlier [15]. 5.2 Rationale for prison smoking bans Several reviews note the results of a 2007 survey of the 52 US Departments of Correction on prison tobacco policies which provided a list of reasons for bans, including: concerns for prisoner and staff health; concerns about legal challenges from non-smokers (prisoners and staff); lower fire Page 10 - Occasional Paper Number 25

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risks; lower maintenance (e.g. cleaning) costs; and lower insurance rates [66]. Further reasons for bans cited in the reviews include prevention of initiation of smoking in non-smoking prisoners [21], making it easier for prisoners to quit smoking [1], reducing the risks of infectious disease outbreaks accelerated by smoking [13], and reducing prisoner health care costs [12]. 5.3 Impacts of prison smoking bans – second-hand smoke The reviews present consistent evidence that levels of SHS are reduced when indoor bans, particularly total bans, are introduced; four studies are frequently mentioned. The earliest was a 2005 study which measured nicotine concentrations in air samples from various areas within prisons in Vermont, finding significant reductions after the introduction of an indoor smoking ban, particularly in overcrowded areas. However, the study also noted that post-ban nicotine levels were still higher than those found in the homes of smokers, suggesting that this may have reflected poor enforcement of the ban [59]. Two other studies had very similar results. A 2008 study, conducted in North Carolina, which tested the air quality in dormitory and common areas before and after an indoor smoking ban, found average levels of respirable suspended particulates (PM2.5) were 77% lower post-ban. No decreases were seen in areas which were tobacco-free before the ban [60]. Likewise, a more recent study (2013) reported a “rapid” (immediate) halving of PM2.5 concentrations in a monitor placed in a staff base of a New Zealand maximum security prison following implementation of the country-wide total ban [67]. In contrast, a 2015 Australian study (too recent for inclusion in any of the reviews) reported an increase in indoor pollutants following a total indoor smoking ban; prisoners could still smoke in the outdoor yard area. This “unexpected” finding was attributed to an inexplicable increase in (clandestine) indoor smoking [68]. More complicated results were reported in a 2012 study of a Swiss prison before and after a partial ban (cigarettes could still be bought by prisoners or brought in by visitors; and smoking was allowed in cells and designated outdoor areas). This study found large and significant reductions in nicotine concentrations but not particulate matter (PM10). The authors suggested this was because of both air movements between cells and shared rooms and poor enforcement of the ban, concluding that “a partial ban is an insufficient protection measure in this setting” (p491) [69]. 5.4 Impacts of prison smoking bans - physical health The reviews cite several studies demonstrating positive health impacts following the introduction of bans. The earliest (1990), largely anecdotal, study, reported one US prison as finding a smoking ban resulted in fewer smoking-related medical problems and a 33% drop in medical calls [70]. A fairly small study from 2010 found 67% of its male participants from a minimum security Wisconsin prison, all prior smokers, thought their health status improved following introduction of a total ban [71], and a 2014 study found a similar proportion (69%) of patients in an Australian forensic psychiatry unit also perceived that their health had improved as a result of not smoking [72]. A more robust paper, published too recently (2015) for inclusion in any of the reviews, examined changes in smoking-related symptoms, reported via a well- validated respiratory instrument, both immediately prior to imprisonment, and recently, among prisoners in a US prison with a total ban. It found that all symptoms significantly improved, with the greatest changes for ‘cough first thing in the morning’ and ‘phlegm production’ [73]. Two reviews [9, 17] cite a US PhD study which found significantly higher heart attack rates in a prison with an indoor-only smoking ban compared with one where smoking was banned both indoors and outdoors and another US study which found a total ban in a women’s prison eliminated differences between smokers and non-smokers in complications following dental extractions. Page 11 - Occasional Paper Number 25

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However, the most important evidence in respect of positive health impacts is a 2014 study, cited by the reviews to which it was available, which used survey data to assess the impact of US smoking bans on deaths due to smoking and years of potential life lost from smoking among prisoners. It found that in prisons with any (partial/total) ban, the mortality rate from smoking-related causes was significantly lower following the ban (prisons with bans had a 9% reduction in smoking-related deaths) and bans in place for longer than nine years had significantly reduced cancer mortality [74]. One review highlights the ‘robust statistical analyses’ used in this study [22]. 5.5 Anticipated and observed impacts of prison smoking bans – behavioural or unintended consequences Violence or riots Suggestions as early as 1990 that “the belief that smoking bans lead to violence appears to be a myth” (p1515)[70] were confirmed in the 2007 survey of tobacco policies in US prisons which reported that no department reported violence or riots associated with transition to a stricter tobacco policy [66]. Based on evidence from English mental health and young offender institutions (see case studies below), the ASH review concludes that pre-ban concerns that they would result in disorder were proved unfounded [1]. Most other reviews present similar conclusions, based on evidence from other countries and including studies in secure hospitals [9, 14, 16, 17, 21, 23]. However, a small number report more mixed findings, including riots in a Queensland (Australia) prison in 1997 and a hunger strike in an Ontario (Canada) prison in 2000, at the same time contrasting this with successful implementations in other places [2, 8]. Enforcement and smoking behaviour Several reviews make the point that staff support is key to enforcement of any ban, some going on to cite a 2001 survey of prison staff in Vermont which at that time had a partial ban. The survey found, unsurprisingly, that support for a total ban was much more likely among non-smokers than smokers: a total ban among prisoners was supported by 56% non-smoking staff, 49% ex-smokers and 15% current smokers; a total ban also including staff was supported by 38% non- and exsmokers and 3% current smokers. Staff who smoked were also more likely to predict negative outcomes following further smoking restrictions [75]. Many reviews link this with a number of studies reporting high levels of prisoner smoking after bans had been implemented. For example, a 2005 study in Indiana following a total ban found that 76% of smokers reported continuing to smoke a month after the ban began, and that this group were more nicotine dependent and reported more withdrawal symptoms than those who quit following the ban. The authors attributed the “surprising” lack of compliance with the ban to poor staff enforcement, particularly by staff who smoked and so were also affected by the ban [76]. A 2007 study in a South Dakota prison found that despite its “smoke-free” status (unclear whether partial or total), 24% of women prisoners reported smoking [77]. A 2011 study in prisons in Quebec following a partial ban (indoor smoking banned, but smoking during exercise in a courtyard allowed) found 93% of smokers reported still continuing to smoke indoors and 48% reported no reduction in use at all. Fewer than half had been caught smoking indoors, disciplinary consequences were unlikely and staff commented on the difficulty of enforcement because prisoners were allowed to bring their tobacco indoors. The authors make the point that these prisoners remained nicotine dependent and so were highly motivated to continue smoking throughout the day [78]. Another 2011 study, of recently arrived prisoners in low-medium secure units in Ohio with partial bans (indoor smoking banned), found no significant change in the overall number of smokers before and after imprisonment, but average cigarette consumption reduced. The authors suggest this finding Page 12 - Occasional Paper Number 25

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

“raises questions about the public health impact of such policies” (p453)[65]. One review [9] suggests greater problems with enforcement in partial ban situations, consistent with findings reported in another review that prisoners’ smoking rates, in a prison with a total ban, were “high” (42%), but not as high as in a prison with a partial (indoor only) ban (64%) [17]. It is also suggested that partial bans may be harder to enforce and more likely to result in unequal treatment: for example. staff may give some prisoners smoking privileges or allow them to ‘get away with’ violations of the ban [9]. Contraband Many of the reviews cite evidence of increasing tobacco black markets following prison smoking bans. A 2001 survey of US adult male prisons found that of those which had implemented a total ban, increased contraband tobacco smuggled into prison was by far the most frequently reported negative outcome, leading the authors to suggest that this “new and lucrative industry” may have been the reason why some other expected outcomes (e.g. violence) had not occurred, since it meant prisoners had not actually stopped smoking [79]. The 2007 survey of the 52 US Departments of Correction on prison tobacco policies reported that several departments with total bans reported tobacco became the dominant contraband item [66]. A qualitative study conducted in 2001, of 16 US prisons and jails with a mix of total and partial bans, suggested the introduction of smoking bans could “transform largely benign cigarette ‘grey markets’ where cigarettes are used as currency, into more problematic black markets, where cigarettes are a highly priced commodity” (p142)[80]. Interestingly, this study also found levels of illegal drugs often dropped following tobacco bans, because the high demand for tobacco products meant that profit margins were higher. The study identified several factors associated with greater black market activity: older facilities (due to the nature of the architecture and more limited opportunities for supervision); less secure facilities with greater opportunities for smuggling; staff who allowed smoking violations; staff who actively smuggled or helped smugglers; and greater black-market skills among prisoners (e.g. those who were in prison for drug crimes). It also found contraband tobacco to be associated with increases in riskier smoking practices (e.g. rolling tobacco with pages from books containing inks which were harmful when burned or removing filters to increase the potency of manufactured cigarettes) [80]. A recent study, prompted by reports of NRT patch misuse associated with prison smoking bans has identified that using the patches as alternatives to cigarettes (eg shredding or boiling them with tea leaves then consuming the product dried and smoked) has the potential to release health-damaging toxins [81]. Several reviews note additional problems of tobacco-associated black markets within prisons, including prisoner-on-prisoner intimidation, arguments, violence, accumulating debt, trading toiletry items or sex for tobacco, the need to police another illegal substance and the possibility that the high prices involved may corrupt staff [5, 9, 12, 13]. Set against this, a 2012 US qualitative study of male prisoners in a minimum security prison with a total ban found that, although some chose to contravene the ban as a signal of defiance, many others described the unavailability of cigarettes as making it easier to cope with abstinence. This latter group chose to go along with the ban not only because of the penalties of not doing so, but also because of negative perceptions of both contraband tobacco (expensive, poor quality), smoking (as secretive, rushed and unpleasant) and contraband smokers (as addicted), and positive personal changes (feeling they had a choice, replacing smoking with other activities or ways of coping) [82].

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5.6 Impacts of prison smoking bans - longer-term cessation Up until about five years ago, reviews were noting only sparse evidence [6] on longer-term smoking outcomes following imprisonment under a smoking ban regime, in part because of difficulties of tracking prisoners following release [14]. However, one review published in 2007 summarised what evidence there was by concluding: “banning and quitting are not the same thing … there is no evidence that simply banning smoking is effective in reducing smoking rates over the long term” (p292)([5]. The evidence base is now much stronger, and despite variation in the dates of studies, length of stay within prisons and prevalence of (male) smoking in the general population at the time of release, conclusions remain largely the same. A very small, early (1992) US study of prisoners from two prisons, one with a total and the other with a partial smoking ban, found over 80% of those who were contemplating stopping smoking continued or resumed smoking within two weeks of release [83], and a 2003 survey of US medical directors from prisons, most of which had some sort of smoking ban, reported that between 76% and 100% of prisoners returned to smoking after release [84]. A much-cited US study (referred to in earlier reviews as a 2002 poster presentation, so unavailable, but subsequently published in 2009) found that among 129 smokers with chronic health conditions released from a jail with a total smoking ban (median stay just over two months), 63% smoked on the day they were released and 97% smoked six months after release [85]. More recent findings include a Taiwanese 2010 qualitative study highlighting the “banning and quitting are not the same” issue: prisoners in a total ban situation perceived themselves as having been forced to stop, but not as having quit and therefore intended to smoke as soon as they were released [86]. Several US studies have now reported smoking rates following release from prisons with total bans, including: a small 2010 study which found rates of only 39% four weeks post-release [71]; a 2013 study which found 93% had returned to smoking three weeks after release [87]; and two (from 2013 and 2014) which both found rates of 84% three weeks after release, with the 2013 study also reporting 6.4 days on average to the first cigarette and highlighting the lack of nonsmoking role models among family and friends as contributing to difficulties remaining abstinent following release [88] [89]. Finally, and importantly, the most recent (2015) ‘Report on the Health of Australia’s Prisoners’ [90] notes that the gradual introduction of smoking bans into Australian prisons since 2013 meant data analysis was possible according to whether or not a total ban was in place. The report only presents such analyses in respect of discharge data. Although there were no differences in the proportions who had been smokers on entry (reported by 72% from prisons with a total ban and 75% from prisons without), being a current smoker was reported by a far smaller proportion (18%) of those in prisons with total ban than those in prisons without a total ban (74%). Smoking more since imprisonment was reported by 4% of those in prisons with a total ban compared with 16% of those in prisons without, and smoking less by 56% (with ban) compared with 22% (without). Importantly, intending to smoke after release was reported be a smaller proportion (47%) of those in prisons with a total ban reported than those in prisons without a total ban (55%), which the authors suggest might indicate “that the reduction in smoking from being in a prison in which smoking is banned may flow through to the community” (p93). 5.7 Impacts of prison smoking bans – economic and environmental There is almost no evidence in this area: a 2015 review of US smoking bans specifically notes that no published studies were identified on the economic impacts of prison smoking bans in their Page 14 - Occasional Paper Number 25

