E-cigarette use in prisons with recently established smokefree policies: a qualitative interview study with people in custody in Scotland

Introduction E-cigarettes were one measure introduced to help people in custody (PiC) to prepare for and cope with implementation of comprehensive smokefree policies in Scottish prisons. Our earlier study explored experiences of vaping when e-cigarettes were first introduced and most participants were dual tobacco and e-cigarette users. Here we present findings of a subsequent study of vaping among a different sample of PiC when use of tobacco was prohibited in prison, and smokefree policy had become the norm. Methods Twenty eight qualitative interviews were conducted with PiC who were current or former users of e-cigarettes in prison, 6-10 months after implementation of a smokefree policy. Data were managed and analysed using the framework approach. Results PiC reported that vaping helped with mandated smoking abstinence. However, findings suggest that some PiC may be susceptible to heavy e-cigarette use potentially as a consequence of high nicotine dependence and situational factors such as e-cigarette product choice and availability in prisons; issues with nicotine delivery; prison regimes; and use of e-cigarettes for managing negative emotions. These factors may act as barriers to cutting down or stopping use of e-cigarettes by PiC who want to make changes due to dissatisfaction with vaping or lack of interest in continued use of nicotine, cost and/or health concerns. Conclusions E-cigarettes helped PiC to cope with smokefree rules, although concerns about e-cigarette efficacy, cost and safety were raised. PiC may desire or benefit both from conventional smoking cessation programmes, and interventions to support reduction, or cessation, of vaping.

Fire Incidents in a Mental Health Setting: Effects of Implementing Smokefree Polices and Permitting the Use of Different Types of E-Cigarettes

Comprehensive smokefree policies in health care settings can have a positive impact on patients’ smoking behaviour, but implementation is impeded by concern that surreptitious smoking may increase fire incidents. We investigated the incidence of routinely reported fire and false alarm incidents in a large mental health organisation in England over an 81-month period when different elements of a smokefree policy were implemented. We used negative binomial regression models to test associations between rates of fire and false alarm incidents and three hospital smokefree policy periods with mutual adjustment for occupied bed days: (1) an indoor policy which allowed disposable e-cigarettes; (2) a comprehensive policy which allowed disposable e-cigarettes; and (3) a comprehensive policy with all e-cigarette types allowed. We identified 90 fires and 200 false alarms. Fires decreased (incidence rate ratio (IRR): 0.35, 95% CI: 0.17–0.72, p = 0.004) and false alarms increased (IRR: 1.67, 95% CI: 1.02–2.76, p = 0.043), each by approximately two-thirds, when all e-cigarette types were allowed, after adjusting for bed occupancy and the comprehensive smokefree policy. Implementation of smokefree policies in mental health care settings that support use of all types of e-cigarettes may reduce fire risks, though measures to minimise effects of e-cigarette vapour on smoke detector systems may be needed to reduce false alarm incidents.

Smokefree policy and medication dispensing for people in prison: interrupted time series analysis

Background Previous evaluations of smokefree prison policies have suggested improvements in self-rated health and some smoking-related symptoms. No studies to date have investigated impacts on medication use as proxy measures of objective ill-health or as indicators of potential negative unintended consequences. These is limited evidence to date on these important outcomes. Methods We obtained from NHS National Services Scotland aggregate data on medication items dispensed in prisons, based on individual named patient medication records, and from the Scottish Prison Service data on the prison population, for the period Jan 2013-Nov 2019. Items of interest comprised those for smoking cessation (varenicline and buproprion); nicotine replacement; specific smoking-related health conditions (glyceryl trinitrate; inhaled bronchodilators and steroids; antibiotics; chloramphenicol eye drops; and proton pump inhibitors and H2 receptor antagonists), and potential unintended mental health consequences (anti-depressants). We also included a set of negative controls for which dispensing was not expected to be affected by the new smokefree policy (anticonvulsants, excluding pregabalin and gabapentin). Analyses were undertaken using AutoRegressive Integrated Moving Average (ARIMA) time series methods, with the dates of the policy's announcement and of implementation included as pre-specified breakpoints. Results The results of ARIMA modelling of medication dispensing are confidential until May 2020 due to their sensitivity and will be available to present at WCPH 2020. Conclusions The use of routinely available dispensing data as an indicator of objective health impacts and potential negative unintended consequences provides novel insights into the effectiveness of smokefree prison policies. Results will be of interest to international jurisdictions considering such policies and to those seeking to harness the potential of administrative data for natural experiments.

