Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis

Binswanger and colleagues (1) clearly describe the prevalence of smoking tobacco among prisoners in the United States and the significant impact of prison tobacco control policies on smoking attributable mortality.

In England (& Wales), prisons are commissioned by the National Offender Management Service (NOMS) and healthcare is directly commissioned by NHS England. Nationally around 80% of prisoners smoke compared with around 20% in the general population (2 ,3 ,4 ,5) with similar levels recorded across the offender journey in police custody and probation services (6 ,7) . These extraordinary high rates of smoking damage health and contribute significantly to health inequalities for prisoners , as well as increasing risk of exposure to second-hand smoke which is damaging to health of non-smoking prisoners, visitors and staff.

A strong case for addressing smoking among offenders is endorsed in ‘Improving Health, Supporting Justice’(8) . This document recognised high levels of health needs among offenders, whether in police custody or under community supervision, and included key objectives such as working in partnership, equity of access to services, improving pathways and continuity of care. In 2007, a comprehensive national smoke-free policy was introduced in England but adult prisons were the only setting exempted. Secure settings accommodating children and young people under the age of 18 years were not exempted, to bring them in line with national policy and the age of sale of cigarettes which was raised to 18 years old. Entirely smoke-free wings can protect staff and prisoners from second-hand smoke and provide an environment conducive to non-smoking. Therefore, these should be promoted.

However, many smokers will need support with nicotine withdrawal when placed in such settings. Recent work by PHE across six prison sites in the South West demonstrated significant variability across the prisons estate in access to smoking cessation services including nicotine replacement therapy (NRT) with reports of long waiting times which often exceeded the length of the period of incarceration. In 2013, Public Health England, NHS England and NOMS published a national partnership agreement which included a joint commitment by all three organisations to work together to reduce smoking amongst prisoners and support the development of smoke-free prisons (9) . Preparations for full implementation of smoke-free prisons across the estate needs to take careful account of the operational realities of running safe, decent and secure prisons, and in particular the impact any smoking ban may have on the general safety of staff and prisoners. Prisons are going through a period of major change and the overall stability of the estate is a crucial consideration in the timing of when a universal smoke-free policy will be implemented. Therefore before a decision is taken on the timing of when prisons in England will go smoke-free, there needs to be confidence around appropriate access to smoking cessation services including NRT.

The funding requirements of full implementation also need to be better understood. One of the workstreams of the cross-organisational Smoke-free Prisons Project involves working closely with NHS England and service providers: first to optimise existing provision and secondly to model the volume, cost, and means of delivering these services to meet demand once prisoners cannot smoke.

Whilst use of licensed nicotine containing products would be the first and most preferential route to harm reduction, the recent popularity of e-cigarettes has demonstrated that many smokers are interested in trying and using non-medicinally licensed sources of nicotine. Providing access to e-cigarettes (once we have determined product safety, quality, and the operational arrangements of their use) could supplement NRT and smoking cessation services. This may be preferable for some prisoners who smoke but who decline NRT and smoking cessation services. International experience of the use of e-cigarettes within the custodial environments is limited but there is encouraging evidence from Guernsey prison which successfully implemented a smoke-free prison policy in 2013. Guernsey prison allowed prisoners the option to purchase e-cigarettes as an alternative to using conventional NRT to facilitate the transition to a smoke-free environment. Senior managers there have reported that e-cigarettes were integral to the successful implementation of the smoke-free policy. We also acknowledge that while the New Zealand Prison Service successfully and smoothly went smoke-free in 2013 without recourse to e-cigarettes, knowledge about the risks and benefits are now more advanced. NOMS is planning a limited trial of use of e-cigarettes which will be available to purchase via prison shops. It will take into consideration the guidance on e-cigarettes published by the Medicines and Healthcare products Regulatory Agency (MHRA); the guidance on smoking cessation and tobacco harm reduction issued by the National Institute for Health and Care Excellence (NICE); advice from the Chartered Institute of Personnel and Development (CIPD), and the requirements of the smoke-free legislation as advised by the Chartered Institute of Environmental Health.

In the BMJ editorial (10) , Catherin Ritter calls for ‘strategies other than restrictive regulation to reduce smoking related mortality [in prisons]’. We believe that a strong partnership approach, with a clear harm reduction ethos and mindful of the need for on-going support on release, can inform further debate on how to get prisoners to quit smoking not only in prisons but for good. This will improve the health and wellbeing not only of prisoners and not only while they are in prisons, but potentially could pay a wider ‘community dividend’ by reducing harmful smoking behaviours among wider peer groups and social networks through peer-modelling and harm reduction behaviours.

1. Binswanger IA, Carson EA, Krueger PM, Mueller SR, Steiner JF, Sabol WJ. Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis. BMJ 2013;349:g4542.
2. Singleton N, Farrell M & Meltzer H, (1999). Substance Misuse among Prisoners in England and Wales. London: Office for National Statistics.
3. Lester C, Hamilton-Kirkwood L, Jones N. Health Indicators in a prison population: asking prisoners. Health Education Journal 2003; 62, 4: 341-349
4. Plugge E.H., Foster C.E., Yudkin P.L., Douglas N. Cardiovascular disease risk factors and women prisoners in the UK: the impact of imprisonment. Health Promotion International 2009; 24: 334-343.
5. NHS. Health Survey for England, 2009. National Health Service, 2010
6. Payne-James J.J., Green P.G., Green N., McLachlan G.M, Munro M.H, Moore T.C. Healthcare issues of detainees in police custody in London, UK. Journal of Forensic and Legal Medicine 2010; 17: 11-17.
7. Brooker C., Fox C., Barrett P., Syson-Nibbs L. A Health Needs Assessment of Offenders on Probation Caseloads in Nottinghamshire & Derbyshire: Report of a Pilot Study. Lincoln: CCAWI University of Lincoln. Available at: http://www.nacro.org.uk/data/files/nacro-2008071500-176.pdf
8. Department of Health (DH) (2007). Improving Health, Supporting Justice. (London, Department of Health)
9. National Partnership Agreement between the National Offender Management Service, NHS England and Public Health England for the co-commissioning and delivery of healthcare services in prisons in England, 2013. http://www.justice.gov.uk/about/noms/working-with-partners/health-and-ju...
10. Ritter, C. Tobacco use in prisons: None is best, but complete bans are not the answer. BMJ 2014;349:g4946