Factors influencing the smoking status of ex-prisoners reintegrating into the community after release: a pilot study

Smoking remains the leading cause of preventable illness and death, and is hugely prevalent among people entering prison. In the most recent prisoner health survey in 2005, 67% of prisoners self-reported as smokers. In 2011, New Zealand became the first country to introduce a nation-wide smokefree prison policy, providing an opportunity to improve the health status of this vulnerable group. A smokefree prison evaluation by the Department of Corrections in August 2012, about a year after the implementation of the smokefree policy, indicated that prisons were indeed smokefree,1 however prisoners’ perspectives have not been investigated, and the proportion who remain smokefree upon release is unknown. Evidence from other countries suggests that prison smoking bans alone are not sufficient to support prisoners to remain smokefree long-term, and most relapse within days or weeks of release.2–4

Our pilot study aimed to provide preliminary data on;

1. the smoking environment within prison,
   
2. factors that influence ex-prisoners’ smoking status,
   
3. how ex-prisoner reintegration programmes could better help ex-prisoners remain or become smokefree.
   

Methods

A short online survey and semi-structured interviews were used to gather data. Participants included 13 clients enrolled in the Salvation Army Reintegration Programme and 10 key informants professionally involved in tobacco control, Corrections, or ex-prisoner reintegration. The clients of the Salvation Army Reintegration Programme completed a short closed-question online survey about their smoking behaviours before, during and after their most recent imprisonment. Subsequently, five clients and 10 key informants took part in a short, semi-structured telephone interview which explored their thoughts and opinions on smokefree prisons, factors that influence smoking post-release and supports available in and out of prison for smoking cessation and relapse prevention. Interviews were transcribed, coded and analysed using a thematic approach.

Results

Our findings suggest tobacco is still present in New Zealand prisons, with four out of the nine clients whose most recent prison sentence was entirely served since 2011 (when smokefree prisons were introduced) reporting they had smoked in prison. Several key informants corroborated this, saying they were aware that some level of tobacco use had continued in prisons despite the ban.

Seven out of 13 clients (54%) reported they were smokers at the time they most recently entered prison. Of these, two were smokefree upon release and had remained smokefree at the time of the survey (1–3 months post-release). A further two were smokefree at release but had since relapsed, despite a stated desire to be smokefree. Three had an ongoing smoking habit before, during and after imprisonment.

Of the six (46%) who were smokefree at the time they most recently entered prison, four had remained smokefree in prison and post-release, but two had become smokers in prison and continued to smoke post-release.

The majority of clients said they wanted to be smokefree, including three out of the seven who were smokers at the time of the survey.

Clients and key informants reported multiple challenges that ex-prisoners face to become or remain smokefree upon release from prison, including inadequate continuity of healthcare between prison and the community, returning to environments in which many friends and whānau smoke, stress of reintegration, and impaired access to smoking cessation support. Staying smokefree during the reintegration process was seen as difficult, and a challenge many were unprepared for: “...I would have thought it [staying smokefree] would be quite a lot easier, as I managed to kick it when I was in prison.” (Client 2)

Discussion

This pilot study suggests that New Zealand prisons continue to be settings for the uptake or continuation of smoking for many prisoners, including those with a stated desire to be smokefree. The smokefree prisons policy seems to be helping some prisoners to quit, but relapse soon after release appears to be common. This is disappointing but unsurprising given the challenges to remaining smokefree highlighted by this study, including reintegration into environments where smoking is the norm and an apparent lack of relapse-prevention support in the pre- and post-release period.

This was a small pilot study, and therefore the findings may not reflect the experiences and views of ex-prisoners or key stakeholders as a whole. A larger survey is needed to provide precise estimates of smoking rates in current and ex-prisoners. Further research on the health needs of ex-prisoners in the post-release period is also needed, along with research to identify the most acceptable and effective smoking cessation and relapse-prevention supports for this population.

Recommendations

We suggest a review of the smokefree prison policy and a reorientation towards prisoners’ long-term smoking cessation goals. Increasing the availability of proven long-term smoking cessation supports, such as NRT, counselling services such as Quitline, behavioural therapy and peer support during imprisonment could help increase quit rates and prevent later relapse. Furthermore, to assist with integration back into society, we suggest providing a ‘discharge pack’ upon release. This could include a supply of NRT to cover the first few weeks of reintegration, as well as smoking cessation and relapse prevention pamphlets and contacts for local stop smoking providers, presented in a way that is culturally appropriate and engaging.

Training for Corrections staff and reintegration programme workers around relapse-prevention, smoking cessation and the available sources of smoking cessation support is recommended. This may help to increase the support available to prisoners in the pre- and post-release period, thus reducing the risk of relapse among those who wish to remain smokefree.

Currently, the primary focus of reintegration programmes is on reducing rates of recidivism. However, we suggest incorporating a focus on health to strengthen these programmes. Reintegration programmes need a whānau ora approach, as they are not only reintegrating the ex-prisoner into the community, but also reuniting the whānau with the ex-prisoner. Enlisting the help and services of marae and other community support groups may help to ensure long-term integration and inclusion of ex-prisoners into their community, which is likely to have positive impacts on both health and recidivism rates. Greater investment in community-based and whanau-focused smokefree initiatives may help ensure that ex-prisoners who want be smokefree return to an environment that supports that aim.

We also suggest action should be taken to bridge the gap between prison and community health services. For example, reintegration programmes or Corrections could organise a free or subsidised GP appointment with a local practice for all ex-prisoners early after release.

Future research should focus on the most effective approaches to helping prisoners to become and remain smokefree while in prison and after their release; how to decrease smoking rate disparities between Māori and non-Māori prisoners and how to improve the health of this high need population more broadly. The last Prisoner Health Survey was conducted in 2005, therefore we suggest this is repeated to get up-to-date data on prisoner health.

There is a real opportunity to work with this vulnerable population, to address their health needs, reduce health inequities and ultimately work towards a smokefree Aotearoa 2025. This study adds to a limited pool of research into prisoner and ex-prisoner health in New Zealand and suggests possible areas of improvement for delivery of programmes for smoking cessation and relapse prevention.

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