Process and impact of implementing a smoke-free policy in prisons in Scotland: TIPs mixed-methods study

Overall aims

• To evaluate the process of implementing a smoke-free policy in Scottish prisons to (1) strengthen the evidence base on what is likely to facilitate successful implementation of smoke-free prison policies for other jurisdictions, and (2) inform planning and communication strategies in Scotland and elsewhere.

• To evaluate the impact of implementing a smoke-free policy in Scottish prisons on (1) changes in smoking status and exposure to SHS, (2) changes in related health indicators among PiC and staff and (3) organisational/cultural impacts.

Objectives

• To understand barriers to and facilitators of the implementation of smoke-free policies in prisons through a scoping of evidence and experiences internationally within other jurisdictions [work package (WP) 1 (WP1)].

• To evaluate changes in smoking and exposures to SHS following the implementation of a smoke-free policy in Scotland’s prisons, associated health-related indicators and costs, and other intended and unintended consequences (WP2).

• To understand staff attitudes to and experiences of smoking-related issues in the prison context, including access to/restriction on tobacco and tobacco-related products (including e-cigarettes) in the prison environment, if/how these vary between prisons and how these changed leading up to and following the implementation of the smoke-free policy (WP3).

• To understand PiC’s attitudes and experiences of smoking-related issues in the prison context, including access to/restrictions on tobacco/tobacco-related products (including e-cigarettes) in the prison environment, if/how these vary between prisons and how these changed leading up to and following the implementation of the smoke-free policy (WP4).

• To evaluate the provision and impact of smoking cessation services across Scottish prisons; experiences of providers, users and potential users of these services in the lead-up to implementation of smoke-free prisons; and efforts to harmonise smoking cessation services from 2016 (WP5).

• To share emerging findings in a timely and ongoing way so that they can inform the development of services, strategies and decision-making in the health and prison services about how best to implement the smoke-free policy, taking account of the views and experiences of PiC and prison staff (WP6).

Staff training and engagement

In preparation for the phase 1 assessments of air quality, representatives from Scotland’s 15 prisons were invited to a half-day training session (29 September 2016) at the SPS College. This provided the opportunity to train attendees as ‘citizen scientists’ through an overview of the TIPS study, training in the air quality measurement and the specific measuring devices used in the study (see Fixed-site monitoring and Alternative Scottish Prison Service exposure measures – fixed-site nicotine concentrations and cotinine concentrations in saliva of non-smoking staff), and the rationale for taking saliva samples from non-smoking staff in phase 1. A half-day training session was also provided for prison staff on 8 November 2018 in preparation for air quality measurements in the week of policy implementation and in phase 3. On completion of these sessions, at least one designated trained staff member from each prison took responsibility for a box containing the instrumentation and associated forms.

Fixed-site monitoring

Following earlier validation studies,34 Dylos DC1700 air quality monitors (Dylos Corporation, Riverside, CA, USA) were used to measure concentrations of PM_2.5 to estimate SHS levels via fixed-site and mobile-task monitoring methods. These devices measure particle concentrations every second and log an average measurement result for each minute of use. Details of the method of converting particle number concentration to PM_2.5 mass concentration, together with calibration of the Dylos monitors against AM510 SidePak Personal Aerosol Monitors (TSI Incorporated, Shoreview, MN, USA) are provided elsewhere. 31 Fixed-site monitoring over a 6-day period was undertaken within the same location, in one residential hall, at the three time points, overseen by the trained designated staff member(s), in each prison: in phase 1 (during 1 week in the period 30 September–22 November 2016),11,33 in the week of implementation (09.00 on 28 November 2018 to 09.00 on 4 December 2018),32 and in phase 3, 6 months after the smoke-free policy was implemented (09.00 on 22 May 2019 to 09.00 on 28 May 2019). 31 During phase-1 training, the designated prison staff had discussed their choice of location for the 6-day fixed-site continuous monitoring in a residential area within their prison with members of the TIPs study WP2 team. On occasion, the TIPs study researchers (KH, HS, ED) also went to the prison site to discuss the exact location of the instruments in more detail with the designated prison staff. The location needed to be secure (e.g. at the staff desk) to prevent accidental or malicious interference, within reach of an electrical plug and within the atrium/landing of one residential hall. The designated prison staff were responsible for ensuring that the location and daily equipment checks were recorded on the forms provided, together with relevant contextual information.

After each 6-day period, the designated prison staff securely packed the device and forms, and returned them either directly to a research team member for immediate download or by secure courier. Data were downloaded using Dylos Logger software (v3.1.0.0) (Dylos Corporation), and typical daily PM_2.5 exposure profiles were constructed for each prison, as described in detail elsewhere. 11,31–33

Mobile-task monitoring

Mobile-task monitoring was undertaken in phases 1 and 3 only; it was not feasible to conduct these measures in the week of implementation because of operational considerations. After the 6-day fixed-site monitoring data were downloaded, the Dylos DC1700 monitors were returned to the designated staff. In 2016, staff were asked to choose four to eight tasks to assess SHS concentrations in various locations (e.g. gyms, workshops) and during specific activities (e.g. cell searches, maintenance, meal service), based on their knowledge and perceptions of areas with potential SHS exposures;11 in 2019, they were asked to include the same monitoring locations/activities assessed in 2016. 31 The monitoring period for each ‘task-based’ measurement lasted ≈ 30 minutes, and staff recorded time, location and associated activity for each measurement. Data from the mobile-task monitoring were downloaded after the instruments had been returned to research staff in person or by secure courier. Time-weighted average exposure concentrations were estimated for the typical shift patterns of residential staff pre and post smoke-free policy implementation (see Demou et al. 31 for full details).

Alternative second-hand smoke exposure measures: fixed-site nicotine concentrations and cotinine concentrations in saliva of non-smoking staff

In phase 1 only, estimates of SHS exposure calculated using the Dylos DC1700 monitors were compared with (1) measures of nicotine concentration from a sodium bisulfate-treated filter in passive diffuse monitors (‘nicotine monitors’) placed next to each Dylos monitor during the fixed-site 6-day measurements; and (2) salivary cotinine measures (a biomarker of recent SHS exposure) obtained from samples collected during fieldwork across all 15 prisons, between 7 November 2016 and 16 January 2017, to enable an estimation of the amount of nicotine inhaled over a work shift. As the main measure of change in SHS exposures over time in this report (see Chapter 4), and in the models reported in Chapter 8, are derived from the fixed- and mobile-task Dylos measurements, here the methods and findings of the nicotine monitor and salivary cotinine measures are summarised only. Full details are published elsewhere,11 but we note that measures from the nicotine monitors demonstrated a high association with the Dylos-derived estimate (R² = 0.91). 11

For the salivary cotinine measures, non-smoking prison staff were invited to provide pre- and post-shift samples of saliva on entry to and exit from the secure area of the prison. Eligible staff were non-smokers not using any nicotine product (e.g. gums, patches, e-cigarettes) who neither lived with a smoker nor travelled to work in a vehicle in which anyone had smoked. Written consent was obtained from all volunteers (n = 422). Saliva samples were collected by TIPs research staff, who had been trained using similar methods developed for other occupational groups. 13 They recorded the exact time of sample collection pre and post shift so that exposure time over the shift could be calculated. The storage, shipping and analysis of samples are described elsewhere. 11 Our revised study protocol12 details the rationale for not repeating saliva measures in phase 3; the principal reasons were high correlations between measures of SHS exposures,11 the burden imposed by the measurement procedures on staff as they entered/left the prison and on the prison regime, and minimising costs to maximise value for money of funding.

Outside air pollution

Fine particulate matter is not specific to SHS and also occurs in outdoor and indoor air from traffic and industrial pollution sources. Most previous studies measuring PM_2.5 in prisons have not accounted for concentrations of PM_2.5 in outdoor air. To identify whether or not ambient/outside air pollution was likely to have contributed significantly to the PM_2.5 concentrations measured in prisons, we acquired data from the nearest local authority PM_2.5 static environmental measuring device. Hourly outdoor PM_2.5 concentration data were downloaded from www.scottishairquality.scot (accessed 30 September 2021) for each monitoring period. 11,31,32 Data for the appropriate measurement periods from the outdoor monitor closest to each prison were used. 11,31,32 The median distance between each prison and the nearest PM_2.5 measuring station was 16 km (range 3–133 km), with all but one within 50 km.

Statistical analysis: second-hand smoke data

Statistical analysis was conducted in Microsoft Excel^® (Microsoft Corporation, Redmond, WA, USA), R version 3.6.1 (The R Foundation for Statistical Computing, Vienna, Austria), and IBM SPSS Statistics v23 (IBM Corporation, Armonk, NY, USA). Analysis of objective measures of SHS followed previously published methods. 34 To test the significance of change between different measurement periods, mean PM_2.5 concentrations were log-transformed and a paired t-test conducted across mean concentrations from all prisons for each comparison (see Demou et al. 31).

Our PM_2.5 data provided time-resolved information on SHS concentrations over the course of each day, with lower levels at night-time and peaks evident during the day and evening periods. These unique data, gathered for 6-day periods from all prisons, enabled the reconstruction of exposures of residential staff during different shift patterns. 35–37 Using information on shifts provided by the SPS, time-weighted average shift exposures were estimated for a ‘typical’ residential officer in a Scottish prison, taking into account the average levels of exposure in an area and the time spent in each area. The four (overlapping) shifts were an ‘early shift’ (modelled as a 6-hour shift; staff on this shift have the responsibility of unlocking cells first thing in the morning), a ‘day shift’ (modelled as 8 hours), a ‘back shift’ (modelled as a 9-hour shift) and the ‘night shift’ (modelled as 10 hours).

Survey circulation/distribution

In each phase, an invitation with information on the TIPs study and a link to the staff survey were circulated to an appointed contact (‘staff contact’) in each prison, with a request to forward these to all prison (but not NHS/visiting) staff. The online survey was housed by information technology (IT) staff at the University of Glasgow, to ensure the highest standards of security. As the TIPs research team, SPS management and union representatives believed that it was very important that the research was clearly seen to be independent of SPS management, the questionnaire link was forwarded directly by the research team to the nominated staff contact in each prison for them to forward to all staff in their prison. 12 Staff were informed that the survey would take 10–15 minutes to complete. Staff surveys were open November–December 2016 (phase 1), May–July 2018 (phase 2) and May–July 2019 (phase 3). One reminder was sent (via the staff contacts) in phase 1, two in phase 2 and three in phase 3. The staff contacts were provided with current response rates when reminders were sent, and this information was sometimes included in the e-mail to staff.

Surveys with PiC were undertaken from November 2016 to April 2017 (phase 1), June to July 2018 (phase 2) and June to July 2019 (phase 3). We wanted to ensure that PiC were provided with information about the questionnaire to enable them to make an informed decision about whether or not they wished to take part. In our original planning,12 we thus wanted to offer the opportunity for PiC to discuss any questions they might have about the study directly with a member of the research team, before deciding whether or not to participate. We also wanted to ensure that people were able to complete their questionnaires without disturbance from other prisoners, given the role of smoking and tobacco products in prison life, including in relation to bullying and intimidation.

We discussed ways to maximise inclusion of any potential participants with literacy or other learning difficulties, including carefully considering the content, wording and layout of the questionnaire. When the SPS conducts its biannual prisoner survey, PiC with literacy/learning difficulties are offered help with questionnaire completion by other PiC. We wanted to avoid this for our surveys (to allow PiC to express their views without concerns about reprisals from any other PiC), and so planned for provision of impartial (research team) assistance if required. This involved offering to make trained fieldworkers available to any PiC who required help.

We anticipated that the administration of questionnaires to PiC would be completed over a short time period in each prison (≈ 1–3 days, depending on operational considerations and prison size), with sufficient fieldworkers available to support administration of the survey. We agreed to liaise closely with the prison governor/their appointed representative(s) about the best way to achieve our aims in respect of prisoner questionnaire administration in their prison (e.g. numbers of fieldworkers required), recognising that operational considerations would determine the preferred means of administration of the survey with PiC in each prison. 12 In our original planning for the phase 1 survey of PiC and our funding application, we anticipated that questionnaires would be distributed to a proportion of PiC by TIPs fieldwork/research staff (who would be available to help with confidential completion), aiming for returns from around 20% of PiC.

In phase 1, in two prisons, TIPs staff were escorted around residential areas and distributed questionnaires to all PiC who said they were willing to complete one, answered queries and helped with completion if necessary. In a third prison, TIPs staff were asked to distribute the questionnaires during an evening meal. 12 However, in the remaining 12 prisons, the staff contacts expressed a strong preference for us to use similar methods to those used in the SPS’s own biennial Prisoner Survey,2,8,41 because the escorting of several research staff in prison residential facilities can prove very onerous to the prison regime. Sufficient questionnaires were therefore supplied to each prison so that prison staff could distribute one to every PiC. To allow PiC the opportunity to complete their questionnaire in private, questionnaires were generally distributed immediately prior to an overnight lock-up. To reassure PiC that no-one in the prison (staff or other PiC) would be able to see their responses, PiC were asked to return the completed questionnaire in a sealed envelope (provided with the questionnaire). Although the method that we were required to use for most prisons in phase 1 (and all prisons subsequently) inhibited confidential support in questionnaire completion for those with literacy or learning difficulties, return rates from the three prisons where TIPs staff distributed questionnaires were below the overall 34% return rate. Because prison staff distribution was preferred by prisons and resulted in higher return rates, this method was used in all prisons in phases 2 and 3.

Survey content

The surveys were designed to take approximately 10–15 minutes to complete (although time to complete was longer for some PiC) and to cover relevant predictors, effect modifiers and mediators, and outcomes. Wherever possible, the questionnaires included identical items for the two participant groups (staff/PiC) and across all phases to maximise opportunities for comparison and to use validated/existing measures. Report Supplementary Materials 1 and 2 detail the survey questions and basic frequencies for surveys for all phases and both groups. Items were based on previous surveys of health;42–44 smoking;42,45–47 experiences of PiC;41 and smoking bans in public places, prisons or secure hospitals,19,43,48–51 and comprised the following:

• basic sociodemographic items (sex, age, education; for staff – work role, band, number of prison-based working hours per week, number of years worked in prisons in total and in their current prison; and for PiC – whether convicted or on remand, with length of sentence and time until release if convicted, and length of time in current prison)

• current smoking, smoking history, e-cigarette use and vaping history, past year smoking cessation attempts and support

• health, including general health, sickness absence (staff), medication use and asthma diagnosis; International Union Against Tuberculosis and Lung Disease self-reported past month respiratory (wheezing/whistling, shortness of breath, morning cough, other cough, phlegm) and sensory symptoms (red/irritated eyes, runny nose/sneezing, sore/scratchy throat);52 and a standardised measure of health status,53 for which we received permission to amend the ‘usual activity’ examples for the survey of PiC

• estimated exposure to SHS and e-cigarette vapour within the prison

• opinions on smoking among PiC, prison smoking bans (adapted from surveys of US prison staff19 and Scottish bar workers’ attitudes to smoke-free places51), e-cigarettes and, in phase 3, the introduction of the Scottish prison smoking ban.

Survey feedback to prisons and participants

In addition to feeding back results to the study’s SPS RAG and at regular meetings of the SPS stakeholder advisory group (SAG) for the implementation of smoke-free prisons, phase 1 and phase 2 survey results (basic frequency distributions) were formatted into easy-to-read documents that were posted on the SPS SharePoint (SPS intranet system, accessible to all staff) and e-mailed to the staff contacts in each prison (phase 1 reports were tailored to include overall and each prison’s individual results). Phase 1 main results were also compiled into summary infographics that were distributed as hard copies (and so were available to PiC) and electronically.

Recruitment and data collection

Approach to qualitative analysis for focus group and interviews with staff, people in custody and representatives from other jurisdictions

All focus groups and interviews were audio-recorded, with permission from all participants involved, and transcribed by an external transcribing service that had signed a confidentiality agreement. To preserve participants’ anonymity, data were de-identified prior to analysis.

De-identified transcripts were thematically analysed, supported by the framework approach, following a process described in Appendix 2 and in publications based on the qualitative data. 38,54,55 In brief, data were organised under themes and summarised and displayed in a grid format (row = focus group/interview; column = theme) in NVivo 12 (QSR International, Warrington, UK). For pragmatic reasons, for two of the data sets, transcripts were summarised against themes in Microsoft Word (Microsoft Corporation, Redmond, WA, USA) [WP1 interviews with representatives from other jurisdictions and WP3 (phase 2) interviews with prison staff]. Detailed thematic analysis entailed comprehensively and systematically searching framework grids and reviewing data excerpts to identify and compare perspectives and experiences. Using an iterative process, different dimensions of the data were organised into themes and subthemes. Extracts from interviews have been selected to evidence and illustrate key findings. In the staff and PiC interviews/focus groups, quotations are attributed to participants (staff/PiC) using a serial number (a letter randomly allocated to each prison specifically for this report and a participant number) and an indication of smoking/vaping status [smoker (S), ex-smoker (ExS), never-smoker (NS), vaper (V), ex-vaper (ExV) and never-vaper (NV)].

