World No Tobacco Day in 2019 marks the six month anniversary of Scotland’s prison estate becoming smokefree on 30th November 2018. Working in close partnership with the Scottish Prison Service, a team of researchers from the Universities of Stirling and Glasgow have been undertaking a large study of the process and outcomes of Scotland’s move to smokefree prisons, generating a body of research which they hope will inform moves to smokefree prisons elsewhere. Here they describe the rationale and early outcomes for the Tobacco in Prisons study.
The dangers of tobacco smoking have been widely recognised since the 1960s, and it has been known for many decades that it is not only smokers themselves who are at risk, but also those exposed to secondhand smoke. For example, it was estimated that over 79,000 adults, including 19,000 non-smokers, died in the EU in 2002 due to exposure to tobacco smoke at home (72,000) and at work (7,300). The recognition that breathing in secondhand smoke causes substantial damage to health was the impetus for the successful bans of smoking in public places that have been introduced in Scotland (2006), England and Wales (2007) and many other EU countries (https://ec.europa.eu/health/tobacco/smoke-free_environments_en).
Until recently, prisons were one of the few indoor or workplace environments that was exempted from broader smoking bans in the UK, and elsewhere. In countries where smoking of tobacco in prisons is still permitted, the prevalence of smoking amongst those in custody is very high. Prior to the recent introduction of Scotland’s prison smoking ban, for example, levels of smoking were around 72% - a level not seen even amongst men in wider society since the early 1960s when the dangers of smoking were only just being widely documented. Over a decade ago, this high prevalence of smoking in prisons was described as “one of the most pernicious public health problems affecting prisons .. all too often.. ignored [in] community based tobacco control policies” (Butler et al, 2007). Research over many years has documented the challenges to introducing smokefree policies in prisons, as smoking had become so embedded within prison culture. Even though surveys suggest that roughly half of smokers in prison say they want to stop (see, for example, Scottish Prison Service. Prisoner Survey 2013. Edinburgh: Scottish Prison Service, 2013), prisons are recognised to be particularly difficult environments in which to become a non-smoker.
Prison smoking bans – developing momentum but an evidence gap?
Given these challenges, several countries have now introduced smokefree prison policies, with New Zealand leading the way with its comprehensive ban in 2011. The English and Welsh prisons began their journey to being smokefree in 2016, with a phased roll-out of smokefree prisons, and in 2018 England and Wales became the largest prison estate in Europe to be smokefree, housing around 85,000 people in 122 prisons. However, to date there has been a gap in the evidence base on: the short and long term outcomes of prison smoking bans for the health and lives of people in custody and the health and working environment of prison staff: what helps and hinders in the journey to the successful transition to smokefree prisons: and impacts on organisational cultures and structures.
The Tobacco in Prisons (TIPs) study in Scotland
All of Scotland’s 15 prisons became smokefree on November 30th 2018. In Scotland, the TIPS research team has been able to work in partnership with the Scottish Prison Service, the National Health Service and tobacco control policy-makers in Scottish Government to create a unique evidence base through a three phase study including six inter-related workpackages (WPs, see Figure 1). The TIPS study is led by researchers at the University of Stirling and funded by the UK’s National Institute for Health Research. WP1 involved literature reviews and interviews with people who had experience of smokefree prison policy in other countries. The main components of WP2 are the measurement of air quality across the prisons, and the modelling of these and other outcomes before and after the implementation of policy. WP3 and WP4 have used both qualitative methods (focus groups and one-to-one interviews) and surveys to elicit the views and experiences of prison staff and people in custody, at repeated intervals between 2016 and 2019. WP5 has documented the experiences and views of those providing and using smoking cessation services within Scotland’s prisons. WP6 has ensured that, through close partnership working, the findings from every Phase of the study can be fed back in a very timely manner to inform those charged with developing, planning and implementing smokefree prison policy in Scotland.
Phase 1 of this study began in 2016 and provided a comprehensive picture of exposures to secondhand smoke, issues related to smoking, and views on the potential introduction of smokefree policies. This enabled the collection of baseline data because, at this time, there were no firm plans to introduce a smoking ban in Scottish prisons, although the Scottish Government and Scottish Prison Service both recognised that this would be essential to Scotland’s vision to create a tobacco-free society by 2034 (Scottish Government 2013) and an important step towards improving the health of people in custody and prison staff.
Phase 1 research measuring air quality in all prisons (looking at the typical concentrations of secondhand smoke) in all fifteen prisons was carried out in autumn 2016 using air quality monitors to measure a marker of cigarette smoke (PM2.5 , fine Particulate Matter less than 2.5 microns in size). Levels of SHS varied by prisons (see Figure 2) and time of day, but showed high peaks during certain tasks, such as entering cells, and notable background levels of SHS on prison landings and communal areas throughout much of the working day. These air measurements were confirmed through analysis of samples of saliva from prison officers at the start and end of their working day. These were used to measure changes in cotinine levels – a biomarker of how much nicotine they had inhaled at work. On average, the data showed that a typical prison officer was experiencing an exposure to SHS that was broadly similar to that experienced by someone who lived with someone who smoked within the home (Semple et al, 2017a,b).
When these results were published in July 2017, they were described as a ‘wake-up call’ by the Chief Executive of the Scottish Prison Service at a press conference in which he announced that the Scottish Prison Service would implement policy for completely smoke-free prisons by November 2018. TIPs Phase 1 data also provided evidence of staff and prisoner attitudes to smoking and potential smoking bans in prisons (Brown et al, 2018; Brown et al, 2019 forthcoming; Sweeting et al, 2019 forthcoming).
