Perceptions and Influences of a State Prison Smoking Ban

Abstract

Prison smoking bans are increasingly common. It is important to consider how those who are incarcerated respond to these bans, and to the subsequent development of contraband tobacco markets. Since there are high rates of smoking in individuals who become incarcerated, along with high rates of chronic illnesses that are exacerbated by smoking, it is critical to examine whether there are health promoting changes in perceptions of and intentions towards smoking and other health behaviors that can be maintained on release to the community. Interviews with incarcerated men experiencing a prison smoking ban revealed their responses to being smoke free, reactions to the presence of contraband smoking, and the influences of this experience on their intentions to smoke following release.

Introduction

There are high rates of incarceration in the United States, and very high rates of cigarette smoking and other health behavior issues in those who become incarcerated (Beck, Bonczar, & Ditton, 2000; Conklin, Lincoln, & Tuthill, 2000; Marrett & Sullivan, 2005; Trosclair et al., 2005; Voglewede & Noel, 2004; Wang & Green, 2010). Individuals who become incarcerated also have higher rates of chronic illnesses that are exacerbated by smoking, such as hypertension (24% among incarcerated vs. 18% in community), diabetes (7.0% vs. 4.8%), and asthma (8.5% vs. 7.8%) (National Commission on Correctional Health Care, 2006).

Concerns regarding disease prevention and health maintenance such as smoking cessation may be less likely to receive attention from these individuals prior to coming to prison and after release, due to multiple personal, social, and structural factors, including mental health issues, substance use, lack of preventive health care, and community norms (Seal et al., 2003). During incarceration, when individuals are receiving health care and are abstinent from drugs and alcohol, they often express great interest in making health behavior changes (Conklin, et al., 2000).

Smoking has historically been a normative part of prison culture (Butler, Richmond, Belcher, Wilhelm, & Wodak, 2007). However, changes in public perceptions of smoking, increased concern over the adverse health effects on both smokers and those exposed to environmental smoke, and fears of litigation by incarcerated people involuntarily exposed to tobacco smoke has prompted correctional authorities to implement tobacco smoking bans (Marrett & Sullivan, 2005).

According to a recent survey (Kauffman, Ferketich, & Wewers, 2008) of 49 state correctional departments and the Federal Bureau of Prisons, 60% of prison systems report having total smoking bans, and 87% don’t allow smoking indoors (Kauffman, et al., 2008). However, smoking cessation programs for those entering prison, or relapse prevention programs for those returning to the community, have not typically accompanied these smoking bans.

There have been few published studies on the effects of smoking bans in prisons and jails. Cropsey and Kristeller (2005) noted that smokers who continued to smoke post-ban were more nicotine dependent, and reported more withdrawal symptoms, even when accounting for dependence and baseline withdrawal scores. Distressed smokers had the highest levels of withdrawal. Additionally, an analysis of intent to smoke upon release from jail found a correlation between future intent to smoke and current desire to smoke (craving), but no relationship to length of incarceration or level of nicotine dependence (Voglewede & Noel, 2004). A group of chronically ill smokers were found to have a relapse rate of 86.3% one month post-release from jail (Lincoln et al., 2009).

Foley, Proescholdbell, Herndon Malek, and Johnson (2010) examined the barriers to and enforcement of smoking bans in two prisons in North Carolina and found consistent, well understood communication of the bans, but significant barriers to compliance and enforcement. Lankenau (2001) points out that smoking bans create a black market for cigarettes, and that this market is influenced by structural factors within each prison. This author (Lankenau, 2001) also found that tobacco smuggling was far more common in minimum security facilities, due to more inmate movement off site (to jobs, etc.) compared to higher security prisons.

Despite the increasing prevalence of smoking bans in prisons and jails, there are few studies exploring how those who are incarcerated experience the bans and the resultant use of contraband tobacco. The Wisconsin Department of Corrections (DOC) implemented a ban on tobacco smoking in state prisons, effective September 1, 2006. This provided an opportunity to conduct open ended interviews with incarcerated men to determine their perspectives of and responses to the ban. This study was conducted within the first year following the ban, and recruitment occurred at a minimum security, all male prison, where there were initially substantial concerns regarding contraband cigarette smoking. We explored men’s perspectives about the impact of the ban on smoking behavior and how incarceration affected their smoking intentions, attitudes, and behaviors.