Interviews with health-care and prison staff providing smoking cessation support

Qualitative interviews were conducted with staff responsible for managing and delivering cessation support across Scotland’s prison estate. Participants were from three main areas: topic specialists working in health board Stop Smoking Services (SSSs), practitioners working in prison health-care and addiction services who were trained to provide cessation support, and SPS officers who had volunteered or been nominated by prison management to support cessation delivery in the lead-up to implementation (see Appendix 3, Table 27). To maximise efficiency, and particularly to reduce burden on participants, the majority of interviews were conducted as one-to-one interviews either face-to-face or by telephone using a semistructured topic guide (see Appendix 1) at participants’ convenience. Interviews lasted 40–60 minutes and were audio-recorded with participants’ consent, fully transcribed and analysed using NVivo software to aid data management.

Phase 1 fieldwork was conducted from February to June 2017, phase 2 from May to August 2018, and phase 3 from May to September 2019. Interviews in phases 1 and 3 were conducted with participants from across the entire Scottish prison estate and the health board cessation services where the prisons were located. Interviews in phase 2 were conducted with participants from the six ‘case study’ prisons and the local health board cessation services supporting these prisons. To preserve anonymity, quotations are attributed to speakers using designation and study phase.

Interviews with about smoking cessation support

During phase 2, one-to-one qualitative interviews were conducted face-to-face with 45 PiC in five of the six ‘case study’ prisons in May and June 2018 using a semistructured topic guide (see Appendix 1). Participants all had recent experiences of using local prison cessation support and were at various stages in their journey to becoming smoke free (see Appendix 3, Table 28). They included PiC who were currently attending a 12-week cessation programme, had relapsed and had successfully completed the programme. All interviews (duration 30–60 minutes) were conducted face-to-face and audio-recorded, with participants’ consent, then fully transcribed, anonymised and analysed using NVivo software to aid data management. Analysis followed similar principles to those outlined above.

Medications

Analyses of medications prescribed for PiC were designed to investigate any associations between the smoke-free prison policy and the dispensing of medications for smoking cessation, nicotine replacement and specific smoking-related health conditions, and potential unintended consequences among people in prisons in Scotland. Data (number of items dispensed in prison) were provided by National Procurement, NHS National Services Scotland (NSS) from January 2014 (3.5 years prior to the announcement of the smoke-free policy in July 2017) to the end of November 2019 (1 year post implementation). The data series’ were analysed using autoregressive integrated moving average (ARIMA) time series methods, incorporating two prespecified breakpoints (date of announcement to 17 July 2017, and date of implementation to 30 November 2018). Two analytical approaches were tested for the presence of structural breaks and outliers using (1) a Wald test applied to the white noise residuals of the seasonal autoregressive integrated moving average (SARIMA) errors model, and (2) an indicator saturation applied to the white noise residuals of the SARIMA errors model. In each approach, the estimated breakpoints were then incorporated into the final intervention model ensuring efficient effect estimates and standard errors. Measures of overcrowding were included in all models as potential confounding factors. Interpretation was informed by the TIPs qualitative workstreams. The primary analysis included the 14 closed prisons only, as the nature, implementation and effectiveness of the smoke-free policy is likely to differ substantially in open versus closed establishments. Secondary analyses included all Scottish prisons. Analyses were delayed by reallocation of staff who were leading the analyses to service public health roles during the COVID-19 outbreak and are reported in detail in a paper published57 after the reporting period for this grant; see Acknowledgements, Publications.

Staff sickness absence

Analyses of staff sickness absence data were designed to explore any changes in staff sickness absence rates before and after the introduction of the smoke-free policy across the SPS. Weekly days lost were provided in anonymised form by the SPS for the 13 publicly managed prisons. Data were requested from June 2016 (1 year prior to the announcement of the smoke-free policy) to the end of November 2019 (1 year post implementation). The data series were analysed using the Box–Jenkins ARIMA time series methodology. For the SPS sickness absence time series, we adopted an input series to allow the change in policy on smoking (intervention) to be modelled. Specifically, the intervention was modelled as a 0 up to 30 November 2018 (date of prisons going smoke free) and then coded as a 1 after that date. The announcement of the date for a change of the smoking policy in Scottish prisons (July 2017) was also taken into account in the model, as this involved designing and implementing the changes necessary for the smoke-free policy to come into effect and, although there was no intervention per se at this point (i.e. policy change), other changes may have occurred (e.g. raised awareness of SHS levels leading to decreased smoking among PiC outwith permitted areas, information on SHS levels affecting strictness in enforcing current rules). We used a dummy variable to account for the announcement (value of 0 from June 2016 to July 2017, value of 1 from July 2017 to November 2018, and value of 0 from November 2018 onwards). As all prisons implemented smoke-free rules on the same date and the policy was the same across Scotland, there was no ‘control/comparator’ population. However, we examined differences by sickness absence causes (self-reported in the data), by job (operational vs. non-operational) and across ‘baseline SHS exposure prison types’. Other sensitivity analyses (SAs) (e.g. placebo intervention dates) were explored. Final analyses were delayed (because the COVID-19 outbreak led to a delay in obtaining all data from the SPS) and will be reported separately.

Overview and overall aims

The aim of the health economic evaluation was to estimate the change in health-related costs and outcomes following the implementation of Scotland’s smoke-free prison policy. The cost-effectiveness of the policy was evaluated over two time periods: first, within the time period of the study (within-study analysis) and, second, over a lifetime (long-term analysis), for both operational staff and PiC, from the perspective of the NHS and including nicotine-related products. The within-study and long-term analyses are reported in line with current best practice. 58 Further detail is provided in Report Supplementary Material 3.

Within-study analysis

Uncertainty

Uncertainty was explored in two SAs:

1. Sensitivity analysis 1 (SA1). The base-case analysis excluded PiC’s costs and outcomes for the open prison, where possible; a SA was conducted where these data were included. A summary of where it was possible to include and exclude the open prison for resource use and outcomes is presented in Report Supplementary Material 3, Table 4.

2. Sensitivity analysis 2 (SA2). In the base-case analysis, medications that were indicators of treatment for nicotine dependence and for smoking-related illnesses or associated symptoms were included only; a SA was conducted where all medications were included.

Long-term analysis

Managing policy implementation

Several dimensions of project management in relation to removing tobacco from prisons were discussed by participants. First, allowing good time – as far as possible – was regarded as helpful, as it gave prisons the opportunity to prepare for the implementation of smoke-free policies and for PiC (and staff) to adjust to changes and prepare to abstain or quit tobacco (‘You can’t start too early I don’t think,’ interview 11). There were some suggestions that it is helpful to set a ‘clear date’ for implementation to generate the impetus to drive forward preparatory work:

. . . we started to prep for going smoke-free [several years] before we actually did. Because we kept getting told it’s going to be introduced, it’s going to be introduced. But it never did. But rather than stand down our preparation . . . we just ran the meeting quarterly to keep it . . . everybody’s agenda . . . as soon as we had a clear date we just cranked things up.

WP1, interview 16

Second, participants articulated the importance of appropriate governance arrangements. This included an adequately resourced implementation team to guide and support prisons, and local implementation groups within prisons, involving local personnel with sufficient capacity and credibility/seniority, to take forward the smoke-free policy. Other examples that participants discussed related to the use of a ‘readiness assessment’ tool to drive and monitor progress (ensuring that associated documents were not too onerous to complete), and processes for foreseeing and responding promptly to potential risks associated with removing tobacco from prisons. Regular and open communication at all levels about progress, successes and challenges in preparing to go smoke free was described as important, as were opportunities for peer-to-peer support and sharing of good practice across the prison estate and from other jurisdictions that had implemented a smoke-free prison policy:

. . . rather than . . . [saying] ‘Right, governors! This is what you’ve got to do, crack on!’, we really did try to go in and support them . . . We would do our reports and we would have a look at their report that they’d submit each month and . . . we would go in and say, ‘Well, we were concerned about this’ or actually, ‘Yes, we’re really happy with your progress’ . . . It was . . . colleagues trying to help other colleagues . . .

WP1, interview 13

Third, participants highlighted that good partnership working, including with external partners, was likely to be beneficial, including prison and health services having shared responsibility for implementation, supporting one another in their respective roles and communicating regularly to monitor progress and identify issues. Support from all functions in prisons (a ‘whole-prison approach’) in preparing for smoke-free rules was also considered beneficial:

I think it can feel for the health providers that this is kind of their project and they’re on their own and it’s just about delivering smoking cessation with as many [PiC] as you can as quickly as you can, but that really isn’t actually the biggest issue. The biggest issue is the whole-prison approach to this and what everybody’s doing to chip in.

WP1, interview 6

Finally, our interview data highlighted the need for ongoing management of smoke-free policies post implementation to support continued success (e.g. strategies for effective management of nicotine dependence among new arrivals) and to support efforts to reduce any unintended adverse consequences of smoke-free policies (e.g. addressing contraband tobacco black markets and supporting PiC who find smoking abstinence challenging).

Communication and engagement

Participants also described how extensive communication and engagement with PiC, staff and other stakeholders about the forthcoming changes to smoking rules could aid successful implementation:

Communication was absolutely crucial and vital in everything that we did . . . we just made sure that it was always communicated where we were at with the project, what the next steps were.

WP1, interview 19

Ideas about ways to build awareness, support and acceptance for smoke-free prison policies included using multiple communication channels to publicise the policy (e.g. posters, leaflets, prison television screens, prisoner radio, announcements over a loudspeaker system, displays in the prison library, publicising smoke-free rules in the visitor centre); cascading information via peer mentors/PiC representatives to enhance message credibility and reduce misinformation and rumours; repeating communications over time to maintain visibility, dispel beliefs that smoke-free rules would not be implemented as intended and ensure that new arrivals were well informed of the impending changes:

It was about the continued promotion of [smoke-free policy]. . . . [C]hanging the posters every time, so that it doesn’t become another piece of paper stuck on the wall. They changed design, they’d change the patterns on it, just to make it more eye-catching, to raise the awareness. . . . Lots of leaflets . . . articles on the prison radio . . . we couldn’t over publicise it, we couldn’t overcommunicate it, there’s no such thing as overcommunication. We just had to keep communicating in different formats for it.

WP1, interview 7

Given that smoke-free rules can be met with negativity or concern from some PiC and staff, participants suggested that it was important to explain the rationale for the policy in positive terms and highlight benefits of eliminating active/passive smoking for the health of everyone working and living in prison, although acknowledging potential short-term problems that might arise:

It’s always key to get the majority of [PiC] to see that we’re doing this for the right reasons and for them not to buy in into any potential trouble . . . [many] influential prisoners would actually buy into this, because they are . . . into their fitness a lot of them.

WP1, interview 4

Strategies to communicate the underlying rationale included using testimonials/quotations from PiC who had successfully quit smoking, debunking myths (e.g. ‘smoking has a calming effect on the body’, ‘smoke-free prisons cause riots’), developing written communications and having briefings for staff (e.g. on contingency planning), and linking smoke-free policies to aspirations among many PiC to live healthier lives. Likewise, some participants thought it was important to acknowledge and mitigate concerns about potential risks of a smoke-free prison policy in written and oral communications with frontline staff and during planning:

The other thing we needed to combat was a lot of naysayers saying that prisoners are going to go extremely violent, they’re going to act out, they’re going to do all these things, they’re going to find other fire equipment and burn down your prisons, I mean, you know, scaremongering going on. And of course we didn’t just dismiss it, clearly we took it very seriously.

WP1, interview 1

Participants suggested that consulting and involving PiC and staff in preparations for the implementation of smoke-free policies and, crucially, acting on feedback were potentially beneficial [‘Straightaway, get them (PiC) involved. They come up with innovation, of ways of how they can cope (without tobacco). And use their ideas on that,’ WP1, interview 7]. Good engagement with the family and friends of PiC, courts and relevant community groups was also mentioned.

Smoking cessation support

Participants stressed that the availability of evidence-based support to help PiC abstain or quit smoking was crucial to the successful implementation and the ongoing management of a smoke-free policy. Although types of smoking abstinence/cessation support and delivery arrangements varied within and across jurisdictions, some potentially transferable ideas were discussed. It was suggested that service capacity could be increased by training prison and/or health-care/drug treatment staff to deliver brief advice or enhanced support on quitting or abstaining to PiC, with appropriate support for financial or logistical issues. Some participants also suggested that involvement of PiC in delivering smoking abstinence or cessation advice may potentially help to ensure that support was available during evenings and weekends and reached those who respond more effectively to peer support.

Participants described various ways to try to address potential barriers to the uptake of smoking abstinence/cessation, for example through actively promoting services and encouraging PiC to seek help, ideally pre implementation. These included posters around the prison, leaflets for PiC and visits to halls by staff/peer mentors to publicise SSSs and carry out carbon monoxide (CO) monitoring (to increase motivation to change smoking behaviours):

We used to visit the wings . . . put a little bit of a display, I’d have the carbon monoxide monitor as well. So, we’d test a few lads and, obviously, a lot of them were quite shocked at how high they were. That worried them, and that was quite a good incentive tool as well, the carbon monoxide monitor, they all wanted to have a go on that, so that was good. Then, obviously, that made them see, obviously, ‘We have got smoking cessation here . . . if you need any support’.

WP1, interview 15

Participants also described organisational strategies that could encourage PiC to cut down or stop smoking. These included ceasing or reducing tobacco sales several weeks prior to the implementation date and creating smoke-free wings (e.g. as part of a phased approach). Some noted that engaging PiC in smoking cessation programmes may present opportunities for other health promotion (e.g. nutrition).

Interview participants from E&W generally believed that e-cigarettes had played an important role in the management of nicotine addiction in prisons and the successful implementation of the smoke-free prison policy:

We really pushed to have supplies of that in the prison before we went smoke-free. And I think that that is one of the crucial factors that made it successful.

WP1, interview 8

Participants suggested that e-cigarettes (or other smoking cessation aids) should be introduced in good time prior to smoke-free rules, together with information on proper use of e-cigarettes, so that PiC could switch from smoking to vaping if they wished and to minimise incorrect/ineffective product use. However, some worries were expressed about the potential misuse of e-cigarettes by PiC and the potential, as yet unknown, health effects of vaping.

Other measures to support policy implementation

Other measures that participants said could support the successful implementation of a smoke-free policy included increasing access to a range of activities to help PiC to achieve and sustain smoking abstinence (e.g. opportunities for physical exercise; prisoner reading groups; diversions such as puzzles, crosswords, colouring and knitting) and improving facilities (e.g. by painting cells or common areas to remove nicotine stains). Participants spoke about the potential need for additional support measures for PiC who are vulnerable to reduce harms and alleviate anxiety:

. . . the key ones . . . in preparation for prisons going live, is about making sure that there is support available to those men and women who are struggling . . . whether they are hard to reach, have mental health issues [at risk of self-harm or suicide]. But equally, we have to watch for prisoners who are of a significant age, and may have smoked for 60 or 70 years.

WP1, interview 5

With respect to prison staff, participants suggested that it may be helpful to offer access to health clinics and cessation support to reduce opposition to new smoke-free rules, particularly if these have an impact on staff smoking behaviour.

Fixed-site measures

Phase 1 measures of PM_2.5 concentrations demonstrated high levels of SHS in residential halls in Scottish prisons, although considerable variation existed between prisons (Figure 3, Table 2, and see Semple et al. 11) and partially informed the decision to introduce the smoke-free policy across Scotland’s 15 prisons. 4 Measures in the week of implementation of the smoke-free policy demonstrated a substantial fall in every prison (overall median reduction 81%) in PM_2.5 concentrations compared with concentrations in 2016. 32 This was sustained or further improved 6 months after implementation (p < 0.001 overall); median PM_2.5 concentrations of the May 2019 6-day fixed-site measurements were reduced by > 91% compared with 2016 concentrations. 31

FIGURE 3.

Area monitoring results from 2016, 2018 (immediately pre and post ban) and 2019. Dashed horizontal line represents the World Health Organization’s (WHO) annual guidance value for PM_2.5 (10 µg/m³). 70 At the time this work was carried out we used the 2005 WHO Air quality guidelines. The WHO have subsequently (September 2021) released new guidelines71 with an annual average PM2.5 guideline of 5 µg/m³.

Mobile ‘task-based’ measures

Analyses of phase 1 data showed that exposures were likely to be highest for operational/residential staff. Analyses of the post-ban (phase 3) task-based measurements showed that all were low in 2019 (the only task with a median > 10 µg/m³ was cell searches), and all were lower in 2019 than in 2016, with an average reduction of 70%. Reductions were marked in areas/for tasks that had high levels in 2016 (e.g. a reduction for morning cell unlocking of 89%) and were lowest for cell searches (median concentrations reduced by 74%). Estimates of time-weighted average exposures for staff working in residential areas of the prisons in 2019 no longer showed the marked diurnal variation that was evident in phase 1, nor the high peak exposures first thing in the morning during cell unlocking (see figure 1 in Semple et al. 11). Indeed, the time-weighted average exposures in 2019 demonstrated reductions of > 90% across all shifts, and all time-weighted average exposure concentrations were lower than PM_2.5 concentrations measured in outdoor air at the nearest measurement centre (see Demou et al. 31 for more details).

