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. Author manuscript; available in PMC: 2016 Dec 19.
Published in final edited form as: J Correct Health Care. 2016 Apr;22(2):146–156. doi: 10.1177/1078345816635187

Goals and Plans of Incarcerated Men Postrelease

Jacob J van den Berg 1, Beth C Bock 2, Mary B Roberts 3, Donna R Parker 4, Rosemarie A Martin 5, L A R Stein 6, Jennifer G Clarke 3
PMCID: PMC5166713  NIHMSID: NIHMS833575  PMID: 26984138

Abstract

Prior research has not examined the self-identified goals and plans of incarcerated people as they approach release from prison. This study analyzed the goals and plans generated during a motivational interviewing counseling session of incarcerated men who participated in a randomized controlled trial of a smoking abstinence intervention in a tobacco-free prison in the northeastern United States. Using thematic analysis, 53 written goals and plans were independently coded by trained research assistants to identify major themes that included (1) staying smoke-free or reducing the number of cigarettes smoked postrelease, (2) engaging in physical activities to improve health and wellness, and (3) spending time with family and/or friends. Implications for working with inmates to identify their plans and goals to remain smoke-free after incarceration are discussed.

Keywords: plans, goals, incarcerated males, healthy behaviors, smoking abstinence

Introduction

Reducing the prevalence of cigarette smoking to less than 12% is one of the national health objectives for 2020 (U.S. Department of Health and Human Services, 2010). Effective smoking cessation and abstinence programs focusing on incarcerated populations are needed to reach this goal, as approximately 9 million people pass through correctional facilities annually throughout the United States (Centers for Disease Control and Prevention [CDC], 2006). Incarcerated people are approximately 3 times more likely to smoke cigarettes than the general population in the United States, and it has been estimated that one in eight cigarette smokers pass through a prison or jail in America every year (CDC, 2006; Lincoln et al., 2009).

Many U.S. jails and prisons have successfully implemented smoking bans, and there is general support by correctional staff for these bans (Carpenter, Hughes, Solomon, & Powell, 2001; Chavez et al., 2005). Health, security, and legality issues have all been identified as reasons for enforcing smoke-free correctional environments (Public Health Law Center, 2012). Despite prolonged periods of forced abstinence, many cigarette smokers need interventions to decrease relapse postincarceration, especially since the majority return to smoking after release from prison (Lincoln et al., 2009). Motivational interventions have been identified as being particularly effective in helping those who are incarcerated to decrease relapse to smoking after forced abstinence (Clarke et al., 2011, 2013).

Motivational interviewing (MI) is an empirically supported method that draws upon an individual’s intrinsic motivation for and commitment to behavior change (Miller & Rollnick, 1991, 2002). MI focuses on exploring and resolving the individual’s ambivalence to facilitate behavior change that is congruent with the person’s values and concerns (Miller & Rollnick, 2009). Three key elements of MI are that it encourages (1) collaboration rather than confrontation to build rapport and facilitate trust in the helping relationship, (2) evocation rather than imposition to draw out the individual’s motivations and skills for behavior change, and (3) autonomy rather than authority to empower the individual to take responsibility and action for behavior change (Rollnick, Miller, & Butler, 2008). Building on these key elements and guiding the practice of MI are four distinct principles that include expressing empathy through respectful listening, developing discrepancy between the present behavior and his or her broader goals and objectives, rolling with resistance to avoid arguing with the individual regarding the need to change, and supporting self-efficacy in his or her ability to carry out and succeed with the specific task (Miller & Rollnick, 2002).

MI is based on personalized feedback that is given to an individual, which in the present study included perceived and real health consequences associated with cigarette smoking and perceived reduction of health risks when quitting smoking. For individuals who lack motivation to remain smoking abstinent after release from prison, more time is spent on exploring motivation for staying abstinent and on creating cognitive dissonance regarding reinitiating cigarette smoking. For more motivated cigarette smokers, additional time is spent on goal setting and discussing strategies to remain tobacco-free postrelease. MI had not been previously used as a treatment for nicotine addiction with the prison inmates who participated in the current study.

This study draws from a randomized controlled trial (RCT) called “Project WISE” (Working Inside for Smoking Elimination) that evaluated the effectiveness of a six-session intervention to increase sustained tobacco abstinence after release from incarceration using cognitive–behavioral therapy (CBT) enhanced with MI in comparison to a general wellness video control condition among prisoners (Clarke et al., 2011, 2013). CBT is a therapeutic approach that works by changing negative patterns of thinking and by solving concrete problems through brief sessions in which a therapist helps a client challenge negative thoughts, consider alternative perspectives, and take effective actions. CBT was included in the intervention since it is an efficacious, extensively studied therapy that has been effective in promoting smoking cessation in diverse populations of smokers (Abrams, Leslie, Mermelstein, Kobus, & Clayton, 2003; Lancaster & Stead, 2008; Vidrine, Cofta-Woerpel, Daza, Wright, & Wetter, 2006).