How does smokefree policy impact nicotine-related and other prisoner spend (e.g. HFSS foods)?

Background People in custody (PiC) have poor health compared to the general population, in part due to high smoking rates. Scotland's prisons became smokefree in 2018. Rechargeable e-cigarettes became available a few weeks before the removal of tobacco from the 'canteen' (prison shop for PiC). Methods Routinely collected weekly 'canteen' purchase data (no of units of given product purchased by an individual by date) were available for 29-7-18 to 31-3-19 (2112638 rows of data, 645 unique products). Products were categorised into: tobacco; e-cigarettes; food/drink; communication; hygiene; NRT; other and graphed as mean/person/week, for 'smokers' and 'non-smokers' (at baseline). Spend by product type pre- and post-implementation was compared in PiC for 31+ weeks over this period, using mixed effects models. Results Mean weekly spend for 'smokers' in custody for 31+ weeks over the pre-post ban comparison period (n = 2541) decreased from £21.36 to £19.80; mean weekly nicotine-related spend reduced from £6.64 (pre-) to £5.55 (post-) (p < 0.001), but showed an increasing trend in nicotine-related spend (£0.08/week) post-ban. No changes were seen for 'non-smokers' (n = 342) overall) or in nicotine-related spend. Trends in mean spend for other products remained flat, suggesting positive transfers of spend noted in qualitative interviews over a comparable period were not evident at population level. Conclusions Whilst there are benefits of removing tobacco from prisons, for staff and PiC, previously heavy smokers may find (mandated) tobacco abstinence difficult. Some jurisdictions have made e-cigarettes available to support people quitting/managing without tobacco, but long-term implications of e-cigarette use in this population are as yet unknown. When the introduction of smokefree policy is facilitated by the introduction of e-cigarettes, nicotine spend by PiC may remain high; the implications for whether or not PiC return to smoking on release from custody are unclear.

29.A. Workshop: Implementation of smokefree prisons across a national prison estate: experience from Scotland

Objective To present findings from the multi-methods, 3-Phase Tobacco in Prisons (TIPs) study, a comprehensive evaluation of the development, preparation for, implementation and outcomes of smoke free policy across Scotland's prison. Prisons had partial exemption from UK policy banning smoking in enclosed public spaces, and became one of few workplaces with continued exposure to secondhand smoke (SHS). Prison smoking bans have been introduced elsewhere, but evidence of the process and impact of implementing smokefree prisons is sparse. By presenting papers using different methods (objective measurements of SHS; qualitative focus group/interview data, surveys with people in custody and staff; prisoner purchasing data and an economic analysis), the workshop will demonstrate the success of implementing smokefree prison policy and the factors contributing to this success and related outcomes. It will discuss some of the challenging issues and decisions which other jurisdictions may face when considering a smokefree policy. Format The format of the workshop will comprise oral presentations from members of the TIPs research team. This will begin with an overview of a) the rationale for and challenges of implementing smokefree policies in the prison context, and b) the methods used during the three phases of the TIPs study. There will then be presentations on: (i) SHS exposure pre-post ban; (ii) experiences and opinions of staff including the use of e-cigarettes in prisons; (iii) the impact of smokefree policy on prisoner spend in the 'canteen' (prison shop); the impact of smokefree prison policy on medications dispensing; (v) the economic impacts of the smoke-free prison policy. As a study of an entire national prison service. This evaluation of the development, planning, implementation and impact of smokefree policy demonstrates the importance of research evidence for policy implementation, providing new evidence for other jurisdictions contemplating bans on smoking in prisons. Key messages Smokefree prison policy can be successfully implemented with support, partnership working and good communication. Exposure to secondhand smoke in prisons rapidly declines.