Return rates, sociodemographic and work-based characteristics

The tables in Report Supplementary Material 1 show the basic frequency distributions of all staff survey items at each phase (numbers and percentages rounded to integers for simplicity of presentation; similar documents were provided to prison staff as feedback). These show the questions as asked in the surveys, but not in the order in which they appeared. The results below are based on these distributions, with most tables showing collapsed categories and between-phase differences tested via chi-squared tests (categorical variables) or F-tests (continuous variables).

Surveys were returned by 1271 (27%) prison-based staff in phase 1, 1494 (31%) in phase 2 and 757 (16%) in phase 3. There was considerable between-prison variation in return rates at each phase (Table 3), despite repeated reminders about the online survey for staff. The variation is likely to reflect staff access to appropriate facilities to complete the questionnaire and pressures on staff time in their daily work, as well as their interest in completing the questionnaire. In each prison, we relied on our designated staff contact to forward the link to the survey and the reminders. Given the levels of response overall, and variation in response by prison and phase, all figures presented below should be interpreted with caution. For published papers relating to results on opinions,39,72 simple weights were derived to adjust for this variation; unweighted and weighted results were virtually identical.

Apart from slightly smaller proportions of males and operational staff in phases 2 and 3, sociodemographic and work-based characteristics were very similar across phases (see Report Supplementary Material 1, Tables 128–132). The proportion of males reflects that of the SPS as a whole (69% in March 201974) and the age breakdown was broadly similar, although there were fewer in the younger and older age bands among TIPs study respondents than in the SPS as a whole (in the SPS as a whole, 28% were aged ≤ 34 years, 49% were aged 35–54 years and 23% were aged ≥ 55; equivalent figures for the TIPs study were 24%, 60% and 16%, respectively, in phase 1; 25%, 56% and 19%, respectively, in phase 2; and 22%, 57% and 20%, respectively, in phase 3).

Self-report exposure to second-hand smoke/second-hand vapour at work

The mean reported average exposure to other people’s cigarette smoke in a prison reduced from 16.3 hours per week in phase 1 to 12.7 hours per week in phase 2, and then markedly (to 3.6 hours per week) in phase 3 (p < 0.001), and the proportion of staff reporting no exposure rose from 19% (phase 1) to 27% (phase 2) to 74% (phase 3) (p < 0.001). Despite very careful question wording, it is possible that, in phase 3, some staff interpreted this question as referring to e-cigarette vapour.

In phases 2 and 3, staff were asked roughly how often (never, sometimes, often, always) they were exposed to ‘other people’s smoke’ and ‘vapour or smells from other people’s electronic cigarettes’ in a range of locations. Figure 4 highlights the marked drop in any (sometimes, often, always) ‘smoke’ and increase in ‘vapour’ exposure between phases 2 and 3. As smoking/vaping was/is permitted in cells with closed doors and during outdoor exercise only, it also suggests that some staff were identifying illicit activity.

FIGURE 4.

Staff (%) reporting any exposure to cigarette smoke/e-cigarette vapour in various location: phases 2 and 3 (with significance of difference, p-value).

Opinions on (rules about) smoking and tobacco in prisons

The proportion of staff reporting that the current rules about tobacco smoking among PiC were not strict enough (vs. too strict/about right) dropped from 67% in phase 1, when smoking was permitted in cells within residential areas and outdoors only, to 51% in phase 2 and 23% in phase 3 (p < 0.001). Over time, the proportion reporting the rules were not well followed by PiC (vs. very/quite well followed) dropped from 43% (phase 1) to 33% (phase 2) to 16% (phase 3) (p < 0.001) (see Report Supplementary Material 1, Tables 20 and 21). Similar questions on e-cigarette use were asked in phase 3 only, when 29% of staff said the rules were not strict enough and 24% said that they were not well followed.

In all phases, staff (and PiC) were asked a series of opinion questions around prison smoking bans, comprising seven items with five answer options, and a single item on agreement with increased smoking restrictions in Scottish prisons (see Report Supplementary Material 1). We have published analyses of phase 1 data40 reporting the structure of opinions in respect of prison smoking bans (whether or not more than one dimension), and correlates of that/those dimension(s). Exploratory factor analyses (principal components analysis, varimax rotation) distinguished two identical factors for both groups, which explained 16% more total variance than an analysis constrained to a single factor. The two factors, the first representing ‘positive about bans’ opinions and the other representing beliefs that ‘bans will be difficult’, were saved and formed the dependent variables in analyses of association.

Staff scores were significantly (p < 0.001) higher than those of PiC for ‘positive about bans’, but lower on ‘bans will be difficult’. In multivariable analyses, staff ‘positive about bans’ factor scores were significantly associated with not smoking, better general health, more respiratory symptoms and working in an operational role, whereas reporting fewer sensory symptoms and lower measured prison SHS levels (see Chapter 2, Fixed-site monitoring), but not own smoking, were independently associated with ‘bans will be difficult’. 40

Further published analyses72 compared opinions of both staff and PiC in respect to prison smoking bans (as above) and the use of e-cigarettes among those in custody across all three phases. Response categories were collapsed (if necessary) so that all were binary outcomes and differences were tested using logistic regression analyses, adjusting for sociodemographic variables associated with both phase and opinions. Table 4 shows these results, along with those of identical analyses relating to more general opinions on smoking in prisons. Staff opinions shifted over time, with differences between phases 1 and 3 and, for several items, between phases 1 and 2 and/or 2 and 3. Support for prison smoking bans increased in anticipation of/following the ban, whereas there were large decreases in the proportions agreeing that prison smoking bans ‘cause a lot of trouble’ and ‘are hard to enforce’, particularly between phases 2 and 3 (note that concerns that bans ‘cause a lot of trouble’ had increased in staff between phases 1 and 2). Staff support for e-cigarette use by PiC increased in anticipation of the ban, remaining stable following its implementation. Agreement that ‘staff should be protected from cigarette smoke at work’ was almost universal at each phase; agreement that ‘prisoners who don’t smoke should be protected from cigarette smoke’ was also very high throughout. Agreement that smoking should not be allowed in any indoor or outdoor prison areas was highest in phase 3, when agreement with both ‘there should be more NHS support for prisoners who want to stop smoking’ and ‘prisoners should not be forced to stop smoking’ was lowest.

Opinions about e-cigarettes generally

In phases 2 and 3, staff were asked a standard question about the relative harms of e-cigarettes and ‘regular cigarettes’. Although the proportion who thought e-cigarettes were (a lot) less harmful or completely harmless remained stable (37% in phase 2 and 40% in phase 3), an increased proportion (from 20% to 27%, respectively) thought that they were equally or (a lot) more harmful and a decreased proportion (from 43% to 33%, respectively) reported that they ‘did not know’. As Table 5 shows, other opinions about e-cigarettes also became more negative among respondents over this period. Differences between phases 2 and 3 were greater in respect of increased agreement that e-cigarettes are ‘addictive’ and ‘raise safety issues’, and increased disagreement that they are ‘as good as other nicotine replacement therapies to help people stop smoking’ and ‘should be allowed in public places where tobacco cigarettes are not allowed’.

Only phase 3 included a series of questions about staff experience of e-cigarette vapour during their daily work (see Report Supplementary Material 1, Tables 41–45). Around 50% of responding staff indicated that they thought that e-cigarette vapour was ‘bad for [their] health’, and 40% that it ‘has an unpleasant smell’; one-quarter to one-third indicated that it made them cough, irritated their eyes or affected their breathing.

Opinions about the introduction of the smoking ban in Scottish prisons

In phase 3, staff were asked their opinions about the lead-up to, and implementation of, the smoking ban. As Table 6 shows, around four-fifths thought that the preparation was good, people were kept well informed and introducing e-cigarettes had ‘made the smoking ban easier for both prisoners and staff’. Almost three-quarters agreed that the introduction of the ban had been ‘largely trouble-free for the prison service’, five times the proportion who disagreed with this statement. Three-quarters also believed that the ban had ‘led to improved working conditions for staff’ and ‘made the prison smell better’, and around half believed that it had helped improve staff health, the quality of life and health of PiC and made the prison look better; only about 1 in 10 disagreed with any of these statements. However, almost half agreed that the ban had ‘led to more use of illegal drugs’, between one-quarter and one-third that it had ‘made prisoners more anxious’, led to more physical or verbal assaults or aggression and ‘made prisoner behaviour more difficult to manage’, and very few thought it had led to more purposeful activity or made PiC happier.

Phase 3 also included questions on how much of a problem certain issues were at the time. As Table 7 shows, by far the most serious perceived problems related to PiC adapting e-cigarettes for drugs or adapting their chargers for various purposes. Around half the staff also identified bullying over e-cigarettes among PiC as a moderate/serious problem and one-quarter to two-thirds thought tobacco-related debt, bullying and illicit trade or use were moderate/serious problems.

Staff smoking

Report Supplementary Material 1, Tables 109–126, report on staff smoking and e-cigarette use. In each phase, around half the staff returning a survey had ever smoked and 1 in 10 currently smoked tobacco cigarettes. Electronic cigarette experimentation increased between phase 1 and phase 2, and current use increased between phase 2 and phase 3.

Among the (relatively small numbers) of current tobacco cigarette smokers, there was a suggestion of reduced craving in phase 3 after implementation of the ban, but no evidence that cigarette consumption or time from waking to first cigarette had reduced, nor of increased efforts to stop smoking. In phase 3, staff who smoked tobacco cigarettes were asked whether not being able to smoke at work had become any easier or harder since implementation of the ban; 29% reported it was (much) easier, 62% about the same and 9% (much) harder.

Staff self-reported health

Frequencies for staff self-reported health are shown in Report Supplementary Material 1, Tables 81–108. Staff ratings of general health remained stable across the study (‘very good’ vs. ‘good’ vs. ‘fair’/’bad’/‘very bad’ reported by 35%, 53% and 12% in phase 1, respectively; 33%, 56% and 11% in phase 2, respectively; and 32%, 54% and 14% in phase 3, respectively). Self-reported doctor-diagnosed asthma also remained stable (20% in phases 1 and 2, 19% in phase 3), as did days off work for health reasons in the past year (50%, 53% and 53% reported none in phases 1–3, respectively; 19%, 19% and 17% reported ≥ 28 days). Past year GP visits reduced slightly (26%, 28% and 31% reported none in phases 1–3, respectively; 31%, 27% and 24% reported three or more, respectively; p = 0.020). GP visits in the past 3 months for a cold, breathing problems or eye irritation (84%, 86% and 88% reported none in phases 1–3, respectively; 7%, 5% and 4% reported two or more, respectively; p = 0.058) changed little, and the number of prescribed medicines for a cold, breathing problems or eye irritation over the past 3 months was stable; over-the-counter purchases reduced between phase 1 and phase 2 (40%, 32% and 32% reported any in phases 1–3, respectively; p < 0.001). As Figure 5 shows, this pattern was evident for eight of the nine International Union Against Tuberculosis and Lung Disease self-reported past month respiratory and sensory symptoms, the only exception being eye irritation, which decreased between phase 2 and phase 3. These patterns may reflect time-of-year effects. The five ‘your health today’ items and visual analogue scale (‘best’ to ‘worst’ health) on the EuroQol-5 Dimensions (EQ-5D) were stable across phases.

FIGURE 5.

Staff (%) reporting past 4 weeks’ experience of each symptom in each phase (with significance of difference, p-value).

Staff focus groups: phase 1 (pre announcement)

Seventeen focus groups and two paired interviews were conducted with staff in 14 of Scotland’s 15 prisons during TIPs phase 1 to explore perspectives on current smoking rules for PiC and on potential implementation of a smoke-free policy in prisons in the future. Key findings from the focus groups are published elsewhere. 54,55

Perspectives on the (then current) smoking rules for people in custody

At the time data were collected, PiC were permitted to smoke in designated rooms (cells) and certain outdoor spaces (the use of e-cigarettes in prison was prohibited). These smoking rules had come into force in 2006 when restrictions on smoking in public places were introduced in wider society in Scotland. Some participants suggested that the introduction of partial rather than comprehensive smoke-free rules in 2006 was due to concerns about the consequences of totally prohibiting PiC from smoking, for example risks of negative organisational impacts (‘a lot of trouble’), as well as understandings that prisons were homes for PiC. Some staff expressed disappointment that the prison service had not taken the opportunity then to fully protect non-smokers from exposure to SHS at work, favouring the ‘rights’ of PiC over theirs:

It [decision about smoking rules in 2006] was based on human rights, it was based on the prisoner having human rights. The argument’s always been from staff, well, what about our human rights? We don’t have a choice, we have to go into a smoke-filled environment.

ExS, I2

Perspectives on the potential future smoke-free policy

In the focus groups, staff deliberated about issues raised by any future comprehensive smoke-free policy. Part of the discussion centred on the perceived fairness of restricting PiC’s smoking behaviours. One reason smoke-free rules were considered potentially unfair was because they would reduce the choices of PiC and remove something PiC associated with pleasure. It was pointed out that PiC would be one of only a few groups in society subject to potentially prolonged periods of mandated smoking abstinence, as smokers in the general public were free to move between smoking-permitted and smoke-free spaces. In addition, staff commented that it might be an odd situation if controlled medications such as methadone were available in prisons, but tobacco, a legal substance, was not:

And that’s the big contradiction here, if they ban smoking, right. It’s OK for the Prison Service to ensure that somebody can get their methadone, or their valium, or whatever drug they happen to be on. But woe betide, they can’t have a cigarette. The cigarette is legal . . .

NS, L5

However, on balance, staff generally believed that smoking restrictions for PiC were equitable, justifiable and necessary to protect the health of non-smoking staff and PiC (provided support was available in prisons to help with nicotine dependence):

They’ve got a duty to look after those who don’t smoke. Forget staff . . .

NS, G5

Prisoners and that as well, yes.

S, G1

So, see prisoners that don’t smoke, the amount of guys that I’ve had to allocate into a smoking cell when they’ve been a non-smoker because we’re chock-a-block.

NS, G5

Some staff saw involuntary exposure to SHS in prisons as a form of injustice, particularly given that the adverse effects of SHS had been known for some time: ‘the time it’s taking. The facts are out there that passive smoking is harmful to your health. It should be finished in the establishments, end of’ [S, A(2)23].

Discussion about a future smoke-free policy for PiC also focused on practical issues in respect of making the transition from a high rate of tobacco use among PiC to smoking abstinence. Concerns were expressed that smoke-free rules for PiC would be unworkable because of the significance some PiC placed on smoking (e.g. to pass time or alleviate negative emotions) and the role of tobacco in prison culture (e.g. a social activity, form of currency):

I think it’s unworkable up here . . . I think . . . there are certain things that keep the roof on a situation, if you pardon the analogy. And for me, in here anyway, it’s the ability for them to smoke. And the likes of TV and stuff. I think you take that away from them, I think you’re opening another can of worms.

NS, A(1)1

In contrast, others expressed more confidence that a change in smoking rules was achievable because similar policies had been introduced in other institutions caring for high-smoking prevalence populations (e.g. state hospital) and the prison service had succeeded in the past in managing other challenging organisational changes:

. . . there’s plenty of things that we’ve maybe done as a service over the decades where we’ve taken something away and people have gone ‘Oh they’ll never cope with that, and, we’ll get this and we’ll get that’. And maybe we’ve had a . . . you know, a few incidents or a couple of months of unrest, but then it settles down again . . .

NS, N3

A range of potential negative consequences of introducing smoke-free rules for PiC were raised: reduced wellbeing, self-harm and suicide, confrontations, violence, riots, contraband, bullying, use of alternatives (e.g. smoking teabags, substance use) and increased staff stress:

It will distress some people [in custody]. I know, because when I was smoking, if I went into a situation where it’s like, right, OK, you cannot smoke now, it would be torture, it would be absolute torture, especially when they’re already distressed . . . a cigarette can really help them calm down . . .

ExS, C1

I think there’s potential for conflict. I think there’s also . . . it’s now . . . it’s just something else just the same as they get drugs in to jail, it’ll be something else for them to smuggle and abuse.

NS, H3

Potential negative consequences of smoke-free rules were discussed by all groups as significant and important, but not necessarily a reason not to change the smoking policy. There was broad consensus across the groups that staff had the experience to manage any problems associated with banned substances in prisons, and some suggested that possible problems would be short-lived, waning once PiC adjusted to the ‘new normal’:

I think it would be a big issue at first, but then it’s like anything, people get used to it. People never thought the [community] smoking ban would come in, and it did, and then they got used to it. And I think there is, I think what we’re talking about . . .

NS, E6

We’d have to suck it up for the first wee while.

NS, E3

. . . in the population of the prison, I’m going to think, my opinion is . . . in the main, they would get, people would get used, the prisoners would get used to it.

