9A.5 People experiencing incarceration

Last update:  September 2021

Suggested citation: Puljevic, C, Greenhalgh, EM, & Scollo, MM. 9.A.5 People experiencing incarceration. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from:  https://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/in-depth/9a5_people-experiencing-incarceration 

 

9A.5.1 Trends in the prevalence of smoking

Traditionally, the prevalence of smoking among people experiencing incarceration has been far higher than among the general population.1, 2 While smoking has decreased substantially over time in the Australian general community, the same is not true for people in custody, whose smoking rates, in facilities which allow smoking, remain high.3 In June 2020, there were about 41,000 adult prisoners in Australia; 92% of prison entrants at this time were men.4 In June 2018, about two in three (66%–69%) prison entrants aged 18–44 were daily smokers, compared with just one in seven (14%–16%) people in the general community5 Three in four (75%) of all Australian prison entrants reported being current smokers, and 85% reported having smoked at some stage in their life. Only 13% of prison entrants reported never having smoked, while 10% were ex-smokers.3 The average age of taking up smoking was 14, although several prisoners reported that they began smoking as young as three.3 Upon entry, female prison entrants (86%) were more likely than male prison entrants (74%) to report they were current smokers. Entrants aged 18–24 were most likely to report being current smokers (80%), with those aged 45 and over the least likely at 62%.3 Similar trends are observed internationally; a systematic review found that rates of smoking among people experiencing incarceration exceed community rates 1.04- to 62.6-fold.6

9A.5.2 Contribution of smoking to health outcomes and social inequality

Prisoners experience poorer physical and mental health than the general population. In 2018, almost one-third (29%) of Australian prison entrants reported a long-term health condition or disability that limited their daily activities and/or affected their participation in education or employment. A similar proportion (30%) reported having a chronic condition. Smoking-related illnesses such as asthma, cardiovascular disease, diabetes, and cancer were among the most common conditions. Almost one-quarter (22%) of entrants reported ever having been diagnosed with asthma, compared with 11% of the general population. A total of 40% of prison entrants reported ever having been told they have a mental health disorder, including alcohol and drug misuse.3 See Section 9A.3 for a detailed overview of the relationship between smoking and mental illness, as well as alcohol and substance use disorders, and Chapter 1, Section 1.10.6 for other drug use.

Epidemiological studies confirm that people who have been in prison experience higher rates of smoking-related illness, including various forms of cancer,7-10 hypertension,8 liver disease,7 asthma,8   and cardiovascular disease,11 further exacerbating their already increased levels of mortality and morbidity when compared to the general population.12-14 A study of over 85,000 people released from New South Wales prisons between 1988 and 2002 found a significantly higher rate of death from smoking-related cancers compared to the general community.9 Similarly, a study conducted in all state prisons in the US in 2014 found significantly higher age-adjusted smoking attributable mortality and potential life years lost as a result of tobacco smoking when compared to the non-incarcerated population.11

9A.5.3 Explanations for higher smoking prevalence

The primary reason for high rates of smoking among people experiencing incarceration is that smoking is common among groups over-represented in the prison population, including those of lower socioeconomic status, Aboriginal and Torres Strait Islander peoples, people with mental health disorders, people with substance use disorders, and people experiencing homelessness.3 For example, in 2019, Aboriginal and Torres Strait Islander prisoners accounted for just over a quarter (28%) of the total prisoner population (while only comprising 2.8% of the Australian population).15, 16 Tobacco use has historically been commonly accepted as part of prison life,2 serving a variety of purposes such as a form of currency,17, 18 a stress or boredom reliever,18-22 or a common ground for socialising. 23 Other reasons for these high smoking rates among prisoners include a lack of smoking cessation programs in prisons (as well as an overall lack of these programs in the community), a lack of evidence regarding best practice for smoking cessation in this population group, and confusion over ownership of the issue between health departments and custodial authorities.20

Prior to entering prison, many inmates had experienced lifetime exposure to cigarette smoking through their primary caregivers and friends.24 The average age at which Australian prison entrants had their first cigarette was 14,3 compared with 17 in the general population.25 A 2016 qualitative study in the US found many prisoners who smoked reported not having been taught by their family members about the dangers of smoking, rather it was more common that these family members themselves were smokers.24 One study found an association between heavy smoking among prisoners and past adverse childhood events such as alcoholism in the family, a psychiatric condition in the family, physical abuse, parental neglect and parental divorce.26 Factors within the prison environment that can increase prisoners’ likelihood of smoking include stress, boredom, lack of social support, high smoking rates among prisoners and staff, shared cells, relationship building between prisoners, and the use of tobacco as currency.27

9A.5.4 Interventions for reducing smoking

Despite very high smoking rates, and fewer than one in 10 (5%–10%) prison entrants having successfully quit smoking in the past, many detainees express an interest in quitting. In 2018, about two in five (41%) prison entrants who were current smokers wanted to quit. Of the 41% of prison entrants who wanted to quit smoking, almost half (47%) thought NRT would help, 25% thought counselling would help, 22% thought a quit program would help, and one-third (33%) said they did not want any help to quit. Upon exiting prison, dischargees, who were current smokers on entry, were asked what cessation assistance they had utilised while in prison. Eighteen per cent had utilised nicotine replacement therapy, 2% had utilised counselling or other, 6% had utilised a quit smoking program, and 27% had not wanted assistance to quit.3  

