Process and impact of implementing a smoke-free policy in prisons in Scotland: TIPs mixed-methods study

Abstract

Background Prisons had partial exemption from the UK’s 2006/7 smoking bans in enclosed public spaces. They became one of the few workplaces with continuing exposure to second-hand smoke, given the high levels of smoking among people in custody. Despite the introduction of smoke-free prisons elsewhere, evaluations of such ‘bans’ have been very limited to date. Objective The objective was to provide evidence on the process and impact of implementing a smoke-free policy across a national prison service. Design The Tobacco in Prisons study was a three-phase, multimethod study exploring the periods before policy formulation (phase 1: pre announcement), during preparation for implementation (phase 2: preparatory) and after implementation (phase 3: post implementation). Setting The study was set in Scotland’s prisons. Participants Participants were people in custody, prison staff and providers/users of prison smoking cessation services. Intervention Comprehensive smoke-free prison rules were implemented across all of Scotland’s prisons in November 2018. Main outcome measures The main outcome measures were second-hand smoke levels, health outcomes and perspectives/experiences, including facilitators of successful transitions to smoke-free prisons. Data sources The study utilised cross-sectional surveys of staff (total, n = 3522) and people in custody (total, n = 5956) in each phase; focus groups and/or one-to-one interviews with staff (n = 237 across 34 focus groups; n = 38 interviews), people in custody (n = 62 interviews), providers (n = 103 interviews) and users (n = 45 interviews) of prison smoking cessation services and stakeholders elsewhere (n = 19); measurements of second-hand smoke exposure (e.g. 369,208 minutes of static measures in residential areas at three time points); and routinely collected data (e.g. medications dispensed, inpatient/outpatient visits). Results Measures of second-hand smoke were substantially (≈ 90%) reduced post implementation, compared with baseline, largely confirming the views of staff and people in custody that illicit smoking is not a major issue post ban. Several factors that contributed to the successful implementation of the smoke-free policy, now accepted as the ‘new normal’, were identified. E-cigarette use has become common, was recognised (by both staff and people in custody) to have facilitated the transition and raises new issues in prisons. The health economic analysis (lifetime model) demonstrated that costs were lower and the number of quality-adjusted life-years was larger for people in custody and staff in the ‘with smoke-free’ policy period than in the ‘without’ policy period, confirming cost-effectiveness against a £20,000 willingness-to-pay threshold. Limitations The ability to triangulate between different data sources mitigated limitations with constituent data sets. Conclusions To our knowledge, this is the first study internationally to analyse the views of prison staff and people in custody; objective measurements of second-hand smoke exposure and routine health and other outcomes before, during and after the implementation of a smoke-free prison policy; and to assess cost-effectiveness. The results are relevant to jurisdictions considering similar legislation, whether or not e-cigarettes are permitted. The study provides a model for partnership working and, as a multidimensional study of a national prison system, adds to a previously sparse evidence base internationally. Future work Priorities are to understand how to support people in custody in remaining smoke free after release from prison, and whether or not interventions can extend benefits to their families; to evaluate new guidance supporting people wishing to reduce or quit vaping; and to understand how prison vaping practices/cultures may strengthen or weaken long-term reductions in smoking. Study registration This study is registered as Research Registry 4802. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information.

A Longitudinal Study of Perceptions of the Massachusetts Menthol Ban and Its Impact on Smoking Behaviors among Marginalized Individuals

“…Mixed-method, triangulated designs have been used to support the design and implementation of tobacco interventions in other settings, such as for pregnant women with substance use disorders and smoke-free policies in prisons [31,32]. To our knowledge, our study is the first to use these methods to understand the perceptions of the Massachusetts menthol ban and its impact on smoking behaviors.…”

Implementation of a national smoke-free prison policy: an economic evaluation within the Tobacco in Prisons (TIPs) study

“…Smoking cessation costs were not included because of the differing mechanisms of provision across prisons, although nicotine dependence medication was included and showed an increase in the study period. Costs were not included for monitoring SHS levels inside prisons (which was undertaken as part of the TIPs research26) when assessing the need for the policy, as this was considered to be a research cost and not an implementation cost. This is an important consideration for other jurisdictions introducing smoke-free prison policies, as the preannouncement phase SHS exposure measurements partially informed the need for and timing of Scotland’s smoke-free prison policy 12.…”

“…TIPs was a natural experiment based on a wide range of bespoke and routine data collected pre-implementation and post implementation of the smoke-free policy in November 2018. Findings on SHS exposures, dispensed medication and the views and experiences of PiC and prison staff, including on the introduction, use and sale of e-cigarettes in the lead up to implementation, are reported in detail elsewhere 12 15–26. Data collected in the TIPs study were used to inform this analysis.…”

“…We were unable to collect data on implementing the policy (intervention costs). Healthcare resource use associated with general practitioner (GP) and nurse visits was derived from TIPs surveys completed by PiC and staff, which provided mean estimates for each of the three phases of the study period 17 18 26. For PiC, routinely collected data (monthly) from SPS and NHS National Services Scotland (NSS) were used to estimate resource use associated with secondary healthcare, including new outpatient visits (receiving treatment in hospital but not requiring an overnight stay), inpatient stays (receiving treatment in hospital requiring an overnight stay), mental health hospital stays (receiving treatment requiring an overnight stay at a mental healthcare unit), accident and emergency visits, ambulance use and dispensed medication for nicotine dependence and smoking-related illness; detailed analysis is described elsewhere 19…”

“…The overall design of the TIPs study, the development of survey instruments and the sampling for the qualitative data were informed by discussions with prison staff, including those working in SPS headquarters and in the prisons, representatives of prison worker unions and of Scottish Government, and NHS staff, in particular those with a remit for prison health and/or smoking cessation. 26 …”