Methods

Research Setting

Flyers were sent to men within one month of their release dates from a local minimum security prison soliciting participation in a study of cigarette smoking. The first 49 respondents who had smoked prior to incarceration provided informed consent and participated in individual face to face qualitative interviews in a private, unmonitored room within the social services department at the prison (where the men typically met with their attorneys). None of those responding to the flyers refused participation. A research nurse with extensive training in qualitative methods and experience performing research in correctional settings obtained consent and conducted all the interviews.

This minimum security prison has an average census of 600 men, a length of incarceration of approximately twelve months, and the population reflects the state-wide prison composition--either African-American (46%) or White (42%). Most of the men are under the age of 40 (average age 34 years). Over 80 men are released from this facility into the community each month.

Participant Selection

Inclusion criteria were at least 18 years of age; self reported daily tobacco smokers in the three months prior to incarceration; release date within 7–30 days; and ability to provide written informed consent and to verbally communicate in English. Participants were not required to be able to read English, as consent forms were read to the participants who then were asked to repeat their understanding of what was said.

Interview Procedure

The oral interviews were audio recorded with participant knowledge. Tapes were identified by a unique study ID and transcribed. Field notes were kept to record pertinent data. The study interviewer reviewed each transcription, comparing it with the audio recording to ensure its accuracy.

The semi-structured interviews lasted approximately 45 minutes and assessed a range of topics, including attitudes, normative beliefs, and past experiences related to tobacco smoking and cessation; expectations about smoking behavior after release from prison; perceived barriers to and facilitators of sustained abstinence from smoking, including individual, interpersonal, situational, and structural factors; and recommendations for intervention programs to help men abstain from smoking after release from prison. Although the interviews were based on a standardized guide, the interviewer exerted minimal control over the order and structure of the session so as to elicit information that was relevant from the participant’s perspective. Participants were allowed to skip any questions they preferred not to answer. Each received a small stipend, which was deposited into their personal prison accounts.

The study was approved by the Institutional Review Boards at the University of Wisconsin School of Medicine and Public Health, the Medical College of Wisconsin, and the Wisconsin Department of Corrections. In addition, a Federal Certificate of Confidentiality was obtained to ensure that any information participants gave to study staff would be protected from involuntary disclosure.

Qualitative data management and analysis was performed using QSR NVivo software (“QSR NVivo7 Software,” 2006). Data analysis began when interviews and field notes were transcribed. These data were used to identify primary coding categories and themes and to subsequently develop a hierarchical coding framework. When suggested by associations, overlap, or diversions in the data, thematic categories were refined, merged, or subdivided. Relations and associations among categories were interpreted and decision trails documented (Hall & Stevens, 1991; Sandelowski, 1986). This process continued iteratively until thematic saturation was achieved and the organization of the conceptual coding framework was stabilized. A formal codebook was then developed to include themes, illustrative texts, and node addresses (i.e., text location in the database). Next, transcripts were formally content coded by two members of the analytic team. Inter-rater discrepancies were discussed and resolved. New categories and themes that did not appear to fit into the conceptual framework were discussed by the investigative team and modifications were made when deemed appropriate. Data were then summarized.

Results

Forty-nine men were included in the final analysis. This falls within the range recommended by Morse (1994) for this type of data collection in order to achieve saturation and redundancy, a marker of sufficient sample size in qualitative research. Participants ranged in age from 19–60 years (mean 36.7), had 8–19 years of education (mean 12.4) and a sentence length of 9 months to 19 years (mean 2.3 years). The race/ethnicity of the sample was diverse, and representative of the prison’s population (47% African-American, 41% White).

Each participant was asked to tell the interviewer how the smoking ban had affected him, whether he had smoked since the ban, and what had led him to smoke or not smoke following the ban. Each man also was asked whether he intended to smoke on return to the community.

Initial response to becoming ‘smoke free’ during incarceration

Initial responses to being unable to smoke, whether in prison or jail, were described. Many men stated that the unavailability of cigarettes made it easier to cope with not being able to smoke. Several respondents also commented that adapting to the prison smoking ban was not that difficult, since most people transition to prison from a jail, all of which are smoke free in Wisconsin.

If I know I can’t get it, it’s not going to bother me. If I know it’s around me, and I can smell it or something, then it bother me because I know I can get it if I want it…Now I’m locked up in the county jail…and I know ain’t no way…so I’m not going to be mad…And then the first few weeks you’re incarcerated you’re not even thinking about cigarettes. You’d be thinking about how you going to do this time or who going to be by your side…then I ain’t going to have no cravings because I already know I can’t get it.

