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Introduction: In jurisdictions permitting prisoner smoking, rates are high (c75%), with smoking embedded in prison culture, leading to secondhand smoke exposures among staff and prison- ers and challenges for smoking cessation. Momentum is building to ban smoking in prisons, but research on staff and prisoner views is lacking. We address this gap, providing evidence on staff and prisoner views throughout all Scottish prisons. Methods: Data were collected prior to the announcement of a (November 2018) prison smoking ban throughout Scotland. Mixed methods were used: surveys of staff (online, N = 1271, ~27%) and prisoners (questionnaire, N = 2512, ~34%); 17 focus groups and two paired interviews with staff in 14 prisons. Results: Staff were more positive than prisoners about bans and increased smoking restrictions, although prisoner views were more favorable should e-cigarettes be permitted. Nonsmokers were more positive than smokers. Whilst 74% staff and 22% prisoners agreed bans were a good idea, both groups acknowledged implementation and enforcement challenges. Staff views were influ - enced by beliefs about: acceptability of the policy in principle and whether/how bans could be achieved. Although some voiced doubts about smoke-free policies, staff likened a ban to other operational challenges. Staff raised concerns around needs for appropriate measures, resources and support, adequate lead-in time, and effective communication prior to a ban. Conclusion: We recommend that regular and open opportunities for dialogue within and between different stakeholder groups are created when preparing for prison smoking bans and that specific measures to address staff and prisoner concerns are incorporated into plans to create and main- tain smoke-free environments. Implications: To our knowledge, this study is the first to research staff and prisoner views across a whole prison system prior to implementation of smoke-free policies. The results highlight potential challenges and suggest measures, which might help to maximize the success of bans. Our results are relevant for prison service managers responsible for the forthcoming introduction of a ban in Scottish prisons (November 2018) and for other prison systems and comparable institutions plan- ning smoke-free initiatives. Given that prison smoking bans may be contentious, we recommend creating regular and open opportunities for dialogue between stakeholders when preparing for and maintaining smoke-free environments. © The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. 1027 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/ntr/article/21/8/1027/4996090 by DeepDyve user on 19 July 2022 1028 Nicotine & Tobacco Research, 2019, Vol. 21, No. 8 25,26 prisoner unrest. These concerns, rather than public health gains, Introduction have dominated much media coverage around the introduction of Smoking bans decrease exposure to secondhand smoke (SHS). In smoke-free prisons. the United Kingdom, prisons had partial exemption from smoke-free To maximize the success and enforceability of smoke-free prison legislation introduced in 2006/7. In the absence of smoke-free poli- policy, it is crucial to understand how tobacco and smoking restric- cies, prisoner smoking rates remained high and have been described tions are viewed prior to, and in anticipation of, any policy change. as “one of the most pernicious public health problems affecting To date, qualitative research on the meaning of smoking in prisons, prisons…all too often…ignored [in] community based tobacco con- and particularly on how this changes in the context of increased trol policies.” The 2015 national biannual survey of prisoners in 28,29 restrictions, is sparse. Two smaller and one larger qualitative Scotland reported that 72% smoke, three times the national aver- studies, all conducted in the United States following the imple- age and in line with figures for Europe (“64 to 88%” according to mentation of a partial/complete prison smoking ban, have noted a European Commission report ), with little evidence of the reduc- the importance of policy “buy-in,” staff support and access to NRT. tions in smoking seen in the general population. This high prevalence These studies reported the possibility of positive prisoner attitudes partially reflects rates in deprived and socially excluded communi - to a ban, while also highlighting the way in which a largely benign ties from which prisoners are disproportionately drawn. However, tobacco “market” can become problematic post-ban. However, no 6–11 imprisonment can lead to uptake of, or increased, smoking, and studies have undertaken a comprehensive overview of staff and pris- high rates of smoking are reflected in high SHS levels within some oner views across a prison system. 12,13 prisons. We have addressed these gaps in research by presenting data WHO considers “there is no safe level of exposure to second- from Phase 1 of the Tobacco in Prisons study (TIPs), a three-phase hand tobacco smoke,” citing evidence that SHS increases the risk evaluation of the transition towards and implementation of smoke- of CHD, lung cancer, breast cancer, and respiratory symptoms and free prisons in Scotland, Phase 1 data on objectively measured SHS illnesses in adults, and, for those exposed during pregnancy, of low from all 15 prisons are presented elsewhere. Here, we document birth weight and preterm delivery. Both prisoners and staff (par- the views of both prisoners and staff, drawing on survey and focus ticularly those entering/opening prisoners’ cells) are potentially at group/paired interview data collected several months prior to the risk and SHS exposure in prisons has attracted concern interna- announcement that Scotland prisons would be smoke-free from tionally. Momentum is building throughout the United Kingdom, November 2018. 