CorrectCare

Progress Report: Issues and Opportunities

Clearing the Air on Tobacco Use in Corrections

By Janet Porter

Developed for correctional facilities, this two-part curriculum provides education on the health effects of tobacco and a lesson on how to quit. It has facilitator instructions, handouts and a resources list. Learn more or order via our online catalog, or call (773) 880-1460.

Tobacco use is the most preventable cause of death in the United States, responsible for one out of every five deaths. But use of this deadly agent is skewed, with high prevalence seen among individuals of low socioeconomic status. This trait is common among the incarcerated, of course, for whom smoking rates are estimated to be as high as 70%, well above the 23% rate for all U.S. adults.

Unfortunately, many correctional facilities lack—or fail to enforce—policies that prohibit tobacco use. This is true even in states with progressive tobacco-control policies. It was only last year that California, a longtime leader in this area, passed legislation to ban the possession of tobacco products by inmates in state prisons and youth facilities.

Even for those in tobacco-free facilities, tobacco use often is only interrupted while they are in custody; it is quickly resumed after release. Clearly, prohibition alone is not enough to change long-term behavior.

To help people of low socioeconomic status eliminate tobacco use altogether, the Centers for Disease Control and Prevention provided the Health Education Council with funding to create the National Network on Tobacco Prevention and Poverty.

From its inception in 2000, NNTPP recognized correctional populations as an important target and enlisted the National Commission on Correctional Health Care as a charter stakeholder organization. Together, NCCHC and NNTPP are working to promote tobacco-use policy as well as educational and cessation programming in correctional facilities. This article describes our efforts to date.

Conflicting Trends
Secondhand smoke is one of the most talked about topics in tobacco control. Helping protect the health of nonsmokers has become the business of many private sector employers and public organizations. State and local governments continue to pass laws to limit or prohibit tobacco use in their buildings.

Along with this trend, a growing number of correctional facilities have had to adopt tobacco-free policies to comply with federal, state or local mandates. This presents a dual challenge since such policies impact both staff and inmates.

When asked, correctional facility staff members often point to the stressful nature of their work as a prime reason for use of tobacco, particularly at work. As a result, it is not uncommon for a significant portion of staff to smoke. As for inmates, cigarettes have traditionally been one of the few “privileges” they could look forward to, one of the few pleasures they could still control.

Given the prevalence of tobacco use among inmates and staff, it is a challenge to keep tobacco products out of correctional facilities, even at those where it is prohibited.

Studying the Problem
In 2002, NCCHC convened a forum to discuss tobacco use and the needs for education and prevention among inmates and correctional staff. Forum participants included correctional health care providers and administrators representing a variety of disciplines and settings in seven states.

The participants shared their facilities’ experiences with going tobacco-free and the effectiveness of their policies. They also identified challenges —many of them unique to correctional settings— they encountered along the way.

Among the challenges noted were dealing with difficult patients, fitting tobacco control in when other health concerns and addictions seemed more pressing, enforcing policies with insufficient staff to monitor inmates and guards, and recruiting and retaining staff (many would-be candidates are smokers).

The rise in tobacco as contraband is another big problem. One participant said, “Once we went tobacco-free, what had been viewed as a privilege and reward became valuable contraband. I’m actually glad, because it has replaced heroin in the top spot.” This lesser-of-two-evils view was a common theme during the discussion.

Forum participants suggested ways to overcome these challenges and enhance tobacco control efforts in prisons and jails. These included providing cessation education materials to staff, inmates and families; toll-free quit lines for inmates and staff; and offering and promoting cessation support and education after release.

Perhaps the most profound message from the discussion was its simplest: “Correctional health care practitioners and others need to see tobacco control as an important, high-profile public health issue with the same sort of status as HIV or tuberculosis. Otherwise, it will continue to get the short end of the attention and health care resources.”

NNTPP and NCCHC also conducted a survey to obtain information on tobacco prohibition and availability, policies, cessation programming and resources. “Policy” questions asked whether the facility had a tobacco-free policy, when it was implemented, what it addressed and how strictly it was enforced. “Clinical” questions addressed issues such as how tobacco cessation clinical guidelines were being used and which components were most useful. “Education” questions sought to identify what cessation resources the facility had and what additional resources would be valuable.

After incorporating input from a field test, the survey was sent to the medical directors of 500 facilities accredited by NCCHC.

Surprising Findings
One hundred completed surveys were returned—48 from  jails, 28 from prisons and 26 from juvenile facilities.