Only a few mentioned unpleasant effects during initial withdrawal from smoking, describing irritability, fatigue, anxiety, boredom, and restlessness.

Choosing not to smoke contraband cigarettes

Participants gave a variety of reasons for why they chose not to smoke contraband, including the penalties associated with being caught smoking or possessing contraband tobacco; negative perceptions of the behavior of contraband smokers; other negative factors related to contraband; and positive personal changes that had occurred during incarceration.

The penalties associated with possessing or smoking tobacco were referenced as a strong deterrent to smoking after the ban. Penalties mentioned included having one’s release date extended; being denied parole; being “kicked out” of programs (program completion is frequently a requirement for early release); being denied transfer or being transferred to another (higher security) prison; being more likely to face revocation post-release due to conduct reports acquired during incarceration; being sent to “the hole” (segregation); getting a ticket (disciplinary notice); and losing compatible “cellies” due to transfer or stay in segregation.

I seen cigarette and lighters, and I smoked. I was doing some off grounds work, I saw the cigarettes, and instantly it kicked in. I can do for one right now… For like nine months I miss my family…and I smoked. I tried to bring them back to the institution, and I got my release date pushed back six months for that.

And like right when I first got there, I was smoking regularly, but then it got like the COs [correctional officers] were coming down on everybody, and people were getting caught and going to the hole…and I was just like screw it, it’s too big of a hassle, and just quit smoking after that.

Contraband smokers’ behavior reframed the perception of smoking as an “addiction” or uncontrollable compulsion for many: “And some of me just knowing what I’m doing. That I’m going to the extreme…and I’m just not comfortable with myself, wow, the things that you’re doing just for a cigarette.” Said another man:

I see people…and they smoke in here terrible. And I hate to say it, but they are addicted bad. They search for that tobacco…and it brings back like memories of me smoking pot. You can see the addiction personalities in them and how bad that, the brain tells them they need to have it.

Having to rush and hide, rather than relax when smoking, further detracted from the pleasure of smoking, and interfered with its use in emotional regulation: “It’s not as much fun to smoke in here because you’ve got to be sneaky.” Several men also stated that the unsteady supply of tobacco means smokers are in constant withdrawal, compared to those who are consistently abstinent from smoking.

One of the main reasons why I stopped was…due to the incarceration. I’ve seen so many guys, how they reacted towards the cigarettes…it became like a drug thing to these guys, like how a fiend fiends for something they really need. And I was like I can’t become a zombie like this.

Other negative aspects of contraband cigarettes or smoking were mentioned. Some men commented on the divisiveness of smokers versus non smokers:

Down here you see a group of smokers…and you’ve got the non-smokers. And the non-smokers don’t like it, but they don’t say anything. So you really got two different, three different groups of people, and…you’ve got all the other stuff, the race issues, the gang issues, and so that just divides people even more.

Others mentioned the high cost of obtaining contraband cigarettes and their inferior quality (loose tobacco rolled into whatever paper is available). Some men said the use of hand-rolled, contraband cigarettes led to yellow stained fingers, bringing to mind a negative image of similarly discolored lungs. The smell of contraband cigarettes also was considered unpleasant. One man commented on the mode of smuggling cigarettes into the prison: “And you couldn’t smoke, but people were still sneaking in roll up cigarettes. And I really didn’t like ass cigarettes, as I call them.” Respondents also mentioned that smokers often share a single cigarette, which is sometimes perceived as a communicable disease transmission risk.

Some men observed that the enforced abstinence from smoking due to incarceration actually allowed them a choice in relation to future smoking behavior, since a true choice depended on being free of a habit or dependence on nicotine. Others commented on physical, mental, or spiritual health changes that had occurred in prison as important influences on their choice to abstain from contraband and their intent to not resume smoking on release. Several referred to the effects of diagnoses (during prison intake) of health problems that could be exacerbated by smoking:

I have high cholesterol. Now I found that out. So… the nurses and doctors…would be telling me that smoking would… increase my risk of heart disease.. I don’t, pray to God I don’t have a heart attack…and don’t want to be doing something that’s going to increase my chances …

Health behavior changes such as regularly exercising or newly embraced spiritual practices that had occurred during incarceration made smoking seem contrary to a new way of life; enhanced emotional coping skills acquired during incarceration made smoking no longer necessary; abstinence from other substances of abuse gave some a new perspective; and other “new me” identities adopted, such as wanting to be a good example for children, were all considered to have changed participants’ motivation to smoke while incarcerated and after release.