Barriers to quitting in this population have included a strong smoking culture in prison; the role of tobacco as a de facto currency and common ground for socialising; high levels of nicotine dependence; mental illness; limited access to nicotine replacement therapy and cessation programs; boredom; and stressful events such as prison transfer, or family and legal stressors.17-19, 22, 23 Further problems include a lack of evidence for best practice for smoking cessation in this group, confusion over the ownership of the problem between the health department and custodial authorities, and poor access to smoking cessation programmes while outside the prison system.2, 18, 20, 28 In 2011, the National Preventative Health Strategy29 identified the prison population as a priority area for future interventions. Similarly, the 2012-2018 National Tobacco Strategy recognised prisons as an important setting for tobacco control efforts and stated that continued leadership is required to reduce the prevalence of smoking among prisoners, and to reduce exposure to second-hand smoke among prisoners and staff working in correctional settings.30

As of September 2021, all Australian territories and states (except Western Australia) have introduced or announced intentions to introduce complete smoking bans in prisons. International studies have found that these bans are effective at improving the health of people who live and work in prisons.12, 31-34 For example, a survey of all state prisons in the US found a 9% reduction in smoking-related deaths in prisons that had implemented a smoking ban, and prisons with bans in place for longer than nine years showed an 11% reduction in all smoking-related deaths, a 19% decrease in deaths from cancer, and a 34% reduction in deaths with pulmonary causes.12 Other studies have found that these bans result in improved air quality,35-39 reduced exposure to harmful second-hand smoke,40 and decreased in-prison dispensing of medication for smoking-related illnesses41

Prior to the implementation of bans in Australia, prisoners were provided with access to intensive cessation support,42 including free nicotine patches and access to Quitline, but this support was discontinued in most jurisdictions within a few months of the ban’s implementation. Access to nicotine replacement therapy remains limited in Australia’s smoke-free prisons, partly due to prisoners creating substitute cigarettes from nicotine patches 43 or lozenges. 44 In The health of Australia’s prisoners 2018 report, about one-third (30%) of dischargees from prisons that had banned smoking said they were current smokers, compared with more than half (56%) of dischargees from prisons which allowed smoking. However, there was only a two percentage point difference between prison dischargees’ intentions to smoke upon release from prisons that had banned smoking and prisons which allowed smoking (42% and 44% respectively).3

A 2018 systematic review investigating factors influencing smoking following release from smokefree prisons found a high and rapid rate of smoking relapse among dischargees.45 This was reflected in findings from a study showing that 72% of a sample of people released from Queensland prisons resumed smoking on the day of release, with 94% relapsing within two months of release.46 A 2016 qualitative study24 from the US found many transitional housing facilities were not smokefree properties, and dischargees from smokefree prisons would relapse due to cigarettes being readily available in these environments. Family members also play an important role in whether prison dischargees are able to remain smoke-free upon release. Seventy per cent of study participants said having family members who smoked influenced their own smoking behaviours during the re-entry process.24

Systematic reviews from 201647 and 20186 similarly found indoor bans on smoking in prisons to have little impact on prisoner smoking behaviour, with prisoners who had experienced a ban typically resuming smoking shortly after release. The 2018 systematic review also concluded that evidence-based interventions for smoking cessation found to be effective outside prisons are effective inside too, and that effects persist after release.6 These effective interventions included in-person delivery of motivational interviewing (to boost intention to remain abstinent post-release)45 and/or cognitive behavioural therapy.48, 49 Multi-component interventions using a combination of behavioural support and smoking-cessation pharmacotherapy have also been found to maximise chances of sustained cessation,45, 47 and there is limited evidence suggesting that refraining from risky drinking may assist in remaining quit post-release.50

Findings from a Queensland-based qualitative study suggest that interventions promoting continued smoking abstinence among people exiting smoke-free prisons should focus on targeting the perceived individual- and environmental-level barriers to maintained smoking abstinence, including pre-release intention to resume smoking, normalisation of smoking in home or social environments, resumption of smoking as a symbolic act of freedom and resistance from and to a restrictive environment, a perception that smoking provides stress relief, and the use of smoking to cope with cravings experienced on release for illicit substances.51 Despite the availability of smoking cessation pharmacotherapy (SCP) at a heavily subsidised rate in Australia, once released, only a small proportion of prison dischargees go on to use SCP, pointing to a missed opportunity in this vulnerable community.52 While maintaining support for dischargees post release is important for successful smoking abstinence, this support has typically fallen outside the scope of the implementation of smokefree prisons.52 Findings from a 2019 pilot study in Victoria Australia suggest more intensive support (provided before and after release) is required in order to reduce post-release relapse to smoking and to encourage those who do relapse to make further quit attempts.53 Finally, there is some limited evidence from the UK that the provision of e-cigarettes may assist to maintain smoking abstinence during incarceration.54, 55

 

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated June 2022)

References 

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2. Belcher JM, Butler T, Richmond RL, Wodak AD, and Wilhelm K. Smoking and its correlates in an Australian prisoner population. Drug and Alcohol Review, 2006; 25(4):343–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16854660 

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