NS, E6

At the same time, staff highlighted the need for measures to mitigate the risks of removing tobacco from prisons. First, there was a need to ensure that PiC and staff were well informed about any planned changes to smoking rules, with adequate time to prepare for the future removal of tobacco: ‘everybody would need to know that it was coming on this date and this is happening. The same as they did in the pubs and clubs’ [NS, A(3)13]. Second, they suggested the importance of involving PiC in planning activities, including identifying people who were willing to champion no smoking rules among their peers:

. . . if you were to get maybe a few prisoners involved who were willing to take this and encourage others as well, rather than it all just coming from . . . it’s . . . you know, it’s something that prison officers are coming out with. If you can get them to participate . . . in this process of how we could bring it in and what would be acceptable in the prisons, that might work a wee bit better.

ExS, A(4)25

Third, some staff identified a need to allocate adequate resources to the smoke-free project, ensuring that frontline staff had full management support. Fourth, participants identified opportunities for learning from other prisons systems that had introduced smoke-free policies and potentially piloting or phasing in smoke-free policies in some residential areas in prisons or parts of the prison estate.

Finally, staff identified the need for PiC to have access to the behavioural support and tools required to move beyond or manage nicotine dependence in prisons:

We [should] ramp things up in custody, get the smoking cessation in place, people on it. If we can get the majority of the population to reduce their smoking prior to the date, your transition is pretty smooth. But if you don’t do any of the leg work . . . we’re gonna be smoke-free, they’ll have big budgets to pay, because there will be big issues.

NS, F14

Although prison staff were generally supportive of nicotine substitutes being available in prisons to help PiC manage without tobacco, divergent views were expressed about whether or not the use of e-cigarettes should be permitted in prisons [alongside nicotine replacement therapy (NRT), as reported in more detail in Brown et al. 55]. Some comments suggested that e-cigarettes could be important for PiC who would want to continue using nicotine or who might not find conventional smoking cessation methods appealing or effective:

I see the benefit in giving prisoners that option, because it’s their choice at the end of the day. Not all of them will want to stop. It’s alright saying ‘give them the help and the benefit to stop smoking’, but most of them might not want to stop.

ExS, E4

Obviously, we can just bring it [smoke-free policy] in and we can say we’re doing it, and that’s the end of it. But to offer them a viable alternative that they might buy into [would be better].

ExS, D10

Some staff thought replacing smoking with vaping in prisons would be a ‘step in the right direction’, because e-cigarette vapour was believed to be markedly less dangerous than SHS to bystanders and might aid a difficult organisational change:

. . . I’ll probably be happier with them having something like that [e-cigarettes] than I would having to deal with second-hand cigarette smoke . . . it might still be a problem down the line and we might need to get rid of them, but if it’s a step in the right direction . . .

NS, H3

In contrast, others expressed anxieties about e-cigarettes being used by PiC because of incomplete evidence on the absolute risks of exposure to e-cigarette vapour:

I don’t think there is [currently] enough evidence to say [whether e-cigarettes should be allowed in prisons]. They are saying that they’re, for argument’s sake, 90 per cent less of a risk than it is with tobacco smoke. But there’s still a risk, and we still don’t know what that risk is, or what that level of risk is.

ExS, O7

There was also a great deal of discussion among staff about distinct potential risks of use of e-cigarettes in the prison context. For instance, staff commonly recognised that the repurposing of items was a part of prison culture and they expected that this would also happen with e-cigarettes (e.g. to conceal contraband, take drugs or charge mobile phones smuggled into prisons). Concerns were also raised about potential harms to staff or PiC from product defects or incorrect use of e-cigarettes:

You see the cynic’s working on me just now, and I’m thinking to myself . . . they’ll end up somehow being able to incorporate whatever drug they wish into the e-cigarette because they’ve got all day to sit and think about these things . . .

ExS, K3

Opinions on the impending smoke-free prison policy

Consistent with the views expressed by staff focus group participants in phase 1, several potential benefits and drawbacks of moving to smoke-free rules were reported by staff interviewed in phase 2. On one hand, anticipated benefits of the impending policy change centred on protecting prison staff from SHS exposures, creating a cleaner and more pleasant working environment for staff and health benefits for PiC who quit or abstained from smoking in prison as a result of the change in smoking rules:

It was something that I was pushing quite a bit for anyway especially on the staff side . . . being a non-smoker and never smoked before I was feeling the effects of somebody that smoked and I was thinking about my own health.

NS, A8

Some staff also suggested that the families of PiC might benefit too, as a result of potential financial savings and children growing up in smoke-free homes, if those leaving custody continued not to smoke post liberation. It is notable that some participants reported that they or other prison staff had become more positive or accepting of the smoke-free policy in the preparatory phase, as a result, for example, of work that was under way in prisons to publicise the forthcoming change in rules among PiC (see Perspectives on measures to support implementation of smoke-free policy in prison).

They’ve [PiC] been told well in advance for it to sink in and it’s been what everyone’s speaking about, so I think that’s a great, great, great, help that they’ve had time to think about it and they know that it’s happening. So, aye, I’m a wee bit more positive on it now, but we’ve still got a few months so we’re working on it.

NS, A3

On the other hand, potential drawbacks of the smoke-free policy still centred on concerns about restricting the individual choice of PiC in respect of smoking [‘If they’re going to smoke, they’re going to smoke, so why not let them smoke outside? . . . that’s the Scottish Government for you, wanting a healthier lifestyle’ (NS, A2)] and the potential for unintended adverse consequences following the removal of tobacco from prisons, as described in Perspectives on potential future smoke-free policy. Consistent with the phase 1 staff focus group findings, there remained a belief that prison staff would find a way to manage any problems that might arise following the implementation of the smoke-free prison policy.

Opinions on making e-cigarettes available in prisons

To our knowledge, single use e-cigarettes had not yet gone on sale in the prisons when these phase 2 staff interviews were conducted, although discussions about their introduction were taking place. In the phase 2 interviews, staff expressed similar opinions about the potential benefits and risks of making e-cigarettes available for use in prison by PiC to those expressed by staff in the phase 1 focus groups. 55 Some regarded e-cigarettes as a safer alternative to tobacco smoking for users and bystanders and suggested that e-cigarettes could reduce potential problems associated with smoke-free prisons for PiC, staff and the prison service. Some likened allowing PiC to use e-cigarettes to harm reduction practices for PiC dependent on illegal drugs such as heroin:

. . . I think we have to offer the prisoners something, and that would soften the blow to nothing, and they use them outside, and if they go down the line of the same as we’re doing here [with respect to current smoking rules], they have it in their cell and they have it in the exercise yard, end of . . . but to just go from tobacco to nothing I think would be a huge risk, and if we can bring in the vapes, it would soften up.

NS, B5

In contrast, several potential risks of making e-cigarettes available in prisons were mentioned in the staff interviews, including potential health harms for PiC who use e-cigarettes and for staff exposed to e-cigarette vapour, possible financial burdens for PiC, problems if PiC are unable to make e-cigarettes last until the next delivery from the prison shop (canteen) and continued high rates of nicotine addiction in the prison population:

Have they been proven safe? What are we going to do in another year, 18 months when you’ve done your studies, there’s other people done studies, ‘Ah, those e-cigarettes are not safe! Right, [their name], go and take the e-cigarette off them’? ‘Oh, right, no bother!’

ExS, E2

. . . you can see what’s going to happen in a few years’ time, you’re going to have people who are very addicted to the e-cigarette, understandably, they’re going to be addicted to nicotine . . .

Unknown, C4

There was also some unease that e-cigarettes might create organisational problems, as it was anticipated that some PiC would find alternative uses for e-cigarettes that violated prison rules, for example to charge mobile phones or take illegal drugs. Hence, there was support among some staff for making e-cigarettes available in prisons for a limited period to reduce potential harms:

I think just the fact that they can be used to charge mobile phones . . . it’s just a big no-no unless they can find a way round that. ‘Cause it would just be a security nightmare.

NS, B2

I think it [e-cigarettes] could be used in the run up, but once the ban’s actually in place, I don’t think there should be any sort of, substitutes because we’ve got a whole year [leading up to smoke-free policy], so I think everybody should be aware of the fact that it’s coming.

S, B3

Staff continued to express some confusion about e-cigarettes generally, and there were requests for information on the specific products that would be available to purchase in prisons.

Perspectives on measures to support implementation of smoke-free prison policy

Preparations in prisons for the implementation of the smoke-free policy were at a relatively early stage at the time of these phase 2 staff interviews (9–12 months prior to implementation). Local co-ordinators and implementation teams were planning and starting to deliver a programme of work to aid the transition to smoke-free rules, led by the national team at SPS headquarters. A member of staff with responsibility for local policy implementation anticipated that the governance arrangements for the transition to smoke-free rules would confer benefits, for example consistency in the implementation of smoke-free rules across the estate and an effective means of sharing learning and good practice. One of the key preparations to date, as reported by staff interviewees, was a communications campaign to raise awareness of the forthcoming policy among PiC, including ‘countdown’ posters in all prisons:

There is information [about the smoke-free policy] coming out quite regular, there is a notice every month now, just a countdown basically, there’s 10 months to go, there’s 9 months to go.

NS, B3

There was support among staff for plans to increase and extend communications in subsequent months, because they expected clarity and dialogue with PiC and staff to be key to the successful implementation of smoke-free rules:

. . . I’m aware that some of the feedback from prisoners and staff will be that they’re not really quite sure what’s happening [about specific details of the smoke-free policy] and to some extent that’s because we’ve not had definitive stuff to put out . . . now that things are starting to progress, we will increase our communication, that’s really our main sort of strategy, I think, is letting people know what is happening, ‘Here’s what’s going to happen, here’s the support that’s available and here’s how you access it’.

NS, A1

Some suggested that it would be beneficial for communications to be delivered through multiple channels and include the benefits of stopping smoking, the rationale for the smoke-free policy and how it would be implemented, and the support available to help PiC to quit or abstain from smoking, including information on tobacco substitutes and if/when e-cigarettes might be available. Staff explained that more detail about the smoke-free policy/e-cigarettes and basic information/training in respect of smoking abstinence/cessation would help with answering questions from PiC, encouraging and assisting their quit attempts and avoiding or diffusing potentially challenging situations. Some expressed an interest in learning from the successes and challenges of the recent implementation of a smoke-free prison policy in E&W. In addition to sharing information, staff suggested that it would be beneficial to consult and involve PiC and staff in the transition to smoke-free rules:

I suppose a lot of things in the prison is about good communication, good engagement, early engagement, involving prisoners, as opposed to doing it to them, doing it with them. That’s how we have set up for the local smoke-free team, we’ve had engagement with the prisoners but we’ll be, once we get into the new year, settling down and have a contribution from the prisoners within the forums that we’ve got . . .

S, B4

Analysis of the interview data suggested a good correspondence between the requests and suggestions for communication and engagement strategies for the smoke-free policy made by frontline staff and the plans and ideas discussed by other SPS staff directly involved in and responsible for policy implementation.

Another major focus for staff interviewed in phase 2 was how to support PiC to reduce, abstain or quit smoking, ideally prior to implementation of smoke-free rules. Their requests, ideas and plans for strengthening smoking abstinence/cessation support in prisons related to three main areas. The first was increasing the capacity of the prison smoking cessation service and encouraging uptake among PiC who smoked, for example by training prison officers to provide specialist smoking cessation support or employing additional specialist health-care staff. Second, they suggested expanding support options and tools in prisons to help individuals to stop smoking (e.g. informal encouragement/assistance from prison staff, especially ex-smokers; peer-to-peer support among PiC; and by making e-cigarettes/nicotine substitutes (widely) available in prison):

It’s all about getting the nicotine substitute right for November [implementation], in my opinion, for a nicotine addict . . . it needs to be right, it needs to be available, it should be available a few months before . . .

S, E1

Third, the importance of providing distractions or alternatives to smoking in prison for PiC was highlighted, although some staff recognised that this was likely be challenging owing to factors such as the prison regime, funding and security restrictions in prisons. Examples of potentially feasible ideas mentioned by staff included dissemination of an in-cell fitness plan, giving PiC access to self-help digital versatile discs (DVDs) and increasing access to/encouraging greater use of the prison gym and/or recreation time where possible:

What do they do when they’re not smoking? How do you manage that? That’s a risk. Do we buy more gymnasium stuff? Do we offer more PT? Do we offer more exercise? All that kind of thing . . . so it’s about kind of working with prisoners as I say, focus groups, having that chat with them and see what they didn’t like, what they might like to kind of have in place and see kind of where we go from there.

NS, E4

Perspectives on the smoke-free prison policy

Staff generally expressed support for the smoke-free policy because of the need to eliminate SHS in prisons for the safety and comfort of staff and non-smoking PiC:

What a difference it makes to your life . . . you go home, you feel better, smell better. Particularly in [one] hall, they smoked very heavily, I found, and although I didn’t smell it during the day, but going to the gym and then having a shower and then putting my clothes back on, I could smell it on my clothes. I’m also asthmatic and I found it didn’t help my asthma to any extent at all.

NS NV, K6

Another reason staff favoured the policy was because of the perceived need to reduce smoking rates among PiC and support health improvement in prisons:

I was always supportive of it because the people who live here are in our care . . . should be really going out healthier than when they come in. You can’t be doing that effectively if they’re sitting in a cell for significant periods of time smoking tobacco . . .

ExS ExV, MA1

It was suggested that the total prohibition of smoking in prisons had created greater parity between rules in prisons and in other public spaces and workplaces in Scotland. Shared cultural norms in respect of smoking were felt to be important for individuals moving between prison and the wider community:

. . . it’s reflective of what’s happening outside . . . when they’re outside and they’re in society, they go into a restaurant, they can’t smoke in that restaurant. If they go into a pub, they can’t smoke in a pub . . . That’s life.

ExS-NV, B5

Some groups expressed disappointment about what some felt had been the lengthy timescale for prohibiting smoking in prisons relative to implementing smoke-free laws in wider society. In one group, a staff member suggested evidence from TIPs on SHS exposure levels in prisons had helped to precipitate the smoking policy change in Scottish prisons:

Ten years it took before they actually got around to actually enforcing it to prisoners, and the only reason they got around to doing that is because you [TIPs] got involved, and that’s the truth. If you hadn’t got involved, if you hadn’t done your studies, pointed out the fact that landings [residential areas] were still . . . passive smoking was still high in the areas and all the rest of the things that happened, the Scottish Government, and especially the SPS, would never have pushed it . . . so I would say thanks to you lot for getting involved and . . . saying, actually, there is a high level of passive smoking . . .

NS-NV, I7

Similarly, staff in another prison described the SHS results as a ‘turning point’ in drawing attention to a workplace hazard (SHS) that had become normalised and to some degree tolerated or accepted in prison:

. . . it’s the environment we’ve worked in for years, the culture, and it just shows you it needs experts and all that to come in and go ‘There’s a risk here’ . . .

Yes.

. . . because you just get caught up and that’s the norm. But it’s a far better place to work now.

We always, kind of, minimised it to a degree to ourselves . . . the second-hand smoke, they smoke in their cells, it’s not affecting us, but when you actually start to see how that smoke can go anywhere within that area the figures support it, you go, ‘Wow!’ That was the turning point, I think.

By contrast, in a few instances, staff voiced (strong) opposition to the smoke-free rules for PiC because they believed that PiC should have choice about smoking as a matter of principle and because it was seen to be unfair to prevent someone using a substance (tobacco) in prison that can legally be consumed in wider society:

It’s not as though we’re doing it to reflect what’s happening in society because that’s all about encouraging people to make healthy choices. We’re not getting people to make healthy choices.

ExS-NV, J2

These staff voiced a need for greater government investment in alternative (or additional) measures to improve PiC’s well-being and holistic health, including measures to help them understand and address the causes of substance use.

Some suggested that making tobacco a banned substance in prison might also be viewed unfavourably by some staff because it created another set of rules for them to enforce:

. . . there’s enough rules that we’re trying to enforce on a daily basis without them moving goalposts and moving the ideas. You can’t just tell folk what to do all the time . . .

ExS-NV, B2

Notably, there was broad consensus among participating staff, irrespective of levels of support for the new smoking rules, that the transition to smoke-free prisons had caused substantially less disruption than expected:

I think we were all expecting there to be a major problem when they actually stopped smoking and I think . . . for 2 weeks we sat on . . . you know, with bated breath waiting for it to happen, and it didn’t. . . . it was a very, very smooth transition, considering what we did with the population that I would suspect 80/90 per cent of them did smoke, you know. It’s an amazing difference . . .

SV, E6

The smooth transition was also said to have enhanced the popularity of the policy among staff:

[. . . in the lead-up to the ban some staff were saying] ‘We’re going to lose this jail, we’re going to lose this!’, really negative aspect of the potential problems. Then as it went on and on, we’ve seen that it’s not as big an impact as we thought it was. Then that negativity then moved to more of a positivity in relation to their health as well as the prisoners they’re dealing with . . .

NS-NV, FA

Staff mentioned several measures that they believed had facilitated the implementation of the smoke-free policy in Scotland’s prisons, including effective planning and oversight of smoke-free policy implementation by staff working in SPS headquarters and individual prisons, taking account of learning from other smoke-free prison systems, key stakeholders having good awareness of impending changes to smoke-free rules thanks to effective communication and engagement, contributions and support from prison staff and partner organisations (particularly the NHS), acceptance of new smoke-free rules by PiC, and availability of tools and support to help PiC to manage without tobacco or quit nicotine in prison.