CBT has shown promise in treating substance abuse (Covi, Hess, Schroeder, & Preston, 2002; Epstein, Hawkins, Covi, Umbricht, & Preston, 2003; Garrett, 1985; Vedel, Emmelkamp, & Schippers, 2008; Weinberg, Rahdert, Colliver, & Glantz, 1998), but skills training approaches may not be appropriate for substance users who are not seeking treatment. Skills training assumes interest and readiness to change; however, substance-abusing adults frequently do not express their interest or desire to alter their behaviors (Melnick, De Leon, Hawke, Jainchill, & Kressel, 1997; Prochaska et al., 1994). Heather, Rollnick, Bell, and Richmond (1996) randomly assigned adult heavy drinkers in a hospital setting to MI or brief skills-based counseling. After 6-month follow-up, participants who were relatively unmotivated to change showed greater reductions in alcohol consumption if they had received MI as compared to brief skills-based counseling. These data indicate that unmotivated people benefit from MI. Thus, MI as a precursor to CBT may benefit people in motivation. Indeed, past research suggests that smoking treatments increase motivation followed by CBT components (Milton, Maule, Backinger, & Gregory, 2003; Myers, 1999; Wagner & Waldron, 2001), but this had not been tested in an RCT in the jail or prison settings prior to Project WISE.

Complete details on the main outcomes of the overall RCT have been published elsewhere (Clarke et al., 2013). In brief, 25% of participants in the intervention group and 7% of participants in the control group were smoke-free at 3 weeks postrelease. Furthermore, participants in the intervention group were 6.6 times more likely to remain smoking abstinent than those participants in the control group at 3 weeks postrelease. At the 3-month follow-up, 12% of participants in the intervention group and 2% of participants in the control group were cigarette smoking abstinent. The purpose of the current study was to (1) examine the written goals and plans that were generated during an MI counseling session by a group of male inmates who participated in the RCT, who we refer to as “planners,” and (2) determine whether there were any differences in demographics, cigarette smoking history, and cigarette smoking outcomes between those who were planners, those in the treatment group who did not complete a goals and plans document, who we refer to as the “nonplanners,” and those in the control group at baseline and 3-week follow-up.

Method

Participants and Procedures

Data were collected from male inmates in a large correctional facility in the northeastern United States as part of an RCT (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 scheduled to be released within 8 weeks of study enrollment) were invited to participate. Trained research assistants (RAs) explained the nature of the study, answered any questions or concerns, and reinforced that participation was completely voluntary. Written informed consent was then obtained from inmates interested in participating. The study was reviewed and 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. A certificate of confidentiality was obtained to provide participants with additional protections. At the end of the study, all participants were given a smoking cessation pamphlet from the American Heart Association, a list of local community resources for smoking abstinence, and a quit line telephone number for them to use after incarceration if needed.

Measures

At baseline, participants completed a full assessment battery using an audio computer-assisted self-interview, which took approximately 60 minutes to complete. The assessment battery included questions on demographic characteristics (e.g., age, race/ethnicity, educational level, and living situation prior to incarceration) and cigarette smoking history (e.g., age started smoking and number of cigarettes smoked prior to incarceration). The 6-item short form of the Decisional Balance Scale was also included to assess the pros and cons of smoking (Velicer, DiClemente, Prochaska, & Brandenburg, 1985). A modified version of the Fagerström Test for Nicotine Dependence (FTND) was used to evaluate nicotine dependence prior to incarceration, with higher scores (range = 0 to 10) indicative of greater dependency (Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991). Readiness, confidence, and motivation to remain tobacco-free following release from prison were measured with a single item for each construct rated on a scale from 1 to 10 (1 = not at all and 10 = extremely). To evaluate plans to remain abstinent after release, participants were asked to rate on a scale from 1 to 6 (1 = I plan to smoke when I get out of here and I will never plan to quit to 6 = I have made plans to not smoke when I get out and I will never smoke again) the following statement: “Which one statement best describes your plans for smoking?”