During 2017 and 2018, the prison service and the health service worked in partnership to prepare for this change in Scotland. Careful planning, information and education, and an increase in smoking cessation services were put into place in the lead up to the ban. E-cigarettes were also made available prior to the ban. Phase 2 research findings, as yet unpublished, were provided on an ongoing basis to these key stakeholders to provide independent data on the views and experiences of prison staff and those in custody in the lead up to November 2018. These were also used to inform communication strategies and to highlight whether key messages about the process and intent had been successfully disseminated throughout the prisons.
Over a six day period spanning the 30 November 2018 when the ban was introduced across Scotland’s prisons, the TIPs research team was able to repeat the measurements of air quality in the same residential areas that were measured within each prison in 2016, with the help of staff in the prisons. This makes Scotland the first country to have objective measures of SHS available across its whole prison estate nationwide, before and after a ban was introduced. The measures provide clear evidence of substantial reductions across all of Scotland’s prisons. Overall, PM2.5 concentrations reduced by 81% on average between 2016 and immediately post-ban. The scale of the reduction is on a par with the reduction seen in pubs following the introduction of the smoking ban in 2006. Mean concentration of particles declined between 2016 and 2018, from median of 31.7 to 5.8 micrograms per cubic metre of air (Semple et al, 2019).
The median level of measured PM2.5 inside the prisons after the ban is almost exactly the same as the levels measured in ordinary outdoor air (at the closest environmental measuring station). This suggests that there was close to zero SHS recorded in these areas almost immediately after the smoking ban was brought in. This level of improvement in air quality will have immediate benefits for prison staff and for people in custody (Semple et al, 2019).
It is a great achievement for any prison service to make the challenging transition from a situation in which almost three quarters of people in custody smoke, to a smokefree environment. Scotland’s success in implementing this is a tribute to careful planning, and the efforts and cooperation of prison staff, those in custody, and NHS and smoking cessation staff. As we reach the six month anniversary of the introduction of a smokefree prison service in Scotland, TIPs Phase 3 data collection is ongoing – including repeat measurements of air quality, repeat surveys with people in custody and prison staff, and extensive qualitative data collection with staff, prisoners and health service staff providing support to those who are managing in a smokefree environment. As the findings from Phase 2 and Phase 3 of TIPs are published during 2019 and 2020, they will provide a comprehensive body of evidence on health and other outcomes of the introduction of smokefree policy, including intended benefits and any unintended positive or negative impacts. They will also provide a unique documentation of what helped and hindered this challenging transition to, and maintenance of, smokefree prison policy. As the research has sought to gather a very wide range of perspectives across the prison service, it will help to inform other jurisdictions about the formulation, implementation and likely consequences of similar policy elsewhere.
References (publications to date from TIPs indicated by *)
* Brown A, Sweeting H, Semple S, Bauld L, Logan G, Hunt K (2018). Prison staff and prisoner views on a prison smoking ban: evidence from the Tobacco in Prisons Study. Nicotine and Tobacco Research https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/nty092/4996090
* Brown A, Sweeting H, Semple S, Bauld L, Logan G, Hunt K (2019) Views of prison staff in Scotland on the potential benefits and risks of e-cigarettes in smoke-free prisons: a qualitative focus group study. BMJ Open accepted for publication
Butler T, Richmond R, Belcher J, Wilhelm K, Wodak A. Should smoking be banned in prisons?
Tobacco Control. 2007;16:291-3.
Robinson A, Sweeting H, Hunt K (2018). UK news media representations of smoking, smoking policies and tobacco bans in prisons. Tobacco Control, 27: 622-30 https://tobaccocontrol.bmj.com/content/tobaccocontrol/early/2018/02/19/tobaccocontrol-2017-053868.full.pdf
Scottish Government. Creating a tobacco-free generation. A tobacco control strategy for
Scotland. Edinburgh: Scottish Government, 2013.
Scottish Prison Service. Prisoner Survey 2013. Edinburgh: SPS, 2013.
* Semple S, Sweeting H, Demou E, Logan G, O’Donnell R, Hunt K on behalf of the Tobacco in Prisons (TIPs) research team (2017a). Characterising the exposure of prison staff to second-hand tobacco smoke. Annals of Work Exposure and Health, 61(7): 809-821 https://academic.oup.com/annweh/article/61/7/809/3965339
*Semple S, Sweeting H, Demou E, Logan G, O’Donnell R, Hunt K (on behalf of the Tobacco in Prisons (TIPs) research team) (2017b). Staff exposure to second-hand tobacco smoke in Scotland’s prisons. A report for Work Package 2 (WP2) of the Tobacco In Prisons study (TIPs) funded by the Public Health Research Programme of the NHS National Institute for Health Research.
* Semple S, Dobson R, Sweeting H, Brown A, Hunt K on behalf of the Tobacco in Prisons (TIPs) research team (2019). The impact of implementation of a national smoke-free prisons policy on indoor air quality: results from the Tobacco in Prisons study. Tobacco Control (published online 7.5.19; doi:10.1136/tobaccocontrol-2018-054895) https://dspace.stir.ac.uk/bitstream/1893/29448/1/tobaccocontrol-2018-054895.full.pdf