Research Paper
Barriers and facilitators of maintained smoking abstinence following release from smoke-free prisons: A qualitative enquiry

https://doi.org/10.1016/j.drugpo.2019.03.018Get rights and content

Abstract

Background

The prevalence of smoking among people entering prisons is high. Despite increasing adoption of prison smoke-free policies, relapse to smoking after release from prison is nearly universal, and policy to effectively mitigate this is largely absent. Informed by a risk environment framework, we aimed to identify key barriers and facilitators to maintaining smoking abstinence among former smokers released from smoke-free prisons.

Method

Twenty-one people released from smoke-free prisons in Queensland, Australia, were followed up from a larger survey of 114 former prisoners. Semi-structured interviews were used to explore the perceived barriers and facilitators of maintained smoking abstinence.

Findings

Identified barriers to continued abstinence included pre-release intention to resume smoking; normalisation of smoking in home or social environments, resumption of smoking as a symbolic act of freedom and resistance from and to a restrictive environment; a perception that smoking provides stress relief to their difficult lives, and the use of tobacco/smoking to cope with cravings experienced on release for illicit substances. A number of interviewees were unable to provide clear reflective reasons for relapse. For those who did manage to remain abstinent for a period of time, identified facilitators included an awareness of the health and financial benefits of smoking abstinence, the use of intrinsic motivation, distraction from nicotine cravings using alternative activities, and social support from family and peers.

Discussion

Interventions promoting continued smoking abstinence among people exiting smoke-free prisons should focus on targeting the perceived individual- and environmental-level barriers to maintained smoking abstinence while simultaneously promoting perceived facilitators, so as to reduce smoking-related health and economic disparities in this marginalised population.

Section snippets

Background

Tobacco smoking is a major cause of illness and death globally (World Health Organization, 2013), responsible for approximately seven million deaths a year (World Health Organization, 2018). Despite overall decreases in tobacco use among the general population in most countries over recent decades (GBD 2015 Tobacco Collaborators, 2017), high levels of tobacco smoking persist among certain sub-groups of the population. For example, 74% of people entering Australian prisons in 2015 were current

Method

Participants in this study represent a subset of participants from a larger, cross-sectional study that used a survey to quantitatively investigate rates of smoking relapse among 114 former smokers released from smoke-free prisons in Queensland (Puljević, Coomber et al., 2018). While our quantitative study reports a rapid rate of smoking relapse following release from prison (Puljević, Coomber et al., 2018), this study uses a qualitative design to explore some of the perceived reasons why

Participant demographics

Twenty-one people who had relapsed to smoking following release from smoke-free prisons took part in this study (see Table 1). Participants ranged in age from 21 to 63 (median age 34), and the majority of participants were male (n = 16) and self-identified as Caucasian Australian (n = 18). Although all participants had resumed smoking following their release from smoke-free prisons, the majority (n = 12) had intended to remain abstinent following release from prison, and almost all (n = 18)

Discussion

This qualitative study found that people released from smoke-free prisons in Queensland experience both structurally specific as well as intuitively perceived barriers that impede quitting smoking, as well as facilitators that may encourage their continued abstinence from smoking. The implications of these findings are clear; structural interventions that aim to promote continued smoking abstinence among former smokers released from smoke-free prisons, implemented at opportune moments, would

Conclusion

The majority of former smokers exiting smoke-free prisons resume smoking upon release, meaning that the health and economic benefits of continued smoking abstinence are largely lost upon return to the community. The perceived barriers and facilitators of maintained smoking abstinence described in this study may assist in the development of targeted interventions promoting continued post-release smoking abstinence. We recommend the provision of brief sessions of motivational interviewing,

Role of funding source

Professor Stuart A. Kinner is supported by NHMRC Senior Research Fellowship APP1078168. No other funding sources to declare.

Conflict of interest

The authors declare no conflicts of interest.

Acknowledgements

The authors gratefully acknowledge participants and Queensland Corrective Services, especially Probation and Parole office staff members, for their assistance with the collection of data for this study.

References (104)

  • T. Rhodes

    The “risk environment”: A framework for understanding and reducing drug-related harm

    The International Journal of Drug Policy

    (2002)
  • T. Rhodes

    Risk environments and drug harms: A social science for harm reduction approach

    The International Journal of Drug Policy

    (2009)
  • T. Rhodes et al.

    The social structural production of HIV risk among injecting drug users

    Social Science & Medicine

    (2005)
  • W. Small et al.

    Impacts of intensified police activity on injection drug users: Evidence from an ethnographic investigation

    The International Journal of Drug Policy

    (2006)
  • S.A. Strathdee et al.

    HIV and risk environment for injecting drug users: The past, present, and future

    The Lancet

    (2010)
  • R.J. Winter et al.

