Maximising the public health benefits of smokefree prisons: a synopsis from a mixed-methods study

Abstract

Background High levels of smoking amongst people who experience imprisonment contribute to their high mortality and morbidity rates and to inequalities. Scotland’s prisons became smokefree in 2018. However, questions remain about how to prevent high relapse to smoking post-release. Objective(s) •summarise evidence on supporting people to reduce tobacco-related harms post-release; •understand experiences, opportunities, and challenges for reducing tobacco-related harms for people leaving smokefree prisons, and families; •feasibility test a household-targeted intervention to support people released from smokefree prisons to reduce tobacco-related harms; •update cost-effectiveness of smokefree prison policy; •partnership-working with key stakeholders. Design and methods Scoping reviews; qualitative; health economic modelling Setting/participants Prisons in Scotland; staff, people in prison, family members Results Our scoping reviews show that evidence on interventions to support people leaving smokefree prisons to remain tobacco-free is weak. There is no evidence on smoking rates among people released from smokefree prisons allowing vaping. Significant barriers remain for people from underserved communities to create smokefree homes. Our modelling highlights that offering effective smoking cessation support to people leaving smokefree prisons would be cost saving at both the personal and societal level. The challenges people face on release from prison and variability in throughcare support often render smoking relapse prevention a low priority for them, their families and service providers. However, in terms of long-term prevention of ill-health and premature death, the high rates of relapse to smoking (~50-80%) continue to fuel inequalities. Supporting people leaving smokefree prisons to remain abstinent will help governments to achieve ambitions to create smokefree societies. Progress may be achieved by greater integration of support for tobacco-harm reduction with services addressing interconnected needs such as harmful use of other substances and underlying mental ill-health. Limitations The extensive impact of Covid-19 in prisons into 2023, alongside challenges due to overcrowding and staffing pressures, limited opportunities for partnership working and the number of interviews we could conduct. This meant we were unable to test the feasibility of delivering a household-based intervention to reduce tobacco-related harms in this population. Conclusions Progress in developing suitable interventions to prevent very high relapse-to-smoking rates following release from smokefree prisons is required. Helping people released from smokefree prisons to remain abstinent from tobacco post-release could deliver considerable benefits. However, in the face of substantial challenges, preventing relapse to smoking has become entrenched as a low priority – for many service providers, people leaving smokefree prisons and their families. Greater success in reducing tobacco-related harms amongst this often-overlooked population may be achieved through more holistic models of service delivery. Aspirations for countries to become tobacco-free may require a rethink of what is needed to support underserved populations in whom smoking remains entrenched. Future work Further research is required to better understand what approaches are feasible and effective for maintaining smoking abstinence following release from prison, including development and evaluation of integrated/holistic approaches which tackle smoking/vaping behaviours in the context of use of other substances and needs.