Tobacco Control Policies and Deaths From Smoking in Prisons
Tobacco Control Policies and Deaths From Smoking in Prisons
Smoking contributes to substantial excess mortality in prisons. Our study suggests that the implementation of smoking bans in prison is associated with reductions in smoking related mortality among people in prisons, particularly cardiovascular and pulmonary deaths. These findings are likely related to reductions in smoking and exposure to secondhand smoke among people in prisons. Bans in place for nine or more years were also associated with reduced cancer mortality.
We might have underestimated smoking attributable mortality for several reasons. First, people who do not smoke might experience a higher intensity of secondhand exposure in cells and indoor prison spaces with poor ventilation. The smoking attributable mortality, morbidity, and economic costs system does not include effects of secondhand smoke in its calculations of smoking attributable mortality. Second, in prisons, people who smoke might smoke more than other populations; thus, the relative risk assumptions used in the system software to calculate smoking attributable mortality might be inappropriately low for this population. Third, in addition to the 19 causes of death thought to be related to smoking in prior reports of smoking attributable mortality in the general populations, additional causes of death might be related to smoking, such as colon cancer. These were not accounted for in the system software we used. Fourth, the smoking attributable mortality, morbidity, and economic costs system does not account for pipe or cigar smoking. In addition, our estimates of smoking attributable mortality and years of potential life lost were limited by the small number of older people in the prison survey. Our estimates of smoking in older people might be unstable, although the decline in smoking prevalence among such people observed mirrors the trend in the general population.
Our analysis of the effects of tobacco control polices on mortality was based on the best available observational data to examine this question. A randomized trial of these policies that is adequately long and of sufficient size to assess mortality outcomes is unlikely to be conducted. Our data do not include deaths in local jails or federal prisons, among individuals on probation or parole, or among people released from prison. Some individuals with major illness could have been released from prison on medical parole or compassionate release before dying from cancer or other illnesses. Our data did not capture these deaths. Underlying cause of death was determined by state prisons systems and Bureau of Justice Statistics by using algorithms that do not necessarily correspond to algorithms used by the Centers for Disease Control and Prevention to classify cause of death when multiple causes contribute.
Our findings on the association between smoking bans and mortality also have limitations. First, as noted by the Institute of Medicine, it can be difficult to separate the direct effects of a ban from dissemination of information about the ban, associated education about secondhand smoke, and associated efforts at smoking cessation. Second, states that implemented prison bans might also have implemented other workplace or public bans, which reduced smoking related mortality. Our sensitivity analyses, however, suggest that our results are robust. Third, because of limitations of our data we could not adjust for differences in the distribution of age across states. The mortality reductions we observed could have occurred as a result of reductions in smoking or exposure to secondhand smoke, or both. Finally, our estimates of the effects of time since the implementation of bans might have been conservative as people might not have been exposed to the bans for the whole time, given transitions in and out of prison.
The association between smoking bans in prison and mortality has not been previously reported. In the population outside prison, smoke-free legislation has been associated with reduced admission to hospital and mortality from coronary events, other heart disease, cerebrovascular disease, and respiratory disease. More comprehensive laws have been associated with greater risk reductions. The Institute of Medicine also suggested that reduced exposure to secondhand smoke from smoking bans led to declines in myocardial infarction. Other studies of workplace and public smoking bans have shown a reduction in visits to emergency departments and hospital admissions for smoking related diseases after implementation. To our knowledge, this is the first study to show an association between smoking bans and reduced cancer mortality over time. The long latency between smoking exposure and the development of cancer might make this association more challenging to demonstrate through epidemiologic studies in populations outside prison that are more mobile and might experience a lower intensity of exposure to smoke than people in prisons. Fry and colleagues noted, however, that compared with people who continue to smoke, those who quit smoking have half the risk of lung cancer 10 years after they quit smoking—a finding that is consistent with our results. Previous research, however, has not documented the effect of smoking bans on cancer mortality; this finding should therefore be replicated in other settings.
Our results suggest that smoking bans in prisons can reduce the risk of death in prison. Smoking bans do not directly reduce mortality but act through effects on smoking and exposure to secondhand smoke. The institution of prison smoking bans has been associated with a reduction in exposure to secondhand smoke and improvements in air quality.Smoking bans can also reduce the initiation of smoking in prison, improve health among correctional officers and other prison staff, improve fire safety, and reduce costs associated with liability insurance, facility maintenance, and healthcare.