During the last intervention session (Session 6), which was approximately 1 week before release, inmates in the active arm of the RCT participated in an MI counseling session. During this motivational counseling session, participants were encouraged to complete a document in order to identify and write down their goals and plans that they anticipated engaging in postrelease (see Figure 1). Participants could refuse to complete a goals and plans document without any consequences. For those participants who chose to complete the document, goals and plans could be related to cigarette smoking or staying quit after release, but they could also be associated with any other areas of their life, such as healthy eating habits, weight loss, or reconnecting with family members and friends. This gave participants the opportunity to pick goals and make plans that were important to them that might not be related to smoking abstinence after release. Participants were first asked to identify and write down one or more goals, to specify the date(s) that they planned to take steps to achieve the goal(s), and to set a target date for attempting to complete these goals/plans. Participants were then asked to identify and write down (a) reasons for action(s), (b) specific steps they planned to take and the people who they believed would be supportive of them, (c) reasons why they thought the goal(s) were attainable, (d) potential barriers and solutions to those barriers, and (e) rewards upon successful attainment of goal(s). A copy of their personalized goals and plans document was given to participants who completed one at the conclusion of the intervention so that they could refer to them after release.

Figure 1.

Figure 1

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Goals and Plans Worksheet.

After prison release, the study RAs contacted participants by phone to conduct a 3-week follow-up assessment. Participants who reported cigarette smoking abstinence of at least 7 days were invited to come in to provide a urine sample to test for cotinine. Cigarette smoking outcomes at 3-week follow-up were assessed as 7-day point prevalence abstinence, days to first cigarette smoked after release, and the average number of cigarettes smoked per day (rate) during the past 7 days.

Data Analysis

IBM SPSS Statistics for Windows, Version 20.0, was used to calculate descriptive statistics (e.g., frequencies, means, and standard deviations) for demographics, cigarette smoking history, and cigarette smoking outcomes at baseline and 3-week follow-up for planners, nonplanners, and control. Significant differences between the groups were set at p < .05. Two trained RAs independently coded each of the goals and plans documents that were completed by participants. The RAs then compared the coded documents to resolve any discrepancies prior to entry into NVivo 9, which was used to facilitate data management and analysis. Entered codes were reviewed in aggregate for thematic analysis to identify major themes (Braun & Clarke, 2006).

Results

A total of 312 inmates were screened during the RCT, with 273 meeting study eligibility and 262 agreeing to participate and completing written informed consent. Out of the 262 participants who enrolled in the RCT, 161 were males with 81 in the control condition and 80 in the treatment condition. Of the 80 in the treatment arm, 53 completed a goals and plans document and 27 did not.

Demographics, cigarette smoking history, and cigarette smoking outcomes are summarized for all three groups (planners, nonplanners, and control) in Table 1. Of particular note, the majority of participants who completed a goals and plans document (planners) reported having less than a high school education (75.5%) and reported living in a stable housing environment prior to incarceration (78.4%); 49.1% self-identified as White. The mean age of the sample who were planners was 33.7 years old (SD = 8.9) and the mean age in which these participants reported that they started to smoke cigarettes was 15.7 years old (SD = 5.0). The number of cigarettes that they smoked prior to incarceration averaged 22.75 (SD = 12.38). In addition, their mean scores for the pros of smoking were 2.94 (SD = 1.11) and cons of smoking were 3.31 (SD = 0.90). Scores on the FTND to measure nicotine dependence averaged 5.56 (SD = 2.20). Mean scores on the variables to assess planners’ confidence, readiness, and motivation to remain quit after incarceration were 5.86 (SD = 2.83), 7.20 (SD = 2.59), and 7.11 (SD = 2.64), respectively. Over half of them (52.8%) indicated that they planned to remain abstinent postrelease. There were no significant differences in demographics and cigarette smoking history between those who were planners, nonplanners, and control at baseline.

Table 1.

Means, Standard Deviations, and Frequencies Examining Differences in Demographics, Cigarette Smoking History, and Cigarette Smoking Outcomes Between Planners (n = 53), Nonplanners (n = 27), and Control (n = 81) at Baseline and 3-Week Follow-Up.