The study results produced many surprises. Some of our assumptions, like how many facilities were truly tobacco-free and how seriously facilities take tobacco control, were off. In many facilities, even the term “tobacco-free” is a misnomer.

Tobacco Prohibition and Availability
Since many states mandate that state-owned properties be tobacco-free, we assumed most correctional facilities would prohibit tobacco use on their grounds, with policies to reinforce the prohibition. While more than 77% of respondents reported having “tobacco-free” policies, this term was interpreted in different ways. For example, 79% of the self-described tobacco-free facilities banned tobacco use by inmates, but only 21% extended the ban to staff.

Tobacco use was permitted at 23% of the facilities. Most of these reported that they sell cigarettes, cigars and chewing tobacco, but few allow staff to purchase these products on site.

Tobacco Policies
While 79 facilities reported having a tobacco policy (including 15 that permit tobacco), many of the policies had not been updated for years. This is likely due to the reason for adopting a policy in the first place: Nearly two-thirds of the tobacco-free facilities were mandated by law to adopt their policies.

The estimated compliance rate for staff was higher than that for inmates (81% vs. 71%), but respondents said that the policies are enforced slightly more stringently on inmates than on staff. This supports the view that while facilities must comply with the law, they don’t want to lose employees.

Cessation Programming
One clear message from the survey results was that tobacco cessation is not a priority in correctional health care. Providers believe that other diseases, addictions and ailments are more pressing.

Consistent with this finding, the survey revealed that very little cessation programming occurs in correctional facilities. In fact, more than 80% of respondents said they offer no cessation programming at all. Nicotine replacement and other cessation aids were not commonly used, meaning that most inmates must quit tobacco “cold turkey.”

Interestingly, 63% of the facilities said they assess inmates’ tobacco addictions at intake. With few, if any, cessation aids or programming, it is not surprising that the respondents estimated that 76% to 100% of their inmates who are reincarcerated resumed tobacco use after their previous release.

This highlights the tremendous need for tobacco control programming upon entry, during incarceration, upon release and during parole or probation. Providing health staff with more advance notification of discharges and resource materials designed for the incarcerated population have been reported as ways to close this gap in potential service.

Resources
A surprisingly large number (44%) of study respondents indicated that no resources would help inmates or correctional staff to reduce tobacco usage. Of the 56% who did think that tobacco prevention and cessation was possible, almost all (96%) of the tobacco-permitting and nearly half (49%) of the “tobacco-free” facilities considered educational materials to be important resources.

The survey also asked about the American Medical Association’s standard on tobacco use in correctional institutions. The standard was revised in 2003 to require that smoking be prohibited inside facilities and that there be tobacco prevention and abatement activities. Few facilities reported using the standard, and most that did used the old version.

One resource that received a positive response was direct patient education, viewed as an important strategy for reaching inmates as well as staff. In fact, 60% said that a tobacco education/cessation curriculum would benefit both audiences.

In response, NNTPP and NCCHC have developed a curriculum for educating inmates about the harmful effects of tobacco use and helping them to quit (see box above).

We also are working to establish a standard for developing tobacco-free policies in correctional facilities. This may include adopting recommendations to use clinical practice guidelines for treating tobacco use.

Lessons Learned

Get the Caregivers On Board
The correctional health care community is pessimistic about their ability to make a difference in long-term tobacco usage. Thus, providers first must be convinced that tobacco prevention and cessation are important enough for them to address in their regular work. They are in the best position to influence the cessation programs and other support mechanisms in their facilities. Without the providers and other staff on board, it will be impossible to maximize the effectiveness of any tobacco cessation efforts.

Analyze Policy Language
Knowing that many states mandated that correctional facilities become tobacco- or smoke-free, NCCHC and NNTPP expected that facilities with tobacco-free policies would disallow tobacco use anywhere on the premises. Not so. By asking in detail about tobacco use policies (e.g., what prompted the policy, how long it had been in place, who it applied to), we could identify discrepancies in the definitions of “tobacco-free.” Had we assumed that all participants defined the term in the same way, we would have missed important nuances in the policies.

Education Is a Continuous Process
Most respondents were receptive to starting with a tobacco cessation curriculum. Once they are informed about tobacco control, they will be more likely to complement their knowledge with policy adherence and guideline compliance to increase the consistency and the effectiveness of their policies and programs.

[This article first appeared in the Spring 2005 issue of CorrectCare.]