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

search [17]. The ASH review [1] cites a 2010 report, produced before the introduction of the New Zealand country-wide ban, suggesting that a total smoking ban in the country’s prisons could potentially save the economy over $113 million dollars annually [91]. Another notes that incidents of fire reduced by 80% in a US prison following introduction of a smoking ban (partial/total not specified) [2]. 5.8 Arguments against prison smoking bans Several reviews note that from a civil rights perspective, a smoking ban represents inhumane treatment on the basis that it represents removal of one of the few freedoms or pleasures available to an already disenfranchised group, although this issue is partially alleviated by partial bans [5, 11, 20, 22, 23]. Somewhat related to this, one review points out that continuing perceptions of tobacco as different from other addictive substances mean that public support for a prison smoking ban might be lower than for other substances [23]. Reviews also suggest other potential negative consequences, including: higher costs resulting from increased security and enforcement (e.g. searches to reduce smuggling) [2]; increased tensions between prisoners and staff (e.g. around searches for hidden tobacco and disciplinary procedures following violations of the ban) and resulting loss of prisoner freedoms (e.g. parole eligibility or work opportunities) [2, 12]; and difficulties in identifying individuals for disciplinary action if several in a group of prisoners are smoking [17]. 5.9 Individual case study experiences of partial and total bans in prisons and high security hospitals The 2014 review conducted by the Offender Health Research Network [16] includes a detailed series of case studies, based on both published material and personal correspondence, reflecting the experiences and perspectives of those working in prisons and high security hospitals which had introduced partial or total smoking bans. These are summarised below in some depth, because of their implications for the Scottish Prison Service’s prospective moves towards a smoke-free policy. Partial smoking bans in prisons Victoria, Australia: • Introduced a policy in 2004 in which staff and prisoners could only smoke in designated outdoor areas or, with special permission for prisoners in “exceptional circumstances” (e.g. acute mental illness) in cells. • All prisoners and staff must be informed of the policy and associated disciplinary procedures for prisoners, visitors and staff. • Prisoner penalties include fines and accommodation moves, while visitors may be asked to leave or refused entry if violating smoking rules. • Prisons are also required to promote the benefit of a smoke-free environment, provide information and cessation programmes to all smokers and provide those who wish to quit with NRT and a place on a group programme (or on the waiting list). • Evidence on impact is sparse, but disciplinary actions were lower in respect of smoking compared with a number of other issues. In 2012 Corrections Victoria were considering implementing a total smoking ban. • (UPDATE – in June 2015, a riot broke out at Victoria’s Ravenhall maximum security prison, apparently after prisoners became angered by the introduction of a smoking ban Page 15 - Occasional Paper Number 25

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

http://www.theguardian.com/australia-news/2015/jun/30/prisoners-riot-at-melbournes-ravenhallremand-centre-over-smoking-ban.) Quebec, Canada: • Introduced a total tobacco ban in prison buildings and grounds in 2008, which was amended after three days to allow prisoners to smoke outside in courtyards during their one-hour daily exercise. News reports that this policy reversal was the result of a prison riot have never been officially confirmed. • A 2011 paper on implementation of the ban [78] noted poor enforcement because there had been little instruction on how staff should enforce the ban, and little enthusiasm from staff to do so, either because they were disappointed the ban was not total or, conversely, because they were sympathetic to smoking prisoners. • Because prisoners were allowed to buy a limited amount of tobacco and keep it with them at all times, it was hard to prevent them from smoking it and there were no indications of disciplinary actions. • There was little evidence of effectiveness: 93% prisoners reported continuing to smoke inside (although most said they smoked fewer cigarettes than previously) and increases in prisoner-staff tensions were reported by 85% of prisoners and 76% of staff. Total smoking bans in prisons Isle of Man: • This small prison (around 100 prisoners) introduced a total smoking ban in 2008, with neither staff nor prisoners allowed to smoke on any parts of prison premises. The total ban option was chosen on the grounds that it would be easier to police and that allowing some smoking opportunities would increase conflict and compromise cessation attempts. • Two weeks before the ban started, prisoners had their last chance to buy tobacco. The opportunity was provided to surrender tobacco and smoking paraphernalia before the ban began, at which point it was removed during searches. • Staff were told that anyone possessing smoking paraphernalia would be subject to disciplinary procedures and visitors warned of a heavy fine (£5,000) for anyone caught trying to smuggle tobacco into the prison. • All prisoners received a newsletter outlining support available for nicotine withdrawal, including: a 14-week withdrawal plan with nicotine patches or inhaler cartridges exchanged new-for-old, extra healthcare staff support, cessation specialist drop-in sessions and cessation support from prison staff who had received additional training. • Adverse incidents following the ban included prisoners smoking alternative items (e.g. tea leaves), a hunger strike by a small number of prisoners and an incident when prisoners refused to return to their cells. Both the latter were reported to have been quickly and fairly easily resolved. • However an unannounced Inspectorate of Prisons visit in 2011 noted bullying to obtain nicotine patches, non-adherence of the new-for-old NRT policy, smoking of alternative substances, dangerous ignition practices, collusion with some staff over illicit smoking and insufficient cessation/withdrawal support. • Despite this, an unpublished study found a 75% reduction in second-hand smoke concentrations (PM2.5) and in 2012, prison management reported improvements over time, with strict enforcement of reducing numbers of disciplinary incidents, reductions in the use of other illicit drugs and prisoners stating the ban had provided an incentive to quit. • In 2013 the Manx government rejected an appeal by a prisoner to use e-cigarettes. Page 16 - Occasional Paper Number 25

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New Zealand (section includes additional material from three other reviews/opinion pieces [4, 8, 13]): • Introduced the first country-wide ban in 2011 on smoking within prisons and outside areas (including prisoners in open-type prisons, who were not allowed to smoke even outside prison grounds). Reasons for the ban included the broader New Zealand objective of a smoke-free nation by 2025 and, within the prison context, reduced risks of fire, litigation from non-smokers (prisoners and staff), violence/bullying associated with tobacco, and the opportunity to impact on health of not only prisoners but also their families. • Careful preparatory work included information-gathering in relation to the experiences of other jurisdictions which had introduced bans, preparation of a detailed communications strategy to increase awareness of changes, and cessation support and planning in relation to potential security issues. • In the year before the ban: prisoners received educational materials; psychological and pharmacological support was offered to both prisoner and staff smokers, a Quitline was promoted; staff had the opportunity to train as “workplace champions” to promote comprehensive cessation and provide advice and support to prisoners and colleagues; and police stations promoted the up-coming ban. Following the ban, families and communities were educated to provide post-release support. • Many prisons increased the availability of group activities (e.g. art, sport), recreational equipment (e.g. board games, gym equipment) and healthy food options (e.g. carrot sticks as snacks, aiming to reduce potential weight gain in those who quit). • Two months before the ban started, prisoners had their last chance to buy tobacco. When the ban began, all tobacco and smoking paraphernalia had to be surrendered; the policy is to search and seize such items from prisoners and visitors. • Nine months before the ban started, voluntary smoke-free units were established, receiving unexpected levels of prisoner support. • Following the ban, negative incidents included: increases in contraband tobacco and a doubling of the black-market price; smoking of alternative substances (e.g. nicotine patches, tea leaves); increased reported violence between prisoners in one prison; and ‘niggles’ from some prisoners who had not been involved in the year-long lead-up. However, no major incidents were reported, prevention of tobacco smuggling improved over time, second-hand smoke concentrations (PM2.5) reduced by 63% compared with pre-ban levels, and both fires and arsonrelated incidents decreased (from 18 in the month before introduction of the ban to four the month after its introduction and one the month after that – attributed to the prohibition of lighters). Prisoners were also reportedly more concerned about relapse following release. A year post-ban, independent evaluation noted: staff understood its purpose and were committed to its success; tension between prisoners and staff had reduced; staff-reported improved working conditions; and some staff had reduced or quit smoking. California, US: • Introduced a total ban within all prison sites in 2005, following a partial ban (allowing smoking outside prison buildings) which had been in place since 1998. The partial ban had not eliminated covert smoking, and legal claims in respect of second-hand smoke had been filed by staff and prisoners. • Six months before it started, prisoners and staff were informed about the up-coming ban, and provided with educational materials. However, neither NRT (which was seen as expensive, potentially subject to misuse and unnecessary, given the short nicotine withdrawal period) nor psychological support (which was seen as unnecessary, given that all prisoners would be withdrawing together) were provided. Page 17 - Occasional Paper Number 25

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• Three months before the ban, prisoners had their last chance to buy tobacco. • On the day of the ban, no extra staff were provided, nor were there extra searches. • After the ban, anyone smoking was subject to disciplinary procedures and staff caught smuggling tobacco were dismissed. • It has been reported that: the Californian ban has had almost no problems (no incidents or rioting), attributed to a strong ‘top-down’ approach; some prisoners quit before the ban and others described an increased sense of empowerment following successful post-ban quitting; health outcomes have improved (40% reduction in cardiology visits); and health costs have reduced. Smoking bans in UK high-security psychiatric hospitals Hospitals were given an extra year before having to adopt the smoking bans in public places which were introduced in Scotland in 2006 and England Wales in 2007. Carstairs (based on an NHS Scotland report [92]) • Carstairs State Hospital is part of the NHS in Scotland. It has 140 high-secure beds and employs around 650 staff. • In 2011 it was rebuilt and as part of the business case around its redevelopment, the Scottish Government agreed it would be a smoke-free environment, both internally and externally. The hospital had an existing Smoking Cessation service. • A partial (indoor) ban was introduced on 1st August 2011, the move to the new hospital site occurred on 21st September and the total ban began on 5th December. • From March 2011: a multi-disciplinary Smoking Cessation Taskforce was formed and two full time Smoking Cessation Advisors were seconded to the service; there was wide communication and consultation, with results from patients including: (1) only 14% favoured a total (rather than partial) ban, and (2) 73% suggested they would need NRT to help them quit and (3) 40-57% (ordered highest to lowest) thought they would need more activities available on wards, smoking cessation groups, increased opportunities to access fresh air, increased opportunities to be active, and support with weight management. • Information provided in the run-up to the ban included: information patient leaflets on stopping smoking, a smoking resource pack for all patients (smokers and non-smokers) and visitor leaflets (patients declined smoking ‘countdown posters’ because they might cause unnecessary panic). • In the run-up, Cessation Service-related activities included: profile-raising activities and initiatives; referral rates increased; a new NRT prescribing protocol was developed, including a wider variety of products; Smoking Cessation staff engaged with every smoker-patient and held NRT awareness days to explain and allow patients to try available NRT products and choose the most appropriate; escorted walks and diversionary activities were offered (with variable take-up). • During the partial ban: efforts directed towards supporting patients to stop smoking intensified; smoke rooms were closed and visual smoking cues (e.g. ashtrays) removed. • During the partial ban: patients went to smoke outside regardless of the weather, congregating around the one external lighter that had been provided; patients tended to ‘power smoke’ and daily schedules revolved around cigarette breaks; there were requests for electronic cigarettes although these were known to be prohibited. • Although patients stated that the non-smoky environment was helpful to those trying to give up smoking, staff concerns over passive smoking continued. • There were staff education and awareness initiatives which included a focus on concerns about increases in patient aggression levels following a total ban. • There was a further consultation, at which 36% (i.e. an increased proportion) of patients stated a preference for a total ban. Page 18 - Occasional Paper Number 25