Characteristic Planners Nonplanners Control Group
p-Value		 Planners vs.
Nonplanners
p Value
Demographics M (SD) or N (%) M (SD) or N (%) M (SD) or N (%)
  Age 33.7 (8.9) 34.1 (9.7) 33.3 (8.5) .905 .857
  Race/ethnicity
    White 26 (49.1%) 12 (44.4%) 41 (51.9%) .508 .344
    Hispanic 10 (18.9%) 8 (29.6%) 14 (17.7%)
    Black 9 (17.0%) 6 (22.2%) 18 (22.8%)
    Other 8 (15.1%) 1 (3.7%) 6 (7.6%)
  Education
    < High school 40 (75.5%) 17 (63.0%) 54 (69.2%) 0.737 .427
    High school 8 (15.1%) 5 (18.5%) 15 (19.2%)
    > High school 5 (9.4%) 5 (18.5%) 9 (11.5%)
  Living situation
    Stable 40 (78.4%) 21 (77.8%) 55 (70.5%) .545 .947
    Unstable 11 (21.6%) 6 (22.2%) 23 (29.5%)
Cigarette smoking history
  Age started to smoke
  cigarettes		 15.7 (5.0) 15.4 (4.1) 15.4 (3.3) .909 .875
  # of cigarettes smoked
  preincarceration		 22.75 (12.38) 18.00 (8.41) 23.63 (13.34) .121 .077
  Decisional balance
    Pros 2.94 (1.11) 3.22 (0.89) 3.35 (0.68) .148 .261
    Cons 3.31 (0.90) 3.44 (0.63) 3.35 (0.75) .765 .483
  FTND 5.56 (2.20) 4.64 (2.22) 5.23 (2.37) .263 .092
  Remain tobacco-free postrelease
    Confidence 5.86 (2.83) 5.59 (2.63) 5.85 (2.56) .916 .659
    Readiness 7.20 (2.59) 6.91 (2.47) 6.91 (2.76) .839 .707
    Motivation 7.11 (2.64) 6.41 (2.81) 6.62 (2.75) .539 .321
  Plans to remain abstinent
    Low 25 (47.2) 10 (37.0) 33 (40.7) .637 .388
    High 28 (52.8) 17 (63.0) 48 (59.3)
Cigarette smoking outcomes
  3-Week follow-up smoking
  status
    Smoking 39 (73.6) 21 (77.8) 75 (92.6) .01** .682
    Quit 14 (26.4) 6 (22.2) 6 (7.4)
  Days to first cigarette
  postrelease		 9.5 (9.7) 8.1 (9.8) 5.7 (8.4) .04* .564
  Average # cigarettes per day
  (rate) during past 7 days		 4.53 (5.84) 6.22 (6.53) 8.54 (7.42) .01** .282
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Note. FTND = Fagerström Test for Nicotine Dependence; Group p value = differences between planners, nonplanners, and control.

*

p < .05.

**

p < .01.

Significant differences in cigarette smoking outcomes were found between those who were planners, nonplanners, and control at 3-week follow-up. In comparison to those who were nonplanners or in the control condition, planners had a greater likelihood of remaining quit at 3 weeks postrelease (M = 14, SD = 26.4), and if smoking, tended to have a higher number of days abstinent before smoking their first cigarette (M = 9.5, SD = 9.7) and a lower number of cigarettes smoked at 3 weeks postrelease (M = 4.53, SD = 5.84). However, when examining treatment group versus control group, the differences in 3-week cigarette smoking outcomes are no longer statistically significant, suggesting that the differences between the three groups may have been due to the intervention itself and not specifically to planning versus nonplanning.

Three major themes that were identified by participants on the goals and plans document included (1) staying smoke-free or reducing the number of cigarettes smoked postrelease, (2) engaging in physical activities to improve health and wellness, and (3) spending time with family and/or friends. Examples of written goal statements made by participants for these three major themes included to “Stay smoke-free after release from prison,” “Lose some weight,” and “Stay free of other drugs and alcohol.” Specific actions identified that were related to these goals included going to the gym/ exercising, spending time with nonsmoking family members and friends, chewing gum, and avoiding other substances or illicit drugs. Family members, primarily parents and siblings, were identified as sources of support in helping participants achieve their goals. Reasons why participants believed their goals were attainable included a desire to live longer, receiving support from others, and feeling motivated/ready to do it. Stress followed by using alcohol and/or other drugs and being around other people who smoke were identified by participants as the primary potential barriers to goal attainment. Common solutions for dealing with these barriers reported by participants included exercising (e.g., going for a walk/jogging), getting treatment (e.g., attending 12-step programs, such as Alcoholics Anonymous and Narcotics Anonymous), and avoiding triggers (e.g., not being around people, events, or situations that positively reinforce smoking). Rewards that most participants identified fell into three major categories: (1) financial incentives (e.g., giving themselves money), (2) travel incentives (e.g., taking a trip/vacation), and (3) food incentives (e.g., having favorite meal).

Discussion

To our knowledge, this is the first study to examine the self-identified written goals and plans of male inmates who were about to be released from prison. Detailed information about the future goals and plans of incarcerated populations is important for professionals working with inmates to know in order to assist them as they transition back into the community. Specific goals and plans of inmates on how they anticipate remaining tobacco-free after forced abstinence are also imperative for developing effective interventions that prevent resumption of cigarette smoking by inmates postrelease.

