Systematic Review of Factors Influencing Smoking Following Release From Smoke-Free Prisons

Systematic Review of Factors Influencing Smoking Following Release From Smoke-Free Prisons Abstract Introduction Given the current proliferation of prison smoke-free policies internationally, and the multiple benefits of continued smoking abstinence for correctional populations, improved understanding of factors influencing postrelease smoking abstinence is required to inform support strategies aimed at individuals exiting smoke-free prisons. Methods We systematically searched health, social science, and criminal justice databases for studies relating to smoking behaviors among people released from smoke-free prisons. Studies were included if: they were published between January 1, 2000 and July 26, 2017; they were published in English; the population was people who were incarcerated or formerly incarcerated in prisons with total smoke-free policies; and the reported outcomes included measures of: (1) prerelease intention to smoke or remain abstinent from smoking following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Both authors independently screened returned citations to assess eligibility and reviewed studies for methodological quality using the Effective Public Health Practice Project’s Quality Assessment Tool for Quantitative Studies. Results Fifteen of 121 publications were included. The evidence base in this area is small, almost exclusively US-based, and is mostly methodologically weak. Interventions delivered both pre and postrelease, that strengthen intention to quit, integrate with other substance-use treatment, and facilitate social support for quitting may help maintain postrelease smoking abstinence. Conclusions There is an urgent need for high-quality research to inform interventions to reduce high smoking relapse rates upon release from smoke-free prisons, to extend the multiple benefits of continued smoking abstinence into the community. Implications Interventions designed to help people remain abstinent from tobacco following release from smoke-free prisons are an important opportunity to improve the health, finances, and well-being of this vulnerable population. Introduction Despite a global decrease in tobacco use in recent decades,1 tobacco smoking among people entering prison is extremely high (estimated at 56% of United States prison entrants in 2014,2 and 74% of Australian prison entrants in 20163) and persists at a rate of two to six times that of the community.4,5 The high rate of tobacco use among people who experience incarceration is largely due to over-representation of groups who smoke at higher rates in the community,6–8 such as those who are socially and economically disadvantaged,3,6 Indigenous people,9,10 or those who experience mental illness11–13 or substance abuse.6,14,15 Globally, prisoners are disproportionately burdened with noticeably higher levels of chronic disease,16–18 mental illness,19–21 and illicit substance use6,22 compared with their nonincarcerated counterparts—with tobacco use contributing to and further compounding these health disparities. Complete indoor/outdoor smoke-free policies have been introduced in prisons in many countries in recent years, including in Australia,23 New Zealand,24 Canada,25 most states of the United States,26 and many European countries.4,27 The primary driver of these smoke-free policies is to reduce the exposure of staff, prisoners, and visitors to environmental tobacco smoke, which is as harmful as smoking itself.28,29 Studies have confirmed the health benefits of correctional smoke-free policies,30,31 with one US study reporting a 9% reduction in smoking-related deaths in prisons that implemented smoking bans.2 In contrast to the common perception that prisoners are not interested in stopping smoking, almost half (46%) of people entering Australian prisons10 and 70% of recently incarcerated men in US prisons32 reported wanting to stop smoking. However, currently the benefits of correctional smoke-free policies are largely confined to prison as studies (all US-based) report that upwards of 60% of former smokers relapse within 24 h of release from prison33–35 and almost all resume smoking within 6 months.34 This high and swift rate of relapse demonstrates that forced tobacco abstinence during imprisonment is insufficient for maintaining cessation in the community. Interventions that increase postrelease smoking abstinence could improve the physical health,36 mental health,37,38 and financial39 outcomes of this vulnerable population. This is particularly important given evidence of increased incidence of chronic disease,18,40–42 drug overdose,22,43,44 and mortality16,45–47 in the weeks following release from prison. To date, no studies have conclusively reviewed the literature reporting on factors that influence intention to smoke and smoking behavior following release from prisons with complete indoor/outdoor smoke-free policies. Two other systematic reviews have covered literature on correctional smoke-free policies (either partial or complete),26,48 but neither focused on smoking behaviors postrelease. The first of these reviews documented the increase in smoke free policies in US prisons and jails over time,26 and recommended that future research focus on the health and economic outcomes of these policies. The second review described the health and behavioral outcomes of prison smoking-cessation interventions48 and concluded that smoking bans and prison-based smoking-cessation interventions can be effective in promoting smoking abstinence when properly enforced. Given the inexorable transition to smoke-free prisons, and the multiple benefits of continued smoking abstinence for correctional populations, improved understanding of factors that influence postrelease smoking abstinence is urgently required to inform support strategies for correctional and community service providers working with individuals exiting smoke-free prisons. This paper reports the results of a systematic review of studies that examined either (1) prerelease intention to smoke or remain abstinent following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Methods This review followed PRISMA guidelines.49 Search Strategy We searched health, criminology, and social science databases in PubMed, Social Services Abstracts, PsycINFO, Science Direct, Embase, and Evidence-based Medicine Reviews for English language articles published between January 1, 2000 and July 26, 2017. The search string used was (((prison) or (jail) or (incarc*) or (imprison*) or (correctional facility) or (penitentiary)) AND ((tobacco) or (smok*) or (cigarette*) or (smoke-free)) AND ((release) or (relapse))). The search was limited to title and abstract, and included journal articles, dissertations, and governmental reports. To identify further relevant articles possibly missed through this search, we used backward snowballing, where reference lists of included articles were searched, and forward snowballing, where article citing included papers were examined. Inclusion and Exclusion Criteria Studies were included if: they presented outcomes of original empirical research; the population was adults or juveniles incarcerated or formerly incarcerated in prisons where full indoor and outdoor smoking bans applied; and they reported at least one of the following outcomes: (1) pre-release intention to smoke or remain abstinent following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Studies were excluded if they reported on smoking behaviors during incarceration only, if tobacco smoking was only partially banned in the facility, or if the study was not published in English. Methodological Quality Assessment We used the Effective Public Health Practice Project’s Quality Assessment Tool for Quantitative Studies to measure the methodological quality of included studies. This tool is recognized as having high interrater reliability, construct validity, and content validity. 50,51 Each study was rated “weak,” “moderate,” or “strong” on six criteria: selection bias, study design, confounders, blinding, data collection, and withdrawals. Finally, an overall global rating was given to each study,50 based on the ratings of the six criteria. Studies with a “strong” global rating could not have a weak rating for any of the six criteria, those with a “moderate” global rating had only one weak rating on any criterion, and those rated “weak” overall were studies with weak ratings on two or more criteria. A “not applicable” rating was applied to the withdrawal criterion in the cases of cross-sectional or retrospective studies (where participants were not followed over time) and to the blinding criterion where studies were not of a randomized nature. Qualitative studies were not rated as the assessment relates to quantitative studies only. The methodological quality ratings were independently assessed by both authors, and the few discrepancies resolved through discussion. Results Search Results An initial database search identified 121 relevant records. After eliminating duplicates, there were 90 records for review. Of these 90, 66 were excluded based on the publication’s title. Of the remaining 24 publications, a further 10 studies were excluded during full-text review due to participants being incarcerated in facilities without smoking bans (n = 2),52,53 reporting on outcomes not related to postrelease smoking intention or behavior (n = 6),2,54–57 or describing study protocols only (n = 2).58,59 Backwards and forwards snowballing identified one further relevant result.60 Fifteen publications met inclusion criteria after full-text review. All were peer-reviewed journal articles. Figure 1 details the publication search and retrieval process. Figure 1. View largeDownload slide PRISMA flow diagram Figure 1. View largeDownload slide PRISMA flow diagram Table 1 describes the characteristics of included studies, whereas the Supplementary Table briefly describes study findings. The fifteen included publications were informed by eight datasets. There was only one randomized controlled trial (RCT) which investigated the effectiveness of a prerelease intensive behavioral intervention (6 × 1-h sessions based on elements of cognitive-behavioral therapy and motivational interviewing) aimed at reducing postrelease smoking.33 This study, called Project WISE (Working Inside for Smoking Elimination), was conducted with a cohort of 247 people (161 men and 86 women) approaching release from a smoke-free prison in Rhode Island, United States. Data from Project WISE informed a further six of the included papers.31,61–65 Two papers (one quantitative and one qualitative) came from a study that conducted pre and postrelease interviews with 49 men released from a smoke-free prison in Wisconsin, USA,66,67 and the six remaining publications relied on unique datasets. Table 1. Characteristics and Measured Outcomes of Included Studies   Authors  Country  Sample size and gender  Study design  Smoking outcomes measured  1.  Bock et al., 201361  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  2.  Clarke et al., 201333  USA (WISE)  247 former prisoners approaching release, 35% female  RCT  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of abstinence postrelease  3.  Clarke et al., 201531  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  4.  Djachenko et al., 201660  Australia  15 prisoners, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  5.  Frank et al., 201635  USA  143 former prisoners who had relapsed postrelease, male and female (% not reported)  Cross-sectional  Postrelease abstinence rates, trying to quit postrelease, predictors of trying to quit postrelease  6.  Howell et al., 201570  USA  172 former prisoners, male  Cross-sectional  Postrelease abstinence rates, predictors of return to smoking postrelease  7.  Indig and Haysom, 201268  Australia  316 people in juvenile detention centres, 12% female  Cross-sectional  Prerelease intention to smoke postrelease, predictors of prerelease intention to smoke postrelease  8.  