8 15 as elsewhere (eg, Australia, USA ), to increase tobacco control or completely ban smoking in prisons, to improve staff and prisoner 16,17 health and address health inequalities, although it has been sug- Methods gested that smoking bans have been motivated “less by public health TIPs Phase 1 data collection was designed to establish baseline values concerns than by fear of lawsuits from institutional staff and other for smoking and cultural/social norms, in addition to levels of SHS, inmates.” Several jurisdictions have implemented total smoke-free health indicators, and provision and experience of smoking cessation policies (ie, all indoor and outdoor areas) across their prison estate. services, across all of Scotland’s 15 prisons. Phase 2 is ongoing and New Zealand was the first to introduce total smoke-free prison poli - entails a process evaluation of initiatives, events, and changes in the 19,20 cies country-wide in 2011, and measurements of indoor air qual- period leading to implementation; Phase 3 will evaluate the impact ity in one prison before and after implementation showed “rapid and of smoke-free policies. substantial” improvements. A systematic review which included Staff perspectives on smoking in prisons, smoking regulations, three studies evaluating the cessation outcomes of an indoor smok- and smoking bans were collected via focus group discussions/ ing ban and seven (all United States) of complete smoking bans paired interviews and an online questionnaire. Prisoner views were concluded that “a complete smoking ban (rather than partial ban) obtained via paper questionnaires. At the time of the data collection, can effectively interrupt smoking behaviour” and an analysis of prisoners were allowed to smoke in designated cells and outdoor US data found prison tobacco control policies are associated with spaces; staff and visitors were prohibited from smoking anywhere reduced mortaility. In the United Kingdom, total smoke-free policies on prison grounds. were adopted by Broadmoor Secure Hospital in 2007, the Scottish The protocol and study tools were approved by the Scottish State Hospital in 2011, Welsh prisons from January 2016, and at Prison Service (SPS) Research Access and Ethics Committee and early adopter (and subsequently many more) prisons in England University of Glasgow’s College of Social Sciences Ethics Committee from March 2016. In July 2017, informed by evidence on SHS in in August 2016 (ref number: 400150214). Research is independent Scottish prisons, the Scottish Prison Service (SPS) announced that of the SPS and Scottish Government; results are being fed back on Scotland’s prisons will be smoke-free from November 2018. an ongoing basis to all key stakeholders (eg, survey results feedback It is widely recognized, however, that making prisons smoke-free to the SPS TIPs Research Advisory Group, prisoners, staff, prison presents particular and considerable challenges. Butler described governors) to inform progress towards implementation. tobacco smoking as “an integral part of prison life and an estab- lished part of the prison culture,” serving a range of functions “as a Staff and Prisoner Surveys surrogate currency, a means of social control, as a symbol of freedom in a group with few rights and privileges, a stress reliever and as a An invitation and link to the online staff questionnaire (live 1st social lubricant.” Cigarettes can thus represent a means of deal- November to 16th December 2016), plus reminders, were sent to ing with the challenge of “killing time” and tobacco-based products an appointed contact within each prison who agreed to make this offer prisoners “cultural capital to buy and exchange items; favours available to all prison officer, managerial and support staff within 23 24 and protection,” as an alternative currency. The decision to their prison. The questionnaire included sections on staff smoking, smoke (or not) has been described as “one of the last functions that health, perceived SHS exposure, and opinions on smoking in prisons the inmate has control over” and its removal raises concerns about and prison smoking bans. The opinions items (detailed in Tables 1 Downloaded from https://academic.oup.com/ntr/article/21/8/1027/4996090 by DeepDyve user on 19 July 2022 Nicotine & Tobacco Research, 2019, Vol. 21, No. 8 1029 Table 1. Prison Staff Opinions (% Agreeing/Strongly Agreeing) With Statements About Smoking in Prisons and Prison Smoking Bans, Overall and by Smoking Status Overall According to smoking status - % N/N (%) Current Ex Never (sig) How much do you agree with these statements about smoking in prisons? (five answer options collapsed to binary categories for analysis, “strongly agree” and “agree” vs. “no opinion,” “disagree,” and “strongly disagree”) Prison staff should be protected from cigarette smoke at work 1218/1270 95.9 82.1 96.6 98.2 (<0.001) Prisoners who do not smoke should be protected from cigarette 1206/1265 95.3 81.3 95.5 98.2 (<0.001) smoke There should be more NHS support for prisoners who want to stop 879/1268 69.3 55.3 67.1 74.6 (<0.001) smoking Prisoners who smoke should not be forced to stop smoking 490/1268 38.6 68.0 42.0 28.8 (<0.001) Prisoners who smoke are unlikely to ever stop long-term 537/1266 42.4 46.3 38.4 45.7 (0.028) Smoking should not be allowed in any indoor areas of prisons 989/1259 78.6 42.1 75.6 89.5 (<0.001) Smoking should not be allowed in any outdoor areas of prisons 480/1269 37.8 14.6 32.5 48.4 (<0.001) You have probably heard that smoking is no longer allowed in any areas (inside and outside) in prisons in some countries around the world like Canada, New Zealand, and Wales. What do you think of prison smoking bans like these? (five answer options collapsed to binary categories for analysis, “strongly agree” and “agree” vs. “no opinion,” “disagree,” and “strongly disagree”) Prison smoking bans are a good idea 937/1268 73.9 35.0 69.1 87.4 (<0.001) Prison smoking bans cause a lot of trouble (eg, prisoner fights, 737/1269 58.1 75.4 60.7 51.7 (<0.001) rioting, tobacco smuggling) Prison smoking bans help prisoners stop smoking long-term (and 640/1269 50.4 29.3 48.0 57.5 (<0.001) after release) Prison smoking bans are hard to enforce 780/1266 61.6 72.1 66.8 53.9 (<0.001) Most prison staff want smoking bans 788/1269 62.1 36.6 55.4 74.6 (<0.001) Prison smoking bans are OK if