Jayes, L.R.
(2017)
Smoking and smoke-free policy in prisons in England.
PhD thesis, University of Nottingham.
Abstract
Background
Awareness of the harmful effects of second-hand smoke (SHS) has led governments in the United Kingdom (UK) and many other countries to introduce smoke-free legislation in almost all enclosed work and public places. Her Majesty’s (HM) Prison Service, which currently holds over 85,000 offenders among whom the prevalence of smoking is high, was granted one of few exemptions from the 2007 smoke-free legislation in England, which allowed prisoners to smoke in their cells. This continued smoking impacts not only on the health of the individual smoker but also, through SHS exposure, on other smokers and non-smokers who live or work in the prison. However there is limited research evidence on levels of SHS in prison; how the current Prison Service Instruction (PSI) 09/2007 relating to smoking restrictions in prisons in England operates in practice and protects staff members and prisoners from SHS; or how feasible, acceptable or successful the extension of smoke-free policies to all areas of the prison are likely to be in preventing further exposure.
Methods
This thesis employs both quantitative and qualitative methods in a pragmatic mixed-methods design to investigate smoking and smoke-free policy in prisons in England. Initially, the concentrations of airborne particulate matter <2.5 microns in diameter (PM₂.₅) were measured, as a proxy measure for SHS, in four English prisons. Samples were taken on wing landings and in smoking and non-smoking cells; and by ambient monitoring as a measure of personal exposure of staff working in these settings. Staff members who participated in this air quality monitoring study were then followed up to complete a one-to-one semi-structured qualitative interview exploring their views on smoking in prison and exposure to SHS, considering how the current PSI worked in practice, and the potential move to a smoke-free prison estate. A proposal to pilot test smoke-free policy in four prisons in England was announced shortly after, and in large part as a result of the findings of these first studies. A mixed methods evaluation of the new smoke-free policy was then conducted at all four sites, involving prisoner and staff questionnaires and focus groups, and air quality monitoring (sampling concentration of PM₂.₅ on wing landings) three months before and three months after the policy implementation date. Questionnaires and focus groups pre-policy were used to establish current smoking prevalence, investigate smoking practices and identify perceived problems and concerns regarding the move towards a smoke-free policy. Post-policy these methods were used to explore the impact of the smoke-free policy, views on its implementation alongside consideration of how it could be improved in the future. Concentrations of PM₂.₅ were used to determine whether going smoke-free reduced levels of SHS exposure.
Results
Initial air quality monitoring measured PM₂.₅ concentrations from 48 static locations and personal monitoring of 22 staff members. Arithmetic mean PM₂.₅ concentrations were significantly higher on landings where smoking was permitted in cells compared to completely non-smoking wings. Concentrations of PM₂.₅ on landings where smoking was permitted in cells often exceeding the World Health Organisation (WHO) upper air quality guidance limit for a 24 hour period. During personal monitoring of staff members, some of the highest concentrations of PM₂.₅ were recorded during duties such as locking or unlocking cells, handing out mail and cell searching. Qualitative interviews with prison officers who took part in air quality monitoring reinforced these air quality monitoring findings, confirming the times of the day and duties undertaken where they felt most at risk from SHS. Prison officers outlined how the current PSI was often unworkable day-to-day, conceding that prisoners would often ignore the smoking restrictions in place.
In the evaluation of the first four pilot sites to go smoke-free in England, findings prior to the implementation reported 65% smoking prevalence amongst prisoners, and highlighted widespread concerns among staff members and prisoners that going smoke-free would lead to an increase in disorder, self-harm, drug use and trading of tobacco. After the introduction of the policy, prisoners reported an increase in disorder and drug use, but staff reports suggested that concerns were predominantly unfounded. Post-policy, 60% of smoking prisoners reported using some form of Nicotine Replacement Therapy (NRT) in an attempt to cut down or quit in advance of policy implementation, but many reported difficulty accessing cessation support, and found the electronic cigarettes purchased as a substitute for smoking unsatisfactory. Support for the future introduction of the smoke-free policy throughout the rest of the English prison estate was much higher among staff members (70%) than prisoners (23%). Only a quarter of former smoking prisoners stated that they would remain smoke-free once released or transferred to a smoking establishment. Prisoners and staff reported positive outcomes from the smoke-free policy, both reporting a cleaner and healthier environment to life and work. There was a 69% median and a 66% mean reduction in PM₂.₅ concentrations three months after smoke-free policy was introduced, compared to the same samples taken three months pre-policy, and these reductions were highly statistically significant in all four prisons (p<0.001). Unintended consequences of the smoke-free policy included smoking alternative substances (such as the contents of NRT patches, tea leaves and lawn grass), the creation of a tobacco black market and related bullying and debt, and the smuggling of tobacco.
Conclusions
Smoking in prisons in England is a source of high SHS exposure for both staff and prisoners, and the current PSI allowing prisoners to smoke in their cells does not protect other prisoners or staff from SHS exposure. Introducing a comprehensive smoke-free policy in four prisons in England proved successful, achieving marked reductions in tobacco use, improved indoor air quality, and healthier living and working conditions. There are however lessons for wider implementation, particularly in relation to setting clear timelines, ensuring that prisoners can access cessation services in advance of policy implementation, consideration of electronic cigarette available, and other unintended factors. Where possible, these factors need to be addressed to safeguard the future successful implementation throughout the rest of the English prison estate.
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