Smoking characteristics of community corrections clients

Abstract

Introduction:

While smoking rates are 3–4 times higher among criminal justice populations than in the general population, no studies have previously examined smoking characteristics in a community corrections population.

Methods:

The current study involved descriptive analyses of self-reported survey data from 217 criminal justice supervisees reporting for urine drug screens during a 5-day period at a community corrections facility in the southeastern United States.

Results:

Most participants were current smokers (72.3%), males (65.9%), and Black (50.2%) who reported smoking three fourths of a pack of cigarettes per day and had been smoking for about 15 years. More than half of smokers reported that they would be interested in receiving cessation assistance if free help were available and of these, 60% were interested in pharmacotherapy. White smokers used more cigarettes per day, were more likely to have already tried medication to help them quit smoking, and were also more interested in pharmacotherapies and less interested in behavioral therapies compared with Black smokers. Female smokers did not differ from male smokers on key smoking characteristics, but male smokers were more likely to have tried or regularly used other tobacco products, such as cigars. Female smokers were significantly more likely to report interest in using a pharmacotherapy agent for future cessation, while male smokers reported more interest in nonpharmacotherapy approaches to quit smoking.

Discussion:

Results from this study highlight important differences among smoking groups and may indicate the need to test tailored smoking interventions.

Introduction

Smoking remains the leading cause of mortality and morbidity in the United States, with almost 450,000 deaths annually attributed to smoking (U.S. Department of Health and Human Services, 2008). While smoking has declined from a high of 42.4% in 1965, smoking prevalence has leveled off at about 20% (Centers for Disease Control and Prevention [CDC], 2007a). For special subpopulations, smoking prevalence remains particularly high in the United States and suggests that effective prevention messages and smoking cessation interventions have not reached these populations. For example, 70%–90% of individuals who abuse alcohol and other drugs are cigarette smokers (Bowman & Walsh, 2003; Budney, Higgins, Hughes, & Bickel, 1993; Darke & Hall, 1995; Kalman, 1998; Patten, Martin, & Owen, 1996), while smoking prevalence among individuals with chronic mental illness is about 60.5% (Himelhoch et al., 2004). Prevalence of smoking also varies among different racial groups, with Native American populations having the highest rates of smoking followed by non-Hispanic Whites, Blacks, Hispanics, and Asians (CDC, 2007b). Finally, smoking prevalence is highest among individuals with low educational attainment and who live below the poverty line (CDC, 2007b).

Another subpopulation with a high prevalence smokers are individuals in the correction system. Smoking prevalence is about four times higher in criminal justice populations than in the general population, and smoking is part of the subculture within the correctional environment (Cropsey & Kristeller, 2003, 2005; Cropsey, Eldridge, et al., 2008). Among male and female prisoners, smoking prevalence ranges between 70% and 80%—a fourfold increase compared with smokers in the general population (Conklin, Lincoln, & Tuthill, 2000; Cropsey & Kristeller, 2003, 2005; Cropsey, Eldridge, & Ladner, 2004). Finally, about 70% of juvenile justice adolescents have tried smoking and about half are daily smokers (Cropsey, Linker, & Waite, 2008). However, in contrast to the huge literature focusing on smoking prevalence, prevention, cessation, and policies in other subpopulations, smoking in criminal justice populations remains virtually ignored in the research literature, despite the enormous human, health, and economic costs that occur both in prison and in the community (Awofeso, 2003; Cropsey et al., 2004).

While prisoners represent a group of low-income high-prevalence smokers, institutional responses to smoking have primarily been to ban or limit smoking within the prison systems (Cropsey & Kristeller, 2003, 2005; Kauffman, Ferketice, & Wewers, 2008), with about 90% of prisons prohibiting smoking in medical, chapel, and vocational and educational areas and about 60% banning smoking altogether within the prison gates (Kauffman et al.). Banning cigarettes does not ensure abstinence as 76% of smokers reported some level of smoking at 1 month after the ban (Cropsey & Kristeller, 2005). However, even if prisoners are forced to quit smoking due to smoking bans during incarceration, about 97% relapse within 6 months of release back to the community (Lincoln et al., 2009), suggesting that banning smoking in prison does not result in abstinence upon return to the community.

Community corrections represent the largest population of individuals under criminal justice supervision, with more than 5.1 million people maintained under supervision each year (U.S. Department of Justice, 2007). While states are constitutionally mandated to provide medical services to prisoners (Estelle v. Gamble, 1976), individuals in community corrections are maintained in the community and must access community-available services, even though most are uninsured and fall below the poverty level. Thus, individuals in the community corrections system represent a group of low-income adults who are under criminal justice supervision but are free to smoke in the community without any smoking restrictions other than what is placed on the average citizen. Targeting community corrections clients for smoking cessation services has the potential to reach a large high prevalence population of smokers, and offering these services at the point of criminal justice contact could be an important way to make the services both convenient and attractive. However, before such interventions can be designed or implemented for this population, more information is needed to understand the smoking characteristics of this population. To our knowledge, this survey of smoking behavior was the first conducted with individuals under community corrections supervision. This survey was conducted to characterize smokers who are under community corrections supervision. We were also interested in determining if there were racial and gender differences in the characteristics of smokers under community corrections supervision.