enough stop smoking support is 849/1266 67.1 40.2 64.7 75.3 (<0.001) available to prisoners Prison smoking bans are OK if prisoners are allowed e-cigarettes 451/1270 35.5 36.6 37.0 33.7 (0.476) or vapes Would you be in favor of increased smoking restrictions in Scottish 1004/1271 79.0 35.0 77.5 90.1 (<0.001) prisons? (three answer options collapsed to binary categories for analysis, “in favour” vs. “no opinion” and “against”) and 2) were adapted from: a US survey of prison staff on restrictions 2017). This included 17 focus groups and, for operational reasons, to smoking in prisons; an Australian study of staff experience and two paired interviews; on these two occasions, other staff were un- attitudes to implementation of a smoke-free policy in a high security able to attend at short notice and we proceeded to allow the people mental health in-patient facility; a Swiss survey of staff and patient who came the opportunity to express their views. We indicated to attitudes to implementation of a smoke-free policy in a psychiatric “gatekeepers,” who facilitated recruitment within each prison, that hospital; and a Scottish study of bar workers’ attitudes to smoke- we wished to include smokers and nonsmokers: 78 never smokers 1,35 free public places legislation. (NS), 27 ex-smokers (Ex), and 14 current tobacco cigarette or e-cig- Results presented here are based on responses from 1271 prison- arette users (S) participated in focus groups (smoking status for 13 based staff (estimated 27% return) and include descriptive and participants not known (NK)). bivariate analyses. The proportion of male respondents (71%) was Focus groups (range = 5–12 participants; mode = 6) and paired identical to that of SPS staff overall. The proportion of smokers was interviews were led by a TIPs researcher using a topic guide which somewhat lower (10% current, 23% ex, and 67% never/never regular included sections on smoking and exposures to SHS, particularly smokers) than Scottish adults (21%, 25%, and 54%, respectively). within prisons; smoking norms and perceived prevalence within the Paper-based questionnaires (covering similar topics to those prison; the “culture’ of smoking within prisons; management of nico- asked of staff) were distributed by TIPs research staff in three pris- tine addiction (including e-cigarettes) in prisons and wider society; and ons; in the remaining 12 prisons questionnaires were handed to restrictions on smoking and opinions on these. The topic guide was prisoners by prison staff at evening lock up and collected in sealed designed to achieve an appropriate level of consistency for qualita- envelopes (to protect confidentiality) the next morning. tive data collection; question wording was not prescribed. Participants Descriptive and bivariate analyses of 2512 completed prisoner were reminded that the researchers were independent of the SPS and questionnaires (estimate 34% response) are presented. The propor- Scottish Government, encouraged to express themselves freely and tion of smokers (74%) amongst prisoner responders was almost honestly, and invited to raise any points or views, which they thought identical to that of prisoners overall (72%). to be pertinent. Discussions were audio recorded and transcribed ver- batim with participants’ written consent; transcripts were reviewed Focus Groups (and Paired Interviews) for accuracy against the audio files and anonymized prior to data From 14 prisons, 132 Scottish prison staff participated in a total analysis. TIPs researchers who had conducted fieldwork read tran - of 19 qualitative data collection encounters (November 2016–April scripts and agreed to a descriptive coding scheme: general tobacco Downloaded from https://academic.oup.com/ntr/article/21/8/1027/4996090 by DeepDyve user on 19 July 2022 1030 Nicotine & Tobacco Research, 2019, Vol. 21, No. 8 and bans; prison bans; smoking culture in prisoners; smoking culture than prisoners. Thus almost all staff (strongly) agreed both that staff in staff; SHS exposures; e-cigarettes; quitting, alternatives, and ces- (96%) and nonsmoking prisoners (95%) should be protected from sation; operational, organizational, and local issues; Wales, England, cigarette smoke whereas equivalent figures for prisoners were 55% and elsewhere; Scottish Prison Service and Scottish Government; and and 68%; most staff (79%) but only a quarter (24%) of prison- TIPs research. All transcripts were organized according to this cod- ers favored increased smoking restrictions in Scottish prisons; and, ing scheme. Outputs from the “prison bans” code were then managed similarly, 74% of staff but only 22% of prisoners (strongly) agreed using the framework approach, facilitated by Nvivo software (QSR that “prison smoking bans are a good idea.” However, support for International). This process involved producing data summaries for increased restrictions varied by smoking status in both staff and pris- every piece of coded data. Data summaries were displayed in a matrix oners (as did almost all statements related to smoking in prisons), and format to facilitate analysis within and between focus groups/paired were notably more positive among never smoking staff and prisoners interviews. Data were thematically analyzed, ensuring that attention (90% and 67%, respectively), than among current smoking staff and was paid to the range and diversity of views. Analytical summaries prisoners (35% and 11%). Nonetheless, many staff (58%) and most were compiled and reviewed in detail by at least one additional prisoners (81%) (strongly) agreed that “prison smoking bans cause member of the authorship team and findings were checked by each a lot of trouble” and around two-thirds (62% staff, 65% prisoners) member against a sub-sample of the transcripts. Illustrative extracts that bans may be “hard to enforce.” Notably, almost half of prisoners, indicate the prison, focus group and speakers’ smoking status, for irrespective of smoking status, (strongly) agreed that prison smoking example, KA04 = prison K, group A, participant 04; NS = nonsmoker, bans “are OK if prisoners are allowed e-cigarettes or