On the other hand, complete (indoor and outdoor) smoking and tobacco bans in prisons strongly limit individual autonomy and might not prepare individuals with tobacco use disorders for life in the community, where they can purchase and consume tobacco. Internationally, various types of incomplete bans are being implemented, such as bans that prohibit smoking in public prison spaces, in cells, or in all spaces except for designated smoking areas. Some prisons have also prohibited correctional facilities from forcing people who do not smoke to share cells with inmates who smoke. In addition, smoking bans do not lead to sustained long term cessation. Many people resume smoking after release from prison, and others might be transferred to or re-incarcerated in jails, halfway houses, and drug treatment facilities without bans. Finally, some inmates smoke despite bans, which can lead to correctional sanctions and negative health outcomes for people with tobacco use disorders. Reduced smoking and smoke exposure, however, can have positive health benefits even if there is not complete adherence with a ban.
Pharmacologically supported tobacco cessation treatment and behavioral interventions are important adjuncts for tobacco use disorders and need wider dissemination in prisons. Prevention of relapse during the transition back to the community is also critical. People with mental health and substance use disorders, which are associated with tobacco use, might require specialized interventions to help maintain long term cessation and manage forced abstinence in prison. Smoking cessation can lead to secondary health benefits in children and families after individuals are released from prison. Other healthcare services that can provide benefit to people with a history of smoking include vaccination against influenza and pneumococcal disease, evidence based management of chronic obstructive pulmonary disease, and primary and secondary prevention of heart and cerebrovascular disease.
Further research is needed on several related issues, such as the effect of tobacco policies among correctional officers and prison staff, who also smoke at disproportionately high rates; public expenditures because of smoking related illness in prisons and after release; the costs of tobacco control and cessation interventions in prisons; whether incarceration in correctional facilities that permit smoking increase smoking initiation or consumption; when maximal effects on cancer mortality are observed (including after release from prison); and the use of smokeless and electronic cigarettes in prisons. We noted an overall increase in the 2011 mortality rate, a finding that needs further investigation if it represents a trend. Whereas death rates in prisons are often similar to or slightly lower than those in the general population, for the same age, sex, and race (in part because of protection from deaths from injury), the risk of death increases after release from prison. Lung cancer and cardiovascular mortality are important contributors to death after release from prison. Prison smoking bans could reduce mortality after release. While we observed significant benefits of smoking bans on mortality, ongoing research and implementation efforts are needed to promote effective long term cessation in prisons and after release as part of a comprehensive tobacco strategy for this high risk group.
Discussion
Main Findings
Smoking contributes to substantial excess mortality in prisons. Our study suggests that the implementation of smoking bans in prison is associated with reductions in smoking related mortality among people in prisons, particularly cardiovascular and pulmonary deaths. These findings are likely related to reductions in smoking and exposure to secondhand smoke among people in prisons. Bans in place for nine or more years were also associated with reduced cancer mortality.
Strengths and Weaknesses of Study
We might have underestimated smoking attributable mortality for several reasons. First, people who do not smoke might experience a higher intensity of secondhand exposure in cells and indoor prison spaces with poor ventilation. The smoking attributable mortality, morbidity, and economic costs system does not include effects of secondhand smoke in its calculations of smoking attributable mortality. Second, in prisons, people who smoke might smoke more than other populations; thus, the relative risk assumptions used in the system software to calculate smoking attributable mortality might be inappropriately low for this population. Third, in addition to the 19 causes of death thought to be related to smoking in prior reports of smoking attributable mortality in the general populations, additional causes of death might be related to smoking, such as colon cancer. These were not accounted for in the system software we used. Fourth, the smoking attributable mortality, morbidity, and economic costs system does not account for pipe or cigar smoking. In addition, our estimates of smoking attributable mortality and years of potential life lost were limited by the small number of older people in the prison survey. Our estimates of smoking in older people might be unstable, although the decline in smoking prevalence among such people observed mirrors the trend in the general population.
Our analysis of the effects of tobacco control polices on mortality was based on the best available observational data to examine this question. A randomized trial of these policies that is adequately long and of sufficient size to assess mortality outcomes is unlikely to be conducted. Our data do not include deaths in local jails or federal prisons, among individuals on probation or parole, or among people released from prison. Some individuals with major illness could have been released from prison on medical parole or compassionate release before dying from cancer or other illnesses. Our data did not capture these deaths. Underlying cause of death was determined by state prisons systems and Bureau of Justice Statistics by using algorithms that do not necessarily correspond to algorithms used by the Centers for Disease Control and Prevention to classify cause of death when multiple causes contribute.