Methods

Participants

Criteria for participation in this study included being 19 years or older (the age of majority in Alabama) and under community criminal justice supervision. Of the 217 participants who completed a survey, 72.3% (N = 157) were current smokers. Participants were young (M = 32.9 ± 9.8), Black (50.2%) or White (48.4%) males (65.9%) with less than high school (15.0%) or high school/GED (45.1%) education. These participant characteristics are similar to the characteristics of individuals who have been under community supervision for the past 5 years (N = 24,373), with most individuals under community supervision at this site being young (M = 31.2 ± 10.6), Black (59.8%) or White (38.6%) males (75.1%) with less than high school (37.1%) or high school/GED (30.7%) level of education (unpublished data). No significant differences were found for smoking prevalence between White and Black smokers (76.9% vs. 70%) or males and females (73.9% vs. 72.6%). About one in five reported previous mental health treatment, while almost half (47.7%) reported previous substance abuse treatment.

Procedures

We surveyed a convenience sample of clients who reported to the community corrections offices for a urine drug screen during a 5-day period in September 2008. This office is the largest Treatment Alternatives for Safer Communities office in Alabama and serves felony offenders in Jefferson County, the largest county in Alabama. Approximately 5,000 individuals who are arrested for felony offenses in the county each year are required to report for community corrections supervision and random urine drug screening. Treatment Alternatives for Safer Communities operates in all 50 states and is a community corrections diversion program designed to maintain individuals with criminal justice involvement in the community preadjudication or postadjudication on probation. These individuals are generally charged with felony drug-related crimes and thefts, and if they do not maintain their requirements to stay in the community (e.g., report regularly, maintain drug-free urine), the terms of their release can be revoked and they can return to jail or prison.

Male and female adult criminal justice clients were asked to complete the anonymous two-page survey when they checked in for their urine drug screening. A cover letter explaining the purpose of the survey and covering the elements of consent was attached to the survey. Locked boxes were placed in the waiting room for participants to return their completed surveys. No financial incentives were used to solicit participation. During that 5-day period, 217 community corrections clients completed the smoking survey. On any given week, approximately 1000 individuals in community corrections report for urine drug screening, giving a response rate of about 22%. The survey included questions about demographic characteristics, history of mental health or substance abuse treatment, smoking status, smoking characteristics (e.g., age of first smoking, number of years smoked, type of cigarette, other tobacco use), as well as smoking cessation history and treatment and interest in future cessation and treatment. This study was approved by the Institutional Review Board of the University of Alabama at Birmingham.

Data analysis

Descriptive analyses were performed using chi-square or t test analysis when appropriate to compare smokers with nonsmokers and ex-smokers. Racial and gender differences were examined by using chi-square or t test procedures between White and Black and male and female smokers, respectively.

Results

Smokers, compared with nonsmokers or ex-smokers, had significantly lower educational attainment (less than high school: 16.8% vs. 10.3%, p < .02) and were more likely to have received mental health (24.2% vs. 11.9%, p < .05) or substance abuse treatment (56.1% vs. 25.4%, p < .001). Table 1 presents the characteristics of smokers. Smokers were generally young when they first tried smoking but progressed to daily smoking by early adulthood. On average, smokers reported smoking about three-fourths of a pack of cigarettes per day (cpd), had smoked almost a pack per day at their heaviest use, and had been a smoker for about 15 years. About one quarter of smokers reported that they were seriously thinking about quitting smoking within the next 30 days, and 60% reported wanting to quit within 6 months. About one third of smokers reported no previous attempts to quit smoking, while 19.7% had made at least one attempt, 18% had made two attempts, and 13.1% reported three previous attempts. Smokers spent an average of $25 on cigarettes per week.

Table 1.