Lincoln et al., 200934  USA  143 former prisoners, 11% female  Prospective  Postrelease abstinence rates  9.  Parker et al., 201462  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  10.  Parker et al., 201663  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  11.  Thibodeau et al., 201066  USA  49 prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of return to smoking postrelease, predictors of abstinence postrelease  12.  Thibodeau et al., 201267  USA  49 prisoners approaching release, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  13.  Valera et al., 201669  USA  60 former prisoners, 50% female  Qualitative  Postrelease abstinence rates, factors influencing return to smoking postrelease  14.  van den Berg et al., 201464  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to return to smoking postrelease, predictors of return to smoking postrelease  15.  van den Berg et al., 201665  USA (WISE)  161 former prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, predictors of abstinence postrelease    Authors  Country  Sample size and gender  Study design  Smoking outcomes measured  1.  Bock et al., 201361  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  2.  Clarke et al., 201333  USA (WISE)  247 former prisoners approaching release, 35% female  RCT  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of abstinence postrelease  3.  Clarke et al., 201531  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  4.  Djachenko et al., 201660  Australia  15 prisoners, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  5.  Frank et al., 201635  USA  143 former prisoners who had relapsed postrelease, male and female (% not reported)  Cross-sectional  Postrelease abstinence rates, trying to quit postrelease, predictors of trying to quit postrelease  6.  Howell et al., 201570  USA  172 former prisoners, male  Cross-sectional  Postrelease abstinence rates, predictors of return to smoking postrelease  7.  Indig and Haysom, 201268  Australia  316 people in juvenile detention centres, 12% female  Cross-sectional  Prerelease intention to smoke postrelease, predictors of prerelease intention to smoke postrelease  8.  Lincoln et al., 200934  USA  143 former prisoners, 11% female  Prospective  Postrelease abstinence rates  9.  Parker et al., 201462  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  10.  Parker et al., 201663  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  11.  Thibodeau et al., 201066  USA  49 prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of return to smoking postrelease, predictors of abstinence postrelease  12.  Thibodeau et al., 201267  USA  49 prisoners approaching release, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  13.  Valera et al., 201669  USA  60 former prisoners, 50% female  Qualitative  Postrelease abstinence rates, factors influencing return to smoking postrelease  14.  van den Berg et al., 201464  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to return to smoking postrelease, predictors of return to smoking postrelease  15.  van den Berg et al., 201665  USA (WISE)  161 former prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, predictors of abstinence postrelease  NRT: Nicotine Replacement Therapy; RCT: Randomised Controlled Trial; SD: Standard Deviation; USA: United States of America; WISE: Working Inside for Smoking Elimination Trial.33 View Large Table 1. Characteristics and Measured Outcomes of Included Studies   Authors  Country  Sample size and gender  Study design  Smoking outcomes measured  1.  Bock et al., 201361  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  2.  Clarke et al., 201333  USA (WISE)  247 former prisoners approaching release, 35% female  RCT  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of abstinence postrelease  3.  Clarke et al., 201531  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  4.  Djachenko et al., 201660  Australia  15 prisoners, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  5.  Frank et al., 201635  USA  143 former prisoners who had relapsed postrelease, male and female (% not reported)  Cross-sectional  Postrelease abstinence rates, trying to quit postrelease, predictors of trying to quit postrelease  6.  Howell et al., 201570  USA  172 former prisoners, male  Cross-sectional  Postrelease abstinence rates, predictors of return to smoking postrelease  7.  Indig and Haysom, 201268  Australia  316 people in juvenile detention centres, 12% female  Cross-sectional  Prerelease intention to smoke postrelease, predictors of prerelease intention to smoke postrelease  8.  Lincoln et al., 200934  USA  143 former prisoners, 11% female  Prospective  Postrelease abstinence rates  9.  Parker et al., 201462  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  10.  Parker et al., 201663  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  11.  Thibodeau et al., 201066  USA  49 prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of return to smoking postrelease, predictors of abstinence postrelease  12.  Thibodeau et al., 201267  USA  49 prisoners approaching release, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  13.  Valera et al., 201669  USA  60 former prisoners, 50% female  Qualitative  Postrelease abstinence rates, factors influencing return to smoking postrelease  14.  van den Berg et al., 201464  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to return to smoking postrelease, predictors of return to smoking postrelease  15.  van den Berg et al., 201665  USA (WISE)  161 former prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, predictors of abstinence postrelease    Authors  Country  Sample size and gender  Study design  Smoking outcomes measured  1.  Bock et al., 201361  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  2.  Clarke et al., 201333  USA (WISE)  247 former prisoners approaching release, 35% female  RCT  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of abstinence postrelease  3.  Clarke et al., 201531  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  4.  Djachenko et al., 201660  Australia  15 prisoners, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  5.  Frank et al., 201635  USA  143 former prisoners who had relapsed postrelease, male and female (% not reported)  Cross-sectional  Postrelease abstinence rates, trying to quit postrelease, predictors of trying to quit postrelease  6.  Howell et al., 201570  USA  172 former prisoners, male  Cross-sectional  Postrelease abstinence rates, predictors of return to smoking postrelease  7.  Indig and Haysom, 201268  Australia  316 people in juvenile detention centres, 12% female  Cross-sectional  Prerelease intention to smoke postrelease, predictors of prerelease intention to smoke postrelease  8.  Lincoln et al., 200934  USA  143 former prisoners, 11% female  Prospective  Postrelease abstinence rates  9.  Parker et al., 201462  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  10.  Parker et al., 201663  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  11.  Thibodeau et al., 201066  USA  49 prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of return to smoking postrelease, predictors of abstinence postrelease  12.  Thibodeau et al., 201267  USA  49 prisoners approaching release, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  13.  Valera et al., 201669  USA  60 former prisoners, 50% female  Qualitative  Postrelease abstinence rates, factors influencing return to smoking postrelease  14.  van den Berg et al., 201464  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to return to smoking postrelease, predictors of return to smoking postrelease  15.  van den Berg et al., 201665  USA (WISE)  161 former prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, predictors of abstinence postrelease  NRT: Nicotine Replacement Therapy; RCT: Randomised Controlled Trial; SD: Standard Deviation; USA: United States of America; WISE: Working Inside for Smoking Elimination Trial.33 View Large Thirteen of the 15 included studies were conducted in the United States, and the two remaining studies were conducted in Australia.60,68 Only one study interviewed young people (aged 13–21 years old),68 as all others comprised adult participants (aged 18 and above). Ten studies measured outcomes for a mixed gender sample,31,33–35,61–64,68,69 and five studies measured outcomes for males only.60,65–67,70 Participants in nine studies received some form of smoking-cessation support while incarcerated (see Supplementary Table for further details). In seven of these studies, all65 or some participants31,33,61–64 received the WISE prerelease behavioral intervention, specifically designed to reduce smoking relapse following release.33 Nicotine replacement therapy (NRT) was not provided on release as part of the WISE intervention as the authors argued that participants had completed physical withdrawal from nicotine.33 In one study,34 some prisoners received education on the benefits of smoking cessation but the degree of involvement was not recorded. Participants in a qualitative study of the experience of forced smoking abstinence60 had access to free nicotine patches on prison entry and a Quitline telephone smoking-cessation support service, but participants’ use of these services was not recorded. No studies examined whether the availability or not of NRT on entry to prison (to help ease nicotine withdrawal symptoms) affected intention to smoke or remain abstinent following release. No studies examined the effectiveness of postrelease smoking-cessation support, either behavioral or pharmacological, for former prisoners. Three of the included studies were qualitative in design, relying on semi-structured interviews for data collection. One was included because it provided a quantitative measure of smoking relapse in the time following release as well as a description of factors influencing return to smoking following release,69 and the other two because they described participants’ perceptions of factors influencing their pre-release intention to remain abstinent following release.60,67 This review examined three smoking outcomes: (1) prerelease intention to smoke or remain abstinent from smoking following release; (2) smoking relapse or abstinence following release; and (3) quit attempts following postrelease smoking relapse. For the first outcome, four studies quantitatively measured participants’ prerelease intention to return to smoking following release,33,65,66,68 four studies described predictors of prerelease intention to smoke,68 or prerelease intention to remain abstinent31,61,64 following release, and two qualitative studies reported factors influencing participants’ prerelease intention to remain abstinent following release.60,67 Regarding the second outcome, six studies measured rates of smoking abstinence in the time following release from prison,33–35,66,69,70 ten studies measured predictors of smoking64,66,70 or smoking abstinence31,33,61–63,65,66 following release, and one qualitative study described factors that impacted postrelease return to smoking.69 Finally, one study described the prevalence and predictors of quit smoking attempts among those who had already relapsed to tobacco use postrelease.68 A meta-analysis was not conducted, as only five of the included studies were of a high methodological quality, and there was considerable heterogeneity in the focus and methodologies of included papers.71 Methodological Quality Of the 15 studies included in this review, only four were given a strong methodological rating (see Table 2). One of these is the study describing the outcomes of a RCT of a prerelease smoking intervention,33 and the other three are publications using the same dataset but measuring other predictors of outcomes in the cohort.31,61,63 A further two papers also used this dataset, but one was rated as methodologically moderate due to their use of measures not yet shown to be valid or reliable,64 whereas another that focused on a subsample of participants was rated as methodologically weak due to biased participant selection.65 Overall, four studies were rated as methodologically moderate 63,64,66,68, and four studies as weak,34,35,65,70 typically due to cross-sectional design or recruitment bias, such as targeting those wanting to quit smoking. Three qualitative studies were not given methodological quality ratings.60,67,69 Table 2. Methodological Quality of Included Quantitative Studies   Study  Selection bias  Study design  Confounders  Blinding  Data collection  Withdrawals  Global rating  1.  