Tobacco in Prisons Study
We know that smoking causes many illnesses and earlier death, and that even breathing in other people’s smoke (‘second-hand smoke’) can damage your health. The World Health Organisation estimated that second-hand smoke caused 603,000 deaths in 2004.
Smoking bans in indoor public places, which began in Scotland in 2006 and in England in 2007, have reduced people’s exposure to second-hand smoke. This was important for people working in places where there was a lot of smoking, such as bars. One workplace that was not fully covered by these smoking bans was prisons, because prisons were seen as both ‘home’ for prisoners whilst serving their sentences and as ‘workplace’ for prison staff. Smoking rates are generally very high among prisoners: in the 2015 Scottish Prison Service survey 72% of prisoners reported they were smokers, over three times the rates in the general population (21% of adults reported being smokers in the 2015 Scottish Health Survey). Very little research has been done on smoking in prison staff.
Partial or complete smoking bans have now been introduced in prisons to protect the health of prisoners and staff in several Countries around the world. The evidence from jurisdictions which have gone smoke-free is that the transition is generally smooth with little evidence of disorder. However, news media representations of smoking and smoking bans in prisons tend to suggest smoke-free prisons might lead to unrest or instability and largely ignore the health benefits to both prisoners and staff.
The Scottish Government wants to make positive steps towards Scotland becoming a smoke-free country. One important step towards this is to create a smoke-free prison environment, implemented in the best ways possible for both staff and prisoners, including providing the right kind of support for prisoners to stop smoking. This will help prisoners to prepare for life outside prison where smoking is now less common and less accepted, as well as protecting the health of people living and working in the prison system.
The Tobacco In Prisons study (TIPs), which began in 2016, is a piece of independent research, funded by the UK National Institute for Health Research Public Health Research Board. It is a collaboration between researchers at the universities of Glasgow, Stirling and Edinburgh, and NHS Lothian (Principal Investigator Professor Kate Hunt, University of Stirling). The independent TIPs research has been helping the Scottish Government and Scottish Prison Service move towards smoke-free prisons by collecting the information that policy makers require to understand everyone’s needs and points of view, and to weigh up the balance of costs and benefits for everyone concerned. This includes gathering data on levels of smoking and second-hand smoke in prisons and on what different groups (such as prisoners and staff, smokers and non-smokers) feel are the good and bad things about smoking, and smoking bans in prisons.
The overall aims of TIPs are
(a) to evaluate the process of implementing enhanced tobacco control in Scottish prisons to:
- strengthen the evidence-base on what is likely to facilitate successful implementation of smoke-free prison policies for other jurisdictions; and
- feed into planning and communication strategies.
b) to evaluate:
- changes in smoking status and exposure to second-hand smoke;
- changes in related health indicators among prisoners and staff; and
- organisational/cultural impacts in Scottish prisons, following the implementation of an indoor smoke-free prison service.
TIPs is a three-phase project and is being conducted in all 15 Scottish prisons:
Phase 1 (2016-17) - before any policy announcements or initiatives: measuring prison staff second-hand smoke exposure and prison staff and prisoners’ smoking levels, health and opinions about smoking in prisons and prison smoking bans.
Staff second-hand smoke exposure was measured in all prisons between October 2016 and January 2017. Two different types of monitors were used to count tiny particles (PM2.5) known to be a sign of second-hand smoke and to measure nicotine in the air. Levels of a chemical called cotinine were also measured in the saliva of non-smoking staff at the beginning and end of their working shifts (cotinine indicates the amount of nicotine in the body). Staff and prisoners’ smoking levels, health and opinions were assessed via an online survey and focus groups (for staff) and a paper survey (for prisoners). Interviews were also conducted with health care staff involved in smoking cessation services within prisons. In addition, we conducted interviews with key personnel in countries which have already introduced smoke-free policies in their prisons, in order to learn from their experiences.
In July 2017, the Scottish Prison Service announced its intention for all prisons in Scotland to become smoke-free on 30th November 2018.
Phase 2 (2017-18) – following the smoke-free prisons policy announcement: an evaluation of any initiatives within Scottish prisons in the period leading up to the implementation of indoor smoke-free prison facilities in Scotland.
