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.
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.
To provide evidence on the process and impact of implementing smoke-free policy across a national prison service.
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).
People in custody; prison staff; providers/users of prison smoking cessation services.
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.
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