Outcomes of the smoke-free prison policy

Issues relating to smoke-free policy in the open prison

Staff reported improvements in air quality in the open prison following the implementation of smoke-free rules (confirmed by objective SHS measures collected as part of the TIPs study). However, there were suggestions that the number of rule violations was larger than in closed prisons. Staff suggested that some clandestine smoking (particularly on prison grounds) was going undetected, partly because of competing pressures on staff time:

I think, from a staffing point of view, with the health and well-being, and the health and safety side of things, I think it’s improved it tremendously, from passive smoke, and the dangers of that. I know they maybe still go out in the fields, and stuff like that, and they’re still not allowed to, it’s their choice to do that. But certainly, in the accommodation, it’s a lot healthier for staff and other prisoners . . .

NS-NV, A9

The reason that the implementation of smoke-free rules had been more challenging in the open prison was because PiC could access (and legally consume) tobacco while on work placement in the community or on home leave. Staff recognised that it was very challenging for some PiC to abstain from smoking when returning to prison after spending time in the community and noted that serious violations of smoke-free rules could come at a personal cost to PiC who are at a critical point in their sentences:

It [smoke-free rules in the open prison] puts individuals, and staff, in a precarious position, whereby they’re out one minute, smoking, and they’re coming back into the establishment, and they’re not allowed to smoke . . . So, you know, we could be setting them up to fail, as such, in a way, as well. I know from stopping for a couple of years at a time . . . the least wee trigger, it doesn’t matter what it is, will pull you back into it.

S-V, A5

In this context, staff noted that the Quit Your Way Prison Programme (NHS Inform, Glasgow, UK) in the open prison was still experiencing a high demand for support from PiC, and staff voiced a need for continued investment to ensure that PiC were adequately helped if they experienced smoking lapses/relapses.

Despite these challenges, staff also spoke about potential benefits for PiC who have succeeded in reducing or stopping smoking following the introduction of smoke-free rules in the open prison:

I think sometimes, we are focusing quite a bit on the negatives, but what about the non-smokers. I’ve seen people that have come out of this, and seem to be doing alright, and doing quite well. I know we’ve got our hardcore guys, but I’ve certainly seen guys, and I’ve had guys, and you must’ve had them, [name], who have done quite well.

NS-NV, A7

There are a few people . . . they’ve maybe been thinking about stopping, and used this as an opportunity. But they’re in the minority. The majority of them are, ‘This has been forced upon us, we don’t want to stop, but if we don’t stop we’re losing our home leaves’, so it’s fighting a losing battle, really.

ExS-V, A1

E-cigarettes

A recurring theme in the focus groups was that making e-cigarettes available in prison had been instrumental in mitigating potential negative effects of the smoke-free prison policy for PiC, staff and the prison service [‘there has to be an alternative (to tobacco in prison) . . . They’ve (e-cigarettes) taken everything away and all the potential problems of violence and stuff like that coming in . . .’ (S-NV, J3)]. [The views of staff and PiC on e-cigarettes have been explored in much more detail in our complementary CRUK-funded study55,73 (see also Acknowledgements, Publications).] However, some staff questioned or expressed doubts about whether or not e-cigarettes would be beneficial overall in prisons, and some suggested they should not have been introduced because they were not without their own challenges. Staff also voiced questions and concerns about the fact that the evidence base on the health risks of e-cigarettes to users and bystanders is still developing. Some staff suggested that it had taken considerable time before the dangers of SHS exposure were understood and that a similar situation might occur with e-cigarette vapour and erode the health gains of prohibiting smoking in prisons:

The long-term effects, again, as somebody who’s worked here for 20 years, we don’t know the effects of second-hand smoke on our lungs, for all those years that it’s caused us. And now we don’t know the effects of a vape, what that’s causing us.

ExS-NV, N6

Unease was expressed by some staff about many PiC continuing to use e-cigarettes 6–8 months into the smoke-free period, for example because of uncertainties about the long-term effects of vaping; beliefs that some e-cigarette users in prisons (and in wider society) were misinformed that e-cigarettes were ‘safe’ to use, rather than less harmful than smoking tobacco; and/or suggestions that e-cigarette use might be at odds with the goals of smoking cessation.

E-cigarettes had reportedly created some problems in prisons similar to those previously caused by tobacco, such as PiC vaping outside designated areas, PiC experiencing difficulties managing e-liquid supplies and borrowing or trading e-cigarettes and potentially getting into debt.

A final problem that staff identified with making e-cigarettes available within prisons was that they could be misused, for example to take illegal drugs such as new psychoactive substances (NPSs). Although NPS use was not new in prisons, staff discussed how e-cigarettes provided some PiC with an easy and discreet means of ingesting NPSs without requiring access to smoking materials:

. . . well, I’d say it’s a big problem, they’d find another way to do it [take NPS] if it wasn’t these vapes. It is a convenient way, I think, for them to do it because we are finding the little broken vapes all over the place all the time.

ExS-NV, G13

I think the handy thing for it is if you were using a lighter and you were trying to smoke that bit of paper, you either need to put it in to a cigarette or just try and inhale the fumes as it burns. Where now they’ve got a device that they can hold and draw it at once . . . It’s like an aid to it.

ExS-NV, G10

However, NPS use in prisons was recognised to be linked to a wider range of factors beyond smoke-free rules and e-cigarettes:

NPS is going to be the drug of choice, anyway. And whether they took it through a vape, or whether they smoked it . . .

That’s the drug of choice.

. . . it’s the drug of choice, just with the change in society. Any mandatory drug testing, it doesn’t show up a lot, because it’s chemicals . . .

Easy to get it into the jails, as well. It’s not like cannabis where you’ve got a lump of it, and you’ve got to try and conceal it somewhere. It can be a bit of paper and you don’t even see it, that’s just . . .

Is it cheaper as well?

Yeah, uh-huh.

Staff voiced concerns about the adverse effects of NPSs in prisons, including risks for bystanders who experience secondary exposures to NPSs and potentially aggressive or violent behaviour by those under the influence of NPSs, as reported and explored in a parallel set of individual interviews with prison staff as part of the CRUK-funded study (Brown et al. 56). There were also a few reports that e-cigarettes had been used as weapons by PiC and that some PiC had tried to adapt e-cigarette chargers to use with illicit mobile telephones (although they questioned how effectively this worked).

Staff voiced support for measures to help to minimise potential unintended adverse consequences of e-cigarette use in prisons (particularly problems in respect of NPS use). Ideas included reviewing e-cigarette products sold in the ‘canteen’ and greater help in prisons for PiC who want to cut down or quit vaping or have co-occurring conditions, such as poor mental health. Arguments for and against a potential outright ban on the sale of e-cigarettes in prisons in the future covered some similar themes to those discussed in earlier phases of the study by staff in respect of tobacco bans, such as whether or not it would be legitimate, fair and practicable to restrict use of a popular, pleasurable product in prisons to protect or improve health.

Return rates, sociodemographic and prison-based characteristics

Surveys were returned by 2512 (34%) PiC in phase 1, 1959 (25%) in phase 2 and 1485 (18%) in phase 3, with considerable between-prison variation in return rates (as for staff, see Chapter 5, Return rates, sociodemographic and work-based characteristics, and Table 3). Return rates tended to be lower in the two privately run prisons, and the notably lower return rate in the post-implementation phase is despite following identical procedures for each phase (with the exception of three prisons in phase 1 described above, see Chapter 2, Survey circulation/distribution). As noted for prison staff (see Chapter 5, Return rates, sociodemographic and work-based characteristics), given the levels of response overall and the variation in response by prison and by phase, all figures presented below should be interpreted with caution. Analyses using simple weights derived to adjust for this variation for published papers relating to results on opinions39,72 produced virtually identical results to those based on unweighted data.

Sociodemographic and prison-based characteristics (see Report Supplementary Material 2, Tables 146–153) were very similar across all phases. The proportion of males returning questionnaires at each phase (91–93%) was slightly lower than the proportion of males across Scottish prisons as a whole (95% in 2018–1974), but the proportion convicted (82–83%) was similar (80% in 2018–1974). Around 50% were aged 31–50 years, and one-fifth or less were aged ≥ 51 years.

Self-reported exposure to second-hand smoke/vapour

In phases 2 and 3, PiC, like staff, were asked how often (never, sometimes, often, always) they were exposed to ‘other people’s smoke’ and ‘vapour or smells from other people’s electronic cigarettes’ in various locations. Figure 6 shows a marked drop in any (sometimes, often, always) reported ‘smoke’ exposure in cells, the halls and during outdoor exercise, paralleled by increases in ‘vapour’ exposure between phases. It also suggests that PiC perceived that illicit tobacco smoking continued at some level, and that there was some e-cigarette use in locations (work-sheds, gyms, education centres) where it was not permitted under prison rules, in phase 3.

FIGURE 6.

Reporting by PiC of any exposure to cigarette smoke/e-cigarette vapour in various locations.

Opinions on (rules about) smoking and tobacco in prisons

The proportion reporting that the current rules about tobacco smoking among PiC were not well followed (vs. very/quite well followed) was stable between phase 1 (24%) and phase 2 (26%), but dropped in phase 3 (18%) (p < 0.001). In phase 3 only, around one-quarter (23%) of PiC reported that rules about e-cigarettes were not well followed.

People in custody were asked the same prison smoking ban opinion questions as staff in each phase,40,72 and factor analyses of phase 1 data identified the same factors in both groups: ‘positive about bans’ (lower scores among PiC than staff) and ‘bans will be difficult’ (higher scores among PiC) (see Chapter 5 and Sweeting et al. 40). In multivariable analyses among PiC, ‘positive about bans’ factor scores were very strongly associated with not smoking, and with reporting no asthma, more sensory symptoms, higher educational level and prisoner status [unconvicted vs. convicted (with different release dates)]. Only current smoking was significantly associated with ‘bans will be difficult’ among PiC (Sweeting et al. 40). Further multivariable analyses restricted to PiC who smoked found the number of cigarettes per day was inversely associated with ‘positive about bans’, and having craved cigarettes and a past year quit attempt were associated with both factors. As described (see Chapter 5, Online surveys of prison staff: phases 1, 2 and 3), further published analyses72 compared opinions of staff and PiC in respect of prison smoking bans and e-cigarette use by PiC across phases.

As shown for staff [see Chapter 5, Opinions on (rules about) smoking and tobacco in prisons], the opinions among the PiC who responded appeared to shift over time (Table 8). Although generally much less positive than staff, support among PiC for prison smoking bans increased somewhat in anticipation of/following the ban, whereas there were substantial decreases between phase 2 and phase 3 in the proportions agreeing that prison smoking bans ‘cause a lot of trouble’ and ‘are hard to enforce’. This was not paralleled by a change in the proportion in favour of increased smoking restrictions in Scottish prisons; just 35% of respondents in phase 3 agreed that prison smoking bans were ‘a good idea’. Nor was there change in agreement that prison smoking bans ‘are OK if prisoners are allowed e-cigs’ or that e-cigarettes should ‘be available to help prisoners stop smoking/manage without tobacco’. Although agreement that smoking should not be allowed in any indoor or outdoor areas was highest in phase 3, as for staff, agreement by PiC that ‘prisoners who don’t smoke should be protected from cigarette smoke’ and that ‘there should be more NHS support for prisoners who want to stop smoking’ was lowest at this point.

Opinions about e-cigarettes generally

In phases 2 and 3, PiC were asked a standard question about the relative harms of e-cigarettes and ‘regular cigarettes’. As with staff, the proportion who thought e-cigarettes were (a lot) more harmful increased (26% in phase 2, 43% in phase 3), whereas the proportion who thought they were (a lot) less harmful dropped (from 37% to 26%), as did the proportion reporting that they did not know (37% to 31%) (p < 0.001).

As Table 9 shows, again, like staff (see Chapter 5, Opinions about e-cigarettes generally), PiC expressed more negative views about e-cigarettes in phase 3 than phase 2, with increased agreement that e-cigarettes are ‘addictive’ and ‘raise safety issues’, and decreased agreement that they ‘can stop people smoking’ and ‘are as good as other nicotine replacement therapies to help people stop smoking’.

Opinions about the introduction of the smoking ban in Scottish prisons

The phase 3 survey included the same questions for PiC as for staff on opinions about the lead-up to and implementation of the smoking ban. In general, PiC were less positive than staff: only around one-third thought that preparation had been good and that implementation had been largely trouble free. However, almost two-thirds thought that people were kept well-informed and the introduction of e-cigarettes had made things easier for both PiC and staff (Table 10). Two-thirds also indicated that the ban had ‘made prisoners more anxious’, around half indicated that it had led to ‘more physical/verbal assaults’ and ‘more use of illegal drugs’ and only 1 in 10 indicated that it had ‘made prisoners happier’. However, around half thought the ban had ‘helped improve prisoner health’ and staff health and had ‘made the prison smell better’, and around one-quarter to one-third thought that it had ‘made the prison look better’, ‘improved prisoners’ quality of life’, led to ‘more purposeful activity’ and ‘helped prisoners stop smoking for good’.

The phase 3 surveys also included questions on how much of a problem certain issues currently were. PiC generally identified problems as less serious than staff did. However, both groups identified PiC adapting e-cigarettes to use for drugs as the most serious problem (Table 11). Around one-third of PiC identified bullying over e-cigarettes and debt over tobacco as moderate/serious problems and one-quarter thought that bullying over tobacco, trading/buying tobacco and tobacco coming into the prison from outside and being smoked were moderate/serious problems. Although around two-thirds of staff identified the adaptation of e-cigarette chargers as a moderate/serious problem (see Table 7), less than one-quarter of PiC did.

In phase 3, PiC who had ever smoked were asked an additional series of question about the smoking ban. Over two-thirds indicated that it was hard not being allowed to smoke and wanted to smoke, and over half felt angry, more bored and reported weight gain as a result of not being allowed to smoke (Table 12). Only around one-quarter indicated that they were not smoking by choice rather than because of the ban. However, approaching half also agreed with three more positive items (the ban ‘is a good opportunity to stop smoking’, not smoking ‘is easier when no-one else smokes’ and feeling ‘healthier’).

Smoking among people in custody

At each phase, almost 9 in 10 of those in custody who returned a survey had ever smoked tobacco cigarettes (Table 13); the average age when a cigarette was first tried (asked in phase 1 only) was 12 years. Almost three-quarters currently smoked in phases 1 and 2, and although rates were significantly lower in phase 2, smokers’ average number of cigarettes smoked (19 per day) and past week cigarette expenditure (£13.33) were identical. In phases 1 and 2, almost every smoker smoked in their cell, and, although around half reported having felt like they wanted to stop smoking during their current prison stay, three-quarters had not stopped at all.

Table 13 also compares current (phases 1 and 2) and ever (phase 3) smokers in respect of current craving and anticipated smoking post release. In phase 3, half of ever-smokers (some of whom would have been smoke free for a significant length of time) reported craving a cigarette ‘somewhat’, ‘quite a bit’ or ‘a great deal’, although only around half thought they would smoke post release (a substantial proportion answered ‘do not know’ to this question).

Finally, Table 13 shows that the proportion of PiC who had ever tried an e-cigarette rose from around half to three-quarters between phases 1 and 3, and highlights the large increase in daily use (from 7% to 62% of all those in custody) and expenditure (from £1.98 to £10.46 per week among e-cigarette users) between phases 2 and 3.

Opinions about support for quitting smoking

In phases 1 and 2, current smokers were asked how much help they thought they would receive from different sources if they wanted to stop or cut down their smoking. Most support was anticipated from family members (Table 14). Only 1 in 10 anticipated a lot of help from prison staff and other PiC, and only one-quarter (phase 2 only) anticipated a lot of help from prison health-care staff, with one-third thinking they that would provide no help at all.

When ever smokers were asked in phase 3 when they stopped smoking, 15% indicated that this was in/before 2017, 10% that this was in January–October 2018, 43% that this was in November–December 2018 (i.e. immediately after the ban) and 32% that this was in January–June 2019. Assuming that the last group predominantly represents those admitted to prison since the introduction of the smoking ban, it seems that the vast majority of PiC continued to smoke right up to the ban’s introduction.

Finally, at each phase, the surveys asked PiC about potential strategies to help stop smoking or manage without tobacco. In phase 1 and phase 2, these were asked of current smokers in respect of the past year; in phase 3, they were asked of PiC, as appropriate, in respect of (1) the year before introduction of the ban and (2) since living in a smoke-free prison. In phases 1 and 2, around one in three had tried to get a place on a prison stop-smoking programme and used nicotine therapy, around one in five had attended a group programme and 1 in 10 had attended a one-to-one programme or used prescribed medication (Table 15). Rates of almost every activity were similar in respect of the year before the introduction of the ban and since living in a smoke-free prison; the exception was use of NRT, which was higher since living in a smoke-free prison. However, the most striking figures relate to the use of e-cigarettes, used to help stop smoking or manage without tobacco by 40% of phase 2 current smokers, 51% in the year before the introduction of the ban and 89% of those who stopped smoking in 2018–19.