Bock et al., 201361  Strong  Moderate  Strong  NA  Strong  Strong  Strong  2.  Clarke et al., 201333  Strong  Strong  Strong  Moderate  Strong  Strong  Strong  3.  Clarke et al., 201531  Strong  Moderate  Strong  NA  Strong  Moderate  Strong  4.  Frank et al., 201635  Moderate  Weak  Weak  NA  Strong  NA  Weak  5.  Howell et al., 201570  Weak  Moderate  Weak  NA  Moderate  NA  Weak  6.  Indig and Haysom, 201268  Strong  Weak  Moderate  NA  Strong  NA  Moderate  7.  Lincoln et al., 200934  Moderate  Moderate  Weak  NA  Weak  NA  Weak  8.  Parker et al., 201462  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  9.  Parker et al., 201663  Strong  Moderate  Strong  NA  Strong  Strong  Strong  10.  Thibodeau et al., 201066  Weak  Moderate  Moderate  NA  Strong  Strong  Moderate  11.  van den Berg et al., 201464  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  12.  van den Berg et al., 201665  Strong  Moderate  Strong  NA  Weak  Weak  Weak    Study  Selection bias  Study design  Confounders  Blinding  Data collection  Withdrawals  Global rating  1.  Bock et al., 201361  Strong  Moderate  Strong  NA  Strong  Strong  Strong  2.  Clarke et al., 201333  Strong  Strong  Strong  Moderate  Strong  Strong  Strong  3.  Clarke et al., 201531  Strong  Moderate  Strong  NA  Strong  Moderate  Strong  4.  Frank et al., 201635  Moderate  Weak  Weak  NA  Strong  NA  Weak  5.  Howell et al., 201570  Weak  Moderate  Weak  NA  Moderate  NA  Weak  6.  Indig and Haysom, 201268  Strong  Weak  Moderate  NA  Strong  NA  Moderate  7.  Lincoln et al., 200934  Moderate  Moderate  Weak  NA  Weak  NA  Weak  8.  Parker et al., 201462  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  9.  Parker et al., 201663  Strong  Moderate  Strong  NA  Strong  Strong  Strong  10.  Thibodeau et al., 201066  Weak  Moderate  Moderate  NA  Strong  Strong  Moderate  11.  van den Berg et al., 201464  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  12.  van den Berg et al., 201665  Strong  Moderate  Strong  NA  Weak  Weak  Weak  NA: Not applicable. View Large Table 2. Methodological Quality of Included Quantitative Studies   Study  Selection bias  Study design  Confounders  Blinding  Data collection  Withdrawals  Global rating  1.  Bock et al., 201361  Strong  Moderate  Strong  NA  Strong  Strong  Strong  2.  Clarke et al., 201333  Strong  Strong  Strong  Moderate  Strong  Strong  Strong  3.  Clarke et al., 201531  Strong  Moderate  Strong  NA  Strong  Moderate  Strong  4.  Frank et al., 201635  Moderate  Weak  Weak  NA  Strong  NA  Weak  5.  Howell et al., 201570  Weak  Moderate  Weak  NA  Moderate  NA  Weak  6.  Indig and Haysom, 201268  Strong  Weak  Moderate  NA  Strong  NA  Moderate  7.  Lincoln et al., 200934  Moderate  Moderate  Weak  NA  Weak  NA  Weak  8.  Parker et al., 201462  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  9.  Parker et al., 201663  Strong  Moderate  Strong  NA  Strong  Strong  Strong  10.  Thibodeau et al., 201066  Weak  Moderate  Moderate  NA  Strong  Strong  Moderate  11.  van den Berg et al., 201464  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  12.  van den Berg et al., 201665  Strong  Moderate  Strong  NA  Weak  Weak  Weak    Study  Selection bias  Study design  Confounders  Blinding  Data collection  Withdrawals  Global rating  1.  Bock et al., 201361  Strong  Moderate  Strong  NA  Strong  Strong  Strong  2.  Clarke et al., 201333  Strong  Strong  Strong  Moderate  Strong  Strong  Strong  3.  Clarke et al., 201531  Strong  Moderate  Strong  NA  Strong  Moderate  Strong  4.  Frank et al., 201635  Moderate  Weak  Weak  NA  Strong  NA  Weak  5.  Howell et al., 201570  Weak  Moderate  Weak  NA  Moderate  NA  Weak  6.  Indig and Haysom, 201268  Strong  Weak  Moderate  NA  Strong  NA  Moderate  7.  Lincoln et al., 200934  Moderate  Moderate  Weak  NA  Weak  NA  Weak  8.  Parker et al., 201462  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  9.  Parker et al., 201663  Strong  Moderate  Strong  NA  Strong  Strong  Strong  10.  Thibodeau et al., 201066  Weak  Moderate  Moderate  NA  Strong  Strong  Moderate  11.  van den Berg et al., 201464  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  12.  van den Berg et al., 201665  Strong  Moderate  Strong  NA  Weak  Weak  Weak  NA: Not applicable. View Large Outcomes of Included Studies Intention to Smoke or Remain Abstinent Following Prison Release Four studies measured participants’ prerelease intention to smoke following release, with two of these studies rated as methodologically strong,33,65 and the other two as moderate.66,68 There was considerable variation across these four studies reporting the percentage of participants intending to smoke following release from prison (22% to 67%).33,65,66,68 Predictors of Intention to Smoke Following Release One of the studies conducted in Australia, rated as methodologically moderate, interviewed 316 young people, with an average age of 17 years (range 13–21) from nine juvenile detention centers, finding that 67% of participants intended to smoke following release.68 Predictors of intention to smoke on release included illicit drug use at least weekly prior to custody (Odds Ratio [OR] = 3.13, 95% CI = 1.51 to 6.49) and having most or all friends identify as smokers (OR = 2.39, 95% CI = 1.20 to 4.76). Predictors of Intention to Remain Abstinent Following Release Three studies (all secondary analyses of the Project WISE trial data) measured predictors of planning to remain smoke-free postrelease among current prisoners. Two studies were rated as methodologically strong,31,61 and the third as moderate.64 The first publication found that social support specific to quitting smoking from family and from friends were each significantly and positively correlated with motivation, confidence, and plans for remaining abstinent postrelease (all p values <.05).61 The second found that constructs of freedom (“Having that first cigarette when I get out will make me feel like I’m really free or not in prison any more”) and independence (“Having that first cigarette when I get out is a way to express my independence”) were negatively associated with plans for smoking abstinence postrelease.64 Finally, the third publication found that forced tobacco abstinence led to significant improvements in self-reported smoking-related respiratory symptoms, but that this improvement was not significantly associated with plans to remain abstinent following release.31 However, participants with greater symptom improvements were more worried about their smoking, leading the authors to suggest that helping people to reflect on changes in respiratory symptoms may be useful in building motivation to remain abstinent postrelease. Two qualitative studies interviewed people prior to their release to ascertain perceived influences on plans to remain smoke-free following release.60,67 Among 49 men approaching release from a US prison, perceived facilitators of staying smoke free included a desire to be physically healthier, the high cost of tobacco, the negative stigma of smoking, and wanting to be positive role models for their children, whereas a key barrier was the stress that they anticipated experiencing following release.67 Fifteen men in an Australian prison reported that their time in a smoke-free prison was likely to facilitate smoking abstinence following release, but that a lack of postrelease cessation support was likely to hinder their attempts to remain smoke-free. 60 Smoking Relapse or Abstinence Following Release Six studies, all conducted in the United States, reported rates of smoking relapse following release from smoke-free prisons.33–35,66,69,70 Of the five quantitative studies, only one was rated as methodologically strong,33 whereas one was rated as moderate,66 and three as weak.34,35,70 Only two of these six studies measured tobacco abstinence longitudinally among ex-smokers released from smoke-free prisons,33,34 three reported tobacco abstinence at a single time point following release,66,69,70 and one reported time to relapse among former prisoners who had all relapsed to smoking within 3 weeks of release.35 Rates of tobacco abstinence cannot be compared across studies, as each measured relapse at differing timepoints following release, however, all studies found that more than 60% of participants relapsed to smoking following release from smoke-free prisons.33,34,66,69,70 Factors Influencing Smoking Relapse or Abstinence Following Release We identified 10 publications that measured factors influencing smoking following release: two evaluated predictors of returning to smoking,64,70 six described predictors of tobacco abstinence,31,33,61–63,65 one paper described both factors predicting return to smoking and those predicting smoking abstinence,66 and one qualitative study described factors influencing return to smoking among a group of former prisoners.69 Of the nine quantitative publications, four were rated as methodologically strong,31,33,61,63 three as moderate,62,64,66 and two as weak.65,70 The three papers64,66,70 measuring predictors of returning to smoking following release were conducted in the United States. The first publication studied a cohort of 172 male former prisoners found that each additional 5 years of history of incarceration was associated with 1.32 times greater odds of smoking postrelease (95% CI = 1.02 to 1.71), and that past illicit substance abuse was associated with a 2.47 higher adjusted odds of smoking postrelease (95% CI = 1.29 to 5.39). 70 The second paper, conducted with 49 male participants, found that returning to smoking postrelease was predicted by pre-release intention to smoke (p = .001) and being of White race (p = .045).66 The third study used Project WISE data to measure whether people awaiting release from prison associated smoking with constructs of freedom and independence, finding that return to smoking postrelease was significantly linked to associating their anticipated first cigarette with feelings of freedom, (r = .134, p < .05), but not independence. 