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• The day before the total ban, the Hospital shop stopped selling tobacco products, following a phased brand-by-brand removal. • Following the total ban: there were no significant problems in respect of implementation and no significant incidents or breaches of security recorded directly related to smoking. There was some patient agitation and aggression, partly attributed to nicotine withdrawal. • Around 90% patients required a reduction in their clozapine (anti-psychotic medication) dose after they stopped smoking. • Patients reported satisfaction with their quit smoking achievements and surprise at their ability to cope; within four weeks, 19 of 70 patients smoking before 5th December stopped their NRT prescription. • The State Hospital’s report on the process concluded that crucial success factors included: appropriate leadership, funding and resources; continual support and encouragement provided to all stakeholders; effective planning and preparation; continual communication with, consultation and involvement of all key stakeholders; provision of appropriate information including research materials; consistent application and enforcement of the smoking policy; and support from key stakeholders. Broadmoor: • Introduced a total ban for patients and staff in 2008. • The lead-in period was reportedly “long”. Information was provided to patients, staff and visitors, and smoking cessation organisations were invited in, to encourage quitting by both patients and staff. • In the months leading up to the ban, staff were asked not to smoke in the hospital and a staff smoking shelter was built outside the gates. • Before the ban, smoking rooms were decommissioned, extra sports and leisure activities provided, and patient rooms searched. • After the ban, NRT (delivered under supervision on a replacement basis to patients) and smoking cessation support continued for patients and staff. Staff received training to help support patients. • A pre-ban negative outcome was excessive smoking by some patients. However, implementation was described as a “non-event” with no major incidents. Initial post-ban issues included: staff smuggling and patient stockpiling of tobacco; covert smoking; smoking of inappropriate alternatives; and patients buying extra food and so gaining weight. However, once hidden supplies ran out, patients were forced to quit, and between 2009 and 2012 there was a marked decrease in smoking-related incidents. Associated drug-use also reportedly reduced. Rampton (section includes additional material from a publication on the impact of the ban [93]): • Introduced a total ban in all buildings and grounds, covering patients, staff and visitors, in 2007, and so was the first smoke-free UK high secure hospital. • Three months before the ban: patients were informed; patients and staff were encouraged to offer ideas for successful implementation; cessation support was offered to patients and staff. • When the ban began, all wards were fully staffed, additional patient activities were provided and all tobacco and smoking paraphernalia were removed. Following the ban; prohibition of tobacco and smoking paraphernalia were rigorously enforced, with dedicated searches if required; psychological and pharmacological support continued; staff smoking cessation training became mandatory; and care-plans for new patients specifically considered smoking cessation at the preadmission stage. Page 19 - Occasional Paper Number 25

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• Reported outcomes include only a small number of minor issues, including smoking alternative items, using alternative forms of ignition (e.g. toasters, hand-dryers), visitor smuggling and difficulties with compliance among some staff. However the ban has reportedly helped both patients and staff quit. Pre-ban concerns about increased patient self-harm, behavioural disturbances and psychotropic medication use were largely unfounded. Although violent incidents increased among smokers, they did not among all patients (because of a drop among non-smokers), the mean dose of regular anti-psychotic medication dropped in the month the ban was introduced and seclusion rates remained stable. There were no incidents of fire or major indiscipline in the four months following the ban. Surveys showed that following its implementation, the proportions of both patients and staff in favour of the ban increased, while prisoner concerns about health impacts and staff concerns about aggressive behaviours, selfharm and medication requirements all decreased. • In May 2008 some patients brought a human rights legal case, arguing a right to smoke in their ‘home’. The High Court ruled that patients had no legal right to smoke and that the ban was rational on the grounds of reducing workplace second-hand smoke exposure. The Court of Appeal also judged that patients had no legal right to smoke. Total bans in UK Young Offenders’ Institutions The 2014 review conducted by the Offender Health Research Network [16] did not include YOIs among their case studies. These examples come from other papers. HMYOI Wetherby, Yorkshire [94] • This institution had a pro-active Governor who decided to implement a total ban in January 2005, over two years before it was legally required. • A participatory approach was taken, including both staff and offenders. • There was early contact with local NHS smoking cessation services, resulting in their input to large-scale staff education on the health impacts of smoking and cessation training for smaller numbers. • Six months before it started, efforts were made to “inundate all [offender, staff and visitor] areas” with information on the ban and no-smoking literature. • Two months before it started, offenders were asked what sort of support they anticipated requiring. • In the month before it started: NHS cessation services held a no-smoking event at the institution, which featured on local tv news; NRT (patches) was supplied to any staff member who requested it; information was sent to courts, visitors and receiving establishments; a staff smoking shelter was built outside the grounds; a protocol was established, requiring assessment of all new offenders for nicotine dependence on admission; and offenders were not allowed to buy tobacco. • The paper describes the implementation of the ban as “successful”, and notes that it has been recognised as an example of good practice, but provides no further details. HMYOI Ashfield, Gloucestershire [95] • This YOI also introduced a total ban over two years before it was legally required (in February 2005). • Local NHS cessation service staff trained prison staff to provide advice to offenders and other staff. • Staff who smoked were provided with NRT (patches/lozenges) for use while at work, and were allowed to leave the prison to smoke on day-shift (but not night-shift) breaks. Page 20 - Occasional Paper Number 25

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• Threatened disruption by offenders did not materialise, but minor disagreements increased in the month after the ban was introduced, perhaps due to nicotine withdrawal. • There were only two fires in the ten months following the ban, compared with 27 in a tenmonth period before it. HMYOI Warren Hill, Suffolk [96] • A study at this YOI in Suffolk which compared rates of bullying six months before, and six months after the introduction of a total smoking ban in April 2007, found that rates had decreased. It also identified currency used within bullying, including toiletries, biscuits/crisps, sweets/chocolate, drinks, rosary beads and stamps [96]. 5.10 Implications of detailed case studies The 2014 review conducted by the Offender Health Research Network [16] concludes its detailed case studies with a section on their implications. These ([16], p28-29) can be summarised as: • Partial bans appear less effective both managerially and in terms of reducing second-hand smoke exposure. Total bans should therefore be considered. • Successful introduction of a smoking ban policy is associated with: thorough planning; a long lead-in; clear communication and consultation with all involved; clear managerial instruction; comprehensive cessation support (prisoners and staff); provision of alternative activities; and strong staff support. • The Rampton case, establishing that there is no legal right to smoke, would inform any future case against a UK prison service following a total ban. A total ban would prevent litigation in respect of second-hand smoke exposure within prisons. • There is no evidence that smoking bans significantly increase disorder. • High prisoner smoking rates will translate into high need for cessation support which should include NRT, helplines, educational materials and professional support. Such services should be available to staff as well as prisoners. • Good prisoner-staff relationships are helped by: clear communication; inviting prisoner involvement in policies and planning; and high levels of staff training and support. • At the start of any ban, activities related to its enforcement are likely to cause disruptions to daily routines. 5.11 Conclusions in respect of prison smoking bans On the basis of such evidence, most (but not all, e.g. [5, 20, 22]) reviews and opinion pieces conclude that, with sufficient careful preparation and communication with both prisoners and prison staff, total bans can be successfully implemented in prisons and/or are preferable to partial bans [1, 7, 8, 14, 23].

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6. Smoking Cessation Services in Prisons Most reviews make the point that to promote the most effective longer term impact, prisons need tobacco-related policies related to both supply (e.g. smoking bans) and demand (e.g. cessation support) [2]). While smoking is associated with significantly reduced life expectancy, cessation (even at older ages) helps to reverse these effects. For example, the UK Doctors’ Study which contributed much early evidence on smoking and mortality, showed that cessation at ages 30, 40, 50 or 60 resulted in gains of about 10, nine, six or three years of life expectancy respectively [42]. Several reviews note that prison represents an opportunity to promote smoking cessation to a “captive audience” [19]. This section draws on the studies most commonly cited in the reviews to address whether prisoners want to quit smoking, to provide a brief international and historical perspective on provisions of cessation services and to provide evidence from cessation interventions. 6.1 Do prisoners want to quit? The 2013 SPS prisoner survey found 60% of smokers wanted to quit [27]. Many reviews cite similar figures or note that large proportions of prisoners would like to stop smoking [1, 3, 6, 9, 11, 14, 18, 19, 21]. Relevant studies 5 from the UK include a 2003 survey of Welsh male prisoners which found 79% wanted to quit [97], and a 2005 study of patients in a forensic psychiatry service which reported that 97% said they would consider quitting sometime in the future [98]. Elsewhere, a 2006 study of male and female Australian prisoners found 58% of smokers had plans to quit [99], a 2011 US survey of male prisoners in prisons with indoor smoking bans reported 70% wanted to quit and 64% thought they were likely to try quitting in the next year [65], and a 2010 study of US prisoners serving community sentences found 60% were thinking about quitting [100]. The 2013 SPS prisoner survey also found 39% had tried to give up in the past year [27] and, again, many reviews cite figures from other studies. Within the UK, the 2005 study of forensic psychiatry patients found 88% had tried to quit in the past, with the most significant barrier (identified by 79%) being seeing other patients smoking [98]. A UK study of prisoner cessation highlighted the sense of accomplishment among those who were successful, with quitting described as “a big achievement to them” by a healthcare provider and a prisoner who reported “I feel good about this achievement” [101]. Elsewhere, a 2006 study of Polish male prisoners found 75% of smokers had tried to quit in the past (54% while in prison), and 48% had tried to quit on more than five occasions [102]. In Australia, a 2006 study of male and female prisoners found 52% of smokers had tried to quit or reduce the amount smoked in the past year [99] and a survey of male and female prisoners found 70% of smokers had tried to quit at some point (63% while in prison), with 74% of this group saying it was harder to quit in prison than in the community [103]. In the US, a 2003 study of female prisoners who smoked found that 52% had attempted to quit in the past year and 80% reported it had been (very) difficult [104], a small 2010 study of male prisoners in prisons with indoor bans reported 86% of smokers had previously attempted to quit on between one and five occasions [71] and a 2011 survey of male prisoners in prisons with indoor bans found 64% had made at least one 24-hr quit 5

Note that since desire to quit might be related to imprisonment in institutions with a smoking ban, study descriptions in this section note if bans were reported. If this is not noted then either the study was conducted in an institution without a ban, or the study report does not mention a ban. Desire to quit might also be related to imprisonment in institutions in the run-up to a ban, but no study mentioned this. Page 22 - Occasional Paper Number 25