    Incidence and predictors of non-fatal drug overdose after release from prison among people who inject drugs in Queensland, Australia

    Drug and Alcohol Dependence

    (2015)
  • AIHW

    Smoking and quitting smoking among prisoners in Australia, Bulletin no. 119. Cat. No. AUS 176

    (2013)
  • AIHW

    Australia’s health 2014, Australia’s Health Series no. 14. Cat. No. AUS 178

    (2014)
  • AIHW

    The health of Australia’s prisoners 2015, Cat. No. PHE 207

    (2015)
  • AIHW

    Australia’s health 2016

    (2016)
  • AIHW

    National drug strategy household survey 2016 key findings

    (2017)
  • D. Apollonio et al.

    Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders

    The Cochrane Database of Systematic Reviews

    (2016)
  • O.P. Atieno

    An analysis of the strengths and limitation of qualitative and quantitative research paradigms

    Problems of Education in the 21st Century

    (2009)
  • A. Baker et al.

    Where there’s smoke, there’s fire: High prevalence of smoking among some sub-populations and recommendations for intervention

    Drug and Alcohol Review

    (2006)
  • E. Baldry et al.

    Australian prisoners’ post-release housing

    Current Issues in Criminal Justice

    (2003)
  • L. Bauld et al.

    Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: Literature review and qualitative study

    Health Technology Assessment

    (2017)
  • M. Baybutt et al.

    Tobacco use in prison settings: A need for policy implementation

    (2014)
  • K. Bell et al.

    Quantitative conversations: The importance of developing rapport in standardised interviewing

    Quality & Quantity

    (2016)
  • I.A. Binswanger et al.

    Release from prison — A high risk of death for former inmates

    The New England Journal of Medicine

    (2007)
  • I.A. Binswanger et al.

    Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population

    Journal of Epidemiology and Community Health

    (2009)
  • I.A. Binswanger et al.

    Return to drug use and overdose after release from prison: A qualitative study of risk and protective factors

    Addiction Science & Clinical Practice

    (2012)
  • I.A. Binswanger et al.

    Prison tobacco control policies and deaths from smoking in United States prisons: Population based retrospective analysis

    BMJ (Clinical Research Ed)

    (2014)
  • I.A. Binswanger et al.

    Clinical risk factors for death after release from prison in Washington State: A nested case-control study

    Addiction

    (2016)
  • R. Bonita et al.

    New Zealand leads the way in banning smoking in prisons

    BMJ (Clinical Research Ed)

    (2013)
  • J. Boyd et al.

    Social-structural factors influencing periods of injection cessation among marginalized youth who inject drugs in Vancouver, Canada: An ethno-epidemiological study

    Harm Reduction Journal

    (2017)
  • K.A. Bradley et al.

    AUDIT-C as a brief screen for alcohol misuse in primary care

    Alcoholism, Clinical and Experimental Research

    (2007)
  • V. Braun et al.

    Using thematic analysis in psychology

    Qualitative Research in Psychology

    (2006)
  • J. Burgess-Allen et al.

    The health needs of ex-prisoners, implications for successful resettlement: A qualitative study

    International Journal of Prisoner Health

    (2006)
  • T.G. Butler et al.

    Smoking bans in prison: time for a breather?

    The Medical Journal of Australia

    (2015)
  • T.G. Butler et al.

    Drug use and its correlates in an Australian prisoner population

    Addiction Research & Theory

    (2003)
  • T.G. Butler et al.

    Should smoking be banned in prisons?

    Tobacco Control

    (2007)
  • J.G. Clarke et al.

    Tobacco use among prisoners

  • J.G. Clarke et al.

    Forced smoking abstinence: Not enough for smoking cessation

    JAMA Internal Medicine

    (2013)
  • R. Collier

    Prison smoking bans: Clearing the air

    Canadian Medical Association Journal

    (2013)
  • K.G. Creswell et al.

    A test of the stress-buffering model of social support in smoking cessation: Is the relationship between social support and time to relapse mediated by reduced withdrawal symptoms?

    Nicotine & Tobacco Research

    (2015)
  • L. Curry et al.

    E-cigarettes made especially for inmates

    Tobacco Control

    (2014)
  • D. de Andrade et al.

    Systematic review of health and behavioural outcomes of smoking cessation interventions in prisons

    Tobacco Control

    (2016)
  • S.L. Dworkin

    Sample size policy for qualitative studies using in-depth interviews

    Archives of Sexual Behavior

    (2012)
  • K. Fagerstrom et al.

    Measuring nicotine dependence : A review of the fagerstrom tolerance questionnaire

    Journal of Behavioral Medicine

    (1989)
  • M. Farrell et al.

    Acute risk of drug-related death among newly released prisoners in England and Wales

    Addiction

    (2008)

    • Cited by (6)

    View full text
    © 2019 Elsevier B.V. All rights reserved.