Evaluating progress towards, and impacts of, implementation of smoke-free prisons in Scotland: the mixed methods Tobacco in Prisons Study (TIPs)


Hunt K, Brown A, Eadie D, McMeekin N, Boyd K, Bauld L, Conaglen P, Craig P, Demou E, Leyland A, Purves R, Dobson R, Mitchell D, O’Donnell R & Semple S (2021) Evaluating progress towards, and impacts of, implementation of smoke-free prisons in Scotland: the mixed methods Tobacco in Prisons Study (TIPs). Public Health Research.

Background: Prisons had partial exemption from the UK’s 2006/7smoking bans in enclosed public spaces,, . They became one of few workplaces with continuing exposure to second-hand smoke, given high levels of smoking amongst people in custody. Despite the introduction of smoke-free prisons elsewhere, evaluations of such ‘bans’ are very limited to date. Objectives: To provide evidence on the process and impact of implementing smoke-free policy across a national prison service. Design: The Tobacco in Prisons study is a three-phase, multi-method study exploring the periods before policy formulation (Phase-1; Pre-announcement), during preparation for implementation (Phase-2; Preparatory), and after implementation (Phase-3; Post-implementation). Setting: Scotland’s prisons. Participants: People in custody; prison staff; providers/users of prison smoking cessation services. Interventions: Implementation of comprehensive smoke-free prison rules across all Scotland’s prisons in November 2018. Main outcome measures: Second-hand smoke levels; health outcomes; perspectives/experiences, including facilitators to successful transition to smoke-free prisons. Data sources: Cross-sectional surveys in each Phase of staff [total n=3522] and people in custody [total n=5956]; focus groups and/or one-to-one interviews with staff [n=237 across 34 focus groups, n=38 interviews], people in custody [n=62 interviews], providers [n=103 interviews] and users [n=45 interviews] of prison smoking cessation services, and stakeholders elsewhere [n=19]; measurements of second-hand smoke exposure [e.g. 369.208 minutes of static measures in residential areas at three time points]; routinely collected data (e.g. medications dispensed, inpatient/outpatient visits). Results: Measures of second-hand smoke were substantially (~90%) reduced post-implementation compared with baseline, largely confirming the views of staff and people in custody that illicit smoking was not a major issue post-ban. Several factors were identified which contributed to the successful implementation of smoke-free policy, now accepted as the ‘new normal’. E-cigarette use became common, and was recognised (by both groups) to have facilitated the transition, whilst raising new issues in prisons. The health economic analysis (life-time model) demonstrated that the ‘with smoke-free policy’ period costs were lower and Quality-adjusted-life-years greater than ‘without’, for people in custody and staff, confirming cost-effectiveness against a £20,000 ‘willingness-to-pay’ threshold. Limitations: The ability to triangulate between different data sources mitigates limitations with constituent datasets. Conclusions: This is the first study internationally to analyse views of prison staff and people in custody, objective measurements of second-hand smoke exposure and routine health and other outcomes, before, during and after implementation of smoke-free prison policy, and to assess cost-effectiveness. Results are relevant to jurisdictions considering similar legislation, whether or not e-cigarettes are permitted. The study provides a model for partnership-working and, as a multi-dimensional study of a national prison system, adds to a previously sparse evidence-base internationally. Future work: Priorities are to: understand how to support people in custody in remaining smoke-free after release from prison, and whether interventions can extend benefits to their families; evaluate new guidance supporting people wishing to reduce or quit vaping; and understand how prison vaping practices/cultures may strengthen or weaken long-term reduction in smoking. Study Registration: Research registry 4802 Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme (15/55/44).

Output Status: Forthcoming Additional co-authors: Jill Pell, Emily Tweed, Tom Byrne, Lesley Graham, Helen Sweeting

Public Health Research

StatusIn Press
FundersNIHR National Institute for Health Research
Publication date online31/12/2021
Date accepted by journal22/04/2021

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