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attempt before their arrest, generally stopping cold turkey (77%) and 29% had made at least one 24-hour quit attempt in prison, again generally stopping cold turkey (77%) [65]. None in this last study reported participating in available group cessation sessions or using NRT and only 6% reported success in quitting in prison. 6.2 Provision of cessation services Several reviews note that, despite the fact “prison arguably presents an ideal opportunity to quit smoking” [13](p100), provision of smoking cessation services, varies considerably (like other healthpromotion opportunities [105]) but is often poor and, as noted above, tends to be given low priority. Many reviews highlight how, in the US, the introduction of prison smoking bans was sometimes associated with reductions in cessation services. This was because it was believed that such services were not only costly, but would also be unnecessary since tobacco products had been removed [9, 11, 12, 21]. Thus, the 2007 survey of tobacco policies in US prisons reported tobacco cessation programmes in around half of prisons without a total ban, but in 39% of those with a total ban; similarly, cessation aids (e.g. NRT) were available in 65% of prisons without, and 35% with, a total ban [66]. Within Europe, an example of variability in cessation services comes from a Swiss study of three prisons, all of which restricted smoking to cells and outdoors but offered very different cessation support: 28%, 69% and 38% prisoners in the different prisons reporting ever having been asked if they wanted to quit, and 20%, 46% and 21% had been offered help to quit [106]. The PHE review [19] notes variability in provision of smoking cessation in England and the 2015 Scottish Specification for a National Prison Smoking Cessation Service highlights “the need for an equitable, consistent and person-centred smoking cessation service to be delivered to all prisoners who want to stop smoking” [107](p5). 6.3 Evidence from prison smoking cessation interventions Several reviews note that evidence is scarce in respect of prison-based smoking cessation interventions. Several (e.g. [2, 19]) include general discussion of factors contributing to cessation success more generally; that is not covered here. This section describes specific studies (or series of studies) on smoking cessation in prisons from the UK, US, Australia and elsewhere. UK prison smoking cessation interventions • A very small (N=10) 2002 report of a pilot study in a Worcestershire category A prison described a group run for eight prisoners and two staff members by a Specialist Quit Smoking Advisor, in consultation with prison healthcare staff. The programme, which included NRT (patches/inhalators), psychological support and, unusually, physical measurements (including blood pressure and respiratory function), resulted in five quitters who all expressed an interest in helping other prisoners to quit [108]. While of interest, this study is too small to permit firm conclusions. • A series of studies, beginning in 2002, have investigated the impact of NRT, social marketing and the introduction of a Criminal Justice Service Tobacco Control Co-ordinator in English prisons [30, 101, 109, 110]. Overall, these studies by MacAskill et al demonstrate that cessation can be achieved in prison settings, although none have included long-term follow-up. The group translated their work into a “best practice checklist”, including the needs for: effective healthcare-prison partnerships; a range of cessation delivery models; protected staff time and Page 23 - Occasional Paper Number 25

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•

•

•

•

role development; clear record keeping; assessment and exploitation of prisoner and staff wishes to quit; ring-fenced/clearly identified NRT budgets; straightforward NRT prescribing and dispensing; staff training and ongoing support; additional support approaches (e.g. peer support, access to exercise programmes); clear care pathways; wider tobacco control (i.e. prison smoking bans); and awareness and anticipation of relevant legislation and guidance [101]. A more recent (2010) paper describes barriers and facilitators to the work of a regional CJS Tobacco Control Co-ordinator, reporting that although they were able to enhance cessation service delivery within prisons, this was more difficult in probation settings and impossible in police custody settings because tobacco control issues were not on the agenda. The authors conclude that while such posts may have potential, more strategic cross-CJS approaches are required [109]. The 2002 MacAskill et al report describes a pilot smoking cessation project in five prisons, operated alongside local NHS smoking cessation services. The aim was to provide an evidencebased service at the same level as offered to the local community, including: staff training as cessation advisors, six weeks of group/individual support, free NRT and staff cessation support. Four-week quit rates among 158 prisoners were 66% for those receiving group and 18% for those receiving individual support; 88% of the 38 staff who participated had also quit. The report notes that these rates are equal to, or higher, than those in community settings. It also describes the importance of NRT provision and support at prison management level [110]. A one-year study, reported by MacAskill in 2005 (including some detailed case studies), examined cessation services and NRT provision in 16 English prisons finding an average fourweek quit rate of 41%, but with a vast range (8-64%) between prisons. All prisons provided NRT in the form of new-for-old patches, but varied in respect of additional support (group/individual/enhanced), and there was no clear relationship between type of support and success. High quit rates were associated with: staff experience, commitment and enthusiasm (“champions”); time and organisational support; prisoner mutual support and recognition of successes; and clearer care pathways, including continued NRT provision on transfer or release [111]. A later (2008) paper by MacAskill et al describes a smoking cessation programme conducted with 159 prisoners in four prisons which included a mix as described above (six weeks group/individual support plus NRT), but with an emphasis on ‘the Ps’ of social marketing. The focus was therefore on enhancing the product (quitting success), emphasising its (high) price (in terms of both health and economic costs), awareness of place (in particular, facilitating access to smoke-free places), use of promotion (materials, word-of-mouth, buddying) and involvement of partners (advisors, seen as separate from prison staff). An unintended negative consequence which required management was the development of an internal market for nicotine patches. However, positive results included four-week quit rates averaging 66% (range 56-100%) following group, and 25-40% following individual support, and a number of long-term outcomes related to awareness of smoking and receptivity to cessation within the prisons [30]. One review [18] describes two Scottish smoking cessation initiatives ([40, 112] – original reports unavailable). The first [40], reported in 2006, occurred in HMP Bowhouse, Kilmarnock. The prison offered cessation support to both staff and prisoners, delivered via a Smoking Cessation Advisor and trained prison staff and comprising NRT (prisoners only) and rolling 10-week group/individual support programmes, promoted via written materials and a DVD, because of low literacy levels. The review does not report quit rates, but highlights that it was difficult for staff to attend, leading the authors to suggest that if staff cannot have time off for prison-based cessation support then community/pharmacy-based services may be more appropriate. The second initiative [112], reported in 2009, occurred in HMYOI Polmont and comprised a 12week group/individual support and NRT programme. Novel aspects included emphasis on peer

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support and participant ownership (input into decisions on order of session delivery), plus brief interventions offered at prison entry and exit. Again, the review does not report quit rates. US prison smoking cessation interventions • A very early (1978) paper reporting on two small studies (N=14, N=28) of male prisoners found significant reductions in smoking at one-week follow-up after four 90-minute (study 1) and ten 30-minute (study 2) weekly group sessions focusing on self-control techniques [113]. This study highlights that recognising the importance of understanding how best to intervene in respect of prisoner smoking is not a new issue. • Cropsey at al (2008) conducted a randomised controlled trial of smoking cessation among female prisoners [114]. The intervention comprised a 10-week group “standard behavioural” and mood management training intervention plus NRT. Quit rates in the intervention group were 18% immediately after the intervention, falling to 14% at 6-months and 12% at 12-month follow-up; rates were significantly higher in the intervention group than a waiting list control group from 4 weeks into the intervention until 6 months post-intervention. The study also found that successful cessation was related to number of sessions attended, and that short- but not long-term cessation was related to compliance with NRT. The authors conclude their study shows smoking interventions with female prisoners are feasible, acceptable and quit rates are “commensurate with those seen in non-prisoner samples exposed to similar smoking cessation interventions” (p1899). • An intervention comprising six weekly sessions of motivational interviewing and cognitive behavioural therapy, designed to prevent return to smoking following release from a smoke-free prison, is described in papers by Clarke et al [87, 115]. Three weeks after release, 25% of the intervention and 7% of the control group (who had watched health-related DVDs) were abstinent; abstinence rates three months after release were 12% and 2% respectively. The study also found continued abstinence was more likely among those who had not smoked for 6 months or longer at the time of the intervention, allowing them to conclude both that intervention to prevent smoking relapse after release can be effective, and that “prolonged forced abstinence can improve smoking outcomes” [87](p793). The motivational interviewing component of this intervention may have been particularly important, given US evidence of associations between: self-initiated smoking reduction prior to participation in a cessation intervention and initial higher quit rates [116]; thinking about quitting and actually managing to quit among prisoners in prisons with a total smoking ban [117]; and pre-release intention to quit and actually managing to continue abstinent from tobacco following release from such prisons [71] Australian prison smoking cessation interventions • A series of studies have been reported by Awofeso et al. A 2001 paper mentions a pilot cessation programme including NRT (no other details given) which, after six months, resulted in four of 24 participants having completely quit and nine having reduced the amount smoked [118]. A 2003 discussion paper on implementation of prison smoking cessation programmes suggests the need to make sure they are tailored for the prisoner population and describes a social marketing approach as appropriate to achieve change in both prison culture and individual smokers’ behaviour. This includes framing smoking as a behaviour (rather than as a habit), raising awareness of the costs (health and financial) of smoking and the benefits of attempting to quit, and using “the Ps” of social marketing as also suggested by MacAskill et al’s 2008 paper. Although based on experience in developing cessation programmes in eight prisons, no results Page 25 - Occasional Paper Number 25

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are included [119]. In contrast a 2008 paper does include evidence of the benefits (in terms of reduced long-term quit rates and increased self-initiated attempts to quit), of the addition of “positive deviance” techniques (drawing attention to non-smokers and quitters and promoting their success strategies) to standard cessation programmes [120]. • Another series of cessation studies is described by Richmond, beginning with a pilot and ending in a randomised controlled trial. A 2006 paper describes the pilot: 30 prisoners received NRT, bupropion (Zyban), two brief cognitive behavioural therapy sessions and self-help materials. At six-month follow-up, six (22%) remained continuously abstinent which the authors described as “encouraging” [121]. This was followed by a qualitative paper, based on focus groups with prisoners, identifying many of the characteristics of prisons as barriers to cessation [122]. Lessons learnt from these earlier studies fed into the development of a multicomponent smoking cessation intervention described in a 2009 paper. The intervention, which was tested in a randomised controlled trial, comprised the addition of antidepressant medication to more standard cessation support (NRT, two brief cognitive behavioural therapy sessions, supportive quitline access and self-help materials). It did not improve abstinence rates compared to those who only received standard support [123, 124]. • In 1998, a tailored prisoner smoking cessation programme, ‘Quitters are Winners’, comprising six two-hour sessions including social marketing and behavioural strategies plus NRT, was developed in Victoria. An evaluation covering 2002-7, based on an intention-to-treat analysis found quit rates of 13% and 7% at one- and three-month follow-ups respectively. Continued smokers had reduced the amount smoked and felt better prepared to quit in future. The authors concluded that the course “demonstrated that a prison based cessation course can be effective in assisting prisoners to quit smoking, to reduce consumption, and to feel better prepared to quit in the future” [125](p2). European evidence on prisoner smoking cessation • A Polish survey identified factors associated with prisoners’ cessation attempts (both in and outside prison) including anxiety about health, wanting to show strength and saving money, [102] and a small Greek study found characteristics associated with successful cessation attempts within prison were older initiation, previous reductions in smoking while in prison, previous quit attempts, no other substance use, fewer cellmates and fewer who were smokers [126]. 6.4 Factors impacting on the success of prison smoking cessation interventions Based on the results of the studies described above and the associated commentaries on process, several reviews [6, 9, 18, 19, 21] draw together factors which impact on the success of smoking cessation interventions. These can be summarised as suggesting that cessation success will be increased by: Operational factors • Adoption of a social marketing framework in the broader presentation and process of prisoner smoking cessation. • A supportive atmosphere, with quit achievements celebrated by both staff and other prisoners and “healthy competition” among quitters. • Using existing groups, committees and management structures to raise awareness. • Offering access to alternative activities and/or facilities to reduce stress or boredom and providing incentives (e.g. sport, private meetings).