64 We identified seven publications reporting predictors of remaining abstinent from smoking following release from smoke-free prisons. The first six publications reporting on this outcome used data from Project WISE. The first is the study by Clarke and colleagues reporting the outcomes of the WISE intervention, a prerelease behavioral smoking relapse prevention program.33 Factors associated with increased likelihood of remaining abstinent were: receiving the intervention (OR = 6.6, 95% CI = 2.5 to 17.0), Hispanic ethnicity (OR = 3.2, 95% CI = 1.1 to 8.7), a plan to remain abstinent (OR = 1.6, 95% CI = 1.2 to 2.3), and being incarcerated for more than 6 months (OR = 4.6, 95% CI = 1.7 to 12.4). The second publication investigated the link between social support specific to quitting smoking and smoking abstinence61 and found that, though social support for quitting was not a significant predictor, it was significantly positively correlated with readiness (r = −.30, p < .01), motivation (r = −.24, p < .01), confidence (−.30), and plans to remain abstinent (.25) which in turn were all significantly correlated with smoking abstinence. The third publication aimed to evaluate the influence of changes in self-rated smoking-related symptoms during incarceration on postrelease smoking,31 but found no significant effect. The fourth paper reported that people with a family history of smoking-related illness were significantly less likely to remain abstinent postrelease (OR = 0.28, 95% CI = 0.12 to 0.68).62 The fifth publication investigated participants’ attitudes of smoking in the presence of children and pregnant women and found no significant relationships between these attitudes and postrelease abstinence.63 The sixth paper reported that men who chose to complete a postrelease smoking plans and goals sheet (part of the WISE intervention) whereas incarcerated (“planners”) were more likely to be abstinent from smoking at 3 weeks postrelease (14% vs. 6% of both nonplanners and controls), more likely to report more days abstinent before relapsing to smoking (M = 9.5 days, SD = 9.7 vs. M = 8.1 days, SD = 9.8 for nonplanners and M = 5.7, SD = 8.4 for controls), and more likely to smoke a lower number of cigarettes at 3 weeks postrelease (M = 4.53 cigarettes, SD = 5.84 vs. M = 6.22 cigarettes, SD = 6.53 for nonplanners and M = 8.54, SD = 7.42 for controls).65 However, these differences did not persist when comparing those who received the WISE intervention with the control group, suggesting that the differences between the three groups may have been due to intervention effects rather than planning versus nonplanning.65 The seventh paper, and the only paper in this category not to use data from the WISE study, found a significant link between perceived better health since the prison smoking ban and tobacco abstinence following release among a group of 49 men recently released from a smoke-free prison in Wisconsin, United States (p = .01).66 One qualitative study interviewed 60 people recently released from smoke-free prisons in the United States, with participants reporting that stress, being surrounded by smokers, availability of cigarettes, and a lack of social support were factors that influenced their return to smoking following release.69 Quit Attempts Following Postrelease Smoking Relapse One study investigated attempts to stop smoking among those who relapsed to smoking following release from a smoke-free prison.35 Forty-two percent of the participants who had resumed smoking after release reported that they were trying to quit smoking. This study also found that trying to quit postrelease was positively associated with the absence of risky drinking behavior (p < .001) and absence of drug use (p = .049) in the past 30 days.35 Discussion This systematic review found a high and rapid rate of smoking relapse among people released from smoke-free prisons. The evidence base in this context was very limited (eight data sets informing 15 papers) and was almost exclusively US-based. The only RCT in this review33 demonstrated that an intensive prerelease cognitive-behavioral program was effective in reducing postrelease smoking relapse. There is an urgent need for further high-quality randomized trials to inform interventions aimed at reducing the high postrelease relapse rate, and encouraging those who relapse to make further cessation attempts. The main limitation of this review is that the limited evidence base precludes the drawing of firm conclusions. The included publications were diverse in focus and methodology, making it difficult to compare outcomes or trends, or to conduct a meta-analysis. The search was restricted to studies published in English, so it is possible that studies in other languages were missed. The predominance of US literature, while commensurate with their high incarceration rate,72 limits the generalizability of the findings, as other jurisdictions may differ considerably in both social context, (eg, incarceration rate, level of economic inequities, or strength of the welfare system) and tobacco control context (eg, availability and quality of smoking-cessation services, price of tobacco, extent of social marketing to encourage cessation, or extent of smoke-free policies). However, this is, to the best of our knowledge, the first study to systematically review literature reporting on factors influencing smoking relapse and abstinence following release from smoke-free prisons, and in the context of the current proliferation of smoke-free policies in prisons around the world,27 and high rates of tobacco use by correctional populations,4 an understanding of these factors is vital to inform best-practice smoking-cessation strategies for stakeholders working with people exiting smoke-free prisons. Despite this limited evidence base, our review’s key findings together with evidence-based smoking-cessation guidelines73,74 provide guidance for the development of interventions for people approaching release from smoke-free prisons. Evidence from our review’s findings showing that prerelease intention to remain abstinent is positively associated with postrelease smoking abstinence,33,61,66 indicating that interventions should ideally begin prerelease and span the pre to postrelease period and should incorporate elements of motivational interviewing33,75 to build intention to remain abstinent from smoking following release. The positive findings of the WISE RCT,33 while in need of replication, provide preliminary evidence for the effectiveness of a prerelease intervention involving motivational counseling to promote postrelease smoking cessation. Prerelease interventions provide people with the opportunity to reflect on their experiences of being smoke-free, articulate for themselves the benefits of continued smoking cessation, and instil optimism about change by helping people plan how to cope without cigarettes outside prison.33 Further evidence from community-based cessation guidelines74 and prison-based studies48,76–81 shows that these interventions should be multi-component in nature in order to maximize chances of successful cessation, relying on a combination of behavioral support and smoking-cessation pharmacotherapy. Effective postrelease interventions should also include both behavioral73 and pharmacotherapeutic74,82 elements, with behavioral skill training focusing on assisting individuals to get back on track following slips or relapses. Further research is needed to address the evidence gap regarding the effectiveness of postrelease interventions, including investigation of whether harm-reduction approaches such as nicotine replacement therapy or electronic nicotine delivery systems might help prevent smoking relapse in the early postrelease period. Our results further identified that people with a history of hazardous substance use were less likely to plan to remain abstinent postrelease,68 less likely to remain abstinent,70 and less likely to attempt to quit smoking following smoking relapse.35 With these studies reflecting findings from community-based studies showing that tobacco smoking is endemic among people with substance-use disorders,83–85 efforts to provide smoking-cessation support for correctional populations pre and postrelease should be combined with coordinated treatment for alcohol and other substance use—an approach with demonstrated effectiveness in the general community.86–88 Historically, smoking cessation was thought to negatively impact substance-use treatment outcomes.87 However, stopping smoking concurrently with other substances does not hinder smoking-cessation efforts, and often has a positive effect on substance-use outcomes.87,88 Addiction workers are well placed to provide tobacco treatment, but the decision to provide smoking-cessation care is often arbitrary.89 Organizational policy and practice changes, including staff education, are needed to facilitate routine tobacco treatment in substance-use treatment settings. Social support for quitting from family and friends was also identified as a common factor that facilitated postrelease abstinence.61,68,69 Community-based studies90–92 confirm the important role of social support in achieving and maintaining smoking cessation, but consensus on the mechanisms behind this association or how to effectively include social support in smoking-cessation programs remains unclear.93–95 Future research might examine the use of peer-workers to provide pre and postrelease smoking-cessation support, or the combined targeting of smoking-cessation treatment to close friends and family members as well as participants.68 Qualitative work identified the overwhelming challenge of trying to maintain a smoke-free lifestyle when paroled to housing facilities and programs where smoking was rife.69 Institution of smoke-free policies into these services may also facilitate smoking abstinence. It is also notable that some people approaching release viewed smoking tobacco as a gateway that had led them to prison, or would lead them back if they were to relapse.67 Smoking cessation, especially where it is a part of a broader change to a healthier lifestyle, may reduce risk factors for re-offending96 as it provides valuable opportunities for people to improve both their physical and mental health and achieve their individual social and economic goals. Our review identified several key areas in need of further research. At present, it is not known whether the provision of NRT on prison entry affects intention to smoke or remain abstinent following release. It is possible that forced nicotine withdrawal without NRT to reduce withdrawal severity may reduce an individual’s motivation to attempt to remain tobacco abstinent following release. This is despite the fact that reduced access to tobacco during imprisonment means that people are likely to experience a milder nicotine withdrawal after leaving prison, with cravings predominantly driven by emotional and social cues rather than nicotine dependence. Further research is also needed to help clarify contradictory findings, for example, whether length of incarceration, is positively or negatively associated with postrelease tobacco abstinence. As noted above, we did not identify any studies measuring the effectiveness of postrelease interventions aimed at reducing smoking relapse or to encourage further quit attempts among those who relapse. A further high priority for future research is to test sustainable models for providing pre to postrelease smoking-cessation support. Brief interventions from corrections, transition, health, and social service professionals that include making a formal referral to existing effective cessation services, such as a Quitline telephone call-back service whose staff could be trained in the complex needs of people leaving prison, could provide convenient and highly accessible continuity of care over the pre to postrelease period.97 In some countries, including Australia and New Zealand, prisoners are already able to call Quitline free of charge,60,98,99 pointing to an opportunity for future research to test the effectiveness of this service in assisting people leaving smoke-free prisons to maintain smoking abstinence. Conclusion To date, support for maintaining postrelease smoking abstinence has typically fallen outside of scope of the implementation of smoke-free prisons. Providing people with the skills to remain smoke-free in the community is an important opportunity to improve the health, finances, and well-being of this vulnerable population who are susceptible to poor health outcomes following prison release. Given the proliferation of complete indoor/outdoor smoke-free policies in correctional facilities internationally, and high rates of tobacco use among this population, there is a pressing need for further, high-quality research in this area to strengthen the evidence-base for the best practice smoking-cessation support provided to people leaving smoke-free prisons. Supplementary Material Supplementary Table 1 can be found online at https://academic.oup.com/ntr/ Funding This work received no external funding. Declaration of Interests The authors declare no conflicts of interest. References 1. GBD 2015 Tobacco Collaborators. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Nicotine and Tobacco Research Oxford University Press

Systematic Review of Factors Influencing Smoking Following Release From Smoke-Free Prisons

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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10.1093/ntr/nty088
