Cigarette Smoking as an Expression of Independence and Freedom Among Inmates in a Tobacco-Free Prison in the United States

Abstract

Introduction:

Most adults report initiation of cigarette smoking during adolescence, a time also marked by developmental striving for independence and freedom. Tobacco use may retain its association with independence and/or freedom into adulthood. This association may contribute to continued tobacco use and/or increased risk of relapse to smoking among some individuals. This study examines the relationship between cigarette smoking and perceptions of independence and freedom among inmates in a tobacco-free prison in the northeastern United States.

Methods:

Questionnaires administered to 247 male and female inmates 6 weeks prior to scheduled prison release assessed demographics, smoking history, nicotine dependence, attitudes toward smoking, and plans for tobacco use or abstinence after prison release. Perceptions of smoking as an expression of independence and freedom were measured using 2 items. Smoking was assessed 3 weeks postrelease.

Results:

Constructs of freedom and independence were correlated but did not overlap completely. Both constructs were negatively associated with plans for smoking abstinence after prison release, and with perceived costs of continued smoking. Number of cigarettes smoked postrelease and perception of the pros of smoking were associated with freedom, but not independence.

Conclusions:

Associations of smoking as an expression of freedom and independence may negatively influence plans for renewed smoking after a forced abstinence. Additional research is needed to determine the degree to which these 2 constructs predict smoking behavior and whether they can be used to improve interventions for incarcerated smokers.

INTRODUCTION

In the United States, it has been estimated by the Centers for Disease Control and Prevention (CDC) that approximately 45.3 million adults are current cigarette smokers (CDC, 2011). Among U.S. incarcerated populations, tobacco use is higher than that of the general population (19% of adults), with estimates as high as 80% of incarcerated adults (National Commission on Correctional Health Care, 2001). Nearly 90% of all adult cigarette smokers in the United States report initiating smoking during adolescence (U.S. Department of Health and Human Services, 2012). Some adolescents use cigarette smoking as a rebellion or a means to establish independence and freedom from their parents or other adult authorities (Jackson, 2002). The association between cigarette smoking and rebellion may be expressed as a sense of freedom or independence developed during adolescence and carried into adulthood (Moolchan, Ernst, & Henningfield, 2000).

In American vernacular, the words “freedom” and “independence” tend to be used interchangeably; however, the current study conceptualizes these two constructs as separate and distinct as they may not operate identically. Freedom may be defined as “the absence of necessity, coercion, or constraint in choice of action (Freedom, n.d.),” whereas independence may refer to “liberation from restraint or from the authority of another” (Independence, n.d.). These two constructs were selected to examine in the current study as they were frequently mentioned by inmates in early pilot work and may be particularly salient for individuals who are facing release from a forced-abstinence environment.

Many correctional facilities in the United States have become tobacco free due to growing concerns over the detrimental effects of secondhand smoke and to reduce health-care costs (Kauffman, Ferketich, & Wewers, 2008). As of 2012, 30 states in the United States instituted policies that ban tobacco use inside their correctional facilities with half of those also prohibiting the use of tobacco on outdoor premises for both inmates and staff (Public Health Law Center, 2012). Other countries with similar bans include Canada, the Isle of Man, Australia, New Zealand, and Sweden (Action on Smoking and Health, 2010). The correctional facility in which the current study took place has been tobacco free (e.g., no tobacco products allowed anywhere on premises by inmates or staff) since 2003. Despite this, the majority of inmates resume smoking after incarceration.

We examined the relationship between attitudes toward smoking and perceptions of renewed smoking after prison release as expressive of independence and freedom among inmates before and after release from a tobacco-free prison to understand how these concepts might be related.

METHODS

Participants and Procedures

Data were collected from men and women inmates in a large correctional facility in the northeastern United States as part of a randomized controlled trial to evaluate the effectiveness of a six-session intervention using cognitive behavioral therapy enhanced with motivational interviewing (Clarke et al., 2011). All inmates who met study eligibility (18 years of age or older, smoked at least 10 cigarettes per day prior to incarceration, English speaking) and who were scheduled to be released within 8 weeks of study enrollment were invited to participate in the study. Trained research assistants explained the nature of the study, answered any questions or concerns, and reinforced that participation was completely voluntary and informed consent was obtained from individuals interested in participating. The study was approved by the Memorial Hospital of Rhode Island Institutional Review Board, the Office for Human Research Protections, and the Medical Research Advisory Group at the Rhode Island Department of Corrections.