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• Ensuring consistent messages about, and approaches to, cessation throughout the CJS (e.g. provision of NRT in police stations, court cells and during transfers). • Providing assessment, information and appropriate support on arrival. • Delivering “joined up care”, ensuring pharmacotherapy and any behavioural or counselling support are maintained on transfer to other prisons and that medical records are transferred with the prisoner. • Providing pre-release support (e.g. ways to avoid common triggers; information about local services). Staff-related factors • Ensuring staff understand the requirement for cessation services and that, with appropriate support, prisoners can quit smokingl. This will require appropriate education of all new staff. • Training staff in smoking cessation. • Supporting staff who choose to make a cessation attempt themselves. • Ensuring dedicated staff time for delivery of, and/or organisation related to, cessation programmes (e.g. managing waiting lists, distributing patches). Cessation service and support-related factors • Involvement of prison staff in cessation support and including external Cessation Advisors. • Managing waiting lists to ensure motivation has not disappeared by the time support is offered. • Interventions which combine pharmacological and behavioural support. • Adopting a new-for-old NRT replacement policy to ensure it is not misused. • Tailoring support materials, particularly addressing low literacy levels. • Considering whether cessation support attendance should be mandatory for all prisoners who smoke (and indeed whether this is feasible given available resources). • Establishing peer support groups for both prisoners and any staff attempting to quit, to facilitate the sharing of experiences and increase a sense of empowerment. • Addressing concerns about weight gain, perhaps by combining smoking cessation and weight interventions. • Providing appropriate additional support to those with mental health and or substance use problems, particularly given evidence that stopping smoking is unlikely to exacerbate their problems and may actually reduce them [127, 128]. • Promoting encouragement from, and involvement of, family members. This might include linking with community cessation programmes to offer support to prisoners’ families. • Linking community cessation and prison programmes and referring automatically on release, to ensure continued support.

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7. Electronic Cigarettes Electronic cigarettes (e-cigarettes) first appeared on the market around 2005 [129]. By 2014, 5% of adult (age 16 and over) Scottish Health Survey participants were current e-cigarette users and 10% previous users. Ever use was highest amongst younger age groups (20% of 16-24 year olds) and current use was highest amongst middle age-groups (6-7% among 35-64 year olds) [26]. E-cigarette use is strongly associated with smoking, with very low rates among never-smokers. E-cigarettes are now also associated with quit smoking attempts: among 2014 Scottish Health Survey participants who had attempted (successfully or unsuccessfully) to quit in the past year, 32% had used ecigarettes [26]. The 2013 Scottish Prisoner Survey found 72% had heard of e-cigarettes and (16%) had used them, but 69% said they would use them if they were available in prison [27]. Few reviews are recent enough (i.e. 2014-15) to include discussion of e-cigarette use in prisons (either generally or in conjunction with a tobacco ban). Opinions, both in terms of evidence and reviews or opinion pieces, are mixed in terms of their support for the use of electronic cigarettes in prisons. In respect of availability of e-cigarettes in prisons, a 2014 US paper notes that e-cigarette manufacturers have begun to lobby criminal justice settings (e.g. providing samples, suggesting that allowing e-cigarettes will eliminate contraband tobacco) and some US prisons have begun to sell ecigarettes. This paper notes the unique risks of such products in prisons (e.g. for hiding illicit substances or making weapons) and describes three new brands targeted specifically at prisons (Crossbar, Lock-up and Precision Vapor e-cigarettes have soft and/or clear plastic, rather than hard metal casings so cannot be used as weapons and are less likely to be used to hide illicit substances) [130]. Within the UK, in December 2014, BBC news reported that e-cigarettes were being sold in a small number of English prison shops, quoting National Offender Management Service officials as suggesting the e-cigarette pilot scheme had been set up to prepare the ground for a total smoking ban 6. The September 2015 announcement of total smoking bans in all four Welsh prisons and four English prisons in 2016 as the start of the process towards smoke-free prisons in all English and Welsh prisons was accompanied by the statement that “Prisoners will have access to e-cigarettes and other support to stop smoking" 7. Evidence on the potential benefits and harms of e-cigarettes is limited, and the views of public health researchers and advocates are divided [131-133]. The 2015 PHE review [19] refers to a 2014 PHE report describing the hazards associated with both use and passive exposure to electronic cigarettes as “likely to be extremely low” [134](p14). However, the conclusion of a more recent (2015) PHE report, that e-cigarettes are “around 95% safer than smoking” [129](p6) has been criticised on the basis of reliance on poor-quality evidence [135]. In respect of their use as a cessation aid, a 2014 Cochrane review concluded, on the basis of only two available trials, that nicotine-containing e-cigarettes “help smokers to stop smoking long-term” compared with ecigarettes without nicotine (p2), but that the available high-quality evidence was low [136]. The 2012 review by Ritter [21] makes general reference to the importance of harm reduction for those unable or unwilling to completely quit, and her 2014 opinion piece suggests that prisoners who smoke “should have access to less hazardous tobacco products (such as electronic cigarettes and smokeless tobacco), just as they would have outside of prison” [22] (p1). In contrast, a 2015 US opinion-piece questions whether e-cigarettes in prisons are “a panacea or a public health 6 7

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problem”, suggesting that although less harmful than tobacco, they may “cue craving among former smokers in this vulnerable population, prolong nicotine dependence, and possibly increase return to traditional cigarettes after leaving jail” [137](p103). The piece also suggests that e-cigarettes may not bring benefits in terms of reduced psychological distress and increased positive mood which are associated with long-term nicotine abstinence and that the likelihood of relapse to tobacco on release may be higher among e-cigarette users than prisoners who have achieved long-term nicotine abstinence [137].

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8. Summary This review of evidence on smoking and smoking restrictions in prisons, produced for the Scottish Prison Service Tobacco Strategy Group, aimed to identify and describe literature relating to: the rationale for restrictions on prisoner smoking; the current position and culture; types of restriction and associated processes; and the experiences of jurisdictions which have introduced bans. The review is divided into five sections: prevalence of smoking in prisons; health impacts of smoking in prisons; prison smoking bans; smoking cessation in prisons; and electronic cigarettes. There was far more empirical evidence in respect of some areas (e.g. prevalence of prisoner smoking) than others (e.g. health impacts of prisoner smoking). The findings of the review can be summarised as follows: Prevalence of smoking in prisons • Smoking rates among prisoners are very high, at around two to four times those of the general population, in all studies internationally. • Evidence of smoking rates among prison staff is scarce, but with some suggestions of higher rates than among the general population. • High prisoner smoking rates can be explained by both: prisoner characteristics (generally from population groups with high smoking rates and high resistance to cessation; and prison characteristics (smoking is a part of prison culture, historically permitted/encouraged, cigarettes/tobacco are used as currency and prisons are challenging settings for cessation services). Health impacts of smoking in prisons • The impact of tobacco on health is well-known, and some studies draw on this to suggest the impact of smoking on prisoner health. • The small number of studies to examine direct associations all show negative impacts of smoking on the health of prisoners who smoke. • Objective measurements show high levels of second-hand smoke (SHS) in prisons. • Evidence that SHS causes diseases and death has been used to make the point that prisoner smoking will impact on the health of all prisoners and prison staff, regardless of their own smoking status. Prison smoking bans • Prison smoking bans vary in respect of who (staff and/or prisoners) and where (all/some indoor/outdoor areas) they cover, and have been gradually introduced, in a number of countries, over the past 25 years. • Rationales for bans include health, economic costs, concerns about litigation and safety. • The few studies to have taken objective measurements have generally found reductions in SHS following implementation of indoor bans. • There is evidence of positive impacts on prisoner health following the introduction of prison smoking bans. • Pre-ban concerns relating to violence or riots generally prove unfounded. • Tobacco black markets are the most frequently reported negative outcome following a ban. • Staff enforcement is key to the success of any ban. • The little available evidence suggests that simply banning smoking has no impact on longer-term cessation. Page 30 - Occasional Paper Number 25

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• A series of detailed case studies suggests that: total bans are more effective both managerially and in terms of reducing SHS exposure; it is possible to identify processes associated with successful introduction of a smoking ban; there is no evidence that smoking bans significantly increase disorder; it has been established that there is no legal right to smoke (Rampton case); bans should be accompanied by cessation support. Smoking cessation services in prisons • A majority of prisoners report that they want to quit smoking. • Although prison represents an ideal opportunity to quit, cessation service provision tends to be patchy and inconsistent. • Studies of prison-based smoking cessation interventions suggest that it is possible to identify operational, staff-related and cessation service/support-related factors which impact on their success. Electronic cigarettes • Although relatively new phenomena, rates of e-cigarette use have increased rapidly in the general population. • E-cigarette use is associated with both smoking and with quit-smoking attempts. • There is evidence of e-cigarette use within criminal justice settings internationally (US) and in England and Wales. • While one recent opinion piece suggests prisoners who smoke should have access to ecigarettes, another urges caution; this disagreement reflecting divided opinion among public health researchers and advocates about e-cigarettes more generally.

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ASH UK: Smokefree Prisons. In. Edited by ASH Action on Smoking and Health UK; 2014. Awofeso N: Reducing smoking prevalence in Australian prisons: a review of policy options. Applied Health Economics and Health Policy 2002, 1:211-218. Baybutt M, Ritter C, Stover H: Tobacco use in prison settings: a need for policy implementation. In: Prisons and Health. edn. Edited by Engqist S, Moller L, Galea G, Udesen C. Copenhagen: WO Regional Office for Europe; 2014. Bonita R: New Zealand leads the way in banning smoking in prisons. BMJ 2013, 346:f3923. Butler T, Richmond R, Belcher J, Wilhelm K, Wodak A: Should smoking be banned in prisons? Tobacco Control 2007, 16:291-293. Butler T, Stevens C: National Summit on Tobacco Smoking in Prisons: report on the summit. In. Perth, Western Australia: National Drug Research Institute, Curtin University; 2011. Collier R: Prison smoking bans: clearing the air. Canadian Medical Association Journal 2013, 185:E474. Collinson L, Wilson N, Edwards R, Thomson G, Thornley S: New Zealand’s smokefree prison policy appears to be working well: one year on. New Zealand Medical Journal 2012, 125:164-168. Cork K: Tobacco Behind Bars: policy options for the adult correctional population. In. St Paul, Minnesota: Public Health Law Center; 2012. Djachenko A, St John W, Mitchell C: Smoking cessation in male prisoners: a literature review. International Journal Of Prisoner Health 2015, 11(1):39-48. Donahue JJ: Tobacco Smoking Among Incarcerated Individuals: A review of the nature of the problem and what is being done in response. Journal of Offender Rehabilitation 2009, 48:589-604. Eldridge G, Cropsey KL: Smoking bans and restrictions in U.S. prisons and jails: consequences for incarcerated women. American Journal of Preventive Medicine 2009, 37:S179-S180. Gautam J, Glover M, Scott A, Welch D: Smoke-free prisons in New Zealand: maximising the health gain. New Zealand Medical Journal 2011, 124:100-106. Globalsmokefree Partnership: Reducing Tobacco Smoke Exposure in Prisons. In. Switzerland: Globalsmokefree Partnership, World Heart Federation; 2009. Hartwig C, Stover H, Weilandt C: Report on Tobacco Smoking in Prison: Final report workpackage 7. In.: Directorate General for Health and Consumer Affairs (DG SANCO). DG SANCO/2006/C4/02.; 2008. Jakeman S, Humber N, Shaw J, Senior J: Smoking in Prisons in England and Wales: An examination of the case for public health policy change. In. Manchester: Offender Health Research Network; 2014. Kennedy SM, Davis SP, Thorne SL: Smoke-Free Policies in U.S. Prisons and Jails: A Review of the Literature. Nicotine & Tobacco Research 2015, 17:629-635. MacDonald L, Angus K, MacAskill S, Eadie D: Rapid Literature Review of Smoking Cessation and Tobacco Control Issues Across Criminal Justice System Settings. In. Stirling: Institute for Social marketing, University of Stirling; 2010. PHE (Public Health England), King's College London: Reducing Smoking in Prisons: management of tobacco use and nicotine withdrawal. In. London: Public Health England; 2015.