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Abstract

Abstract Introduction Given the current proliferation of prison smoke-free policies internationally, and the multiple benefits of continued smoking abstinence for correctional populations, improved understanding of factors influencing postrelease smoking abstinence is required to inform support strategies aimed at individuals exiting smoke-free prisons. Methods We systematically searched health, social science, and criminal justice databases for studies relating to smoking behaviors among people released from smoke-free prisons. Studies were included if: they were published between January 1, 2000 and July 26, 2017; they were published in English; the population was people who were incarcerated or formerly incarcerated in prisons with total smoke-free policies; and the reported outcomes included measures of: (1) prerelease intention to smoke or remain abstinent from smoking following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Both authors independently screened returned citations to assess eligibility and reviewed studies for methodological quality using the Effective Public Health Practice Project’s Quality Assessment Tool for Quantitative Studies. Results Fifteen of 121 publications were included. The evidence base in this area is small, almost exclusively US-based, and is mostly methodologically weak. Interventions delivered both pre and postrelease, that strengthen intention to quit, integrate with other substance-use treatment, and facilitate social support for quitting may help maintain postrelease smoking abstinence. Conclusions There is an urgent need for high-quality research to inform interventions to reduce high smoking relapse rates upon release from smoke-free prisons, to extend the multiple benefits of continued smoking abstinence into the community. Implications Interventions designed to help people remain abstinent from tobacco following release from smoke-free prisons are an important opportunity to improve the health, finances, and well-being of this vulnerable population. Introduction Despite a global decrease in tobacco use in recent decades,1 tobacco smoking among people entering prison is extremely high (estimated at 56% of United States prison entrants in 2014,2 and 74% of Australian prison entrants in 20163) and persists at a rate of two to six times that of the community.4,5 The high rate of tobacco use among people who experience incarceration is largely due to over-representation of groups who smoke at higher rates in the community,6–8 such as those who are socially and economically disadvantaged,3,6 Indigenous people,9,10 or those who experience mental illness11–13 or substance abuse.6,14,15 Globally, prisoners are disproportionately burdened with noticeably higher levels of chronic disease,16–18 mental illness,19–21 and illicit substance use6,22 compared with their nonincarcerated counterparts—with tobacco use contributing to and further compounding these health disparities. Complete indoor/outdoor smoke-free policies have been introduced in prisons in many countries in recent years, including in Australia,23 New Zealand,24 Canada,25 most states of the United States,26 and many European countries.4,27 The primary driver of these smoke-free policies is to reduce the exposure of staff, prisoners, and visitors to environmental tobacco smoke, which is as harmful as smoking itself.28,29 Studies have confirmed the health benefits of correctional smoke-free policies,30,31 with one US study reporting a 9% reduction in smoking-related deaths in prisons that implemented smoking bans.2 In contrast to the common perception that prisoners are not interested in stopping smoking, almost half (46%) of people entering Australian prisons10 and 70% of recently incarcerated men in US prisons32 reported wanting to stop smoking. However, currently the benefits of correctional smoke-free policies are largely confined to prison as studies (all US-based) report that upwards of 60% of former smokers relapse within 24 h of release from prison33–35 and almost all resume smoking within 6 months.34 This high and swift rate of relapse demonstrates that forced tobacco abstinence during imprisonment is insufficient for maintaining cessation in the community. Interventions that increase postrelease smoking abstinence could improve the physical health,36 mental health,37,38 and financial39 outcomes of this vulnerable population. This is particularly important given evidence of increased incidence of chronic disease,18,40–42 drug overdose,22,43,44 and mortality16,45–47 in the weeks following release from prison. To date, no studies have conclusively reviewed the literature reporting on factors that influence intention to smoke and smoking behavior following release from prisons with complete indoor/outdoor smoke-free policies. Two other systematic reviews have covered literature on correctional smoke-free policies (either partial or complete),26,48 but neither focused on smoking behaviors postrelease. The first of these reviews documented the increase in smoke free policies in US prisons and jails over time,26 and recommended that future research focus on the health and economic outcomes of these policies. The second review described the health and behavioral outcomes of prison smoking-cessation interventions48 and concluded that smoking bans and prison-based smoking-cessation interventions can be effective in promoting smoking abstinence when properly enforced. Given the inexorable transition to smoke-free prisons, and the multiple benefits of continued smoking abstinence for correctional populations, improved understanding of factors that influence postrelease smoking abstinence is urgently required to inform support strategies for correctional and community service providers working with individuals exiting smoke-free prisons. This paper reports the results of a systematic review of studies that examined either (1) prerelease intention to smoke or remain abstinent following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Methods This review followed PRISMA guidelines.49 Search Strategy We searched health, criminology, and social science databases in PubMed, Social Services Abstracts, PsycINFO, Science Direct, Embase, and Evidence-based Medicine Reviews for English language articles published between January 1, 2000 and July 26, 2017. The search string used was (((prison) or (jail) or (incarc*) or (imprison*) or (correctional facility) or (penitentiary)) AND ((tobacco) or (smok*) or (cigarette*) or (smoke-free)) AND ((release) or (relapse))). The search was limited to title and abstract, and included journal articles, dissertations, and governmental reports. To identify further relevant articles possibly missed through this search, we used backward snowballing, where reference lists of included articles were searched, and forward snowballing, where article citing included papers were examined. Inclusion and Exclusion Criteria Studies were included if: they presented outcomes of original empirical research; the population was adults or juveniles incarcerated or formerly incarcerated in prisons where full indoor and outdoor smoking bans applied; and they reported at least one of the following outcomes: (1) pre-release intention to smoke or remain abstinent following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Studies were excluded if they reported on smoking behaviors during incarceration only, if tobacco smoking was only partially banned in the facility, or if the study was not published in English. Methodological Quality Assessment We used the Effective Public Health Practice Project’s Quality Assessment Tool for Quantitative Studies to measure the methodological quality of included studies. This tool is recognized as having high interrater reliability, construct validity, and content validity. 50,51 Each study was rated “weak,” “moderate,” or “strong” on six criteria: selection bias, study design, confounders, blinding, data collection, and withdrawals. Finally, an overall global rating was given to each study,50 based on the ratings of the six criteria. Studies with a “strong” global rating could not have a weak rating for any of the six criteria, those with a “moderate” global rating had only one weak rating on any criterion, and those rated “weak” overall were studies with weak ratings on two or more criteria. A “not applicable” rating was applied to the withdrawal criterion in the cases of cross-sectional or retrospective studies (where participants were not followed over time) and to the blinding criterion where studies were not of a randomized nature. Qualitative studies were not rated as the assessment relates to quantitative studies only. The methodological quality ratings were independently assessed by both authors, and the few discrepancies resolved through discussion. Results Search Results An initial database search identified 121 relevant records. After eliminating duplicates, there were 90 records for review. Of these 90, 66 were excluded based on the publication’s title. Of the remaining 24 publications, a further 10 studies were excluded during full-text review due to participants being incarcerated in facilities without smoking bans (n = 2),52,53 reporting on outcomes not related to postrelease smoking intention or behavior (n = 6),2,54–57 or describing study protocols only (n = 2).58,59 Backwards and forwards snowballing identified one further relevant result.60 Fifteen publications met inclusion criteria after full-text review. All were peer-reviewed journal articles. Figure 1 details the publication search and retrieval process. Figure 1. View largeDownload slide PRISMA flow diagram Figure 1. View largeDownload slide PRISMA flow diagram Table 1 describes the characteristics of included studies, whereas the Supplementary Table briefly describes study findings. The fifteen included publications were informed by eight datasets. There was only one randomized controlled trial (RCT) which investigated the effectiveness of a prerelease intensive behavioral intervention (6 × 1-h sessions based on elements of cognitive-behavioral therapy and motivational interviewing) aimed at reducing postrelease smoking.33 This study, called Project WISE (Working Inside for Smoking Elimination), was conducted with a cohort of 247 people (161 men and 86 women) approaching release from a smoke-free prison in Rhode Island, United States. Data from Project WISE informed a further six of the included papers.31,61–65 Two papers (one quantitative and one qualitative) came from a study that conducted pre and postrelease interviews with 49 men released from a smoke-free prison in Wisconsin, USA,66,67 and the six remaining publications relied on unique datasets. Table 1. Characteristics and Measured Outcomes of Included Studies   Authors  Country  Sample size and gender  Study design  Smoking outcomes measured  1.  Bock et al., 201361  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  2.  Clarke et al., 201333  USA (WISE)  247 former prisoners approaching release, 35% female  RCT  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of abstinence postrelease  3.  Clarke et al., 201531  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  4.  Djachenko et al., 201660  Australia  15 prisoners, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  5.  Frank et al., 201635  USA  143 former prisoners who had relapsed postrelease, male and female (% not reported)  Cross-sectional  Postrelease abstinence rates, trying to quit postrelease, predictors of trying to quit postrelease  6.  Howell et al., 201570  USA  172 former prisoners, male  Cross-sectional  Postrelease abstinence rates, predictors of return to smoking postrelease  7.  Indig and Haysom, 201268  Australia  316 people in juvenile detention centres, 12% female  Cross-sectional  Prerelease intention to smoke postrelease, predictors of prerelease intention to smoke postrelease  8.  Lincoln et al., 200934  USA  143 former prisoners, 11% female  Prospective  Postrelease abstinence rates  9.  