Changes in exposure to second-hand smoke following a smoking ban across a national prison system

Background Prisons were one of few workplaces where smoking was still permitted after the smoking ban in indoor public places in Scotland in 2006. This study compares SHS exposure assessments in Scotland's 15 prisons six months after smokefree policy was introduced (in Nov 2018) with levels measured in 2016 before the policy was announced. Methods In 2016, 128,431 mins of PM2.5 (marker of SHS) concentration data were collected from residential halls and 2,860 mins for 'task-based' measures; 2019 figures were 126,777 and 3,073 mins. Six days of fixed-site monitoring in halls in each prison commenced on 22.5.19. Task-based measurements were conducted to assess SHS for specific locations and activities (e.g. cell searches). Typical daily PM2.5 exposure profiles were constructed for the prison service and time-weighted average exposure concentrations were estimated for shift patterns for residential staff pre- and post-implementation of the policy. Staff self-reports of exposure to SHS were gathered via surveys. Results Measured PM2.5 in residential halls declined markedly; median fixed-site concentrations reduced by > 91% compared to baseline. Changes in the task-based measurements (89% average decrease for high-exposure tasks) and time-weighted average concentrations across shifts (>90% decrease across all shifts), provide evidence that staff exposure to SHS has significantly reduced. The percentage of staff reporting no exposure to SHS rose post-ban. Conclusions This is the first study to objectively measure SHS levels before, during and after implementation of smokefree policy across a country's prison system. The dramatic reduction in SHS exposures confirm complementary qualitative data and stakeholder reports of the ban's success in removing tobacco. The findings show that SHS can be effectively eliminated through a well-applied smoking ban in the challenging context of prisons; and are highly relevant for other jurisdictions considering changes to prison smoking rules.

Opinions and experiences of a national smokefree prison policy: evidence from the TIPs study

Background Removal of tobacco from prisons poses distinct challenges, as prisons are 'homes' and smoking rates are high. TIPs is unique in comprehensively studying a smoking ban using data collected before, during and after the ban. This paper presents opinions and experiences of people in custody (PiC) and staff in Scotland, and identifies implementation success factors and lessons that are highly relevant for other jurisdictions and areas of public health. Methods Surveys of staff and PiC (response rates) were conducted in Nov-Dec 2016 (27%, 34%), May-Jul 2018 (31%, 26%) and May-Jul 2019 (16%, 18%), with questions on smoking, smoking cessation/abstinence and smoking restrictions in the prison context. Topics were also explored qualitatively with staff/PiC at similar time points (34 focus groups, 99 interviews). Survey responses were analysed using descriptive statistics and logistic regression analyses. Qualitative data were thematically analysed to identify the diversity of views and experiences. Results Smokefree policy is widely accepted as the new 'norm', but support was higher among staff than PiC before, during and after implementation. Surveys and qualitative data suggest perceptions of some of the potential difficulties (e.g. 'hard to enforce') and negative consequences (e.g. 'cause a lot of trouble') of smokefree policy reduced post implementation. Participants identified several implementation success factors relating to: planning and communication, smoking abstinence/cessation products/services, and partnership working. Conclusions Smokefree prison polices can be successfully implemented, providing the removal of tobacco is well managed and support measures are available for smokers. Some factors shaping the successful introduction of smokefree prisons in Scotland are relevant to other areas of public health transformation e.g. setting clear objectives and timescales; collaboration and teamwork; and involving staff at all levels and end-users.

From Smoking-Permitted to Smokefree Prisons: A 3-Year Evaluation of the Changes in Occupational Exposure to Second-Hand Smoke Across a National Prison System