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C. L, K. J: Issues in running smoking cessation groups with forensic psychiatric inpatients: results of a pilot study and lessons learnt. The British Journal of Forensic Practice 2005, 7:22-28. Sykes G: The society of captives: a study of a maximum security prison. Princeton, NJ: Princeton University Press; 1958. Liebling A: Doing research in prison: breaking the silence? Theoretical Criminology 1999, 3:47-173. de Viggiani N: Unhealthy prisons: exploring structural determinants of prison health. Sociology of Health & Illness 2007, 29:115-135. UK Prison Reform Trust: Bromley Briefings Prison Factfile. In. London: Prison Reform Trust; 2011. Clark C, Dugdale G: Literacy Changes Lives: the role of literacy in offending behaviour. In. London: National Literacy Trust; 2008. Cancer Institute NSW: Literature Review: Smoking and Mental Illness, other drug and alcohol addictions and prisons. In. Sydney NSW: Cancer Institute; 2008. Douglas N, Plugge E: A Health Needs Assessment of Young Women in Young Offender Institutions. In. London: Youth Justice Board 2006. Fischer E, Brownson R, Heath A, Luke D, Sumner W: Cigarette smoking. In: Handbook of clinical health psychology: Volume 2 - Disorders of behavior and health. edn. Edited by Raczynski J, Leviton L. Washington DC: American Psychological Association; 2004: 75-120. Darrall K, Figgins J: Roll-your-own smoke yields: theoretical and practical aspects. Tobacco Control 1998, 7:168-175. Romero C, Connell F: A survey of prison policies regarding smoking and tobacco. Journal of Prison and Jail Health 1988, 7:27-36. Vaughn MS, Del Carmen RV: Smoke-free prisons: policy dilemmas and constitutional issues. Journal of Criminal Justice 1993, 21:151-171. Douglas N, Plugge E, Fitzpatrick R: The impact of imprisonment on health: what do prisoners say? Journal of Epidemiology & Community Health 2009, 63:749-754. Awofeso N: Controlling tobacco use within prisons. International Journal of Tuberculosis and Lung Disease 1999, 3:547-548. Clemmer D: The Prison Community. New Braunfels, US: Christopher Publishing; 1940. Liebling A: Prisons and their Moral Performance: A study of values, quality and prison life. Oxford: Oxford University Press; 2004. Crawley E, Sparks R: Hidden injuries? Researching the experiences of older men in English prisons. The Howard Journal of Criminal Justice 2005, 44:345-356. Farnworth L, Nikitin L, Fossey E: Being in a secure forensic psychiatric unit: every day is the same, killing time or making the most of it. he British Journal of Occupational Therapy 2004, 67:430-438. Williams V, Fish M: Convicts, Codes and Contraband: The prison life of men and women. Cambridge, US: Ballinger; 1974. Greer K: The changing nature of interpersonal relationships in a women's prison. The Prison Journal 2000, 80:442-468. Medlicott D: Surviving the Prison Place. Aldershot: Ashgate; 2001. Dittmar H: Material possessions as stereotypes: material images of different socio-economic groups. Journal of Economic Psychology 1994, 15:561-585. Crewe B: The Prisoner Society: Power, adaptation and social life in an English prison. Oxford: Oxford University Press; 2009. Beck G: Bullying among young offenders in custody. Issues in Criminological and Legal Psychology 1995, 22:54-70. Page 42 - Occasional Paper Number 25

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235. 236.

Edgar K, O'Donnell I, Martin C: Tracking the pathways to violence in prison. In: Researching Violence: Essays on methodology and measurement. edn. Edited by Lee R, Stanko E. London: Routledge; 2003. Ireland J: Bullying among prisoners: a review of research. Aggression and Violent Behaviour 2000, 5:201-215. File S, Fluck E, Leahy A: Nicotine has calming effects on stress-induced mood changes in females, but enhances aggressive mood in males. The International Journal of Neuropsychopharmacology 2001, 4:371-376. Australian Institute of Health and Welfare: Smoking and quitting smoking among prisoners 2012. In. Canberra: Australian Institute of Health and Welfare; 2013. Leigh Day issues legal proceedings on behalf of non-smoking prisoner. In.; 2012. Voglewede JP, Jr., Noel NE: Predictors of current need to smoke in inmates of a smoke-free jail. Addictive Behaviors 2004, 29(2):343-348. Spurgeon D: Canadian prisoners strike over smoking ban. BMJ 2000, 321:402. Raemisch R, Listug D, Norwick J, Black J, Loveland R, Krause H, Anderson H: Cigarette smoking bans in county jails. Morbidity and Mortality Weekly Report 1992, 41:101-103. Felding J: Banning worksite smoking. American Journal of Public Health 1986, 76:957-959. Wodak A: Cigarettes or syringes: which is the best model for frug policy. Health Promotion Journal of Australia 2000, 10:95-99. NSW Department of Juvenile Justice: Young people in custody health survey. Key findings report. In. Sydney: NSW Department of Juvenile Justice; 2003. Foley KL, Proescholdbell S, Malek SH, Johnson J: Implementation and Enforcement of Tobacco Bans in Two Prisons in North Carolina: A Qualitative Inquiry. Journal of Correctional Health Care 2010, 16:98-105. Falkin G, Strauss S, Lankenau S: Cigarette Smoking Policies in American Jails. American Jails 1998, 12:9-14. Connell A: Tobacco-free Prison Policies and Health Outcomes Among Inmates, Doctoral Dissertation. University of Kentucky; 2010. Drach L, Morris D, Cushing C, Romoli C, Harris R: Promoting smoke-free environments and tobacco cessation in residential treatment facilities for mental health and addictions. Prevention of Chronic Disease 2012, 9:110080. O'Dowd A: Smoking ban in prisons would lead to more assaults on staff. BMJ 2005, 331:1228. Lincoln T, Chavez RS, Langmore-Avila E: US experience of smoke-free prisons. BMJ 2005, 331:1473. Awofeso N: Why fund smoking cessation programmes in prison? BMJ 2005, 330:852. Sweda E: Litigation on behalf of victims of exposure to environmental tobacco smoke. The experience from the USA. European Journal of Public Health 2001, 11:201. Vaughn MS, del Carmen RV: Research Note: Smoking in Prisons—A National Survey of Correctional Administrators in the United States. Crime & Delinquency 1993, 39:225-239. Heng C, Badner V, Clemens D, Mercer L, Mercer D: The relationship of cigarette smoking to postoperative complications from dental extractions among female inmates. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 2007, 104:757-762. Levy M: Prisons: issues to ponder. Of Substance - the national magazine on alcohol, tobacco and other drugs 2010, 8:12-13. Lawn S, Pols R: Smoking bans in psychiatric inpatient settings? A review of the research. Australian and New Zealand Journal of Psychiatry 2005, 39:866-885. Page 43 - Occasional Paper Number 25

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237. 238. 239. 240. 241. 242. 243. 244.

Campiona J, Lawn S, Brownliea A, Huntera E, Gynthera B, Polsc R: Implementing smokefree policies in mental health inpatient units: learning from unsuccessful experience. Australasian Psychiatry 2008, 2:92-97. Ratschen E, Britton J, McNeill A: Implementation of smoke-free policies in mental health in-patient settings in England. The British Journal of Psychiatry 2009, 194:547-551. Hehir AM, Indig D, Prosser S, Archer VA: Implementation of a smoke-free policy in a high secure mental health inpatient facility: staff survey to describe experience and attitudes. BMC Public Health 2013, 13:315. Perka E: A Targeted Training and Technical Assistance Initiative Affects Tobacco-Related Attitudes and Beliefs in Addiction Treatment Settings. Health Promotion and Practice 2011, 12:159S-165S. Long C, Jones K: Issues in running smoking cessation groups with forensic psychiatric inpatients: results of a pilot study and lessons learnt. British Journal of Forensic Practice 2005, 7:22-28. Jones L, Hayes F, MacAskill S, Angus K, Stead M, Amos A: Evaluation of the impact of the PATH Support Fund - Final Report. In. Edinburgh: ASH Scotland; 2007. Chassin L, Knight G, Vargas-Chanes D, Losoya S, Naranjo D: Substance use treatment outcomes in a sample of male serious juvenile offenders. Journal of Substance Abuse Treatment 2009, 36:183-194. Condon L, Hek G, Harris F: Public health, health promotion and the health of people in prison. Community Practitioner 2006, 79:19-22.

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Appendices Appendix 1 - Literature review strategy Papers were identified via two literature searches conducted in July-August 2015. The first was conducted by NHS Scotland’s Health Management Library and Information Service in response to the search question “Literature on smoke-free prisons i.e. tobacco bans introduced in prisons, detention centres or secure hospitals in other countries” and covered six databases (Medline; Embase; CINAHL Cumulative Index to Nursing & Allied Health Literature; PsychInfo; Social Services Abstracts; ASSIA Applied Social Sciences Indexes & Abstracts). The second was conducted by the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow using the search terms “smok*”; “tobacco”; “prison*”; “jail”; “e-cig*”; “electronic cig*”; “inmate”; “smoke free prison”; and “health” and covering seven databases (Medline; Embase; Web of Science; Psychinfo; Socindex; Planex – useful for grey literature; and Google Scholar – useful for very new material). Following this, there were two stages: 1. Twenty-four review or opinion pieces (based on reviews) were identified and, in order to make the task of reviewing the literature manageable, it was decided to use these to guide the present review. The reviews are summarised in Table 1, with more detail of each being provided in Appendix Table A1. However, what is presented here is much more than a review of reviews. 2. Literature included in these reviews was identified. Appendix Tables A2 to A5 detail this in respect of empirical sources related to the various sections of this review: Table A2 – Prevalence of smoking in prisons; Table A3 - the place of smoking in prison culture; Table A4 – Health impacts of smoking in prisons; Table A5 – Experience of prison smoking bans; Table A6 Smoking cessation in prisons. (Note these tables include published journal papers and reports, but not smaller local reports or news pieces available via web-links.) The aim of the Appendix tables is to provide a more extensive list of references to those who are interested. A small number of sub-sections in this review draw mainly from the 24 review or opinion pieces. These (explanations for high smoking rates among prisoners; history of prisons smoking bans; rationale for prison smoking bans) cover areas where great detail was not thought necessary. All other sections are more detailed, and include individual empirical studies, including some published too recently to have been picked up by the other reviews. These cover areas where it was thought that more in-depth information might be of use to the Scottish Prison Service as it formulates plans on how indoor smoke-free prison facilities will be delivered. The aim was not to produce a systematic review 8, but rather one based on the strongest evidence in relation to the key questions 8

“The purpose of a systematic review is to sum up the best available research on a specific question. This is done by synthesizing the results of several studies. A systematic review uses transparent procedures to find, evaluate and synthesize the results of relevant research. Procedures are explicitly defined in advance, in order to ensure that the exercise is transparent and can be replicated. This practice is also designed to minimize bias. Studies included in a review are screened for quality, so that the findings of a large number of studies can be combined. Peer review is a key part of the process; qualified independent researchers control the author's methods and results.” – see http://www.campbellcollaboration.org/what_is_a_systematic_review/ While systematic reviews are strong form of evidence, they are extremely time-consuming and often very long and detailed. Steps include: (1) Formulating the review question; (2) Defining literature inclusion and exclusion criteria; (3) Developing a search strategy and locating studies; (4) Selecting studies; (5) Extracting data; (6) Assessing study quality; (7) Analysing and interpreting results; (8) Disseminating findings. For more details, see, for example: Uman L (2011) Page 45 - Occasional Paper Number 25

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identified by the Scottish Prison Service. Several of the included reviews were systematic and/or aimed to identify all relevant literature [10, 17, 20, 21], so it is unlikely that significant relevant material has been missed. This review is divided into five sections, four of which (Prevalence of smoking in prisons; Health impacts of smoking in prisons; Prison smoking bans; Smoking cessation in prisons) are covered in other reviews, the fifth (electronic cigarettes) is not. In the text: • The reviews/opinion pieces are consistently referred to as reviews and the original empirical papers as studies. • Study descriptions include date of publication and country, given the impact that social context and attitudes towards tobacco control might have had on the results (e.g. adult smoking rates in Scotland were 23% in 1999[25] and 22% in 2014[26]; it might be hypothesised that lower population smoking rates might mean lower prisoner smoking and higher desire to quit rates among prisoners). • Numbered referencing is used, with reference numbers 1-24 referring to the reviews, so allowing them to be easily distinguished from the studies.