Parker et al., 201462  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  10.  Parker et al., 201663  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  11.  Thibodeau et al., 201066  USA  49 prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of return to smoking postrelease, predictors of abstinence postrelease  12.  Thibodeau et al., 201267  USA  49 prisoners approaching release, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  13.  Valera et al., 201669  USA  60 former prisoners, 50% female  Qualitative  Postrelease abstinence rates, factors influencing return to smoking postrelease  14.  van den Berg et al., 201464  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to return to smoking postrelease, predictors of return to smoking postrelease  15.  van den Berg et al., 201665  USA (WISE)  161 former prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, predictors of abstinence postrelease    Authors  Country  Sample size and gender  Study design  Smoking outcomes measured  1.  Bock et al., 201361  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  2.  Clarke et al., 201333  USA (WISE)  247 former prisoners approaching release, 35% female  RCT  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of abstinence postrelease  3.  Clarke et al., 201531  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  4.  Djachenko et al., 201660  Australia  15 prisoners, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  5.  Frank et al., 201635  USA  143 former prisoners who had relapsed postrelease, male and female (% not reported)  Cross-sectional  Postrelease abstinence rates, trying to quit postrelease, predictors of trying to quit postrelease  6.  Howell et al., 201570  USA  172 former prisoners, male  Cross-sectional  Postrelease abstinence rates, predictors of return to smoking postrelease  7.  Indig and Haysom, 201268  Australia  316 people in juvenile detention centres, 12% female  Cross-sectional  Prerelease intention to smoke postrelease, predictors of prerelease intention to smoke postrelease  8.  Lincoln et al., 200934  USA  143 former prisoners, 11% female  Prospective  Postrelease abstinence rates  9.  Parker et al., 201462  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  10.  Parker et al., 201663  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  11.  Thibodeau et al., 201066  USA  49 prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of return to smoking postrelease, predictors of abstinence postrelease  12.  Thibodeau et al., 201267  USA  49 prisoners approaching release, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  13.  Valera et al., 201669  USA  60 former prisoners, 50% female  Qualitative  Postrelease abstinence rates, factors influencing return to smoking postrelease  14.  van den Berg et al., 201464  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to return to smoking postrelease, predictors of return to smoking postrelease  15.  van den Berg et al., 201665  USA (WISE)  161 former prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, predictors of abstinence postrelease  NRT: Nicotine Replacement Therapy; RCT: Randomised Controlled Trial; SD: Standard Deviation; USA: United States of America; WISE: Working Inside for Smoking Elimination Trial.33 View Large Table 1. Characteristics and Measured Outcomes of Included Studies   Authors  Country  Sample size and gender  Study design  Smoking outcomes measured  1.  Bock et al., 201361  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  2.  Clarke et al., 201333  USA (WISE)  247 former prisoners approaching release, 35% female  RCT  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of abstinence postrelease  3.  Clarke et al., 201531  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  4.  Djachenko et al., 201660  Australia  15 prisoners, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  5.  Frank et al., 201635  USA  143 former prisoners who had relapsed postrelease, male and female (% not reported)  Cross-sectional  Postrelease abstinence rates, trying to quit postrelease, predictors of trying to quit postrelease  6.  Howell et al., 201570  USA  172 former prisoners, male  Cross-sectional  Postrelease abstinence rates, predictors of return to smoking postrelease  7.  Indig and Haysom, 201268  Australia  316 people in juvenile detention centres, 12% female  Cross-sectional  Prerelease intention to smoke postrelease, predictors of prerelease intention to smoke postrelease  8.  Lincoln et al., 200934  USA  143 former prisoners, 11% female  Prospective  Postrelease abstinence rates  9.  Parker et al., 201462  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  10.  Parker et al., 201663  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  11.  Thibodeau et al., 201066  USA  49 prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of return to smoking postrelease, predictors of abstinence postrelease  12.  Thibodeau et al., 201267  USA  49 prisoners approaching release, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  13.  Valera et al., 201669  USA  60 former prisoners, 50% female  Qualitative  Postrelease abstinence rates, factors influencing return to smoking postrelease  14.  van den Berg et al., 201464  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to return to smoking postrelease, predictors of return to smoking postrelease  15.  van den Berg et al., 201665  USA (WISE)  161 former prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, predictors of abstinence postrelease    Authors  Country  Sample size and gender  Study design  Smoking outcomes measured  1.  Bock et al., 201361  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  2.  Clarke et al., 201333  USA (WISE)  247 former prisoners approaching release, 35% female  RCT  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of abstinence postrelease  3.  Clarke et al., 201531  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to remain abstinent postrelease, predictors of abstinence postrelease  4.  Djachenko et al., 201660  Australia  15 prisoners, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  5.  Frank et al., 201635  USA  143 former prisoners who had relapsed postrelease, male and female (% not reported)  Cross-sectional  Postrelease abstinence rates, trying to quit postrelease, predictors of trying to quit postrelease  6.  Howell et al., 201570  USA  172 former prisoners, male  Cross-sectional  Postrelease abstinence rates, predictors of return to smoking postrelease  7.  Indig and Haysom, 201268  Australia  316 people in juvenile detention centres, 12% female  Cross-sectional  Prerelease intention to smoke postrelease, predictors of prerelease intention to smoke postrelease  8.  Lincoln et al., 200934  USA  143 former prisoners, 11% female  Prospective  Postrelease abstinence rates  9.  Parker et al., 201462  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  10.  Parker et al., 201663  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of abstinence postrelease  11.  Thibodeau et al., 201066  USA  49 prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, postrelease abstinence rates, predictors of return to smoking postrelease, predictors of abstinence postrelease  12.  Thibodeau et al., 201267  USA  49 prisoners approaching release, male  Qualitative  Factors influencing prerelease intention to remain abstinent postrelease  13.  Valera et al., 201669  USA  60 former prisoners, 50% female  Qualitative  Postrelease abstinence rates, factors influencing return to smoking postrelease  14.  van den Berg et al., 201464  USA (WISE)  247 former prisoners approaching release, 35% female  Prospective  Predictors of prerelease intention to return to smoking postrelease, predictors of return to smoking postrelease  15.  van den Berg et al., 201665  USA (WISE)  161 former prisoners approaching release, male  Prospective  Prerelease intention to smoke postrelease, predictors of abstinence postrelease  NRT: Nicotine Replacement Therapy; RCT: Randomised Controlled Trial; SD: Standard Deviation; USA: United States of America; WISE: Working Inside for Smoking Elimination Trial.33 View Large Thirteen of the 15 included studies were conducted in the United States, and the two remaining studies were conducted in Australia.60,68 Only one study interviewed young people (aged 13–21 years old),68 as all others comprised adult participants (aged 18 and above). Ten studies measured outcomes for a mixed gender sample,31,33–35,61–64,68,69 and five studies measured outcomes for males only.60,65–67,70 Participants in nine studies received some form of smoking-cessation support while incarcerated (see Supplementary Table for further details). In seven of these studies, all65 or some participants31,33,61–64 received the WISE prerelease behavioral intervention, specifically designed to reduce smoking relapse following release.33 Nicotine replacement therapy (NRT) was not provided on release as part of the WISE intervention as the authors argued that participants had completed physical withdrawal from nicotine.33 In one study,34 some prisoners received education on the benefits of smoking cessation but the degree of involvement was not recorded. Participants in a qualitative study of the experience of forced smoking abstinence60 had access to free nicotine patches on prison entry and a Quitline telephone smoking-cessation support service, but participants’ use of these services was not recorded. No studies examined whether the availability or not of NRT on entry to prison (to help ease nicotine withdrawal symptoms) affected intention to smoke or remain abstinent following release. No studies examined the effectiveness of postrelease smoking-cessation support, either behavioral or pharmacological, for former prisoners. Three of the included studies were qualitative in design, relying on semi-structured interviews for data collection. One was included because it provided a quantitative measure of smoking relapse in the time following release as well as a description of factors influencing return to smoking following release,69 and the other two because they described participants’ perceptions of factors influencing their pre-release intention to remain abstinent following release.60,67 This review examined three smoking outcomes: (1) prerelease intention to smoke or remain abstinent from smoking following release; (2) smoking relapse or abstinence following release; and (3) quit attempts following postrelease smoking relapse. For the first outcome, four studies quantitatively measured participants’ prerelease intention to return to smoking following release,33,65,66,68 four studies described predictors of prerelease intention to smoke,68 or prerelease intention to remain abstinent31,61,64 following release, and two qualitative studies reported factors influencing participants’ prerelease intention to remain abstinent following release.60,67 Regarding the second outcome, six studies measured rates of smoking abstinence in the time following release from prison,33–35,66,69,70 ten studies measured predictors of smoking64,66,70 or smoking abstinence31,33,61–63,65,66 following release, and one qualitative study described factors that impacted postrelease return to smoking.69 Finally, one study described the prevalence and predictors of quit smoking attempts among those who had already relapsed to tobacco use postrelease.68 A meta-analysis was not conducted, as only five of the included studies were of a high methodological quality, and there was considerable heterogeneity in the focus and methodologies of included papers.71 Methodological Quality Of the 15 studies included in this review, only four were given a strong methodological rating (see Table 2). One of these is the study describing the outcomes of a RCT of a prerelease smoking intervention,33 and the other three are publications using the same dataset but measuring other predictors of outcomes in the cohort.31,61,63 A further two papers also used this dataset, but one was rated as methodologically moderate due to their use of measures not yet shown to be valid or reliable,64 whereas another that focused on a subsample of participants was rated as methodologically weak due to biased participant selection.65 Overall, four studies were rated as methodologically moderate 63,64,66,68, and four studies as weak,34,35,65,70 typically due to cross-sectional design or recruitment bias, such as targeting those wanting to quit smoking. Three qualitative studies were not given methodological quality ratings.60,67,69 Table 2. Methodological Quality of Included Quantitative Studies   Study  Selection bias  Study design  Confounders  Blinding  Data collection  Withdrawals  Global rating  1.  