Our findings on the association between smoking bans and mortality also have limitations. First, as noted by the Institute of Medicine, it can be difficult to separate the direct effects of a ban from dissemination of information about the ban, associated education about secondhand smoke, and associated efforts at smoking cessation. Second, states that implemented prison bans might also have implemented other workplace or public bans, which reduced smoking related mortality. Our sensitivity analyses, however, suggest that our results are robust. Third, because of limitations of our data we could not adjust for differences in the distribution of age across states. The mortality reductions we observed could have occurred as a result of reductions in smoking or exposure to secondhand smoke, or both. Finally, our estimates of the effects of time since the implementation of bans might have been conservative as people might not have been exposed to the bans for the whole time, given transitions in and out of prison.
Strengths and Weaknesses in Relation to Other Studies
The association between smoking bans in prison and mortality has not been previously reported. In the population outside prison, smoke-free legislation has been associated with reduced admission to hospital and mortality from coronary events, other heart disease, cerebrovascular disease, and respiratory disease. More comprehensive laws have been associated with greater risk reductions. The Institute of Medicine also suggested that reduced exposure to secondhand smoke from smoking bans led to declines in myocardial infarction. Other studies of workplace and public smoking bans have shown a reduction in visits to emergency departments and hospital admissions for smoking related diseases after implementation. To our knowledge, this is the first study to show an association between smoking bans and reduced cancer mortality over time. The long latency between smoking exposure and the development of cancer might make this association more challenging to demonstrate through epidemiologic studies in populations outside prison that are more mobile and might experience a lower intensity of exposure to smoke than people in prisons. Fry and colleagues noted, however, that compared with people who continue to smoke, those who quit smoking have half the risk of lung cancer 10 years after they quit smoking—a finding that is consistent with our results. Previous research, however, has not documented the effect of smoking bans on cancer mortality; this finding should therefore be replicated in other settings.
Meaning of the Study
Our results suggest that smoking bans in prisons can reduce the risk of death in prison. Smoking bans do not directly reduce mortality but act through effects on smoking and exposure to secondhand smoke. The institution of prison smoking bans has been associated with a reduction in exposure to secondhand smoke and improvements in air quality.Smoking bans can also reduce the initiation of smoking in prison, improve health among correctional officers and other prison staff, improve fire safety, and reduce costs associated with liability insurance, facility maintenance, and healthcare.
On the other hand, complete (indoor and outdoor) smoking and tobacco bans in prisons strongly limit individual autonomy and might not prepare individuals with tobacco use disorders for life in the community, where they can purchase and consume tobacco. Internationally, various types of incomplete bans are being implemented, such as bans that prohibit smoking in public prison spaces, in cells, or in all spaces except for designated smoking areas. Some prisons have also prohibited correctional facilities from forcing people who do not smoke to share cells with inmates who smoke. In addition, smoking bans do not lead to sustained long term cessation. Many people resume smoking after release from prison, and others might be transferred to or re-incarcerated in jails, halfway houses, and drug treatment facilities without bans. Finally, some inmates smoke despite bans, which can lead to correctional sanctions and negative health outcomes for people with tobacco use disorders. Reduced smoking and smoke exposure, however, can have positive health benefits even if there is not complete adherence with a ban.
Pharmacologically supported tobacco cessation treatment and behavioral interventions are important adjuncts for tobacco use disorders and need wider dissemination in prisons. Prevention of relapse during the transition back to the community is also critical. People with mental health and substance use disorders, which are associated with tobacco use, might require specialized interventions to help maintain long term cessation and manage forced abstinence in prison. Smoking cessation can lead to secondary health benefits in children and families after individuals are released from prison. Other healthcare services that can provide benefit to people with a history of smoking include vaccination against influenza and pneumococcal disease, evidence based management of chronic obstructive pulmonary disease, and primary and secondary prevention of heart and cerebrovascular disease.
Unanswered Questions and Future Research
Further research is needed on several related issues, such as the effect of tobacco policies among correctional officers and prison staff, who also smoke at disproportionately high rates; public expenditures because of smoking related illness in prisons and after release; the costs of tobacco control and cessation interventions in prisons; whether incarceration in correctional facilities that permit smoking increase smoking initiation or consumption; when maximal effects on cancer mortality are observed (including after release from prison); and the use of smokeless and electronic cigarettes in prisons. We noted an overall increase in the 2011 mortality rate, a finding that needs further investigation if it represents a trend. Whereas death rates in prisons are often similar to or slightly lower than those in the general population, for the same age, sex, and race (in part because of protection from deaths from injury), the risk of death increases after release from prison. Lung cancer and cardiovascular mortality are important contributors to death after release from prison. Prison smoking bans could reduce mortality after release. While we observed significant benefits of smoking bans on mortality, ongoing research and implementation efforts are needed to promote effective long term cessation in prisons and after release as part of a comprehensive tobacco strategy for this high risk group.