Systematic reviews and meta-analyses. Journal of the Canadian Academy of Child and Adolescent Psychiatry; 20: 57–59 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024725/

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Appendix Table A1 - Details of reviews and opinion pieces Ref

Author

Date

Title

Author country UK

[1]

ASH

(2014)

Smokefree prisons

[2]

Awofeso

(2002)

Reducing smoking prevalence in Australian Australia prisons; a review of policy options

[3]

Baybutt et al

(2014)

Tobacco use in prison settings: a need for UK policy implementation.

[4]

Bonita

(2013)

[5]

Butler et al

(2007)

New Zealand leads the way in banning New smoking in prisons Zealand Should smoking be banned in prisons Australia

[6]

Butler et al

(2011)

National summit on tobacco smoking in Australia prisons: report on the summit

[7]

Collier

(2013)

Prison smoking bans: clearing the air

[8]

Collinson et al

(2012)

New Zealand’s smokefree prison policy New appears to be working well: one year on Zealand

Canada

Details A four-page ASH UK fact sheet reviewing the rationale for making prisons smokefree and identifying which jurisdictions have smokefree prisons, the impact of smokefree policies in prisons and related issues. A paper examining the appropriateness of policy options for reducing smoking prevalence in Australian prisons, including supply-side policies (prohibition of tobacco products; other restrictive tobacco policies; limiting the range of available tobacco brands) and demand-side policies (unstructured and structured smoking cessation interventions). A chapter from a WHO ‘Prisons and Health’ publication, covering prevalence, significance of tobacco use in prison and how the issue has been addressed, including a case study of local action for tobacco control in a UK criminal justice setting and an outline of tobacco control policy in German prisons. A letter reviewing the approach taken by New Zealand in relation to the 2011 country-wide complete ban on smoking in prison. A commentary outlining arguments for and against banning smoking, noting that banning and quitting are not the same, and discussing future policy options. A report from an Australian summit which aimed to reach a consensus on the best way to approach high rates of smoking among prisoners and to reduce harms caused by tobacco in custodial settings and including a list of recommendations and priority themes. A medical journal news piece comparing smoking bans Internationally. A paper comparing the outcomes of the New Zealand 2011 country-wide complete ban on smoking in prison with experiences from other countries.

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Ref

Author

Date

Title

Author country Tobacco behind bars: policy options for the US adult correctional population

Details

[9]

Cork

(2012)

Smoking cessation in male prisoners: a Australia literature review Tobacco smoking among incarcerated US individuals: a review of the nature of the problem and what is being done in response

A US policy brief covering tobacco control policies in US local and state prisons and jails, the healthcare cost, regulatory challenges, policy options and opportunities in relation to tobacco use among inmates. A systematic review of literature relating to smoking cessation among male prisoners. A narrative review of literature relating to smoking in correctional institutions, including the impacts on inmates and wider society and actions to address the issue.

[10]

Djachenko et al

(2015)

[11]

Donahue

(2009)

[12]

Eldridge et al

(2009)

[13]

Gautam et al

(2011)

[14]

Globalsmokefre e Partnership

(2009)

Reducing tobacco smoke exposure in prisons

[15]

Hartwig et al

(2008)

Report on tobacco smoking in prison

[16]

Jakeman et al

(2014)

Smoking in prisons in England and Wales: an UK examination of the case for public health policy change

A report prepared for the UK Offender Health Research Network covering existing research evidence, describing a small International case series of prisons and high security hospitals which had implemented bans and identifying areas of best practice.

[17]

Kennedy et al

(2015)

Smoke-free policies in US prisons and jails: a US review of the literature

A paper reviewing the extent, nature and impact of smoke-free policies in US prisons and jails.

Smoking bans and restrictions in US prisons US and jails: consequences for incarcerated women Smoke-free prisons in New Zealand: New maximising the health gain Zealand

A commentary summarising the literature relating to smoking among male inmates, with the implication that there may be similar, but as yet unexplored issues among female inmates. A paper reviewing the literature on smoking in prisons, noting lessons from experience internationally, describing the situation in New Zealand and areas for action in the lead-up to the New Zealand 2011 country-wide complete ban on smoking in prison. Switzerland One in a series of background papers on challenging issues in smokefree air policy not fully addressed by the Framework Convention on Tobacco Control (FCTCT) and covering prevalence, variations in prison smoking restrictions, the impact of smokefree prisons on air quality and evidence on smoking cessation support in prisons. Germany An EU report covering the literature on prevalence of smoking in prisons, regulations, smoking ban policies in EU prisons, prevention and cessation programmes and experiences of prison smoking bans.

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Ref

Author

Date

Title

Author country Rapid literature review of smoking cessation UK and tobacco control issues across criminal justice system settings

[18]

MacDonald et al

(2010)

[19]

Public Health (2015) England

Reducing smoking in prisons: management of UK tobacco use and nicotine withdrawal

[20]

Ritter et al

(2011)

Smoking in prisons: the need for effective and Germany acceptable interventions.

[21]

Ritter

(2012)

Tobacco use and control in detention Germany facilities: a literature review

[22]

Ritter

(2014)

Tobacco use in prisons: none is best, but a Germany complete ban is not the answer

[23]

Sullivan

(2014)

Smoking bans in secure psychiatric hospitals Australia and prisons

[24]

Taylor et al

(2012)

Tobacco smoking and incarceration - UK expanding the ‘lost poor smoker thesis’: an essay in honour of Dr David Ford

Details A review (undertaken to inform the development of the Regional Criminal Justice Coordinator role in North West England) which describes smoking cessation initiatives implemented within criminal justice settings (mainly, but not exclusively prisons) in the UK and internationally. A report reviewing UK evidence on tobacco use in prisons, interventions to support smoking cessation across the criminal justice system and treatment for nicotine dependence. A paper, based on a systematic literature search, summarising recent US, Australian and UK data on smoking in prisons and discussing examples of policies for responding to second-hand smoke. A lengthy and detailed review of the literature on prevalence of smoking in prisons and factors relating to this, tobacco control and smoking cessation in detention facilities. An editorial briefly reviewing the impact of prison tobacco bans on health against the background of more holistic tobacco control policies. A review covering prevalence, issues, objections and implementation experiences associated with smoking bans in secure institutions. A sociological paper covering literature on the culture of smoking in prisons.

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Table A2 - Papers referred to in sections of review / opinion pieces relating to prevalence of smoking in prisons. (ITALICS = a review - i.e. one review citing another review.) REVIEWS / OPINION PIECES

X X

X X

X X X X X X X X X X X X X X X X X X X X X

X

X X X X X X X

X X X

X

X X

X X X

X X X

X

X X

X X Page 50 - Occasional Paper Number 25

X X X X X X X X X X X X X X X X X X X X X

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al (2008) [15] Globalsmokefree Partnership (2009) [14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

Ritter et al (2011) [20] UK RC Physicians & RC Psychiatrists (2013) [28] Awofeso et al (2001) [138] Patrick et al (2001) [79] Lincoln et al (2009) [85] Kauffman et al (2010) [139] Butler et al (2007) [5] Lekka et al (2007) [140] Papadodima et al (2010) [141] Sannier et al (2009) [142] Tielking et al (2003) [143] Narkauskaite et al (2007) [144] Etter et al (2012) [106] Sieminska et al (2006) [102] Heidari et al (2007) [29] MacAskill et al (2008) [30] Rezza et al (2005) [145] Eldridge et al (2009) [12] Durrah (2005)[146] Holmwood et al (2008) [147] Narkauskaite et al (2010) [148] Plugge et al (2009) [34] Knight et al (2005)[35] Butler (1997) [149] Butler et al (2003)[150]

ASH (2014) [1]

Studies cited re prevalence of smoking in prisons

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow REVIEWS / OPINION PIECES

X X X X X

X

X

X

X X

X

X

X

X

X X

X X

X X X

X

X

X X

X X X X X X X

X X X X

X X X X X X X X

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X X

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al (2008) [15] Globalsmokefree Partnership (2009) [14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

Butler et al (2008) [151] Lasnier et al (2011) [78] Thibodeau et al (2010) [71] Chavez et al (2005) [84] Australian Inst of Health & Welfare (2010) [152] Conklin et al (2000) [153] Cropsey et al (2004) [104] Cropsey et al (2006) [154] NZ Ministry of Health (2006) [155] Hartwig et al (2008) [15] UK Dept of Health & HM Prison Service (2007) [156] UK Office for National Statistics (1999) [31] Sahajian et al (2006) [157] Scottish Prison Service (2006) [38] Belcher et al (2006) [99] Carpenter et al (2001) [75] NHS Health Information Centre (2011) [32] Binswanger et al (2009) [51] US Centers for Disease Control and Prevention (2005) [158] Nihawan et al (2010) [159] Cropsey et al (2005) [49] Cropsey et al (2010) [100] Scottish Prison Service (2010a) [160] Scottish Prison Service (2010b) [161] Brooker et al (2008) [36] Payne-James et al (2010) [37]

ASH (2014) [1]

Studies cited re prevalence of smoking in prisons

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow REVIEWS / OPINION PIECES

Knox et al (2006) [40] Singleton et al (1999) [162] Lester et al (2003) [97] MacDonald et al (2010) [18] UK Department of Health SW Regional P.H.G. (2007) [33] Richmond et al (2009) [122] Scollo et al (2008) [163] D’Souza et al (2005) [164] Scottish Prison Service (2008) [39] Stuart et al (2006) [165] Heng et al (2006) [166] Office of the Inspector of Custodial Services (2008) [167] Cropsey et al (2011) [116] Stover et al (2011) [168] Guyon et al (2010) [61] Cropsey et al (2008) [114] Hammond et al (2005) [59] Kauffman et al (2011) [65] US National Center in Addiction & Substance Abuse (2010) [169] Proescholdbell et al (2008) [60] Kauffman et al (2008) [66] Stuart et al (2004) [170] Awofeso et al (2008) [120] Lai et al (2008) [171] Chang et al (2010) [86]

X X X X X

X

X

X

X X X X

X X X X X X X X X X X X X X X X

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Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al (2008) [15] Globalsmokefree Partnership (2009) [14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

ASH (2014) [1]

Studies cited re prevalence of smoking in prisons

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow REVIEWS / OPINION PIECES

Dupont (2008) [172] Pauly et al (2010) [173] Nobile et al (2011) [174] Elger (2004) [175] Eytan et al (2010) [176] Wolff et al (2011) [177] Jamrozik (2004) [178] Khavjou et al (2007) [77] Stuart et al (2005) [179] Allsworth et al (2007) [180] Young et al (2005) [181] Nara et al (1998) [182] WHO (2007a) [183] WHO (2007b) [184] Lavigne et al (2010) [185] Baker et al (2006) [186] Bond (2007) [187] Butler et al (2011) [6] Australian Inst of Health & Welfare (2013) [188] Lawn (2004) [189]