vapes.” Ex = exsmoker, S = smoker, NK = smoking status not known. Codes were randomly allocated to prisons by the research team. Reasons Staff Supported or had Doubts About a Prison Smoking Ban Results Analysis of the staff focus group/paired interview data suggested that perceptions of prison smoking bans were influenced by: Levels of Staff and Prisoner Support for a Prison (1) beliefs about whether a ban was acceptable in principle and Smoking Ban: Survey Data (2) views on whether a ban could be successfully achieved. These are The percentage of staff and prisoners agreeing or strongly agreeing discussed below. with a series of statements about smoking in prisons and compre- hensive indoor/outdoor prison smoking bans (hereafter referred to as “prison smoking ban”) are shown in Tables 1 and 2. Perhaps un- Beliefs About Whether a Ban was Acceptable in Principle surprisingly, staff indicated higher support for protection (for staff Views on whether a smoking ban was a fair and justifiable policy and prisoners) from SHS, restrictions of smoking, and smoking bans varied. Prisons were discussed as “homes” as well as workplaces, and Table 2. Prisoner Opinions (% Agreeing/Strongly Agreeing) With Statements About Smoking in Prisons and Prison Smoking Bans, Overall and by Smoking Status Overall According to smoking status—% N/N (%) Current Ex Never (sig) How much do you agree with these statements about smoking in prisons? (five answer options collapsed to binary categories for analysis, ‘strongly agree’ and ‘agree’ vs. ‘no opinion’, ‘disagree’, and ‘strongly disagree’) Prison staff should be protected from cigarette smoke at work 1337/2414 55.4 46.1 78.9 84.9 (<0.001) Prisoners who don’t smoke should be protected from cigarette smoke 1644/2411 68.2 60.1 88.3 94.2 (<0.001) There should be more NHS support for prisoners who want to stop smoking 1836/2404 76.4 76.5 74.7 77.6 (0.684) Prisoners who smoke should not be forced to stop smoking 1900/2421 78.5 87.2 59.2 46.9 (<0.001) Prisoners who smoke are unlikely to ever stop long-term 1042/2416 43.1 45.3 31.7 41.9 (<0.001) Smoking should not be allowed in any indoor areas of prisons 1066/2408 44.3 33.1 68.6 84.5 (<0.001) Smoking should not be allowed in any outdoor areas of prisons 432/2411 17.9 12.7 24.6 41.2 (<0.001) You have probably heard that smoking is no longer allowed in any areas (inside and outside) in prisons in some countries around the world like Canada, New Zealand, and Wales. What do you think of prison smoking bans like these? (five answer options collapsed to binary categories for analysis, “strongly agree” and “agree” vs. “no opinion,” “disagree,” and “strongly disagree”) Prison smoking bans are a good idea 542/2415 22.4 10.2 48.8 67.1 (<0.001) Prison smoking bans cause a lot of trouble (eg, prisoner fights, rioting, tobacco 1954/2407 81.2 87.8 65.8 58.6 (<0.001) smuggling) Prison smoking bans help prisoners stop smoking long-term (and after release) 495/2394 20.7 14.3 34.8 43.6 (<0.001) Prison smoking bans are hard to enforce 1545/2397 64.5 65.5 58.4 64.6 (0.047) Most prison staff want smoking bans 782/2390 32.7 29.6 40.4 42.7 (<0.001) Prison smoking bans are OK if enough stop smoking support is available to 877/2393 36.6 27.6 59.9 64.9 (<0.001) prisoners Prison smoking bans are OK if prisoners are allowed e-cigarettes or vapes 1158/2395 48.4 47.7 49.7 50.3 (0.620) Would you be in favor of increased smoking restrictions in Scottish prisons? 564/2395 23.5 11.3 50.0 67.1 (<0.001) (three answer options collapsed to binary categories for analysis, “in favour” vs. “no opinion” and “against”. Downloaded from https://academic.oup.com/ntr/article/21/8/1027/4996090 by DeepDyve user on 19 July 2022 Nicotine & Tobacco Research, 2019, Vol. 21, No. 8 1031 concerns raised about restricting prisoner smoking while tobacco recognized as potential barriers to implementation. Implementation remains a legal substance in wider society. was expected to be particularly difficult for certain groups, such as new admissions and prisoners on remand or with mental health (KA03[NS]) “Me personally, I’m a non-smoker, I’m an anti- problems or drug addictions: smoker, I think it’s disgusting…but to say to somebody, you’re not getting to smoke in your own home, and it is their home, it’s LA05[NS] “I struggle to see how we can be completely smoke their cell, sort of thing, I know it’s complicated with staff have got free, because we’ve got prisoners in here that have been here for to access that as well, but I think it’s going to be a very, very diffi - 20 years [who have] absolutely no interest in stopping smoking, cult thing to justify… especially when it’s still a legal substance.” guys that’s coming in on remand from the community, might only be here a few weeks, they’ve been smokers, they’re not going to Some staff thus regarded smoking as an unpleasant but expected quit within a few weeks…” hazard of working in a prison environment, as illustrated below: In contrast, reasons for believing a ban “could” be successfully HA02[S] …I understand the workplace ban….but this isn’t a implemented included the widespread public acceptance of tobacco normal job…I mean some of the stuff that comes your way work- restrictions in enclosed spaces, despite initial doubts about the policy, ing in this job you wouldn’t choose and you don’t welcome and and introduction of bans in other challenging environments such as all the rest of it, but it comes. It’s a risk and we manage that risk. mental health hospitals. Thus, many staff believed prisoners would HA05[NS] …Working in [a prison] is totally different… people adapt to the ban, as they did to other prison rules, as illustrated in say it’s your place of work, aye it’s my place of work but it’s noth- the following exchange in which a member of staff draws a parallel ing like any other job… between the management of prisoners addicted to illegal drugs and Nonetheless, some voiced a need for alternative measures to limit those addicted to tobacco: SHS exposure, such as improved ventilation, and greater efforts to CA07[Ex] Because you could stop it in the jails, and everybody help prisoners