At every phase, the surveys for staff and PiC asked how good they thought their local NHS prison smoking cessation support was. Staff results suggested a perceived improvement over time (from 45% rating as ‘very’ or ‘quite good’ in phase 1 to 61% in phase 3); however, for PiC, the percentage saying ‘very’ or ‘quite good’ remained stable (40% in phase 1, 42% in phase 2, 43% in phase 3).

Health of people in custody

Ratings of general health among PiC were much lower than for staff. They were lowest in phase 3 (‘very good’ vs. ‘good’ vs. ‘fair’, ‘bad’ or ‘very bad’ reported by 19%, 41% and 40% in phase 1, respectively; 22%, 39% and 39% in phase 2, respectively; and 16%, 41% and 43% in phase 3, respectively) (p < 0.001). Self-reported doctor-diagnosed asthma remained stable (25% in all phases), as did any contact with medical staff in the past 3 months (reported by 20–22%, depending on phase), prescribed medicines (15–17%) and purchase of over-the-counter medicines (6–8%) for a cold, breathing problems or eye irritation.

Self-reported experience in the past month of the nine International Union Against Tuberculosis and Lung Disease respiratory and sensory symptoms40 varied across phases (Figure 7). Three (coughed first thing in the morning, coughed at other times of day, phlegm) reduced between phases and one (eyes red or irritated) increased; three others (cold, nose runny/sneezing, sore/scratchy throat) reduced between phases 1 and 2, increasing again in phase 3. In contrast to patterns observed among staff, these patterns do not appear to reflect time-of-year effects.

FIGURE 7.

People in custody (%) reporting past 4 weeks’ experience of each symptom in each phase.

Three of the five ‘your health today’ items (self-care issues, pain/discomfort, anxiety/depression) included in the EQ-5D-5L increased between phase 2 and phase 3 (see Report Supplementary Material 2, Tables 72–76). There was a small decrease in ratings on the visual analogue scale (where 100 represents ‘the best’ health you can imagine).

Facilitators of and barriers to smoking abstinence or cessation in prison

Participants suggested several potential facilitators of smoking abstinence or cessation in prison that may support implementation of smoke-free rules. First, some discussed motivations to stop smoking in the future, including general concerns about the health effects of smoking or specific health problems, wanting to make positive lifestyle changes while in prison (e.g. quitting drugs and tobacco, losing weight and/or improving physical fitness), the high price of tobacco in prison, dislike of the smell of smoke, growing ‘sick’ of feeling dependent on tobacco and a family member (e.g. child) asking them to stop.

Second, as reported by a separate sample of users of smoking cessation services in prison (see Chapter 7), participants in the WP4 sample with experience of the service were also generally positive about its work:

So I went down . . . and I spoke to the lady [smoking cessation advisor], the lady was really, really nice, so open, we could sit and talk about things, and things like that.

S, F2

Third, certain features of the prison environment appeared to have the potential to help with smoking abstinence or cessation, such as lack of access to drugs and alcohol, which was reported to be a potential relapse trigger in wider society. Purposeful activity (e.g. involvement in work parties/education or going to the prison gym) was seen as potentially helpful to smoking reduction or cessation, because smoking was prohibited in these spaces and PiC were able to occupy their time and reduce boredom.

In contrast, potential barriers to smoking abstinence or cessation in prison, and consequently to the implementation of smoke-free rules, centred on three main themes. First, smoking tobacco was considered an important part of many PiC’s daily routines and a social activity that brought PiC together. Participants reported that smoking could provide an ‘escape’ from prison life and a way of managing recurring and sometimes acute feelings of boredom, stress and anxiety, particularly during evenings and weekends. There was a perception that smoking had a calming influence and helped to avert ‘trouble’ in prisons:

So, to me, smoking’s an escape. When I think about bad things, sometimes I have a smoke and it will take my mind off things . . . there’s people in here that need that, they need that escape . . .

S, E2

Second, some participants reported attitudes and beliefs about smoking that may inhibit abstinence/cessation, such as beliefs that smoking is effective for managing stress, misunderstandings or minimisation of the health risks of smoking, and perceptions that willpower alone is the best way to quit smoking and so those lacking willpower to quit will inevitably fail:

And what about in terms of some gyms offer one-to-one help or group help for people who want to give up. Did you ever think about that?

No, because what can they do? They can talk about it, everyone can talk about what you’re going to do, but it’s willpower inside of you, if you haven’t got the willpower to quit smoking, then you’re never going to stop.

Third, several potential barriers linked to smoking cessation services in prison were discussed, including waiting times, a desire for staff to take greater account of individual need and circumstances in the delivery of support, delays receiving NRT from the prison pharmacy and disruption to smoking cessation treatment when PiC transfer between prisons.

Opinions of the impending smoke-free prison policy

Opinions of the impending smoke-free policy varied. Arguments against the introduction of total restrictions on PiC smoking centred on two main themes. First, some expressed strong beliefs that the policy was unfair, as it would remove individual freedom (sometimes referred to as a ‘right’) to smoke and take away a pleasurable activity and a potential tool for managing stress and boredom in prisons, particularly as tobacco is a legal substance to purchase outside prisons:

They’re just taking another thing away from us, they’re just taking another thing . . . which I can understand, the health benefits of it. But if it’s people’s choice, do you know what I mean? So where is it going to end.

S, C1

I don’t understand why they’re doing it [banning smoking] in a jail though because they’re not going to stop smoking out there, so I don’t see why they should stop it in here.

S, B1

Second, some suggested that current restrictions on PiC smoking (e.g. only allowing indoor smoking in designated cells) should provide staff with adequate protection from SHS exposure. Some PiC advocated for alternative measures in prisons to reduce SHS exposure, such as stricter enforcement of existing smoking rules, implementation of indoor-only smoke-free policies or creating voluntary smoke-free wings.

On the other hand, arguments in favour of the smoke-free prison policy related to two main sets of issues. It was acknowledged that the smoke-free rules may improve the health of PiC and might enable them to spend more of their income on other items they valued, such as telephone calls to friends and family. Protecting non-smoking staff and PiC from SHS exposure was seen as another important potential benefit, and it was acknowledged that the smoking ban may also improve the living and working environment in prison (e.g. by removing the smell of stale smoke):

. . . it is becoming a healthier country, so I reckon it’s just inevitable and a good idea to do it in the prisons, because even if a certain percentage of the people that come into prison stop smoking or they’ve stopped smoking before they come in, and they come in, and if there’s an environment there to keep it going, that’s a good thing. Even if there’s people come in and don’t smoke for whatever length of time they’re in prison and they go out, it’s still a healthier thing. If they’re going out with other people that don’t smoke it could stick . . .

S, D5

Participants also identified a number of potential negative unintended consequences of a smoke-free policy for PiC, including increased feelings of stress, anxiety and anger; increases in unhealthy behaviours such as the consumption of sugary drinks or snacks or illegal drugs; increases in prisoner-to-prisoner and/or prisoner-to-staff conflict or violence; and negative effects of sanctions on those unable or unwilling to comply with the smoke-free policy.

People in custody were asked to identify specific groups who might face particular challenges in respect of the smoke-free rules. The examples they provided included PiC with high levels of smoking dependence and/or low motivation or ability to quit, older people who had smoked habitually for many years and PiC with mental health problems. Some identified unique challenges relating to the length and stage of custodial sentences. For instance, it was suggested that people on longer sentences might feel anxious or angry about the prospect of a very long period of smoking abstinence or worry about having to change their established routines, as continuity is often valued by those serving long sentences in prison. By contrast, there were perceptions that, although not without its challenges, smoke-free rules could be less challenging for PiC serving shorter sentences. Participants suggested new arrivals into prison might struggle with lack of access to tobacco while adjusting to a new and challenging environment; many said that the early days and weeks of life in smoke-free prisons would be especially hard for people with complex needs, such as dependency on illegal drugs and/or alcohol:

. . . I know myself if I was coming in, getting detoxed off the drugs and I get my Valium and then they detox me off of smoking as well, I think that’d be a bit much.

You think that might tip people over the edge?

I think I’d be a bit mouthy. Right. I would be banging my door. And wouldn’t be . . . want to be mouthy. It would just be the situation, know what I mean, stop smoking plus stop the drugs. Getting detox, detox off two of them. I think that’d be a bit much.

As contraband was acknowledged to be part of prison culture, some believed that the prison service would be unable to prevent tobacco from being smuggled into smoke-free prisons and sold at inflated prices, contributing to (ongoing) problems of debt and bullying for some PiC:

I read in that prison paper that like a pouch of good tobacco is £100 or something it was going for in England. It could end up getting people that havnae [haven’t] got money into a lot of debt.

And other things like bullying around that maybe?

That’s what I mean; there always ends up bullying with debt because if people cannae [can’t] pay their debt – I’ve seen it loads of times, and that’s just in the 7 months I’ve been in.

The potential for smoke-free rules to lead to disturbances or ‘riots’ in prisons was frequently discussed. Participants often regarded the idea of getting involved in disturbances or riots as foolish and likely to be ineffective. However, some believed that other PiC, such as those who felt angry about the smoke-free rules or with ‘nothing to lose’, might try to cause problems.

Measures to support the implementation of the smoke-free prison policy

Support was expressed for a range of measures to aid the implementation of smoke-free prison policies. It is important to note first that many PiC found it challenging initially to consider any measures that may aid implementation of the smoke-free policy without verbal prompting (from the researcher) to stimulate the discussion where necessary.

There was good awareness of plans to implement smoke-free prison policies among the PiC interviewed in phase 2. Even so, participants supported a continued focus on and expansion of communication in the lead-up to their implementation:

I think giving more information on it and let guys know a wee bit more about it, rather than stick a note up on the wall saying ‘come November next year there’ll be no smoking in the prison’. That’s it . . . What’s coming? What’s going to replace it, you know what I mean? Are we going to get . . . can we get an e-cigarette even if we’ve got [to] purchase it ourselves? Or whatever. If you are supplying it, what’s it going to be? So that we know. And we can get ourselves prepared for it.

S, D6

Some suggested that it would be useful for communications to cover issues such as the rationale for smoke-free rules and how these will be implemented (e.g. when tobacco sales would end), the health effects of smoking and benefits of smoking cessation, and options to help PiC to abstain from or quit smoking. There was support for greater consultation with PiC about how smoke-free rules are introduced and opportunities for dialogue about smoking rule changes between PiC and staff.

Although it was not yet known at the time of these phase 2 interviews whether or not e-cigarettes would be allowed, there were expectations that an enhanced package of stop smoking aids and support would be available to support people to abstain or quit smoking, similar to the help available for PiC who are dependent on illegal drugs or alcohol:

I mean, when you come in here, if you’re on alcohol, instantly you can get Librium or whatever and you can detox that way. Or if you’re on heroin you can get meth [methadone] or whatever. They do that instantly and they’re going to have to do exactly the same thing with smoking, the exact same process as that. That would work . . .

S, D2

People in custody felt that it was important that waiting times for specialist services were reduced and that additional strategies could be tried to increase awareness and engagement with services (e.g. drop-in sessions in residential areas for PiC who wanted to reduce or stop smoking). It was suggested that incentives might be provided to PiC who successfully became smoke free prior to smoking rule changes. One participant suggested that PiC who managed to give up smoking should have the opportunity to sample different foods (as smoking cessation can lead to an improvement in sense of taste); another suggested offering more gym sessions. Although PiC did not always feel that they would benefit from peer support, they recognised this might help others, particularly during periods when cessation advisors were unavailable.

High (but not universal) support was expressed about making e-cigarettes available to PiC to support cessation or as an alternative to tobacco. However, some uncertainties or concerns were raised, for example about what e-cigarettes contain, the health benefits and risks of vaping, and whether or not e-cigarettes would be affordable:

I’d bring them [e-cigarettes] in as soon as because, you know, all you’re going to do is if you wait is you’ll get a changeover but people are going to . . . people that are going to smoke up to the date are going to smoke but a lot of guys . . . you’ll maybe get . . . even if you were to get a quarter or a third of the people going, . . . ‘I’m going to switch just now, so it’s easier’, it just means that you’ve got a quarter less people to worry about when the time comes . . .

S, C2

The analysis also suggested that engagement in purposeful activity, particularly during evenings and weekends, might enhance well-being and support smoking abstinence or cessation. Examples of potentially valuable activities identified by PiC included opportunities to participate in new work parties or courses, going to the prison gym and playing sport. Suggestions for in-cell activities included chess/drafts, arts and crafts and colouring books.

Opinions on the smoke-free prison policy

Consistent with the phase 2 interviews, there was substantial variation in opinions about the smoke-free policy. Some PiC expressed either predominantly negative or, in a few cases, very positive views of the smoke-free rules. Others voiced mixed opinions, reflecting tensions between autonomy and health protection/improvement. Smoke-free prison rules created internal conflict for some PiC:

Personally it [smoke-free rules] didn’t bother me, I, it was actually probably better for me, saves me money. I’m getting healthier, you know it is probably going to save years of my life but it is just one of those things again about, well it is my choice really about where does it stop, you know, really? Now you can’t drink, you can’t smoke, you can’t have sex, you know. What else is there to be at? Smoking was the last thing you could really do, you know?

ExV, B3

People in custody also recognised potential tensions between their own needs and the needs of others living (or working) in prison:

What’s your views on the smoking ban now?

. . . I don’t think I can speak for everybody . . . I think it’s been good for me because I’ve came so far now that I don’t think, there’ll not be any turning back. So yeah, I’ve made that change in my life and I’m going to stick to it.

And what if other [countries were considering smoke-free prison rules?] Do you have thoughts on whether it’s the right direction for a prison system to go?

I don’t know, because it, in another sense it’s like taking people’s, that, a lot of girls [women in custody] that’s the only thing they maybe had was smoking . . .

There were several suggestions that an alternative measure (e.g. indoor smoking ban) would have allowed PiC to retain some control over smoking and protect non-smokers from SHS:

. . . people should be allowed to smoke, it’s like your human right, isn’t it? Even if it was an outdoor thing or something, when you go out for exercise you can smoke or something, but I do think you should be allowed to smoke . . . but at the same time I understand why as a non-smoking staff member I wouldn’t want to be in a wing that smelled of smoke, I understand why for the health benefits . . .

ExV, B2

Outcomes of the smoke-free policy

E-cigarettes

The use of e-cigarettes among PiC in Scotland is explored in detail elsewhere. 38 E-cigarettes were seen as likely to have been crucial in implementing the smoke-free policy without major disorder in prisons.

It was more of a non-event because people weren’t being asked just to stop the habit, do you know what I mean, so people had something else to replace it with, it’s healthier. But, yes, I think it would have been a bigger ask and I think it would have been more difficult to manage if the vaping [had not been allowed] . . .

V, A4

E-cigarettes were reportedly helping many PiC to cope with smoking abstinence in prison, including for nicotine withdrawal and cravings: ‘Yes, it takes the craving away, yes, it does, yes. I thought I’d be gasping again, but, no it’s alright’ (V, E2). They were seen as a replacement for previous psychological and cultural aspects of smoking in prisons; some PiC found e-cigarettes or flavoured e-liquids pleasurable [‘I enjoy it now because of the flavours. I know that sounds mental, but I buy different flavours and a new one comes on, I want to try the new flavour’ (F4-CV)] and e-cigarettes were used to pass time, particularly when PiC reported having few distractions or activities that they considered meaningful, and in response to stressors:

. . . if anything smoking is one of the things that gives you time . . . passes the time. See if you [were] sitting in your cell and you’ve nothing to do, just have a wee fag here and there. Then if you take that away, you’ve . . . I found myself sitting staring at the walls, what am I doing? . . . But when they brought out the vapes, they gave everybody that chance to still have that . . . hand-to-mouth . . . action and stuff.

V, C1

However, PiC also indicated that e-cigarette use in prisons brought challenges. Although e-cigarettes were helping previous smokers to cope with abstaining from smoking in prison, they were not always satisfied with e-cigarettes [‘I’m just struggling, I’m not getting what I need out of it [vaping]’ (V, C4)]. Some were opting, from the relatively small range of products on sale in prisons, for lower-strength e-liquids to avoid compromising on flavour and this may have contributed to problems with nicotine withdrawal and cravings. In addition, PiC were not always comfortable with ‘swapping’ one form of dependence for another and did not necessarily intend to continue using e-cigarettes in the future (for various reasons):

I would have preferred to just stop [using nicotine], and that was it. Because now, I’m addicted to the vape, even though I think it’s rubbish.

V, F5

Some PiC who wanted to cut down or stop vaping in prison expressed a need for behavioural or pharmacological support to help them achieve their goals:

[you said] that long term [you would] prefer not to vape. Is that something that you think you’ll be able to do by yourself? Or would it be useful if there was a service you could go to and get a bit of help . . .?

Uh-huh. That would probably be good, because I think the support that we had, gave each other in the smoking group, was good. Like egging each other. ‘You can do it!’ Or watching somebody that had done it and it gave you that wee push . . .