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al (2008) [15] Globalsmokefree Partnership (2009) [14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

ASH (2014) [1]

Studies cited re prevalence of smoking in prisons

X X X X X X X X X X X X X X X X X X X X

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Table A3 - Papers referred to in sections of review / opinion pieces relating to the place of smoking in prison culture. (ITALICS = a review - i.e. one review citing another review.) REVIEWS / OPINION PIECES

X X

X

X

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

X X X X X X X X X X X X X X X X X

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al

(2008) [15] Globalsmokefree Partnership (2009)

[14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

Butler et al (2007) [5] Richmond et al (2009) [122] Long et al (2005) [190] Sykes (1958) [191] Liebling (1999) [192] De Viggiani (2007) [193] Narkauskaite et al (2007) [144] Plugge et al (2009) [34] Papadodima et al (2010) [141] Richmond et al (2006) [121] Lawrence et al (2008) [96] Heidari et al (2007) [29] MacAskill et al (2007) [101] UK Prison Reform Trust [194] Clark et al (2008) [195] NSW Cancer Institute (2008) [196] Douglas et al (2006) [197] Kauffman et al (2008) [66] Richmond et al (2012) [123] Fischer at al (2004) [198] Awofeso (2003) [119] Belcher et al (2006) [99] Baker et al (2006) [186] Sieminska et al (2006) [102] Darrall et al (1998) [199]

ASH (2014) [1]

Studies cited re the place of smoking in prison culture

X X X

X

X X

X

X X

X X

X X X X X X X X

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X X X

X

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow REVIEWS / OPINION PIECES Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

Cropsey et al (2004) [104] Lankenau (2001) [80] Cropsey et al (2008) [114] Gautam (2011) [13] MacDonald et al (2010) [18] Romero et al (1988) [200] Vaughn et al (1993) [201] Condon et al (2008) [105] UK Dept of Health and HM Prison Service (2003) [156] Eldridge et al (2009) [12] Douglas et al (2009) [202] MacAskill et al (2008) [30] Awofeso (1999) [203] Lawn (2004) [189] Clemmer (1940) [204] Liebling (2004) [205] Crawley et al (2005) [206] Farnworth et al (2004) [207] Williams et al (1974) [208] Greer (2000) [209] Medlicott (2001) [210] Dittmar (1994) [211] Crewe (2009) [212] Beck (1995) [213] Edgar et al (2003) [214] Ireland (2000) [215] File et al (2001) [216]

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al

(2008) [15] Globalsmokefree Partnership (2009)

[14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

ASH (2014) [1]

Studies cited re the place of smoking in prison culture

X X X

X X X

X X X X X

X X X X X X X X X X X X X X X X X X X

Page 55 - Occasional Paper Number 25

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

Table A4 - Papers referred to in sections of review / opinion pieces relating to health impacts of smoking in prisons. REVIEWS / OPINION PIECES

X

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al

(2008) [15] Globalsmokefree Partnership (2009)

[14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

Personal smoker health Kariminia et al (2007) [50] Wilper et al (2009) [45] Mumola (2007) [47] Conklin et al (2000) [153] Binswanger et al (2009) [51] D’Souza et al (2005) [164] Fazel et al (2001) [46] Cropsey et al (2006) [49] Australian Inst of health & Welfare [217] SHS and non-smoker health Proescholdbell et al (2008) [60] Hammond et al (2005) [59] McCaffrey et al (2012) [218] Wilcox (2007) [64] Kauffman et al (2011) [65] Guyon et al (2006) [61]

ASH (2014) [1]

Studies cited re the health impacts of smoking in prisons

X X X

X

X

X X X X X X X X

X X

X

X X

X X

X X X

Page 56 - Occasional Paper Number 25

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

Table A5 - Papers referred to in sections of review / opinion pieces relating to the experience of prison smoking bans. (ITALICS = a review - i.e. one review citing another review.) REVIEWS / OPINION PIECES

X

X

X

X X

X X

X

X

X

X

X

X X

X

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

X

Ritter (2012) [21] Ritter et al (2011)

X X X X X X X X X X X X X X

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al

(2008) [15] Globalsmokefree Partnership (2009)

[14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

Kauffman et al (2008) [66] Collier (2013) [7] Collinson et al (2012) [8] Proescholdbell et al (2008) [60] Hammond et al (2005) [59] Binswanger et al (2014) [74] Lasnier et al (2011) [78] Jakeman et al (2014) [16] Cork et al (2012) [9] Lankenau (2007) [80] Kipping et al (2006) [95] Voglewede et al (2004) [219] Eldridge et al (2009) [12] Williams (2010) [91] Skolnik (1990) [70] Spurgeon (2000) [220] Raemisch et al (1992) [221] Felding (1986) [222] Awofeso et al (2001) [118] Wodak (2000) [223] Carpenter et al (2001) [75] Ritter et al (2012) [69] NSW Dept of Juvenile Justice (2003) [224] Cropsey et al (2004) [76] Lincoln et al (2009) [85]

ASH (2014) [1]

Studies cited re experience of prison smoking bans

X

X X

X X

X

X

X

X X X

X

X X

X X

X

X

X X

X X

X

X X X X X X X X X

X

X X

X X X

X

X

X X

X

X

X

X X

X

X

X

Page 57 - Occasional Paper Number 25

X

X

X X

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow REVIEWS / OPINION PIECES Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

X X X

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al

(2008) [15] Globalsmokefree Partnership (2009)

[14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

Foley et al (2010) [225] Chang et al (2010) [86] Globalsmokefree Partnership (2009) [14] Falkin et al (1998) [226] Connell (2010) [227] Drach et al (2012) [228] Kauffman et al (2011) [65] Ritter et al (2011) [20] Romero et al (1988) [200] Chavez et al (2005) [84] Cropsey et al (2005) [76] Patrick et al (2001) [79] Cropsey et al (2003) [117] Awofeso (2003) [119] Khavjou et al (2007) [77] Cropsey et al (2008) [114] Richmond et al (2006) [121] Butler et al (2007) [5] Hartwig et al (2008) [15] Plugge et al (2009) [34] O’Dowd (2005) [229] Lincoln et al (2005) [230] Awofeso (2005) [231] Sweda (2001) [232] Thornley et al (2013) [67] Vaughn et al (1993) [233] Heng et al (2007) [234] Thibodeau et al (2010) [71]

ASH (2014) [1]

Studies cited re experience of prison smoking bans

X X X X X X

X X X

X

X X

X X X

X X X X

X X X X X X X X X

X

X

X X X X

Page 58 - Occasional Paper Number 25

X X

X X X X X

X

X

X X X X X X

X

X X

X

X X

X X X X X X

X X

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow REVIEWS / OPINION PIECES Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al

(2008) [15] Globalsmokefree Partnership (2009)

[14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

Pezzino et al (1992) [83] Bock et al (2013) [88] Clarke et al (2013) [87] Van den Berg et al (2014) [89] Thomson et al (2007) [94] MacAskill et al (2007) [101] MacAskill et al (2002) [110] UK Dept Health SW Region P.H.G. (2007) [33] Levy (2010) [235] Belcher et al (2006) [99] Guyon et al (2010) [61] Richmond et al (2009) [122] Lawrence et al (2008) [96] Kauffman et al (2010) [139] Lawn et al (2005) [236] Campion et al (2008) [237] Ratschen et al (2009) [238] Cormac et al (2010) [93] Hehir et al (2013) [239]

ASH (2014) [1]

Studies cited re experience of prison smoking bans

X X X X X X X X

X X X X X X X X X

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MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

Table A6 - Papers referred to in sections of review / opinion pieces relating to smoking cessation in prisons. (ITALICS = a review i.e. one review citing another review.) REVIEWS / OPINION PIECES

X X

X X

X

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

Ritter (2012) [21] Ritter et al (2011)

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al

(2008) [15] Globalsmokefree Partnership (2009)

[14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

Indig et al (2010) [103] MacAskill et al (2008) [30] Awofeso et al (2001) [118] MacAskill et al (2007) [101] Condon et al (2008) [105] Douglas et al (2006) [197] Richmond et al (2006) [121] Butler et al (2011) [6] Plugge et al (2009) [34] Kauffman et al (2011) [65] Clarke et al (2011) [115] Thibodeau et al (2010) [71] Perka (2011) [240] Richmond et al (2012) [123] McCarthy et al (2009) [125] Makris et al (2012) [126] Jenkins (2002) [108] Sieminska et al (2006) [102] Richmond et al (2013) [124] Cropsey et al (2004) [104] Voglewede et al (2004) [219] Chavez et al (2005) [84] Cropsey et al (2008) [114] Edinger et al (1978) [113] Awofeso (2003) [119]

ASH (2014) [1]

Studies cited re smoking cessation in prisons

X

X X X X X X X

X

X X X X X

X X

X

X

X X

X

X X X X X

X X X X X X X

X X X

X X

X X X X X X Page 60 - Occasional Paper Number 25

X X

X X

X

X X

X X

X

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow REVIEWS / OPINION PIECES

X

X

X X X

X

X

X

X

X X X X X

X X X X X X X X X X

X X X X X X X X X

Page 61 - Occasional Paper Number 25

X

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22]

X X

Ritter (2012) [21] Ritter et al (2011)

Kauffman et al (2008) [66] Awofeso (2005) [231] Carpenter et al (2001) [75] Hartwig et al (2008) [15] Richmond et al (2009) [122] UK Dept of Health and HM Prison Service (2007) [156] Romero et al (1988) [200] Falkin et al (1998) [226] Cropsey et al (2003) [117] Clarke et al (2013) [87] Dickens et al (2005) [98] Long et al (2005) [241] Knox et al (2006) [40] Jones et al (2007) [242] Platt et al (2009) [112] Chassin et al (2009) [243] MacAskill et al (2008) [30] Lawrence et al (2008) [96] Awofeso et al (2008) [120] MacAskill et al (2002) [110] UK Dept of Health (2003) [156] Eadie et al (2012) [109] Lester et al (2003) [97] Condon et al (2006) [244] Barnham et al (2010) [128] Baca (2009) [127] UK Dept of Health South West Regional P.H.G.

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al

(2008) [15] Globalsmokefree Partnership (2009)

[14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2]

ASH (2014) [1]

Studies cited re smoking cessation in prisons

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow

REVIEWS / OPINION PIECES

X

Taylor et al (2012) [24] Sullivan (2014) [23] Ritter (2014) [22] Ritter (2012) [21] Ritter et al (2011)

Page 62 - Occasional Paper Number 25

X X X X X X (2007) [33] Cropsey et al (2010) [100] Belcher et al (2006) [99] Etter et al (2012) [106] Proescholdbell (2008) [60] Cropsey et al (2011) [116]

[20] Public Health England (2015) [19] MacDonald et al (2010) [18] Kennedy et al (2015) [17] Jakeman et al (2014) [16] Hartwig et al (2008) [15] Globalsmokefree Partnership (2009) [14] Gautam et al (2011) [13] Eldridge et al (2009) [12] Donahue (2009) [11] Djachenko (2015) [10] Cork (2012) [9] Collinson et al (2012) [8] Collier (2013) [7] Butler et al (2011) [6] Butler et al (2007) [5] Bonita (2013) [4] Baybutt et al (2014) [3] Awofeso (2002) [2] ASH (2014) [1]

Studies cited re smoking cessation in prisons

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3QB. Tel: 0141 353 7500 Fax: 0141 332 0725 email: [email protected] A University Unit funded by the Medical Research Council and the Scottish Government Chief Scientist Office, at the University of Glasgow.