It’s just like cigarettes, they calm me down. So when…I didn’t have all the stress…I didn’t feel like shooting nobody. In here, lifting weights, it’s like the same thing for me. I lift weights, I don’t feel like knocking one of these guys out.

I started going to church a lot…I found out that my body is also a temple…I’m supposed to keep my body clean and free of all the impurities. So… smoking would be against my religion now.

My time was dead time before this. I’ve made it worth something… I’ve got my HSED [High School Equivalence Degree] now…I’ve learned the working out thing…So to just get out and smoke…I’m smarter than that; it’d be useless.

Choosing to smoke contraband cigarettes

Those who chose to smoke contraband almost universally spoke of it in terms of defiance or rebellion:

I get off on it, knowing that I’m breaking the rules and not getting caught… It’s like a rush to get done smoking before that guard comes up the stairs and catches you.

Defiance. That’s a big one with me. I won’t even lie. Defiance. You can’t tell me what to do. Everything else is small and mediocre compared to it.

These individuals reported unanimous intent to continue smoking upon release to the community.

Well, I smoke less, but I still smoke. It really didn’t affect nothing…like this incarceration, they’re going to be feeding me until (release date), and I already had it planned, as soon as I get out, I’m going to buy me a pack. I’m talking about as soon as they drop me off at the bus station… So this ain’t nothing but feeding me to continue when I get out.

Other reasons stated for illicit smoking were boredom (“In here I smoke just because it’s something to do…but on the street, I didn’t smoke at all.”), isolation, or stress:

Being stressed from being close to home, you know, not having people doing what they supposed to be doing for you… I’m really alone right now… I’m so used to being, on the streets, I have everything I want. I spoil myself this and that. But in here… It’s like a baby or something that can’t feed they self… I want things, I can’t get them, so I just say, fuck it, I’ll smoke a cigarette just to keep my mind off of it because I know I can’t get what I want.

Correctional officers and the smoking ban

Participants commented on tobacco use by correctional officers post ban, as well as attitudes of officers towards contraband smoking, and how staff attitudes affect smoking by men who are incarcerated. Several individuals mentioned that illicit smoking by some of those incarcerated brings unwanted attention by officers to others in the unit who aren’t smoking. There was also discussion of some staff being more tolerant of smoking by inmates, making this practice more common during their shifts. One person believed the ban on staff smoking made them “ornery” and more likely to write tickets (conduct reports). In addition, staff considered more “difficult” were thought to trigger more smoking during their shifts.

You see…COs [Correctional Officers] walking around with a big old dip in their mouths, or you smell smoke on them, you know they just in from outside smoking, or they shut their office door…they smoke in the bathroom. You’re like, they made this a law for all of us…not just for the inmates…so we wouldn’t…get treated unfairly. But yet here you’re yelling at me because I smell like smoke, and you got dip in your mouth. I’m going upstairs smoking another cigarette as soon as you walk downstairs, because you ain’t going to tell me I can’t do it.

Smoking upon release

In discussing a return to the community where smoking would again be possible, participants reflected on society’s changes towards smoking since they’d been incarcerated. The increased cost of tobacco, restrictions on smoking in public accommodations, and the stigma of smoking were mentioned. Others indicated a resolve to abstain from smoking in order to be a good role model:

I don’t want to smoke around my son…out there. I’m going to be around him, and that’s going to be a big thing…so I don’t want to bring that same influence on him, he’s going to grow up to be a smoker and stuff like that, worry about his health…Hopefully I can just be a positive influence all the way around…I haven’t been there in the last three years…I don’t want to bring no negativity,…and smoking is negative to me.

Some feared an unwanted relapse to smoking on release, associated with the stress of a return to the community (finding a job, staying out of trouble, housing, finances, etc.). A few men commented that smoking was a gateway that had led them to prison in the past, or would lead to their return to prison in the future if they were to relapse: In contrast, other men described smoking as a legal activity versus other forms of illegal substance use that would lead to reincarceration: “The only reason I would stop smoking weed is because I ain’t going to come back to jail for no dirty UA [urinalysis]…but cigarettes is cool, you know. You ain’t, it’s not illegal. If it was illegal, I wouldn’t do it.” Others felt that smoking was part of their identity:

Honestly, I can sit here and think about my life 5 or 10 years from now and I can imagine myself having a cigarette…I’ve sat here and had those visions of myself still smoking in the future, knowing what it’s doing to me.