to quit smoking. that’s been in the jail a while will get used to that. But if you’ve By contrast, other staff expressed very strong views that SHS got somebody coming in for the first time, off the street, who’s a exposure at work was unacceptable, given its detrimental effect on heavy smoker, how do we deal with that? health. Staff often described how tobacco smoke within prisons was CA03[NS] They’re in a high stress situation, first time in jail, unpleasant, even offensive, to experience. Some commented on the they’re maybe missing their families…they’ve got mental health “disgusting” smell of smoke in prisons and complained how it could issues, drugs…And then you’ve got to take their tobacco off them. linger on hair and clothes after leaving work: Interviewer: So you think that’s almost like the last ‘domino’, yeah. CA03[NS] Yeah, well, they’ll either hurt themselves, or try and EA05[NS] “I go home from work and my husband will say oh hurt us, or hurt somebody else you stink. And you don’t realise until you come out of the envi- CA06[NS] … I totally agree with what you’re saying... But ronment and when you don’t smoke and no one in your house then, at the same time, for those that are [addicted to] heroin, or smokes it’s horrible, your clothes are absolutely reeking, it’s really cocaine… I know we have the detox, and methadone, but…they’re bad.” still not gonna get the same level, and they guys have to deal with it CA07[Ex] That’s right. Some groups voiced a sense of injustice that prison staff were not CA06[NS] Because we can’t give them the illegal drugs that afforded the same legal protection from SHS as other workers, frus- they’re used to… So it’s the same thing, it’s an addictive substance tration with the decision to partially exempt prisons from smoke- free legislation introduced in Scotland in 2006, and a perception that All groups/paired interviews expressed concerns about potential there was insufficient regard to staff welfare: negative consequences of a ban. These included: increased prisoner distress, self-harm, and suicide; episodes of unrest, violence, or riots; BA03[NS] …the government says there’s no safe secondary greater risks of physical or psychological harm to staff; creation of smoke anywhere, but yet they’re quite content for every Scottish tobacco as contraband and associated problems such as smuggling, prison officer to go in that environment every day they’re at their bullying, and debt; and use of alternatives (such as illicit tobacco, work… it’s a routine part of their job but it’s an expected part… smoking tea bags, taking illegal substances) and associated problems and that’s wrong…. such as using exposed wires from kettles as an ignition source. The BA01[Ex] Well the thing that’s wrong is the fact that we work in the only workplace where we’re expecting them to smoke and extracts in Box 1 illustrate these concerns. nobody else is expected to do that and that’s what’s wrong. Nonetheless, some staff stated that such potential risks were not BA07[NS] There’s nobody. Can’t think of anybody sufficient reason to reject smoking bans given the significant benefits to staff and prisoner health that could be achieved through making Furthermore, the complete prohibition on staff, but not prisoner, prisons smoke-free. Some challenged the view that major incidents, smoking on SPS premises was described by some as unfair. such as riots, might occur, as illustrated in the following extract where several participants agreed that a ban should be introduced Views on the Degree to Which a Ban Could be Successfully despite any short-term difficulties it might create: Achieved GC13[NS] …all you need to look at a…night in here right All groups/paired interviews discussed whether and how a smok- before they have got their canteen [shop from which prisoners ing ban could be successfully achieved in a prison environment if can buy items]…and they have ran out of tobacco…it is a differ- policies were to change, and views were again mixed. Current prison ent shift in here… So, if you banned it…of course there would be smoking culture, including perceptions that prisoners smoke in issues, but I personally don’t think that that should be a reason to part to alleviate stress, anxiety and boredom, and possible defiance stop going ahead with it... of a ban by prisoners unwilling or less able to quit smoking, were GC14[NS] To stop it, no. Downloaded from https://academic.oup.com/ntr/article/21/8/1027/4996090 by DeepDyve user on 19 July 2022 1032 Nicotine & Tobacco Research, 2019, Vol. 21, No. 8 Perceptions That a Ban was Inevitable Box 1: Staff views on potential unintended consequences Staff perceived that, sooner or later, a ban was inevitable, not least of a ban because of Government aspirations to make Scotland smoke-free by 2034. In this context, staff spoke pragmatically about a ban, liken- Risks to prisoners and prison staff ing the task of implementation to other challenges faced at work. “It would make a nicer working environment for us, but is that Thus, it was often stated in exchanges of simple “facts” that staff had worth the backlash that would come as a result of that? It might the experience to “deal with” any problems associated with a ban, as make it a nicer place to work, but would it make it as safe a they did with other challenges: place to work? That’s what you’d have to weigh up, because it AA05[S] … it will be implemented and do you know what, it’ll might affect your health in a different way.” (KA04[NS]) be dealt with… “Some prisoners who are just on the verge of taking their AA06[NS] We’ll deal with it ‘cause you’ve got to. AA05[S] …and within a month it’ll be in and it’ll be no differ- own lives, who can’t smoke...if they can’t smoke, how do we ent. It’s like everything else. People stand up against it and they calm them down? If they’ve got nothing there to calm them say this and they say that and do you know what, it just goes down, it could tip them over the edge. So suicides will go up.” through and it gets done and before you know it, you’re going (NA06[NS]) [saying], “Remember you used to smoke in