Characteristics of smokers in community corrections (N = 157)

Variable	Smokers
	M (SD)	%
Age, years	32.4 (9.8)
Male		65.8
Race
White		51.0
Black		47.8
Other		1.3
Education
<HS		16.8
HS or GED		49.0
>HS or trade school		34.2
Received mental health treatment (% yes)		24.2
Received substance abuse treatment (% yes)		56.1
Age at first-tried smoking	15.4 (4.2)
Age of daily smoking	18.5 (4.6)
Average cigarettes per day (CPD)	14.0 (9.1)
Highest CPD	18.6 (13.0)
Total years of smoking	14.7 (9.8)
Other tobacco products tried or regularly used
Cigars		39.9
Pipe		10.5
Hookah		9.1
Cigarillos		22.3
Smokeless tobacco		15.0
Number of previous quit attempts	2.1 (3.2)
Interested in receiving a intervention to quit smoking (% yes)		58.7
Type of cessation intervention tried in past (% yes)
Nicotine replacement		21.3
Self-help materials		18.9
Other medication		10.1
Hypnosis		3.9
Psychotherapy		3.1
Thinking about quitting smoking
Within 30 days		24.8
Within 6 months		35.2
No, not considering quitting		40.0
Interventions you are most interested in to help you to quit smoking
Pharmacotherapy		60.5
Other therapy		19.8
Do not know		19.8

Note. HS = high school.

More than half of smokers reported that they would be interested in receiving help to quit smoking if free help were available; almost one quarter reported previous use of nicotine replacement therapy and 10.2% reported use of other medications to help them quit smoking. Of smokers who reported wanting smoking cessation interventions, about 60% would be most interested in trying some form of pharmacotherapy, about 20% would prefer some other type of psychotherapy, while another 20% did not know what type of intervention they would prefer.

While no significant differences were found between racial groups on smoking status, differences were found between Black and White smokers on smoking characteristics (see Table 2). Whites smoked cpd both currently and in the past and were more likely to have received both mental health and substance abuse treatment compared with Black smokers. Furthermore, while no racial differences were found between the groups on interest in receiving an intervention to help with quitting smoking or intentions to quit smoking in 30 days, Whites were more likely to have tried medication in the past to help them quit smoking and were also more interested in pharmacotherapies and less interested in behavioral therapies for smoking cessation compared with Black smokers.

Table 2.

Smoking characteristics between racial and gender groups in community corrections (N = 157)

Variable	White (n = 80), M (SD) or %	Black (n = 77), M (SD) or %	t Test, chi-square	Male (n = 102)a, M (SD) or %	Female (n = 53), M (SD) or %	t Test, chi-square
Age	33.3 (9.2)	31.5 (10.4)	1.31	31.1 (9.6)	34.8 (9.7)	5.1*
White	—	—	—	44.1	66.0	6.7**
Education
<HS	12.7	21.1	4.7	16.0	15.1	4.3
HS or GED	45.6	52.6		55.0	39.6
>HS	41.8	26.3		29.0	45.3
Received mental health treatment (% yes)	35.0	13.0	10.3***	21.6	28.3	0.9
Received substance abuse treatment (% yes)	71.2	40.3	15.3***	56.9	54.7	0.07
Age at first-tried smoking	15.1 (4.4)	15.6 (4.0)	0.49	15.0 (3.6)	15.9 (5.1)	1.3
Age of daily smoking	18.1 (4.7)	18.8 (4.5)	0.67	18.4 (4.1)	18.4 (5.5)	0.01
Average cigarettes per day (CPD)	17.3 (9.0)	10.5 (8.0)	21.1***	14.1 (9.8)	13.8 (8.1)	0.04
Highest CPD	24.3 (12.5)	12.1 (10.2)	37.0***	17.8 (13.0)	19.8 (12.8)	0.72
Total years of smoking	15.7 (8.9)	13.6 (10.7)	1.5	13.9 (10.0)	16.0 (9.6)	1.3
Other tobacco products tried or regularly used
Cigars	43.8	35.6	1.1	46.5	26.9	5.4*
Pipe	15.0	5.5	3.7	16.2	0	9.4**
Hookah	15.0	2.7	6.9**	13.1	1.9	5.1*
Cigarillos	22.5	21.9	0.1	30.3	7.7	10.0**
Smokeless tobacco	25.0	4.1	13.0***	23.2	0	14.3***
Number of previous quit attempts	2.3 (4.2)	2.1 (2.2)	0.2	2.6 (4.0)	1.6 (1.7)	2.3
Interested in receiving a intervention to quit smoking (% yes)	60.9	56.5	0.6	56.4	63.0	3.6
Thinking about quitting smoking
Within 30 days	20.0	30.0	2.6	26.0	23.9	2.0
Within 6 months	33.8	36.7		31.2	43.5
No, not considering quitting	46.2	33.3		42.9	32.6
Type of cessation intervention tried in past
Nicotine replacement	33.3	11.1	7.7**	15.2	32.2	5.2*
Behavioral therapy	1.6	4.8	1.1	3.8	2.2	0.25
Self-help materials	10.9	27.0	5.3*	20.3	17.4	0.15
Medication	18.8	1.6	10.2***	8.9	13.0	0.5
Interventions you are most interested in to help you to quit smoking
Pharmacotherapy	76.7	42.1	10.1**	49.0	77.4	7.5*
Other therapy	11.6	28.9		28.6	6.5
Do not know	11.6	28.9		22.4	16.1

Note. ^aTwo participants did not disclose their gender. HS = high school.

