by Dr Eamonn O'Moore, National Lead for Health & Justice, Public Health England and Director UK Collaborating Centre, WHO Health in Prisons Programme (European Region).
On 30th April 2018, the final two prisons in England implemented their smoke free policies bringing the total number to 102- the largest smoke-free prison estate in Western Europe. This is a momentous public health achievement accomplished against a background of often hostile media coverage, real concerns about the welfare of people in prison, increasing use of new psychoactive substances and high levels of violence, self-harm and suicide. At an event in Newbold Revel on July 9th, colleagues from HMPPS, NHS England, Public Health England (PHE) and others came together to reflect on the journey to date and the challenges ahead.
Smoking tobacco is a leading cause of preventable death in the UK. In 2016, around 78,000 deaths were attributable to smoking in England & 5,500 deaths in Wales[i]. Exposure to second-hand smoke can lead to a range of diseases, many of which are fatal. Reducing the prevalence of cigarette smoking is therefore a main objective for the government who have set a smoking prevalence target for England of 12% by 2022.
People in prison often experience significant health inequalities but none starker than the difference in smoking rates. In England, 14.9% of adults smoke tobacco1. But about 80% of people in prison smoke tobacco. Since the completion of air quality testing in prisons in 2015 which identified a significant health threat to both prisoners and staff, HMPPS, with NHSE and PHE, implemented a project to move to a smoke free environment in all closed prisons in England and Wales. This partnership approach has been essential to the success of the programme and was enshrined in the 2015/16 National Partnership Agreement[ii].The collaborative work has been informed also by research from the United States clearly demonstrating the benefits of implementation of smoke-free prisons, which is associated with reductions in smoking related mortality, particularly cardiovascular and pulmonary deaths[iii]; improved health among prison staff, improved fire safety, and reduced costs associated with liability insurance, facility maintenance, and healthcare.
The approach in England was characterised by a rigorous assessment of the ‘state of readiness’ of prisons and their healthcare services, including the availability of nicotine-replacement therapy. But a report by PHE published in August, 2015 PHE[iv] showing that “that e-cigarettes are around 95% less harmful than smoking”, paved the way from the real ‘game changer’ with the introduction of e-cigarettes and subsequently vaping devices in prisons. Prior to the project starting around 50,000 prisoners were buying tobacco, now prison canteens are selling over 65,000 vaping products weekly to over 33,000 prisoners- a significant harm reduction impact.
Implementation of the smoke-free prisons programme has the potential to change forever smoking behaviour not only in prison but also as people return to the community. We may yet drive down harmful tobacco smoking behaviour in offenders who are parents, realising the possibility of a generation free of tobacco health harms.
More work is required to consolidate the achievement of a smoke-free prison culture. As Nelson Mandela reminds us “I have discovered the secret that after climbing a great hill, one only finds that there are many more hills to climb”. But sometimes it is important to stop and admire the view, realising the scale of the accomplishment to date. This work may be the most significantly impactful public health programme I will ever deliver in my medical career- literally life-saving and ensuring we leave ‘no one behind[v]’.
[i] Source: ONS, Adult smoking habits in the UK 2017 published July 3, 2018 https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2017
[ii] The National Partnership Agreement for Commissioning Prison Healthcare in England 2015-16 http://www.justice.gov.uk/downloads/about/noms/work-with-partners/national_partnership_agreement_commissioning-delivery-healthcare-prisons2015.pdf
[iii] Binswanger et al, BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014);
[v] United National Development Programme’s Sustainable Development Goals (SDGs) http://www.undp.org/content/undp/en/home/sustainable-development-goals.html