Measures

After obtaining informed consent, an audio computer-assisted self-interview was used to administer the full assessment battery, which took participants approximately 60min to complete. Questionnaires included demographic characteristics and cigarette smoking history. Nicotine dependence was measured using the Fagerström Test for Nicotine Dependence (FTND), with items modified to reflect back to when the participant was smoking (prior to incarceration). Scores on the FTND range from 0 to 10 with higher scores indicating a greater dependence (Heatherton, Kozlowski, Frecker, & Fagerström, 1991). We also asked participants to report the number of cigarettes per day that they smoked in the month prior to incarceration. Plans to remain cigarette smoking abstinent versus resume smoking after release were measured by a single item using a modified version of the Ladder of Change (Biener & Abrams, 1991). Low scores indicate planning to resume smoking cigarettes after prison release, whereas high scores indicate planning to remain smoking abstinent. Decision making regarding cigarette smoking was assessed using the Decisional Balance Scale (short form), which includes six items on the pros and cons of smoking (Velicer, DiClemente, Prochaska, & Brandenburg, 1985). Independence and freedom associated with smoking were measured using two items (“Having that first cigarette when I get out is a way to express my independence” and “Having that first cigarette when I get out will make me feel like I’m really free or not in prison any more”), which were developed by the research team based upon clinical observations of comments made by participants in prior studies. These items were scored on a 4-point scale (1 = strongly disagree to 4 = strongly agree).

Cigarette smoking outcomes were measured 3 weeks postrelease and included smoking status (smoking vs. quit) and smoking rate as the average number of cigarettes per day during the past 7 days.

Data Analysis

All analyses were performed using IBM SPSS Statistics for Windows, version 20.0. Descriptive statistics (e.g., means, SDs, frequencies) were used to describe sample characteristics including age, gender, race/ethnicity, and educational level, as well as plans to quit and smoking status at 3-week postrelease. Pearson correlation coefficients were calculated to examine the associations between independence, freedom, pros and cons of smoking, nicotine dependence, and plans to remain smoking abstinent. Spearman’s rank-order correlation was calculated to investigate the associations between length of incarceration, independence, and freedom.

RESULTS

Of the 312 inmates screened, 273 were eligible; 262 agreed to participate. Data were excluded from 15 participants (nine due to lost baseline survey data resulting from a computer glitch and six due to not being released from prison). Of the remaining 247 participants, 228 completed the follow-up assessment at 3 weeks.

Approximately 65% of participants were men. Participants ranged in age from 19 to 56 years (M = 35.6; SD = 9.2). About 52% of participants self-identified as White, 20% as Hispanic, 18% as Black, non-Hispanic, and 10% as other or multiracial. Approximately 85% of participants had completed 12^th grade or less, and 15% had education beyond 12^th grade. The mean length of incarceration for the sample was 1.22 years (SD = 1.60 years, range = <1 month to 9 years).

The mean age in which participants began smoking cigarettes daily was 15.7 (SD = 4.5, range 10–30), and the mean number of years of smoking cigarettes prior to incarceration was 19.4 (SD = 10.0, range = <1–48). The mean number of cigarettes per day that participants smoked in the month prior to incarceration was 21.7 (SD = 11.7, range = 2–90). Mean scores on the modified FTND were 5.1 (SD = 2.3), suggesting a moderate nicotine dependence among participants. Plans to resume smoking cigarettes or remain smoking abstinent postrelease, as measured by the modified Ladder of Change, indicated that only 29.2% of participants had definite plans to remain tobacco abstinent after release. Over half of participants (51%) reported that they planned to smoke cigarettes postrelease. No direct smoking cessation support was provided to participants upon postrelease. However, all participants were given a pamphlet on smoking cessation from the American Heart Association, a list of community resources, and the telephone number for a quit line to use after incarceration.

Mean scores on the items measuring the constructs of independence and freedom were 2.1 (SD = 1.1) and 2.4 (SD = 1.2), respectively, with a good distribution across all answer categories (Figure 1). Independence and freedom were positively correlated (r = .669, p < .001). Participants who planned to resume smoking (low scores on the Ladder) were more likely to endorse that their first cigarette upon postrelease would express both independence and freedom compared with participants who planned to remain abstinent after release (high Ladder scores). The perceived benefits of smoking cigarettes (pros) were significantly and positively correlated with endorsement of the first cigarette upon postrelease as expressing freedom (r = .127, p = .048). As participant’s level of the perceived costs of smoking (e.g., health hazards and social disapproval) increased, their endorsement of their first cigarette upon postrelease as expressing both independence and freedom decreased (r = −.184, p = .004). The longer participants were incarcerated the less likely they were to endorse that their first cigarette upon postrelease would serve as an expression of both independence and freedom (r = −.144, p = .030), or just independence separately (r = −.187, p = .005). See Table 1 for details.

Figure 1.

Distribution of scores endorsing smoking as indicators of freedom and independence.

Table 1.