*p < .05; **p < .01; ***p < .001.

Female smokers were significantly older and were more likely to be White compared with male smokers but did not differ on level of education (see Table 2). Female smokers did not differ from male smokers on key smoking characteristics, such as smoking prevalence, average number of cpd, age of smoking initiation, age of daily smoking, number of years of smoking, number of previous quit attempts, or interest in quitting smoking. Male smokers were significantly more likely to have tried or have regularly used other tobacco products compared with female smokers, including cigars, pipe, hookah, cigarillos, and smokeless tobacco. While male and female smokers did not differ on their interest in smoking cessation or intentions to quit within the next 30 days, female smokers were more likely to have used nicotine replacement to help quit in the past compared with male smokers. Female smokers were also significantly more likely to report interest in using a pharmacotherapy agent for future cessation, while male smokers reported more interest in nonpharmacotherapy approaches to quit smoking.

Discussion

This study is the first to our knowledge to describe the characteristics of smokers who are in community corrections, as well as their interest and preferences for smoking cessation interventions. Individuals in community corrections are unique in that they are linked with the criminal justice setting through pending or adjudicated charges but are awaiting trial or serving their sentence in the community and must access community-available medical treatment. Similar to what is found among smokers in institutional correctional settings, individuals in community corrections had a high prevalence of smoking (more than 70%; Conklin et al., 2000; Cropsey et al., 2004, 2008). This suggests that it is not the characteristics of the institutional setting itself (e.g., boredom, access) that increases smoking prevalence among prisoners but likely reflects other similar characteristics between these populations, such as histories of substance abuse, mental illness, poverty, and low educational attainment, all of which are associated with increased prevalence of smoking (Krejci et al., 2003; Novotny, Warner, Kendrick, & Remington, 1988).

The sample for this study was young (average age of 32 years), which is consistent with other reported studies with correctional populations and suggests that the group of individuals under criminal justice supervision are generally young adults (Cropsey and Kristeller, 2003, 2005; Cropsey et al., 2008). This is important, as these individuals may not yet be at an age where the medical effects of their smoking have become apparent. Without clear evidence of disease related to their smoking, this population may have less impetus to seek out cessation services or to quit smoking at this time. However, intervening at this point prior to disease development is an opportunity to maximize healthy years for this high-risk population.

While no differences were found among different racial or gender groups on smoking prevalence or level of smoking cessation interest, differences in preferences for pharmacotherapy versus other therapy were found, with Whites and women more likely to report interest in receiving pharmacotherapy compared with Blacks and men. Whites and women also reported more prior use of pharmacotherapies compared with men and Blacks. Previous studies have noted that racial minorities are less likely to participate in smoking cessation treatment (U.S. Department of Health and Human Services, 1998), and studies that compared racial groups in smoking cessation showed racial differences in the efficacy of pharmacotherapies. For example, in a study using bupropion, nicotine replacement, and counseling, fewer Blacks were able to quit compared with Whites (38% vs. 60%), with an adjusted odds ratio of 0.44, even when controlling for potential moderators (Covey et al., 2008). More recently, racial differences were found between Black and White incarcerated women in smoking cessation using nicotine replacement and group therapy, even when the intervention was delivered onsite with equal access to treatment (Cropsey et al., 2009). Thus, differences in efficacy of pharmacotherapy may partially account for why Black smokers in the general population have lower cessation rates compared with their White counterparts (Covey et al., 2008; U.S. Department of Health and Human Services, 1998).

These differences suggest that the type of intervention offered to these groups may be important and may impact retention and cessation rates. Similar to previous findings, Whites smoked more cigarettes per day and were more likely to use other tobacco products than Blacks (Cropsey et al., 2004), characteristics that would normally suggest more difficulty with quitting smoking. Despite smoking fewer cigarettes, Blacks may have similar exposure and dependence on nicotine and tend to have similar or worse health outcomes from their smoking compared with White smokers (see Fagan, Moolchan, Lawrence, Fernander, & Ponder, 2007, for a review). Unfortunately, few studies have examined racial differences in response to tailored treatment interventions, and the few studies that have examined tailored treatments, only included Blacks (Ahluwalia et al., 2002) with no White comparison group. It remains puzzling as to why Black smokers experience more difficulty with cessation but highlights the importance of further investigation in tailored interventions.

The most notable strength of this study is that it is the first to examine smoking characteristics of individuals under community corrections supervision. Furthermore, this study demonstrated clear differences in past use of pharmacotherapy and preferences for type of cessation treatment between racial and gender groups. This is important as it suggests that cessation treatments may need to be tailored to patient preferences for maximal efficacy. Limitations of this study include relatively small sample size, convenience sampling, and no use of biochemical verification of smoking status or standardized smoking instruments.

Funding

No financial support.

Declaration of Interests

None declared.