jails!” AA06[NS] ..it’s going to happen. Prisoner unrest AA05[S] And it’ll happen and it’ll be done. “There’s gonna be so many positives to it, with the ban, AA06[NS] And we’ll deal with it. but there’s gonna be so many negatives, like you were say- AA07[S] Exactly. ing, concerted [in]discipline in, obviously, your adult jails…” (CA06[NS]) Staff Views on Factors Important to Successful Implementation of a Future Ban “This blanket ban of smoking isn’t taking into account any of When asked what might contribute to successful implementation the ripple effect that it’s going to have, let alone the trouble it’s of a future smoking ban in Scottish prisons, staff identified sev - going to cause. Eventually we’ll manage the trouble in prisons eral facilitators. These were: sufficient lead-in time; proactive and like we’ve done before but it’s all the other things it’s not quite supportive management of the policy; adequate funding and other taking into account.” (CA02[S]) resources; effective consultation and communication with staff and Contraband and associated problems prisoners; adequate prisoner smoking cessation support and meas- ures to manage nicotine withdrawal; potentially piloting a ban prior “… [if] we ban [tobacco] completely…It’ll still be smuggled to wider roll-out where appropriate; and learning from other juris- in. It’ll become even more of a commodity than it is now…” dictions which have gone smoke-free. These views are illustrated (FA03[NS]) in Box 2. “I think you will also get an increase in the extent of bully- However, there was debate between staff over the details of how ing, because you have another commodity that’s become more a future ban should be implemented. For example, there was no valuable because you’ve made less of it, and…. I think you’ll obvious consensus on an optimum timescale from announcement to increase in vulnerability because prisoners will be getting bul- implementation. Suggestions generally ranged around 6–18 months, lied for the tobacco, or even if they don’t smoke, they’ll be told, but some believed that 5 or more years’ preparation would be needed, you will be buying tobacco for me this week at the canteen.” whereas others, particularly those expressing a high degree of sup- (LA04[NK]) port for a smoking ban, called for a much shorter timescale (eg, days/ weeks), likening exposure to SHS to other workplace hazards: Alternatives to tobacco, lighters and matches “A blanket ban on smoking I can think of the knock-on effect DA05[NS] …if this was asbestos we were talking about, would we say we’re going to wait another six months before we do any- of that. Everything from the health issues if guys are smoking thing about it? No, they would be shutting down this building… cannabis which use tobacco, what will they do? They’ll move on they’d be putting up special measures, control measures in place…. to harder drugs, I’ll guarantee it.”(DA01[S]) “…when some of our prisons haven’t got tobacco in the halls Others in this group, while recognizing the need to protect staff from here, they’ll smoke teabags. They’ve got to smoke something SHS, favored a longer lead in time to ensure adequate cessation sup- and the smell of tea bags, it’s actually worse than tobacco.” port for prisoners was in place: (HA03[N]) Interviewer [addressing different group members who had expressed opinions on time scale] Are you saying “Monday”, and GC13[NS] ...because [there’s] so many other risks to other you’re saying “Maybe six months”? people if you let them continue to smoke. So, I think obviously DA05[NS]: I don’t think opinions come into it. It’s a matter of there would be problems, there would be potentially big prob- law. lems, but I think eventually you would manage to get a grip of it DA03[NS]: I think you need to give folk time to be… prepared and that’s a personal opinion. to actually support folk and be able to do it. It’s an addiction that GC14[NS] I’m with you…I think there’s always problems. they’ve got and that has to be considered…we’re still a caring GC13[NS] It’s easy you can hide behind the fact that…if we stop profession although we should be caring for our staff and I totally this…this is going to be happening in jail, your job is going to be agree with that… harder. I accept that, but I don’t think you can hide behind that… DA05[NS]: Yes, we come first. Downloaded from https://academic.oup.com/ntr/article/21/8/1027/4996090 by DeepDyve user on 19 July 2022 Nicotine & Tobacco Research, 2019, Vol. 21, No. 8 1033 Box 2: Continued Box 2: Factors important to successful implementation of “…a cigarette can really help them calm down and if they’re a future ban then told they’re not allowed to smoke and here are some Sufficient lead-in time patches, maybe an e-cig would be a good compromise because it would be a good similarity.” (MA01[Ex]) “There would need to be a…reduction…not just…the ban’s coming in tomorrow. It’d need to be plenty of time, people “They’re going to have to employ far more counsellors or peo- being told, here’s the alternatives…essentially it would be a new ple that are trained in trying to help people stop smoking… sort of education for people….to say…come 18 months’ time they’re going to have a lot more than four folk dealing with it.” you will not be allowed to smoke tobacco within anywhere in (EA04[NS]) the jail. (IA11[S]) Potentially piloting a ban Proactive and supportive management of the policy “…Small steps. If you’re going to introduce something like this, “…as long as you get the back up from the governors and it has to be small steps. Trial, did that work? No. What do we management and says, right okay, we’ll deal with this. This do next? It has to be introduced gradually.” (HA02[S]) might cause problems for the next six months, but we’ll deal Learning from other jurisdictions which have gone smoke-free with it because this is the way forward - we are not deviating from this. It is now a non-smoking jail. That’s it.” (GD04[N]) “If they can come up with what other people have done, take all the best bits from other people’s mistakes, and then say, right Adequate funding and other resources this is what