For some, perspectives on using e-cigarettes in prison were complex. On the one hand, they described a physical or psychological ‘need’ or desire for e-cigarettes to help with smoking abstinence. On the other hand, they expressed annoyance or frustration about some aspects of vaping. Such internal conflict was potentially heightened because PiC were not choosing to use e-cigarettes in the same way as other groups of e-cigarette users in wider society. In our sample, exogenous factors (i.e. smoke-free rules) were a primary driver for the uptake of e-cigarettes in prison.

What can you do, you know what I mean, there’s nothing I can do about it. I can’t say ‘right, you know, I [don’t] want this vape, I don’t want to smoke [vape] these’ . . .

V, D1

Although some PiC mentioned health benefits from switching from smoking to vaping in prison, a recurring theme was that the long-term effects of e-cigarette use were not yet known. This led to some suggestions that PiC were ‘testing’ e-cigarettes. A related issue was reports that some PiC were experiencing health problems that they suggested may be linked to/exacerbated by e-cigarettes (e.g. sore throat, chest tightness/pains, breathlessness):

That’s the problem, we don’t have the research . . . we’ve got a few years of research on vapes, but not the same amount of research as we have on cigarettes . . .

V, B2

People in custody who managed to reduce spending on nicotine by switching to e-cigarettes (or who stopped buying nicotine products altogether post implementation) appreciated the financial gains. Nonetheless, concerns about the affordability/value for money of e-cigarettes recurred in the data, particularly for people without external financial support or on lower prison wages:

You feel it for the people living off maybe a fiver a week, and these things are £3.20, you buy a packet of them then you’ve got £1-odd left to buy . . . food is better than e-cigs [e-cigarettes].

V, E2

They’re [e-cigarettes] dear. They’re, like, £7 for the actual vape and you have to buy the charger and that’s another £4 . . . that’s £11 to start without the capsules to put in them. So even the girls [women in custody] that have got jobs, you only get paid, like, £10.80. In most jobs anyway. So you wouldn’t even be able to afford them, like, to buy them off one canteen, unless you’ve got money sent in.

V, E5

E-cigarettes, like tobacco previously, were a sought-after commodity and participants discussed difficulties that could occur when PiC ran out of e-liquids (e.g. borrowing e-liquids at a potentially inflated cost):

You see people actually running up and down . . . Chasing the capsules [e-liquids] . . . cause the capsules in here are like gold dust. As soon as somebody’s got, ‘Oh can I get a loan of it, can I get a loan of it? I’ll get you two back’. . . anything just to get . . . and I’ve seen me sitting watch people like that, you know, it’s quite ridiculous how . . . for a wee tiny bit of nicotine, you’re offering to buy them two back . . . three back.

V, F2

People in custody described differences between borrowing e-liquids (currently) and tobacco (pre implementation) because tobacco was easily divisible into small quantities whereas pre-filled e-liquids are not:

. . . people just don’t have money, do you know what I mean, but they want to smoke [vape]. Before it wasn’t that bad giving somebody a bit of snout [tobacco] every day but you can’t really give somebody a packet of capsules every day. . . . you can’t give them a bit, you know, it is a capsule or nothing. So, personally, I feel sorry for people.

ExV, B3

A final risk of e-cigarettes in prisons raised by some participants was that e-cigarettes were providing a (discreet) way for some PiC to take illicit drugs such as NPSs: ‘people can adapt them or whatever to their own ends, but they can do that with other stuff that was already there’ (V, A4).

Expectations and beliefs regarding the smoke-free policy

Before the announcement of the ban, the prospect of prisons going smoke free was a major topic of discussion among SSSs and prison health-care staff responsible for delivering cessation support, with questions raised about how it should be introduced and potential implications for the organisation of cessation support. There was broad support for the move towards smoke free, with many describing it as a positive development for prisoner health and an opportunity to limit smoking uptake on release:

There will be health benefits for everybody. Even for the prisoners who don’t smoke . . . Even for prisoners who are digging their heels in saying ‘You can’t introduce this – my rights’ but there’s going to be health benefits to them as well.

SSS, advisor, phase 1

I think it is an important thing . . . It gives them an ideal opportunity, because one of the things we say to them is ‘Turn a negative by being in the prison into a positive!’ whereby, when you get discharged, at least you are walking out those gates a lot healthier than you were when you came in.

SSS, manager, phase 1

Although the smoke-free policy was widely welcomed on public health grounds, many recognised that its introduction brought significant challenges, reporting that this topic was frequently raised by PiC using health-care and cessation services. Most took the view that a comprehensive indoor and outdoor smoking ban throughout the prison estate was necessary to achieve compliance and maximise health gains. Few involved in delivering cessation services supported the concept of a partial ban or a phased introduction within individual prisons.

There were reports of some PiC actively welcoming the policy, but it was a focus of anxiety for others (particularly smokers serving long sentences):

Maybe it’s their first time in prison. They’ve got a different mind-set. If you’ve got someone who’s been smoking for umpteen years . . . it’s their form of currency, it’s their income, it’s what they use to gamble, it’s what they use for relationships, it’s what they use for comfort and all of a sudden you’re taking that away . . .

Addictions caseworker, trained advisor, phase 1

Such concerns were echoed by some SSS and health-care staff, who feared that the policy could result in clients who were less motivated to quit being compelled to engage with the service, and being hostile to cessation support. There were calls for information regarding how other jurisdictions (particularly E&W) had adapted to similar bans: ‘I think we have to look at successful models down in England and we have to replicate that’ (addictions caseworker, trained advisor, phase 1).

Response to and preparations for the smoking ban

Much of the attention in anticipation of potential changes to smoking rules focused on how services would cope with expected increases in demand for cessation support. Hence, early preparations and a long lead time were considered important, to ensure that capacity was in place to respond in a timely manner as smokers came forward for support and to flatten demand by giving smokers sufficient opportunities to quit:

If there’s a longish lead in time, then it may well not be a huge demand for Stop Smoking Services because people will start preparing for it.

Health improvement senior manager, phase 1

If we get plenty of lead-up time, we are able to say ‘You can come back and we will do it again’ . . . it might take them several attempts. I think that will be helpful rather than just saying to somebody who has come for the first time, ‘Oh God, I am struggling [to help you]’.

Health-care manager, phase 1

At the time of the phase 1 interviews, before the policy announcement was made, interviewees noted no noticeable change in demand for cessation services. However, by phase 2, advisors started to note significant increases, typically from smokers wishing to retain more autonomy and avoid being forced to quit as the ban was implemented:

It tends to be a group where . . . they [PiC] want to do it for them[selves], they don’t want to wait until November [2018] when they take it [smoking] away. So, I think it’s like a kind of power trip that they have got. ‘Oh, I’m going to stop smoking now, not just because you’re telling me to!’

SPS officer, trained advisor, phase 2

Most prisons had also established service planning groups by phase 2, although ensuring the engagement of key stakeholders, particularly senior prison management, could be challenging in the early stages. Interviewees in other prisons reported investing in additional staff resources to reduce waiting times, which exceeded 16 weeks in some cases, and many described making changes to service protocols to help manage waiting times, most significantly a decision to move to a rolling group programme, allowing new users to join groups as existing members dropped out.

Consideration was also given to additional forms of support for PiC, such as drop-in sessions, peer support networks and recruiting peer educators, or PiC who had been through the quit process, as local champions:

. . . what we need to look at is how we build that network of informal support so that when people are trying to stop smoking they are given encouragement and help when things aren’t going so well.

Health improvement senior manager, phase 1

. . . we need to work stronger to get champions, smoking cessation champions within the prisons. Staff and prisoners doing that work for us in the setting of the prison.

SSS manager, phase 1

Similarly, many recognised the importance of engaging prison staff as advocates – promoting the service on residential halls, encouraging referrals and supporting PiC to attend group sessions:

. . . if they are smokers themselves [prison staff], there can often be a barrier there, because a lot of the staff might think the actual same as what the prisoners think. So staff can help, but they need a bit training first.

SSS advisor, phase 2

Although evidence from phase 1 interviews indicated that most prisons were starting to consider how services might be reconfigured to meet increased demand, decision-making was tempered by unknowns, particularly whether or not NRT would be made more widely available and, most significantly, whether or not e-cigarettes would be introduced into prisons.

. . . depends what other options they put in if they put the ban in. If they leave it as it is the now, and the only option people have is to come through our service to get NRT, then yeah, you would need more staff. But, if they offer the e-cig [e-cigarettes] or people the chance to purchase their own NRT, or some other NRT management service away from the Stop Smoking Service then . . .?

Addictions caseworker, trained advisor, phase 1

By the time of the phase 2 interviews, a number of significant changes had been implemented following the announcement that prisons would go smoke free, mostly focused on building capacity. Many were designed to streamline access to support groups and pharmacotherapies and included reducing reliance on prison staff to escort PiC to sessions by arranging meetings in residential areas, using improved access to residential areas to raise awareness of the service and fast-track referrals, enabling smoking advisors to distribute NRT directly to service users and providing additional staff support to reduce administrative burdens (e.g. recording the distribution of NRT). Many interviewees also reported delivering cessation training to prison staff volunteers. In some prisons, these officers were able to co-facilitate cessation groups. However, there was often a lack of clarity about their role, and in many prisons this support did not materialise as a result of other work pressures and lack of confidence in operating in a therapeutic role:

I’m not too keen on the whole idea of being involved in medications and stuff like that . . . don’t feel like the training that I’ve done at the time would be enough for something like that . . . it’s not something I’ve ever known anything about so it’s all brand new to me so I still feel it’s a bit raw for me to be doing something like that.

SPS officer, trained advisor, phase 2

Most frontline workers delivering cessation support found that they had sufficient time to plan for the introduction of the ban. However, the decision by prison authorities to introduce e-cigarettes late in the preparatory phase presented significant challenges, such as services needing to reallocate resources at short notice and delays in the implementation of new pathways for supporting prisoners who smoked:

There was an issue when SPS suddenly announced it’s going to [provide] free vapes, because the NHS had no knowledge . . . nobody had told us this is what is happening. They were writing the guidelines at that point, and suddenly, it’s like, ‘What’s that about, where did that come from?’ . . . We had to rewrite the specification.

SSS co-ordinator, phase 3

It meant we didn’t get the plans for the prisons pathways out until the ban came in. We were meant to be delivering a service post-ban and the pathway didn’t come in until the day [of the ban] . . . It was a massive piece of work.

Senior SSS manager, phase 3

It was suggested that larger prisons, with more diverse populations and greater prisoner turnover, were less able to adapt to increased demand than smaller prisons, and there was some evidence that prisons that relied on existing health-care staff to deliver cessation support were under greater pressure than those that were not, because of other demands on their time:

We really need to change the service. We just couldn’t cope, because there is a lot of other things other than smoking . . . we’ve got a lot of people with alcohol addiction, drug addiction and then all the primary care stuff. And, as I say, we’ve only got two members of staff.

Health-care manager, phase 1

In addition to changes made, participants working in smoking cessation identified areas where the service would need to adapt and develop, the most significant being a need to implement measures for identifying and supporting smokers on entry to prison (e.g. through provision of free NRT):

. . . we’d need to look at the possibility of giving people NRT as they come in the door. ‘Cause it’s not fair to leave somebody if they have a billion other things going on, and to have nicotine withdrawal in there as well. So I think it would be an idea to look at maybe the admissions process, and if they could access something at that point, and then maybe come into our group.

Addictions caseworker, trained advisor, phase 1

Prison reception was recognised as a key pressure point, with significant demands already on admissions staff. Some smoking advisors working on the frontline also saw a need to reconfigure the service to cater for people with limited motivation to quit who would nevertheless require support in managing nicotine withdrawal using NRT and/or e-cigarettes. Although there was wide recognition that prisons had a duty of care to offer symptom relief for those not prepared to make a quit attempt, questions were raised about who would have responsibility for delivering this support and the long-term implications of providing ongoing access to NRT on health and prisoner smoking rates post release:

There’ll be two types of person who come into prison . . . you’ll have some people who will engage with our service and want to address the whole health behaviour change and make the necessary adjustments to their life, and they will require the support that we currently deliver . . . As opposed to the group of people who only want symptomatic relief . . . at the moment we’re focusing everything on providing service for people who want to quit.

Health improvement manager, phase 1

. . . there’ll be a lot of prisoners who are coming in . . . they’ll take the NRT because they have to and they can’t smoke. But the minute they go out the door they haven’t got the slightest intention of staying stopped.

SSS manager and advisor, phase 1

Implicit within these discussions was a belief that many PiC, particularly more vulnerable prisoner groups and those with poor literacy, would struggle to use NRT as an effective cessation aid in the prison environment without structured support, and that it was more likely to be relied on (intentionally or otherwise) as a form of symptom relief or substitute for tobacco.

Attitudes towards introducing e-cigarettes

As noted, a decision to introduce free e-cigarette starter packs in September 2018 was made reportedly without adequate notice or consultation with local cessation services and national planners. Prior to this decision, the introduction of e-cigarettes to support the implementation of smoke-free rules was much discussed, with many frontline workers suggesting that it would prove extremely popular with PiC who smoked. Its potential was seen largely as a direct replacement for smoking. Some questioned whether or not SSS should have an active role in their use by PiC and some suggested that e-cigarettes might undermine existing cessation programmes:

I’m not sure that there would be a role for the NHS to supply them [e-cigarettes], or for there to be a provision. I think if they [PiC] want to use them they should be able to buy that at the canteen, . . . if they want to use their money on that, then so be it.

Health-care manager, phase 1

They need to know that the e-cigarette is maintaining that high nicotine level. We have to say to them of course it’s still a lot safer than smoking a cigarette, but by using the e-cigarette they’re keeping it high, so when it comes to coming off the patches, they will find they probably increase their use of their e-cigarette to maintain the original level, and then by the time they finish the programme, they’re still quite addicted to nicotine.

Health-care nurse, trained advisor, phase 2

This led to calls for lower strength nicotine e-liquids to be available on canteen lists.

Staff in cessation services and prison health care had mixed attitudes towards introducing e-cigarettes. Some (a number of whom described their services as ‘e-cigarette friendly’) expressed support for their introduction. It was argued that e-cigarettes were a more appropriate product than NRT for managing short-term abstinence and so had the potential to make the transition to living in smoke-free prisons more manageable:

. . . it’s much easier when you’re taking away something to be able to give them something. I think they will see it more favourably than NRT.

SSS manager and advisor, phase 1

Others held varying views: they agreed that e-cigarettes could potentially aid the transition process, but were concerned about possible, as yet, unknown dangers of long-term use, and about substituting a smoking culture with a vaping culture and how this would have an impact on nicotine addiction and tobacco use in the longer term:

I can see it both ways. If you could go smoke-free without it [e-cigarettes], I think it would be the best thing but – you are just worried about everyone – a few years down the line, everyone would be using an e-cig in the prison . . . everyone would try it and before you know it the whole prison would be smoking them.

SSS advisor, phase 1

I think that [introducing e-cigarettes] would act as a deterrent on people actually trying to stop smoking. I know the message is, it is safer than actually smoking tobacco. But I don’t think you would get as many people as focused on an actual total quit.

SSS manager, phase 1

These views were partly borne out by experience, with demand for cessation support reported to have fallen significantly immediately after (rechargeable) e-cigarettes were introduced (see below). However, despite reservations, most agreed that, on balance, e-cigarettes were worth serious consideration: ‘I’m not a fan of e-cigarettes, but I’d rather have something as opposed to nothing’ (addictions caseworker, trained advisor, phase 1). Nonetheless, participants were conscious that e-cigarettes raised security issues, reporting concerns that they could be doctored as a delivery device for illicit drugs: ‘because of the nature of what they are, I would be surprised if they would ever be allowed’ (SSS advisor, phase 1).

Following their introduction, many found the rechargeable e-cigarettes a more viable product than single use e-cigarettes, which were frequently described by PiC to be ‘useless’ or ineffective. However, levels of familiarity and understanding of vaping and the specific devices introduced into Scottish prisons was thought to be poor, with some recognising this as an important area of new learning. Cessation services’ response to such gaps varied between prisons and health boards. Some services assumed a proactive role, helping to ensure that PiC and prison staff were properly informed on e-cigarette use and nicotine content; others (at least initially) took the position that, as prison authorities were responsible for the decision to introduce e-cigarettes and to distribute starter packs, it was the responsibility of prison staff to offer support and explain their use:

. . . there’s a real learning need for us there to understand them better. Devices change and things change all the time so we really need to get our heads round about it to support people well because I don’t know that our knowledge is great on it. We go from delivering a service that we know inside out to this whole new ball game.

Health-care worker, trained advisor, phase 2

These differences potentially meant that PiC in some prisons were better supported. Importantly, irrespective of the position assumed within each prison, many smoking advisors on the frontline reported that PiC frequently approached them for advice when they had problems with vaping or their device and that e-cigarettes were a common topic of discussion in cessation groups, particularly leading up to implementation.