Means, SDs, and Correlations Between Variables of Interest and Independence and Freedom at Baseline and 3-Week Postrelease

	Independence	Freedom	Independence and freedom
Baseline (M and SD)
Total sample (n =247)	2.05 (1.10)	2.38 (1.23)	4.43 (2.12)
Gender
Male (n = 161)	1.97 (1.07)	2.28 (1.22)	4.27 (2.04)
Female (n = 86)	2.19 (1.14)	2.55 (1.24)	4.75 (2.25)
Race
White (n = 128)	2.02 (1.10)	2.24 (1.22)	4.26 (2.16)
All other (n = 119)	2.09 (1.11)	2.53 (1.22)*	4.62 (2.08)
Education
≤12 (n = 206)	2.04 (1.08)	2.42 (1.22)	4.48 (2.08)
>12 (n = 37)	2.03 (1.19)	2.08 (1.26)	4.11 (2.31)
Plans to quit
Low (n = 126)	2.26 (1.44)**	2.64 (1.20)**	4.90 (2.17)**
High (n = 120)	1.81 (.99)	2.09 (1.19)	3.91 (1.94)
Decisional Balance (correlations)
Pros	0.075	0.127*	0.108
Cons	−0.179**	−0.147*	−0.184**
Fagerström Test for Nicotine Dependence	0.027	0.071	0.051
Ladder of Change	0.180*	0.221**	0.216**
Length of incarceration	−0.187**	−0.099	−0.144*
Smoking at 3-week postrelease (M and SD)
Smoking status
Quit (n = 39)	1.9 (1.1)	2.2 (1.3)	4.1 (2.1)
Smoking (n = 208)	2.1 (1.1)	2.4 (1.2)	4.5 (2.1)
Smoking rate	0.082	0.134*	0.117

Note. *p < .05, **p < .01.

At 3 weeks postrelease, 16.2% were abstinent from smoking cigarettes. Among those who returned to smoking, the mean number of cigarettes per day during the past 7 days was 10.5 (SD = 8.9; range = 0–50). The number of cigarettes smoked postrelease and perception of the pros of smoking were significantly associated with freedom (r = .134, p = .057 and r = .127, p = .022, respectively), but not independence.

DISCUSSION

Perceptions of smoking cigarettes as an expression of independence and freedom exist, but the relationships among freedom, independence, and cigarette smoking were more complex than anticipated. On the surface, independence and freedom seem like similar constructs, and they are highly correlated, but our results suggest that they do not operate identically. For instance, we found a significant link between both freedom and independence and the cons of smoking cigarettes on the Decisional Balance Scale; however, the pros scale and number of cigarettes smoked were only significantly associated with freedom (not independence).

The large difference between the mean number of cigarettes smoked per day preincarceration (21.7) and the mean number of cigarettes smoked per day postrelease (10.5) may be reflective of attempts to reduce the number of cigarettes smoked to maintain or improve their health, particularly for participants who received the intervention. It is important to note that assessment of the number of cigarettes per day postrelease was at 3-week follow-up. Thus, another explanation for the wide variation in the number of cigarettes smoked is that some participants may not have had the money to purchase larger numbers of cigarettes within the immediate 3 weeks after release. Prolonged forced abstinence may also increase self-efficacy for quitting or a reduction in habitual cigarette use in the short term. However, since tobacco use may fluctuate over time, it will be important for future research to evaluate the longer term impact.

This study has some limitations. First, data on nicotine dependence were obtained retrospectively since participants were not currently smoking while incarcerated. Consequently, the true relationship between preincarceration levels of nicotine dependence and postrelease smoking may be different than we were able to assess. Second, this study was conducted in a smoke-free prison, and thus, results may not apply to those incarcerated in prisons that allow smoking. Finally, our measures of freedom and independence consisted of only one item for each construct; it may be that a scale with multiple items would more fully assess these variables.

Despite these limitations, a strength of our study is its introduction of freedom and independence as an expression of continued smoking after forced abstinence. Of note, freedom and independence were tested based upon past clinical observations with inmates, and to our knowledge, no other empirical studies have begun to look at these two constructs in relation to cigarette smoking behaviors. Professionals working with inmates to eliminate or reduce their cigarette smoking behaviors might benefit from assessing their perceptions of smoking cigarettes in relation to independence and freedom. For inmates who endorse that their first cigarette upon postrelease would express their independence and/or freedom, it would be important for professionals to explore with inmates how these specific thoughts might encourage renewed smoking after a forced abstinence. Reframing these thoughts as independence and/or freedom from cigarettes and identifying healthier, alternative options to smoking for expressing freedom and independence are two potential strategies that may be useful to professionals in working with inmates around maintenance upon postrelease.

Future research on the constructs of independence and freedom should delineate their potential influence on smoking, continued abstinence, and relapse trajectories. Additional work is also needed to understand cultural influences and the relative importance of these constructs as they pertain to smoking abstinence and relapse within and across different countries. In particular, qualitative work on these constructs is needed to provide greater understanding of these complex relationships and help to generate an item pool to be used in the development of multi-item scales evaluating the constructs of freedom and independence. Furthermore, the development of prerelease and postrelease counseling strategies to address these two constructs might lead to more effective smoking-related interventions for those in correctional environments and facilitate inmates’ continued abstinence from cigarette smoking after prison release.

FUNDING

This study was funded by a grant from the National Institutes of Health (R01 DA024093) to Dr. Clarke.

DECLARATION OF INTERESTS

None declared.