we’re gonna do.” (NA01[NS]) “…if you did put a blanket ban on smoking inside the jail… if we were allowed to, we could be robust and strict, and we There were also diverse opinions on the need to phase in a ban could…possibly prevent any major incidents of indiscipline. But prior to wider roll-out, either within designated residential areas we would need to be supported in that, we would need to be of a single prison (eg, introducing voluntary smoke-free wings) or given the time, and we’d need to be given the resources to be in designated prisons (eg, piloting of a smoking ban). In the fol- able to deal with that.” (EA03[Ex]) lowing extract, staff discuss the pros and cons of introducing vol- “Where do then the cuts come from for everything else, like let’s untary smoke-free wings after one participant suggested the idea: try and manage the system that we have just now, find some money to do that before we like absolutely take this off the table, GC14[NS]: Can staff volunteer to work in that environment? because the [health services] don’t have the money…” (KA05[S]) GC11[S]: That would be it that would be the downside, some- body has got to work in the scabby smoking area. Effective consultation and communication with staff and prisoners [Conversation shifts topic, then returns to smoke-free wings] The communication part is key…In custody, great, but it also GC16[NS]: I think it would be a good idea…if you maybe has to be outwith custody, in police cells, court houses… So started off at the beginning by saying…‘This is a no smoking that they’re aware it’s happening, that kind of seed is planted. area’…see how the uptake was on [prisoners] wanting to go there (JA14[N]) and how it went… GC14[NS]: But...how many people [prisoners] would manipu- “…staff quite often…things get handed down from on high…I late that as well just to get a single cell … think it’s really important that staff are involved at every stage, GC13[NS]: But, I mean as soon as you caught anybody in what the alternatives might be”. (N04[NK]) smoking in there [smoke-free wing] then they are shipped straight back. ..You would just say, “Right, well that’s you, “…get the staff buy-in and say, right, this is what we’re wanting you’re back then!” to do, you guys are at the coalface, so to speak Will this work and if not, why won’t it work and what do we need to do to Finally, there were discussions about the desirability or otherwise make it work? (MA02[NS]) of introducing e-cigarettes into prisons as an alternative to tobacco. “…I think…we have to try and make [prisoners] an important This issue is considered in more detail elsewhere; in brief, some staff part of it, and say we’re not doing it because we are particularly regarded e-cigarettes as important to policy success, whereas others fed up with opening doors and being stinking, but we’re actu- expressed concerns about their implications for staff and prisoner ally more concerned that you are looking after your health.” health and organizational safety. (IA11[S]) There was some uncertainty about the extent to which adequate meas- ures and support, as described above, would be in place prior to introduc- Adequate prisoner smoking cessation support and withdrawal tion of a ban in Scottish prisons. Specific fears were raised in respect of management the need for: effective leadership of a ban (eg, sufficient consideration and management of risk); implementation strategies suited to local context “I think, an admission process…is the key. Because you’re (eg, adequate preparation time and avoidance of unnecessary delays in expecting somebody with an addiction, in the community, to introducing a ban); and ways of working around constraints on public then come into an area where, until such times as addiction spending or the complexities of financing the support needed to help pris - recovery or support is put in place, they’re coming in and having oners manage withdrawal and quit/abstain from smoking. to do cold turkey.” (CA01[NS]) Downloaded from https://academic.oup.com/ntr/article/21/8/1027/4996090 by DeepDyve user on 19 July 2022 1034 Nicotine & Tobacco Research, 2019, Vol. 21, No. 8 often stressful environment. High rates of mental health problems in Discussion prisons may create further challenges in banning smoking, particu- To our knowledge, this study is the first to research both staff larly as tobacco is (mistakenly) perceived to be effective in manag- and prisoner views across a country’s prison system prior to the ing anxiety. Additionally, contextual factors such as increases in announcement, or implementation, of a prison smoking ban. Using the prison population in recent decades, longstanding pressures mixed methods, we found that opinions on a smoking ban differed on prison finance and staffing, and the relatively recent (2011) between staff within and between prisons, between prisoners and transfer of healthcare from Scottish prisons to health services staff, and also by smoking status. Focus groups and paired inter- have the potential to exacerbate problems in introducing smoke- views with prison staff revealed that opinions were influenced by free policy in Scotland’s prisons in November 2018. Although the differing interpretations of: the legitimacy of restricting a prisoner’s scale of the task should not be underestimated, it is important to freedom to smoke; the obstacles posed by current prisoner smok- highlight that bans have been introduced into prison systems around ing culture; and the trade-off between health improvement and the world experiencing common operating pressures, with evidence protection, potential physical and psychological risks to prisoners suggesting that implementation of smoke-free initiatives is often and staff, and threats to prison discipline. Consistent with previous smoother than anticipated and fears of major unrest do not gener- 19,38 studies, staff thought the success of prison smoking bans might 19,38,43,44 ally materialize. depend on good governance and leadership; adequate time, support, The findings of our study support the need for prison smok - and resources; good stakeholder