Bock et al., 201361  Strong  Moderate  Strong  NA  Strong  Strong  Strong  2.  Clarke et al., 201333  Strong  Strong  Strong  Moderate  Strong  Strong  Strong  3.  Clarke et al., 201531  Strong  Moderate  Strong  NA  Strong  Moderate  Strong  4.  Frank et al., 201635  Moderate  Weak  Weak  NA  Strong  NA  Weak  5.  Howell et al., 201570  Weak  Moderate  Weak  NA  Moderate  NA  Weak  6.  Indig and Haysom, 201268  Strong  Weak  Moderate  NA  Strong  NA  Moderate  7.  Lincoln et al., 200934  Moderate  Moderate  Weak  NA  Weak  NA  Weak  8.  Parker et al., 201462  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  9.  Parker et al., 201663  Strong  Moderate  Strong  NA  Strong  Strong  Strong  10.  Thibodeau et al., 201066  Weak  Moderate  Moderate  NA  Strong  Strong  Moderate  11.  van den Berg et al., 201464  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  12.  van den Berg et al., 201665  Strong  Moderate  Strong  NA  Weak  Weak  Weak    Study  Selection bias  Study design  Confounders  Blinding  Data collection  Withdrawals  Global rating  1.  Bock et al., 201361  Strong  Moderate  Strong  NA  Strong  Strong  Strong  2.  Clarke et al., 201333  Strong  Strong  Strong  Moderate  Strong  Strong  Strong  3.  Clarke et al., 201531  Strong  Moderate  Strong  NA  Strong  Moderate  Strong  4.  Frank et al., 201635  Moderate  Weak  Weak  NA  Strong  NA  Weak  5.  Howell et al., 201570  Weak  Moderate  Weak  NA  Moderate  NA  Weak  6.  Indig and Haysom, 201268  Strong  Weak  Moderate  NA  Strong  NA  Moderate  7.  Lincoln et al., 200934  Moderate  Moderate  Weak  NA  Weak  NA  Weak  8.  Parker et al., 201462  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  9.  Parker et al., 201663  Strong  Moderate  Strong  NA  Strong  Strong  Strong  10.  Thibodeau et al., 201066  Weak  Moderate  Moderate  NA  Strong  Strong  Moderate  11.  van den Berg et al., 201464  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  12.  van den Berg et al., 201665  Strong  Moderate  Strong  NA  Weak  Weak  Weak  NA: Not applicable. View Large Table 2. Methodological Quality of Included Quantitative Studies   Study  Selection bias  Study design  Confounders  Blinding  Data collection  Withdrawals  Global rating  1.  Bock et al., 201361  Strong  Moderate  Strong  NA  Strong  Strong  Strong  2.  Clarke et al., 201333  Strong  Strong  Strong  Moderate  Strong  Strong  Strong  3.  Clarke et al., 201531  Strong  Moderate  Strong  NA  Strong  Moderate  Strong  4.  Frank et al., 201635  Moderate  Weak  Weak  NA  Strong  NA  Weak  5.  Howell et al., 201570  Weak  Moderate  Weak  NA  Moderate  NA  Weak  6.  Indig and Haysom, 201268  Strong  Weak  Moderate  NA  Strong  NA  Moderate  7.  Lincoln et al., 200934  Moderate  Moderate  Weak  NA  Weak  NA  Weak  8.  Parker et al., 201462  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  9.  Parker et al., 201663  Strong  Moderate  Strong  NA  Strong  Strong  Strong  10.  Thibodeau et al., 201066  Weak  Moderate  Moderate  NA  Strong  Strong  Moderate  11.  van den Berg et al., 201464  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  12.  van den Berg et al., 201665  Strong  Moderate  Strong  NA  Weak  Weak  Weak    Study  Selection bias  Study design  Confounders  Blinding  Data collection  Withdrawals  Global rating  1.  Bock et al., 201361  Strong  Moderate  Strong  NA  Strong  Strong  Strong  2.  Clarke et al., 201333  Strong  Strong  Strong  Moderate  Strong  Strong  Strong  3.  Clarke et al., 201531  Strong  Moderate  Strong  NA  Strong  Moderate  Strong  4.  Frank et al., 201635  Moderate  Weak  Weak  NA  Strong  NA  Weak  5.  Howell et al., 201570  Weak  Moderate  Weak  NA  Moderate  NA  Weak  6.  Indig and Haysom, 201268  Strong  Weak  Moderate  NA  Strong  NA  Moderate  7.  Lincoln et al., 200934  Moderate  Moderate  Weak  NA  Weak  NA  Weak  8.  Parker et al., 201462  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  9.  Parker et al., 201663  Strong  Moderate  Strong  NA  Strong  Strong  Strong  10.  Thibodeau et al., 201066  Weak  Moderate  Moderate  NA  Strong  Strong  Moderate  11.  van den Berg et al., 201464  Strong  Moderate  Strong  NA  Weak  Strong  Moderate  12.  van den Berg et al., 201665  Strong  Moderate  Strong  NA  Weak  Weak  Weak  NA: Not applicable. View Large Outcomes of Included Studies Intention to Smoke or Remain Abstinent Following Prison Release Four studies measured participants’ prerelease intention to smoke following release, with two of these studies rated as methodologically strong,33,65 and the other two as moderate.66,68 There was considerable variation across these four studies reporting the percentage of participants intending to smoke following release from prison (22% to 67%).33,65,66,68 Predictors of Intention to Smoke Following Release One of the studies conducted in Australia, rated as methodologically moderate, interviewed 316 young people, with an average age of 17 years (range 13–21) from nine juvenile detention centers, finding that 67% of participants intended to smoke following release.68 Predictors of intention to smoke on release included illicit drug use at least weekly prior to custody (Odds Ratio [OR] = 3.13, 95% CI = 1.51 to 6.49) and having most or all friends identify as smokers (OR = 2.39, 95% CI = 1.20 to 4.76). Predictors of Intention to Remain Abstinent Following Release Three studies (all secondary analyses of the Project WISE trial data) measured predictors of planning to remain smoke-free postrelease among current prisoners. Two studies were rated as methodologically strong,31,61 and the third as moderate.64 The first publication found that social support specific to quitting smoking from family and from friends were each significantly and positively correlated with motivation, confidence, and plans for remaining abstinent postrelease (all p values <.05).61 The second found that constructs of freedom (“Having that first cigarette when I get out will make me feel like I’m really free or not in prison any more”) and independence (“Having that first cigarette when I get out is a way to express my independence”) were negatively associated with plans for smoking abstinence postrelease.64 Finally, the third publication found that forced tobacco abstinence led to significant improvements in self-reported smoking-related respiratory symptoms, but that this improvement was not significantly associated with plans to remain abstinent following release.31 However, participants with greater symptom improvements were more worried about their smoking, leading the authors to suggest that helping people to reflect on changes in respiratory symptoms may be useful in building motivation to remain abstinent postrelease. Two qualitative studies interviewed people prior to their release to ascertain perceived influences on plans to remain smoke-free following release.60,67 Among 49 men approaching release from a US prison, perceived facilitators of staying smoke free included a desire to be physically healthier, the high cost of tobacco, the negative stigma of smoking, and wanting to be positive role models for their children, whereas a key barrier was the stress that they anticipated experiencing following release.67 Fifteen men in an Australian prison reported that their time in a smoke-free prison was likely to facilitate smoking abstinence following release, but that a lack of postrelease cessation support was likely to hinder their attempts to remain smoke-free. 60 Smoking Relapse or Abstinence Following Release Six studies, all conducted in the United States, reported rates of smoking relapse following release from smoke-free prisons.33–35,66,69,70 Of the five quantitative studies, only one was rated as methodologically strong,33 whereas one was rated as moderate,66 and three as weak.34,35,70 Only two of these six studies measured tobacco abstinence longitudinally among ex-smokers released from smoke-free prisons,33,34 three reported tobacco abstinence at a single time point following release,66,69,70 and one reported time to relapse among former prisoners who had all relapsed to smoking within 3 weeks of release.35 Rates of tobacco abstinence cannot be compared across studies, as each measured relapse at differing timepoints following release, however, all studies found that more than 60% of participants relapsed to smoking following release from smoke-free prisons.33,34,66,69,70 Factors Influencing Smoking Relapse or Abstinence Following Release We identified 10 publications that measured factors influencing smoking following release: two evaluated predictors of returning to smoking,64,70 six described predictors of tobacco abstinence,31,33,61–63,65 one paper described both factors predicting return to smoking and those predicting smoking abstinence,66 and one qualitative study described factors influencing return to smoking among a group of former prisoners.69 Of the nine quantitative publications, four were rated as methodologically strong,31,33,61,63 three as moderate,62,64,66 and two as weak.65,70 The three papers64,66,70 measuring predictors of returning to smoking following release were conducted in the United States. The first publication studied a cohort of 172 male former prisoners found that each additional 5 years of history of incarceration was associated with 1.32 times greater odds of smoking postrelease (95% CI = 1.02 to 1.71), and that past illicit substance abuse was associated with a 2.47 higher adjusted odds of smoking postrelease (95% CI = 1.29 to 5.39). 70 The second paper, conducted with 49 male participants, found that returning to smoking postrelease was predicted by pre-release intention to smoke (p = .001) and being of White race (p = .045).66 The third study used Project WISE data to measure whether people awaiting release from prison associated smoking with constructs of freedom and independence, finding that return to smoking postrelease was significantly linked to associating their anticipated first cigarette with feelings of freedom, (r = .134, p < .05), but not independence. 