Title: Evaluating graduated progress towards and impacts of the implementation of indoor smoke free prison facilities in Scotland
Funder: Chief Scientist Office, Scotland

Abstract: Declines in smoking in wider society have not been seen in prisoners. Their high rates of smoking (c75%) partly reflect the socially deprived populations from which they are disproportionately drawn, but many take up or increase smoking when incarcerated. Prisons are one of the few indoor public spaces with partial exemption from UK smokefree legislation, but concerns about exposing staff and prisoners to secondhand smoke (SHS) are mounting. The UK governments are committed to progress towards smokefree prisons, but the persistence of high smoking levels in prisons and the integral place of tobacco in prison life and culture present particular and considerable challenges to the implementation of such policies. Experience from countries with prison smoking bans suggests careful preparation is crucial to successful implementation, but research on process and impact have been sparse to date. We plan a three phase study (in 6 workpackages) allowing a rigorous evaluation of the implementation of any revised prison tobacco strategy in Scotland via before (Phase 1) and after (Phase 3) measures, and formative and process evaluation (Phase 1-2), to inform Scotland’s strategy and address evidence gaps internationally. From this multi-methods research, we will draw out generalisable lessons to inform governments’ implementation of prison smokefree policies, to benefit the health and wellbeing of prisoners, staff, and visitors. Phase 1 will scope the international landscape through published evidence and interviews with key personnel in countries with prison smoke-free policies (WP1). We will establish baseline values for: a) objective measures of SHS (WP2); b) smoking, health indicators and attitudinal data via surveys with staff (WP3) and prisoners (WP4); and c) cultural and social norms, through detailed in-depth interviews/focus groups with staff (WP3) and in-depth interviews with prisoners (WP4). We will also map provision and experiences of smoking cessation services and support from provider/user perspectives (WP5). Data from Phase 1, and subsequent phases, will be fed back to key stakeholders as early as possible to inform ongoing policy and communication strategies (WP6). In Phase 2 we will repeat the staff/prisoner surveys and conduct further qualitative work (WPs3-5) to analyse if and how smoking behaviours, attitudes and cultures are beginning to change in anticipation of implementation of new prison tobacco control policy. We will continue to examine cessation support, services and provision, evaluating the success of attempts from 2015 to harmonise provision of cessation services across prisons and Health Boards (WP5). In this period leading to the implementation of any revised tobacco strategy in prisons in Scotland, we will also explore the impacts of communications about potential smoke-free policies; any changes in regulation, use and sale of electronic cigarettes within prisons; and other events within or outwith the Scottish Prison Service (e.g. media reports of smoke-free policies in pilot prisons in England and Wales). In Phase 3 we will collect outcome data, repeating measurements of SHS (WP2) and smoking and health outcomes in prisoners and staff (WPs 3-4), and evaluate the impact and success of the implementation of an indoor smokefree prison policy and predictors of success or difficulties. An economic model will be developed to examine the short and long term health impacts and costs, and further qualitative research will explore cultural impacts.

Lay abstract: We know that smoking causes many illnesses and earlier death and that even breathing in other people’s smoke (so called ‘secondhand smoke’) can damage your health. The World Health Organisation estimated that secondhand smoke caused 603,000 deaths in 2004. Smoking bans in indoor public places in Scotland in 2006 and in England in 2007 reduced people’s exposure to secondhand smoke. This was important for people working in places where there was a lot of smoking, such as bars. One workplace that was not fully covered by these bans was prisons, because prisons were seen as both ‘home’ for prisoners whilst serving their sentences and ‘workplace’ for prison staff. About three-quarters of prisoners are smokers. This means prisoners are three to four times as likely to smoke as the general population. Very little research has been done on smoking in prison staff. Around the world, for example in New Zealand and the USA, partial or complete smoking bans have been introduced in prisons to protect the health of prisoners and staff. The advice from places where prison smoking bans and restrictions have already been brought in is that it is really important to understand the attitudes and needs of all groups living and working in prisons, including prisoners, prison officers, health workers and so on. It is important to listen to smokers and non-smokers in each of these groups. The Scottish Government wants to make positive steps towards Scotland becoming a smokefree country. They know this will take time to achieve. As one important step towards this they want to work out how more restrictions on smoking in prisons can be introduced in a way that suits most people affected, including providing the right kind of support for prisoners to stop or reduce smoking. This will help prisoners to prepare for life outside prison where smoking is now less common and less accepted. We want to help the Scottish Government do this with research that tells them not just about levels of smoking in prisons, but also what different groups (such as prisoners and staff, smokers and non-smokers) feel are the good and bad things about smoking in prisons, and their views on introducing smokefree prison facilities in the future. This research will collect the information that policy makers require to understand everyone’s needs and points of view, and to assess the balance of costs and benefits for everyone concerned. It will find out how many people are smoking in prisons and measure levels of secondhand smoke in prisons before and after any changes are introduced. This means it will be able to measure changes over time, seeing what happens after support for stopping smoking and restrictions on smoking begin to change. It will feed back the findings about all groups’ points of view so that support for stopping smoking can be provided in the right ways. It will also help Prison Services, Governments and policy makers in other countries to decide how they can best move towards smokefree prisons. The findings will also be published in academic, health and prisons journals and they will be given back to all groups of people who take part in the research. Over the three years of the study, the researchers will feed back useful information to Scottish Government, the NHS and the Scottish Prison Service as quickly as possible so they can understand what information and support people need as they develop new policies, services and rules about smoking in prisons.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;3.2 INTERVENTIONS TO ALTER PHYSICAL AND BIOLOGICAL ENVIRONMENTAL RISKS
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;RESPIRATORY;STROKE