communication and engagement; ing bans to be accompanied by effective smoking cessation sup- and effective management of nicotine addiction. port, access to satisfactory tobacco alternatives and training for Strengths of this study include collection of data from staff and frontline staff on the effects of nicotine withdrawal and ideas for prisoners in all Scotland’s prisons, representing a range of prison supporting quit attempts. In addition, there should be reviews of environments and populations. However, the overall return rates safeguarding procedures for vulnerable prisoners and increased to the staff and prisoner surveys were 27% and 34%, respectively. promotion and investment in activities, which help to reduce anxi- Thus, a degree of caution is required when generalizing from our ety, stress, and boredom. Ongoing measures will be needed for results to the population of Scottish staff and prisoners. Although the maintenance of smoke-free environments, including contin- the sampling and recruitment approaches used for the question- ued strategies for management of nicotine addiction and fair and naires and focus groups were dictated by ethical, logistical, and robust policing of bans. operational considerations, and devised after extensive consultation Given that prison smoking bans may be contentious, we recom- with TIPs’ SPS-convened Research Advisory Group (which included mend that prison service managers create opportunities for regu- representation from management, government, legal and health and lar and open dialogue within and between stakeholder groups. It safety staff, residential staff and union members), we recognize that is important that specific measures to address staff and prisoner participants were recruited using convenience sampling; those who concerns are incorporated into plans to bring about and maintain volunteered to participate may not be representative of all Scottish smoke-free environments. staff and prisoners. In particular, it should be noted that a lower proportion of prison staff were smokers compared with the general population. However, Scottish prison staff have not been allowed Funding to smoke anywhere on prison premises since 2008, so it is possi- The TIPs study was funded by the National Institute for Health Research ble that rates of smoking in this group are actually lower than Public Health Research Programme (project number 15/55/44). The authors among Scottish adults, especially as movement through and out of acknowledge funding from the Medical Research Council (MC_UU12017/12 a prison to smoke during a break may be considerably more dif- and MC_PC_13027 to ED) and Chief Scientist Office (SPHSU12). The views ficult than in other workplaces. To our knowledge, no data exist and opinions expressed are those of the authors and do not necessarily reflect to test this hypothesis. For operational reasons, paired interviews those of the Public Health Programme, NIHR, NHS, or the Department of were conducted instead of focus groups on two occasions. While Health. we acknowledge methodological differences between interviews and focus groups, we believe that these methods are complementary and Declaration of Interests can be combined effectively within a study. Logistical issues meant the present study could not explore prisoner attitudes qualitatively; None to declare. this is planned for a subsequent phase of work. Finally, we acknowl- edge that levels of SHS vary greatly between and within prisons, no Acknowledgments doubt influencing the strength of feelings and views in participants. Novel contributions of this study are that it provides compre- We are grateful to the staff and prisoners who completed the surveys, hensive and comparable evidence on how staff and prisoners view staff who took part in the focus group discussion, and staff at the Scottish Prison Service and the two non-SPS-run prisons (HMP Addiewell and HMP smoking bans prior to any decision on the introduction of smoke- Kilmarnock) who assisted with the study and facilitated access. We would free policy and highlights potential challenges to implementation as also like to thank colleagues at MRC/CSO Public Health Research Facility well as measures which might help to maximize success. Our results for help with data management and input (in particular David Walker, Kate are timely and highly relevant for the forthcoming introduction of Campbell, and Matthew Tolan). We gratefully acknowledge the contribution smoke-free prisons across Scotland in November 2018 and may be of our co-investigators in TIPs research team to the overall design of the study informative for other prison systems and comparable institutions (Linda Bauld, Kathleen Boyd, Philip Conaglen, Peter Craig, Douglas Eadie, planning smoke-free initiatives. In particular, the results highlight Alastair Leyland, Jill Pell, and Richard Purves). We would particularly like to that the introduction of prison smoking bans removes an estab- thank Sarah Corbett, Linda Dorward, Ruth Parker, and members of the SPS lished activity and rare pleasure (sometimes even seen as a “right” Research Advisory Group for their helpful input during the design and con- or “privilege”) from individuals who are living in a difficult and duct of this research. Downloaded from https://academic.oup.com/ntr/article/21/8/1027/4996090 by DeepDyve user on 19 July 2022 Nicotine & Tobacco Research, 2019, Vol. 21, No. 8 1035 23. Taylor P, Ogden C, Corteen K. Tobacco smoking and incarceration: References expanding the ‘Last Poor Smoker’ thesis an essay in Honour of David 1. Semple S, Maccalman L, Naji AA, et al. Bar workers’ exposure to Ford. Internet Journal of Criminology. 2012; 1–19. second-hand smoke: The effect of Scottish smoke-free legislation on occu- 24. Richmond R, Butler T, Wilhelm K, Wodak A, Cunningham M, pational exposure. 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Nicotine and Tobacco Research – Oxford University Press
Published: Jul 17, 2019
Keywords: prisoners; smoke; correctional facilities; public smoking laws; smoking; tobacco
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