While the future goals and plans that inmates in this study identified could have been related to cigarette smoking, they also could have been connected to other areas of their life. It is interesting to note that many of the participants identified goals and plans that focused on their overall health and wellness and reconnecting with family members and/or friends after being incarcerated, which is consistent with research on the transtheoretical model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992; Prochaska & Velicer, 1997) that suggests some behavior change seems to occur and is perhaps enhanced by changing multiple related behaviors, referred to as covariation or coaction (Prochaska, 2008). This suggests that inmates are able to articulate and write down their goals and plans for when they leave prison, and many of them focused on ways to lead healthier and more productive lives in multiple ways. Our finding counters the incorrect assumption that most inmates are unfocused and not goal oriented in their plans for the future. Furthermore, it is evident that the majority of the inmates who completed the goals and plans document in the present study believed that they could achieve their goal(s) with support from nonsmoking family members, especially parents and siblings. This information is especially important when designing smoking-cessation interventions that incorporate nonsmoking family members whom the participant perceives as being supportive and role models (Bock et al., 2013).

Our finding that cigarette smoking outcomes were significantly different among planners, nonplanners, and control was interesting. While it may not be surprising that planners had a greater likelihood of remaining quit at 3-week follow-up since this was an established goal of many participants who completed the goals and plans document, it was somewhat surprising that the planners who were smoking tended to have a higher number of days abstinent before smoking their first cigarette and a lower number of cigarettes smoked at 3 weeks postrelease in comparison to those who were nonplanners or in the control condition. While these significant differences disappeared when examining treatment group versus control group, suggesting that the differences may have been due to the intervention itself, it also means that the planners may have benefited from completing a goals and plans document. That is, completing a goals and plans document may have helped the planners to delay gratification by not smoking as quickly and as much as those who were either nonplanners or in the control condition at 3 weeks postrelease.

A meta-analysis of 23 smoking cessation studies by Hettema and Hendricks (2010) found that MI may be particularly effective for people low in motivation or with low levels of tobacco dependence. In addition, the authors reported that 13% of these studies combined MI with a skills-based behavioral intervention, such as CBT or relapse prevention that showed favorable short-term outcomes. However, follow-up studies are clearly needed to determine whether MI+CBT interventions are actually more effective than no intervention or either treatment alone for both smoking cessation and smoking abstinence programs targeted to incarcerated populations in the United States.

Although the present study illuminates an area of research with no prior data on the self-identified written goals and plans of male inmates, our findings must be interpreted with caution. First, since our participants had the option of not completing this exercise as part of the intervention, the ones who did may have been highly motivated individuals who may have differed from those inmates who chose not to complete the goals and plans document. Reasons for completing or not completing the goals and plans document were not collected in the present study. Second, these participants were in a tobacco-free prison in which they had not smoked for an extended period of time and had moved past the withdrawal symptoms of nicotine dependence (Clarke et al., 2015). It is quite possible that for inmates in a prison or jail that allows cigarette smoking or other tobacco use, their goals and plans for the future may differ from the ones we found in the present study. Future research could compare the goals and plans of inmates in a smoke-free prison to those in a prison that allows smoking to explore potential differences. Third, the goals and plans that were identified by inmates in this study were ones that they hoped to achieve after being released from prison. While setting goals and plans is an important first step to eventually reaching them, they are aspirational in nature and do not necessarily mean that they will be attained. Follow-up data on whether the goals and plans of inmates had been reached could help to determine how successful they were after release. Fourth, this study examined the goals and plans of male inmates, but female inmates are likely to identify different goals and plans that are important to them in comparison to their male counterparts. Examining possible gender differences is critical for additional research to consider in understanding the future goals and plans of inmates who are female.

Conclusions

The current study provides empirical evidence for the ability of inmates to articulate their future goals and plans for maintaining healthy and productive lives after incarceration. Smoking-cessation interventions should take into consideration the data presented here as it highlights the major goals and plans that inmates may have for their lives outside of prison. Professionals working with inmates can use the goals and plans document that we developed to help inmates identify and write down their goal(s), reasons for actions, specific actions, supportive people, reasons for attainability, possible barriers, solutions to those barriers, and rewards that inmates can engage in and look forward to postincarceration.

Acknowledgments

We would like to thank the men who participated in this study and the Rhode Island Department of Corrections for supporting this research.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by a grant from the National Institutes of Health (R01 DA024093) to Dr. Clarke.

Footnotes

Declaration of Conflicting Interests

The authors disclosed no conflicts of interest with respect to the research, authorship, or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Program.

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