64 We identified seven publications reporting predictors of remaining abstinent from smoking following release from smoke-free prisons. The first six publications reporting on this outcome used data from Project WISE. The first is the study by Clarke and colleagues reporting the outcomes of the WISE intervention, a prerelease behavioral smoking relapse prevention program.33 Factors associated with increased likelihood of remaining abstinent were: receiving the intervention (OR = 6.6, 95% CI = 2.5 to 17.0), Hispanic ethnicity (OR = 3.2, 95% CI = 1.1 to 8.7), a plan to remain abstinent (OR = 1.6, 95% CI = 1.2 to 2.3), and being incarcerated for more than 6 months (OR = 4.6, 95% CI = 1.7 to 12.4). The second publication investigated the link between social support specific to quitting smoking and smoking abstinence61 and found that, though social support for quitting was not a significant predictor, it was significantly positively correlated with readiness (r = −.30, p < .01), motivation (r = −.24, p < .01), confidence (−.30), and plans to remain abstinent (.25) which in turn were all significantly correlated with smoking abstinence. The third publication aimed to evaluate the influence of changes in self-rated smoking-related symptoms during incarceration on postrelease smoking,31 but found no significant effect. The fourth paper reported that people with a family history of smoking-related illness were significantly less likely to remain abstinent postrelease (OR = 0.28, 95% CI = 0.12 to 0.68).62 The fifth publication investigated participants’ attitudes of smoking in the presence of children and pregnant women and found no significant relationships between these attitudes and postrelease abstinence.63 The sixth paper reported that men who chose to complete a postrelease smoking plans and goals sheet (part of the WISE intervention) whereas incarcerated (“planners”) were more likely to be abstinent from smoking at 3 weeks postrelease (14% vs. 6% of both nonplanners and controls), more likely to report more days abstinent before relapsing to smoking (M = 9.5 days, SD = 9.7 vs. M = 8.1 days, SD = 9.8 for nonplanners and M = 5.7, SD = 8.4 for controls), and more likely to smoke a lower number of cigarettes at 3 weeks postrelease (M = 4.53 cigarettes, SD = 5.84 vs. M = 6.22 cigarettes, SD = 6.53 for nonplanners and M = 8.54, SD = 7.42 for controls).65 However, these differences did not persist when comparing those who received the WISE intervention with the control group, suggesting that the differences between the three groups may have been due to intervention effects rather than planning versus nonplanning.65 The seventh paper, and the only paper in this category not to use data from the WISE study, found a significant link between perceived better health since the prison smoking ban and tobacco abstinence following release among a group of 49 men recently released from a smoke-free prison in Wisconsin, United States (p = .01).66 One qualitative study interviewed 60 people recently released from smoke-free prisons in the United States, with participants reporting that stress, being surrounded by smokers, availability of cigarettes, and a lack of social support were factors that influenced their return to smoking following release.69 Quit Attempts Following Postrelease Smoking Relapse One study investigated attempts to stop smoking among those who relapsed to smoking following release from a smoke-free prison.35 Forty-two percent of the participants who had resumed smoking after release reported that they were trying to quit smoking. This study also found that trying to quit postrelease was positively associated with the absence of risky drinking behavior (p < .001) and absence of drug use (p = .049) in the past 30 days.35 Discussion This systematic review found a high and rapid rate of smoking relapse among people released from smoke-free prisons. The evidence base in this context was very limited (eight data sets informing 15 papers) and was almost exclusively US-based. The only RCT in this review33 demonstrated that an intensive prerelease cognitive-behavioral program was effective in reducing postrelease smoking relapse. There is an urgent need for further high-quality randomized trials to inform interventions aimed at reducing the high postrelease relapse rate, and encouraging those who relapse to make further cessation attempts. The main limitation of this review is that the limited evidence base precludes the drawing of firm conclusions. The included publications were diverse in focus and methodology, making it difficult to compare outcomes or trends, or to conduct a meta-analysis. The search was restricted to studies published in English, so it is possible that studies in other languages were missed. The predominance of US literature, while commensurate with their high incarceration rate,72 limits the generalizability of the findings, as other jurisdictions may differ considerably in both social context, (eg, incarceration rate, level of economic inequities, or strength of the welfare system) and tobacco control context (eg, availability and quality of smoking-cessation services, price of tobacco, extent of social marketing to encourage cessation, or extent of smoke-free policies). However, this is, to the best of our knowledge, the first study to systematically review literature reporting on factors influencing smoking relapse and abstinence following release from smoke-free prisons, and in the context of the current proliferation of smoke-free policies in prisons around the world,27 and high rates of tobacco use by correctional populations,4 an understanding of these factors is vital to inform best-practice smoking-cessation strategies for stakeholders working with people exiting smoke-free prisons. Despite this limited evidence base, our review’s key findings together with evidence-based smoking-cessation guidelines73,74 provide guidance for the development of interventions for people approaching release from smoke-free prisons. Evidence from our review’s findings showing that prerelease intention to remain abstinent is positively associated with postrelease smoking abstinence,33,61,66 indicating that interventions should ideally begin prerelease and span the pre to postrelease period and should incorporate elements of motivational interviewing33,75 to build intention to remain abstinent from smoking following release. The positive findings of the WISE RCT,33 while in need of replication, provide preliminary evidence for the effectiveness of a prerelease intervention involving motivational counseling to promote postrelease smoking cessation. Prerelease interventions provide people with the opportunity to reflect on their experiences of being smoke-free, articulate for themselves the benefits of continued smoking cessation, and instil optimism about change by helping people plan how to cope without cigarettes outside prison.33 Further evidence from community-based cessation guidelines74 and prison-based studies48,76–81 shows that these interventions should be multi-component in nature in order to maximize chances of successful cessation, relying on a combination of behavioral support and smoking-cessation pharmacotherapy. Effective postrelease interventions should also include both behavioral73 and pharmacotherapeutic74,82 elements, with behavioral skill training focusing on assisting individuals to get back on track following slips or relapses. Further research is needed to address the evidence gap regarding the effectiveness of postrelease interventions, including investigation of whether harm-reduction approaches such as nicotine replacement therapy or electronic nicotine delivery systems might help prevent smoking relapse in the early postrelease period. Our results further identified that people with a history of hazardous substance use were less likely to plan to remain abstinent postrelease,68 less likely to remain abstinent,70 and less likely to attempt to quit smoking following smoking relapse.35 With these studies reflecting findings from community-based studies showing that tobacco smoking is endemic among people with substance-use disorders,83–85 efforts to provide smoking-cessation support for correctional populations pre and postrelease should be combined with coordinated treatment for alcohol and other substance use—an approach with demonstrated effectiveness in the general community.86–88 Historically, smoking cessation was thought to negatively impact substance-use treatment outcomes.87 However, stopping smoking concurrently with other substances does not hinder smoking-cessation efforts, and often has a positive effect on substance-use outcomes.87,88 Addiction workers are well placed to provide tobacco treatment, but the decision to provide smoking-cessation care is often arbitrary.89 Organizational policy and practice changes, including staff education, are needed to facilitate routine tobacco treatment in substance-use treatment settings. Social support for quitting from family and friends was also identified as a common factor that facilitated postrelease abstinence.61,68,69 Community-based studies90–92 confirm the important role of social support in achieving and maintaining smoking cessation, but consensus on the mechanisms behind this association or how to effectively include social support in smoking-cessation programs remains unclear.93–95 Future research might examine the use of peer-workers to provide pre and postrelease smoking-cessation support, or the combined targeting of smoking-cessation treatment to close friends and family members as well as participants.68 Qualitative work identified the overwhelming challenge of trying to maintain a smoke-free lifestyle when paroled to housing facilities and programs where smoking was rife.69 Institution of smoke-free policies into these services may also facilitate smoking abstinence. It is also notable that some people approaching release viewed smoking tobacco as a gateway that had led them to prison, or would lead them back if they were to relapse.67 Smoking cessation, especially where it is a part of a broader change to a healthier lifestyle, may reduce risk factors for re-offending96 as it provides valuable opportunities for people to improve both their physical and mental health and achieve their individual social and economic goals. Our review identified several key areas in need of further research. At present, it is not known whether the provision of NRT on prison entry affects intention to smoke or remain abstinent following release. It is possible that forced nicotine withdrawal without NRT to reduce withdrawal severity may reduce an individual’s motivation to attempt to remain tobacco abstinent following release. This is despite the fact that reduced access to tobacco during imprisonment means that people are likely to experience a milder nicotine withdrawal after leaving prison, with cravings predominantly driven by emotional and social cues rather than nicotine dependence. Further research is also needed to help clarify contradictory findings, for example, whether length of incarceration, is positively or negatively associated with postrelease tobacco abstinence. As noted above, we did not identify any studies measuring the effectiveness of postrelease interventions aimed at reducing smoking relapse or to encourage further quit attempts among those who relapse. A further high priority for future research is to test sustainable models for providing pre to postrelease smoking-cessation support. Brief interventions from corrections, transition, health, and social service professionals that include making a formal referral to existing effective cessation services, such as a Quitline telephone call-back service whose staff could be trained in the complex needs of people leaving prison, could provide convenient and highly accessible continuity of care over the pre to postrelease period.97 In some countries, including Australia and New Zealand, prisoners are already able to call Quitline free of charge,60,98,99 pointing to an opportunity for future research to test the effectiveness of this service in assisting people leaving smoke-free prisons to maintain smoking abstinence. Conclusion To date, support for maintaining postrelease smoking abstinence has typically fallen outside of scope of the implementation of smoke-free prisons. Providing people with the skills to remain smoke-free in the community is an important opportunity to improve the health, finances, and well-being of this vulnerable population who are susceptible to poor health outcomes following prison release. Given the proliferation of complete indoor/outdoor smoke-free policies in correctional facilities internationally, and high rates of tobacco use among this population, there is a pressing need for further, high-quality research in this area to strengthen the evidence-base for the best practice smoking-cessation support provided to people leaving smoke-free prisons. Supplementary Material Supplementary Table 1 can be found online at https://academic.oup.com/ntr/ Funding This work received no external funding. Declaration of Interests The authors declare no conflicts of interest. References 1. GBD 2015 Tobacco Collaborators. 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Nicotine and Tobacco ResearchOxford University Press

Published: May 4, 2018

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