This phase repeated surveys with staff (online) and prisoners (paper questionnaires) in all Scottish prisons. In six ‘case study’ prisons, it also gathered more in-depth data from prison staff, prisoners and smoking cessation workers to assess progress towards implementation of a smoke-free policy as new policies on smoking begin to be discussed.
On 30th November 2018, all 15 Scottish prisons became completely smoke-free (indoors and in prison grounds). TIPs measured levels of second-hand smoke during the week that the policy was implemented.
Phase 3 (2018-20) – following policy implementation: an evaluation of the impact of the implementation of smoke-free policies on health, economic, cultural and organisational outcomes, and predictors of success or difficulties.
This phase includes: repeat measures of levels of second-hand smoke in all prisons; gathering data (on health, smoking and e-cigarette use, and opinions on smoking, electronic cigarettes and smoking bans in prisons) from prison staff and prisoners via surveys and staff focus groups in all prisons; gathering more detailed data via interviews with staff and prisoners in the six ‘case study’ prisons; and gathering data from health care staff involved in smoking cessation services in all prisons.
In addition to all the data collected by TIPs, we plan also to gather anonymous data on overall levels of health/sickness among prison staff and prisoners from before and after the smoke-free policy implementation, available via the Scottish Prison Service and NHS.
The design of TIPs means it will be able to measure changes over time, seeing what happens in the run-up to, and after the implementation of the smoke-free policy.
Feeding back findings
Although TIPs is independent of the Scottish Government and Scottish Prison Service, the researchers are committed to feeding back the findings to all stakeholders. We are committed to rapid and timely reporting of results to help policy-makers in Scotland and elsewhere decide how they can best move towards smoke-free prisons and to make sure that support for stopping smoking can be provided in the right ways. TIPs researchers were members of the multi-agency Smoke Free Prisons Stakeholder Advisory Group, along with key staff from the Scottish Prison Service, Scottish Government and NHS Health Scotland. Results from TIPs are also being published in academic journals and presented at conferences.
Results and dissemination
A literature review providing evidence on smoking and smoking restrictions in prisons was conducted in 2015 for the Scottish Prison Service's Tobacco Strategy Group to inform decisions on how best to introduce a smoke-free prisons policy.
TIPs background and methodology was shared via a poster at the 2016 Scottish Smoking Cessation Conference.
A peer-reviewed, scientific paper describing the Phase 1 findings in respect of prison staff exposure to second-hand smoke was published on 17th July 2017 and is available via the website of the journal ‘Annals of Work Exposures and Health’.
On 17th July 2017 the Scottish Prison Service announced its intention for all prisons in Scotland to be smoke free by the end of 2018. In making the announcement the service said that the move to smoke free prisons has been further informed by the Tobacco in Prisons study (TIPs).
The detailed results of the Phase 1 online survey of staff working in Scottish prisons conducted November-December 2016, and survey of prisoners in all Scottish prisons conducted November 2016-April 2017, were made available to all Scottish Prison Service staff and those from the Scottish Government and NHS involved in implementation of Scottish smoke-free prisons policy. Results from the Phase 2 staff and prisoner surveys have also been made available to key stakeholders.
A peer-reviewed, scientific paper on prison staff and prisoner views on a prison smoking ban, based on data collected in Phase 1 (before any policy announcements or initiatives) was published in the journal Nicotine & Tobacco Research in May 2018 and is available here.
A study on The Role of E-cigarettes in the Implementation of Smokefree Prisons and Ongoing Management of Prisoner Populations (funded by Cancer Research UK, (Principal Investigator Professor Kate Hunt, University of Stirling) is extending the TIPs research by exploring the role of e-cigarettes in the implementation of smoke-free prisons and ongoing management of prisoner populations.
It involves interviews with staff and people in custody (prisoners) to better understand perspectives and experiences of e-cigarettes in the prison setting before and after the implementation of a smoking ban. It will also analyse prisoner spending on items such as tobacco, e-cigarettes and food and drink, against critical stages in the implementation and routine management of smoke-free prisons.
Kate Hunt (University of Stirling)
Jill Pell (Public Health, University of Glasgow)
Kathleen Boyd (Health Economics and Health Technology Assessment, University of Glasgow)
Sean Semple (University of Stirling)
Linda Bauld (University of Edinburgh)
TIPs Research Associate
Ashley Brown (University of Stirling)