I’d feel weird when I got out on the streets if I didn’t smoke. I wouldn’t know…like who I am…and I’d feel different.

Discussion

Most people entering U.S. prisons are smokers, and this group has relatively high rates of smoking related health problems (NCCHC, 2006). Recently, many prisons have implemented smoking bans, but almost none have relapse prevention programs to help maintain abstinence post-release (Kauffman, et al., 2008). In this qualitative study we interviewed incarcerated men experiencing a smoking ban to explore their responses to the ban, to the presence of contraband smoking, and the influences of this experience on their intentions to smoke following release.

Prior to widespread implementation of prison smoking bans there were predictions that they would have little long term benefit, as incarcerated people would immediately resume smoking on release (Butler, et al., 2007). Although there are studies reporting high rates of relapse on release from jail (Lincoln, et al., 2009) where incarceration is short term, length of stay in prison is generally one or more years, which may lead more people to remain smoke-free after release (Thibodeau, Jorenby, Seal, Kim, & Sosman, 2010). Many of the participants in these interviews came to view the smoking ban in a positive, or neutral, light. Multiple reasons were cited for not smoking, despite the availability of contraband tobacco. Those who continued to smoke post ban stated they did so mainly out of a sense of rebellion.

Participants had strong responses to contraband smoking, either positive or negative. The availability of contraband tobacco led some participants to adopt a more negative perception of smoking, based on an evaluation of contraband smokers as “addicts” and lacking in self control. Since contraband smoking occurred covertly and was rushed, many of the functions of smoking in the community were lost. For example, in the absence of using smoking for emotional regulation, individuals turned to exercise, spiritual practices or other, healthier techniques for emotional coping. They expressed pride and increases in self efficacy as a result, along with an intent to carry these behaviors into the community on release. This is not entirely surprising as many individuals who are incarcerated have a genuine desire to make positive changes in their lives in response to the experience (Conklin, et al., 2000).

There are limitations to this study. Social desirability may have influenced participant responses to the in-person interview. Because the interviews occurred within the prison setting, individuals may have been reluctant to fully disclose behavior that was prohibited. The use of a self selected sample (those who responded to a flyer) may have led to self exclusion of those with viewpoints not described here. However, the fact that many of the participants openly discussed contraband smoking and their own participation in it makes these limitations unlikely to be significant. The use of a private room where incarcerated individuals typically met with their lawyers likely allowed the men to more freely express their perspectives.

Because this study occurred in a minimum security facility within the first year the smoking ban was implemented, results may be a reflection of this environment. Contraband tobacco is generally more difficult to obtain in higher security settings (Lankenau, 2001), and even within the study facility contraband tobacco has become more difficult to obtain over time, according to formerly incarcerated individuals (personal conversation, February 7, 2010). Transfers to and from other institutions are common in a minimum security prison, and participants discussed their experiences in other smoke free jails and prisons during interviews. They stated that contraband is more or less difficult to obtain in various settings, but no differences in response were expressed. It would be interesting to study this issue further.

It appeared there were distinct groups of smokers: Those who smoked out of a sense of rebellion and who intended to smoke on release; those who abstained from contraband, considered themselves quitters, and intended to be smoke free on return to the community; and those who may or may not be contraband smoking and who are unsure of whether they will stay smoke free on release. Of this last group, most stated they would like to be smoke free after release, but were unsure if they would be able to do so.

Time spent in prison may have a significant impact on future smoking intent and behavior. A prison sentence is typically a year or more in length, a sufficient time period to be past physiologic dependence on nicotine if one abstains from contraband smoking. Incarcerated people may receive diagnosis and treatment of smoking related health conditions for the first time while imprisoned. Incarceration is often a time when people are (relatively) substance free and can be open to making positive changes in health behavior. The time of release is, therefore, an ideal time to implement a relapse prevention intervention to support those who wish to stay smoke free in the community.

These results provide useful contextual information for guiding the design of this type of intervention. Maintaining or increasing a sense of control related to the desire to stay quit, and a perception of choice, are likely to resonate with many individuals. Education tailored to each person’s health problems and how smoking affects this might be incorporated. Anticipatory planning to continue behaviors such as exercising and spiritual practice upon return to the community and reinforcing acquired emotional coping skills would utilize the themes these men discussed.