Objectives Prisons in Scotland were one of the few workplaces exempt from the 2006 comprehensive smoking ban in indoor public places, excluding the prison workforce from the health benefits of smokefree workplaces. The November 2018 introduction of comprehensive restrictions on smoking in Scottish prisons aimed to protect prison staff and people in custody from the harmful impacts of second-hand smoke (SHS) exposure. This study presents SHS exposure data gathered after smokefree policy implementation and compares these with data gathered during and before policy development. Methods Dylos DC1700 monitors were used to measure concentrations of fine particulate matter (PM2.5) derived from SHS across Scotland’s 15 prisons. Six days of fixed-site monitoring (09.00 22 May 2019 to 09.00 28 May 2019) were conducted in residential halls in each prison 6 months post-smokefree policy implementation. Prison staff task-based measurements were conducted to assess concentrations of SHS in various locations (e.g. gyms and workshops) and during specific activities (e.g. cell searches, maintenance, and meal service). Utilizing the fixed-site monitoring data, typical daily PM2.5 exposure profiles were constructed for the prison service and time-weighted average (TWA) exposure concentrations were estimated for the typical shift patterns of residential staff pre- and post-smokefree policy implementation. Staff perceptions of changes to SHS exposure were assessed using online surveys. Results Analysis of both fixed-site and mobile task-based PM2.5 measurements showed the smokefree policy implementation was successful in reducing SHS exposures across the Scottish prison estate. Measured PM2.5 in residential halls declined markedly; median fixed-site concentrations reduced by more than 91% compared with measures in 2016 before policy announcement. The changes in the TWA concentrations across shifts (over 90% decrease across all shifts) and task-based measurements (89% average decrease for high-exposure tasks) provide evidence that prison staff exposure to SHS has significantly reduced. Following smokefree policy implementation, the majority of staff reported no longer being exposed to SHS at work. Conclusions To our knowledge, this is the first comprehensive international study to objectively measure SHS levels before, during, and after implementation of a smokefree policy across a country’s prison system. The findings confirm that such a policy change can be successfully implemented to eliminate occupational exposures to SHS. The results are highly relevant for other jurisdictions considering changes to prison smoking legislation.

Perspectives on smokefree prison policy among people in custody in Scotland

Purpose This paper aims to explore smokefree prison policy, from the perspective of people in custody in Scotland. Design/methodology/approach In total, 77 people in custody in Scotland were interviewed in the period leading up to implementation of a nationwide prison smokefree policy. Data were thematically analysed to identify the diversity of views and experiences. Findings Participants described a widespread awareness in prisons of plans to implement a smokefree policy from 30 November 2018. Opinions about smokefree prisons varied among participants based on perceptions of the fairness, and anticipated positive and negative consequences of removing tobacco from prisons. At the time of the interviews, people in custody were responding to the impending smokefree policy, either by proactively preparing for the smokefree rule change or by deploying avoidance strategies. Participants described opportunities and challenges for implementing smokefree policy in prisons across three main themes: the role of smoking in prison, prison smoking cessation services and motivations for quitting smoking among people in custody. Originality/value This study exploring smokefree prisons from the perspectives of people in custody has several novel features which extend the evidence base. The findings highlight measures for jurisdictions to consider when planning to prohibit smoking in their prisons in the future. These include the need for evidence-based smoking cessation support in advance of smokefree policy, effective communication campaigns, consideration of broader structural determinants of health in prison and ongoing measures to reduce rates of return to smoking post release.

Initial Views and Experiences of Vaping in Prisons: A Qualitative Study With People in Custody Preparing for the Imminent Implementation of Scotland’s Prison Smokefree Policy

Introduction Scotland is one of the few countries in which e-cigarettes were available in prisons before the introduction of a comprehensive national smokefree policy, to assist in its implementation. This qualitative study explores the initial views and experiences of vaping in this specific context, from the perspective of people in custody (prisoners). Aims and Methods Twenty-eight people in custody were interviewed approximately 1–2 months after rechargeable e-cigarettes were made available in prisons and 2–5 weeks before implementation of a smokefree policy. Data were thematically analyzed to identify the range and diversity of views and experiences. Results Participants expressed support for e-cigarettes in preparation for the smokefree policy, describing their symbolic and practical value in this context. Uptake of vaping was strongly influenced by the need for participants to manage without tobacco in the near future. Participants evaluated their initial vaping experiences, either positively or negatively, in relation to the utility of e-cigarettes for mandated smoking abstinence and in providing satisfaction, pleasure, and novelty. Participant views on several issues related to e-cigarette use, both specific to the prison population (product choice and cost) and more generally (safety and long-term use), are explored. Conclusions Our findings suggest possible benefits of e-cigarettes as one means of supporting smokefree policy in a population with many smokers. They also point to potential challenges posed by vaping in prisons and smokefree settings caring for similar populations. There is a need for ongoing measures to maximize the health benefits of smokefree settings and for further research on vaping in situations of enforced abstinence. Implications To our knowledge, no published studies have explored views and experiences of vaping in prison, when rechargeable vapes were new and the removal of tobacco was imminent. The results can inform tobacco control policy choices, planning and implementation in prisons and similar settings. In prison systems that permitting vaping, it is important that other measures (eg, information campaigns and nicotine dependence services) are implemented concurrently to minimize potential risks to the health or personal finances of people in custody.