Impact of the ban on approaches to delivering cessation support

Inevitably, this was a period of considerable change for those supporting people in managing nicotine addiction or wanting to quit smoking. The 2018 ‘Smoke-free prison pathway’ service specification79 outlines requirements for the delivery of behavioural and pharmacological support for managing nicotine additions in prisons and describes how the NHS Quit Your Way Prison programme is expected to deliver pharmacotherapy and/or behavioural support to PiC wanting to ‘withdraw from nicotine’ while in prison and to PiC with no funds in need of (free) NRT to manage withdrawal symptoms. (Subsequent guidance in 2020 – after TIPs data were collected – provides advice on delivery of pharmacotherapy and/or behavioural support to PiC who want to cut down or stop use of e-cigarettes. 80) Interviews with service providers highlighted some differences in precisely how Quit Your Way Prison programmes were operating in different prisons. Three main approaches were identified.

The first approach was geared to establishing a process of rapid referral and improved availability of free NRT, resulting in a corresponding reduction in provision of behavioural support. Although some specialist group support was retained for specific sections of the prisoner population, the provision of rolling groups (ramped up during the lead-up to implementation) was replaced post implementation with weekly 5-minute one-to-one sessions to provide NRT and brief advice as required. Despite the high numbers receiving support, waiting times were short. Ability to meet high levels of service demand was facilitated by the switch to one-to-one support and changes to processes for dispensing NRT.

The second approach involved delivering a conventional ‘smoking cessation’ programme for smokers entering prison. The programme was intended to follow a conventional 12-week programme, combining free NRT with behavioural support, mirroring support offered to smokers in the wider community. Significant improvements in delivery had been achieved by enabling advisors to meet service users on prison halls, and, more recently, by advisors having the authority to distribute NRT to PiC directly.

The third approach involved delivering a hybrid service to meet the diverse needs of PiC. The conventional 12-week programme was modified to a 6-week programme (or one-to-one sessions on the halls, where required) post implementation in response to increased demand and to match the service’s changing behavioural goals. The provision of free NRT was conditional on group attendance to help users manage their e-cigarette use and nicotine intake, and to limit NRT wastage and stockpiling. Post implementation, programme content changed to meet a range of PiC’s needs, incorporating guidance on the use of e-cigarettes and how to cut down and stop vaping. These changes reflected a belief that it had evolved into an ‘e-cigarette focused service’ with an emphasis on managing nicotine use, a journey that was seen as a process of trial and error. To support the evolution of the service, senior service staff invested time and energy into familiarising themselves with the e-cigarette products sold in prisons, and delivered information sessions for PiC (and SPS staff). Advisors experimented with providing separate support groups to address the divergent and reportedly more pressing needs of new admissions, who were often dealing with continued enforced nicotine withdrawal for the first time. They also responded to existing PiC looking for advice on how to control their vaping, often because of rising expenditure on vapes and emerging health concerns. However, this sometimes proved to be impractical because of logistical challenges and pressures on staff resources. It was also noted that prioritising new admissions could create tensions with PiC who had self-referred and were required to wait for a place. In some prisons, all PiC were eligible to receive support, irrespective of whether someone was classified as a smoker or vaper. However, referral to ongoing support for stopping vaping on liberation was contentious, as some local community services only provided support to smokers wishing to quit. In this sense, advisors saw the programme as a test bed for potential e-cigarette-focused services in the community, providing insight into issues such as how to monitor nicotine intake and titrate using different e-liquid concentrations.

Several potential challenges in delivering in the new context of smoke-free prisons were identified in the provider interviews. Examples included difficulties in respect of rapid identification of needs/wishes of smokers being admitted to prisons and issues with referral pathways on entry and exit from prison, differing interpretations of new service goals and outcomes (e.g. some advisors voiced reluctance to work with e-cigarette users), knowledge deficits (e.g. understandings of e-cigarettes) and challenges in making NRT (widely) available in prison for those requiring symptom relief and minimise potential risks of waste.

Views and expectations regarding the smoke-free prison policy

In interviews conducted in the preparatory phase, PiC who had used the service displayed a similar range of views to the wider prison population (see Chapter 6, Surveys of people in custody and Brown et al. 75), although these tended to vary according to where they were in their quit attempt. Those expressing predominantly negative opinions about the policy tended to still be smoking or had relapsed, perhaps reflecting a general anxiety about quitting, even where they acknowledged real personal health benefits:

It’s a bad thing as far as I’m concerned because I’m being pushed to change my ways . . . the last time I gave up I wanted to do it, you know. But, I mean, I should still want to do it because I’ve got bad legs. I could end up getting them chopped off or something because I’ve got diseased arteries in my legs . . . but I think people just hate to get pushed without being asked.

Male, never tried stopping smoking in prison

Others (often PiC who had given up, were non-smokers or making good progress in their quit attempt) held more complex positions on the ban. These participants often recognised tangible benefits for their health and living environment (e.g. removal of the smell of smoke or cues that might trigger relapse), but also understood the challenges for peers who were unable or unprepared to stop smoking, expressing strong solidarity with them. Particular concern was expressed for those seen as most likely to be affected by the ban (i.e. those on longer sentences or who were more vulnerable) who relied on smoking to cope. A few in this group also acknowledged the position of prison staff and their exposure to SHS:

It depends on what way you’re looking at it. For me personally I think, I think it is a good idea for people’s health. But at the same time I think people should be allowed to do what they want to do with respect to smoking, something that’s legal if you’re over 16.

Female, tried stopping smoking in prison

Like other PiC (see Chapter 6, Surveys of people in custody), all believed that there would be some pushback post implementation, ranging from an expectation that some PiC might get ‘a bit grumpy’ or ‘nippy’, to suggestions that groups might coalesce around the issue. These narratives appeared to be fuelled by hearsay about the implementation of smoking bans in E&W, which were believed to have caused trouble or ‘riots’ in some prisons. Key trigger points and areas of tension (beyond the implementation itself) included Christmas, when PiC typically experience greater stress; the removal of tobacco from the canteen (rumours were circulating at the time of the interviews about when this would be); and the inability of certain prisons/prisoner groups to cope with the ban. Some PiC were viewed as less prepared for and less able to cope with the removal of tobacco:

. . . 30 November is a bad time. See with Christmas coming up . . . it’s a particularly bad period, sort of stressful period . . . you’re away from your family . . . So the added of not being allowed to smoke for guys that want to smoke, it’s going to be even harder . . .

Male, tried stopping smoking in prison

I think the guys have got enough warning . . . enough opportunities available. But certainly jails like Barlinnie where it’s shorter-term prisoners, yeah, it will cause problems . . . guys coming in have big drug habits, they’ll be relying on nicotine . . . For them it’s going to be a massive shock and it’s going to come out of the blue . . . So in here I don’t think there will be a problem. In other prisons, yeah.

Male, tried stopping smoking in prison

There was also discussion regarding the ban’s potential impact on the emergence of illicit tobacco, competition for tobacco products and ensuing tensions, such as debt and jealousies about inequitable access:

Not everyone’s going to be able to afford that, that’s crazy money. Obviously, there’s going to start a bit of jealousy, maybe a little bad talking behind people’s backs. Some might lead to fighting. It might lead to people telling officers, like, such-and-such has got such-and-such. People getting themselves searched, things getting taken off them.

Male, tried stopping smoking in prison

It is noteworthy that, within this prisoner group, negative effects rarely manifested in resentment towards prison staff, despite recognition that concerns for staff health had been a driving force behind the policy. Indeed, as noted, some PiC expressed sympathy about staff exposure to SHS, although it was also believed that any failure by staff to comply with the ban post implementation (e.g. ‘fly smoking’ in unoccupied cells) could lead to heightened tensions:

There’s a lot of staff in here that go into cells and have a fly smoke, right? . . . I’ll turn a blind eye to it just now, because they shouldn’t be doing it anyway, even when it’s allowed [for PiC] to smoke. But when the ban comes in . . . I’ll be saying something about it because if we can’t do it then they shouldn’t be doing it.

Female, tried stopping smoking in prison

Finally, although most anticipated some negative reactions, many PiC (whatever their views) felt that any resistance was likely to be relatively short-lived while ‘things settled down’.

Facilitators of and barriers to initiating and maintaining a successful quit attempt

Views and experiences of e-cigarettes and vaping

Similar to the support from staff and PiC for e-cigarettes described in Chapters 5 and 6, PiC interviewed for WP5 generally welcomed e-cigarettes as a potential alternative to tobacco, often viewing them as a means of ameliorating the likelihood of trouble or unrest following implementation of the ban. However, few who were actively seeking to stop smoking expressed a desire to take up any of these products. Although some of those trying to quit had experimented with (single-use) e-cigarettes and bought them as a back-up to deal with cravings and possible relapses, most making a concerted effort to quit expressed a strong desire to ‘beat’ their nicotine addiction, often indicating that this was their primary motivation for attending the cessation programme:

I don’t really want to give up one addiction for another . . . swapping one addiction for another, isn’t it? I don’t see vapes as being a device to help you give up. I see them purely as a replacement.

Male, never tried stopping smoking in prison

Personally, if you’re stopping, then go the whole hog, don’t just do it half measures, kind of thing. Because at the end of the day, they’re still taking nicotine into their system, and they’ll go back to cigarettes . . .

Male, tried stopping smoking in prison

For some, switching to e-cigarettes was perceived to increase PiC’s risk of returning to smoking on release. Indeed, some thought that PiC who wished to take up smoking after they were released regarded vaping as a temporary means of abstaining from smoking while in prison:

. . . until you’ve actually given up all of it, you know, you’re still taking nicotine. You potentially could start smoking tomorrow, you know what I mean . . . the nicotine would still be there like.

Male, tried stopping smoking in prison

They’ll just stop smoking tobacco and start smoking them [vapes] . . . So [if] you don’t want to continue smoking in between November and your exit from prison, they’ll just use e-cigarettes so they can still get their nicotine and then continue smoking when they get out.

Male, tried stopping smoking in prison

There was a general awareness that single-use e-cigarettes had been available from the canteen (these interviews were conducted during the 2 months before the decision to introduce rechargeable vaping devices), but they were viewed predominantly negatively, with numerous reports of poor product reliability and value for money:

. . . these daft [single-use] e-cigarettes . . . they’re garbage . . . bought a couple off the canteen sheet and they’re quite expensive . . . £2.50 for one ‘cigarette’ and you get 250 puffs out of it. You weren’t even getting what it says. No, so they’re shite.

Male, tried stopping smoking in prison

Some PiC who were more knowledgeable about e-cigarettes were strong advocates for the introduction of rechargeable devices, which were believed to be more effective replacements for tobacco:

. . . they’re really good, really, really good but they’re obviously going to be available on the shop with the vapes as well, I think the vapes are coming in. But obviously that is a good thing for people that just don’t want to stop smoking, they’re just going to maybe smoke that until they get released. But I don’t want to move from fags to another thing and then get released and I’m smoking e-cigs and that, I just want to try and cut it off all together.

Female, never tried stopping smoking in prison

However, as reported earlier (see Chapter 6, Surveys of people in custody), PiC’s knowledge of e-cigarettes and vaping was limited and participants identified a need for additional information and education on their use, and a workable mechanism to enable PiC to purchase more expensive rechargeable devices.

Perceived gaps in provision and suggested improvements

Suggested improvements to the cessation service at the time of interview focused predominantly on two areas, reflecting previous findings relating to barriers to service delivery, although other perceived gaps were raised.

Cost–consequences analysis

The regression framework analysis compares costs and outcomes across all three phases. Results demonstrate no statistically significant change between phases (Table 16). For staff, there was a trend for GP costs to decrease each phase, and there was a small increase in tobacco spend between the pre-announcement and preparatory phases, and a decrease between the preparatory and post-implementation phases: an overall decrease across the study period. For PiC, both SAs and base-case analyses demonstrated a trend for GP/nurse costs to increase over the three phases.

The interrupted time series analysis compared costs and outcomes across the three phases and adjusted for overcrowding. Time series graphs for costs and outcomes with statistically significant results are included in Figure 8; the remaining graphs are available from the corresponding author.

FIGURE 8.

Interrupted time series results (statistically significant costs and outcomes). (a) Outpatient attendances; (b) cost of inpatient length of stay; (c) cost of mental health length of stay; (d) cost of A&E attendances; (e) cost of ambulance incidents; (f) cost of smoking-related illness medications; (g) cost of e-cigarettes; (h) number of fires; and (i) number of people managed on MoRs policy. MoRs, management of offenders at risk due to any substance.

There was no consistent pattern in the results in terms of changes between specific phases (Table 17). However, all resource categories showed a trend towards decreasing costs over the study period, except ambulance incidents, medication for nicotine-dependence and e-cigarettes. Outpatient attendances and smoking-related illness medication costs saw a decrease each phase, ambulance incidents and medication for nicotine-dependence saw an increase each phase, and inpatient, mental health, and A&E costs decreased from the pre-announcement to the post-implementation phase.

Statistically significant changes between phases comprised the following: outpatient attendance costs decreased between the preparatory and post-implementation phases, inpatient length of stay costs decreased between the pre-announcement and preparatory phases and costs increased between the preparatory and post-implementation phases with a decrease in slope. The cost of mental health stays decreased between the preparatory and post-implementation phases. For A&E costs, the slope showed a decrease between all phases. The ambulance cost decreased from the pre-announcement to the preparatory phase. E-cigarette costs increased between the preparatory and post-implementation phases, a statistically significant step and slope change; however, this was expected as e-cigarettes became available to purchase in the preparatory phase and sales increased once tobacco was removed from the canteen list at the end of the preparatory phase.

None of the medication categories in sensitivity or base-case analyses shows a statistically significant change between phases, although it is worth highlighting an outlier in smoking-related illness medications in month 11 skewing results, because of single special line prescription; this resulted in an inflation of the predicted mean in the pre-announcement phase and so should be interpreted with caution. Analysis of the medication dispensed for PiC over the study period is also described in more detail elsewhere (see Acknowledgements, Publications).

Table 18 presents CCA outcomes from the regression framework analysis. The mean PM_2.5 level decreased in each phase, from 38.44 µg/m³ in phase 1 to 11.15 µg/m³ in phase 2 and to 3.14 µg/m³ in phase 3, a statistically significant result. 11,31,32 There was a trend for staff health utilities to increase each phase, but this was not statistically significant. Health utilities for PiC decreased between phases; the decrease between the preparatory and post-implementation phases was statistically significant. Further analysis on the PiC health utility decreases showed that this was largely because of responses to the anxiety/depression domain of the EQ-5D (see Report Supplementary Material 2, Table 76).

Similarly to the costs analysis, there was no consistent pattern in terms of changes in outcomes between phases (Table 19). Overall numbers of ‘prisoner on staff’ assaults and deaths in custody remained constant, and numbers of ‘prisoner on prisoner’ assaults, fires and MoRs increased. The predicted monthly mean remained constant for ‘prisoner on staff’ assaults and showed changes between phases, and all-cause deaths in custody remained constant across the phases. Statistically significant results comprised a small increase for ‘prisoner on prisoner’ assaults between the preparatory and post-implementation phases, a small increase in fires between the pre-announcement and preparatory phases and a slighter larger decrease in the number of fires between the preparatory and post-implementation phases, and an increase in the number of PiC managed under MoRs policy between the pre-announcement and preparatory phases (see Figure 8). All SAs confirm these results (see Report Supplementary Material 3).

Cost-effectiveness analysis

Annual costs used in the CEA analysis were broken down into components for the pre-announcement and post-implementation phases of the smoke-free policy (Table 20). Total staff costs were higher in the pre-announcement phase (£33 more) than in the post-implementation phase; this is mirrored by the PiC results (£65 more). The PiC difference in costs was largely driven by inpatient costs, medication for smoking-related illnesses and spending on e-cigarettes when compared with tobacco; however, for smoking-related illness medication this was largely due to the outlier described in Cost-consequences analysis. Cost categories that were more costly post implementation, compared with pre announcement for PiC, include GP/nurse visits, mental health stays, ambulance incidents and medication for nicotine dependence. The largest component cost was mental health stays. In SAs where all medications were added (i.e. SA1), costs were higher post implementation than with pre announcement; when data for the open prison were added (i.e. SA2) results mirrored base-case results (see Report Supplementary Material 3, Table 9).

Table 21 presents the cost-effectiveness results, described as a cost per additional 10 µg/m³ reduction in PM_2.5. Base-case results were similar for staff and PiC. The post-implementation phase dominated the pre-announcement phase; this means that the post-implementation phase was less costly and there were lower levels of SHS than in the pre-announcement phase. This result was mirrored in SA2. In SA1, the cost per additional 10 µg/m³ reduction in PM_2.5 was £149; the post-implementation phase was more costly and had lower levels of SHS than the pre-announcement phase.

Cost–utility analysis

Costs are the same as those in the CEA. Table 22 presents the CUA results using a cost-per-QALY measure. For the staff base-case analysis, the post-implementation phase dominated the pre-announcement phase; this means that the post-implementation phase was less costly and had lower levels of SHS than the pre-announcement phase. For the PiC base-case analysis, the cost-per-QALY change was £1200; the post-implementation phase was less costly and less effective than the pre-announcement phase, and the resulting ICER was positive, with negative incremental costs and QALYs. In SA1, the pre-announcement phase dominated the post-implementation phase, being less costly and more effective. In SA2, results mirrored the base-case results.

Base-case results

A breakdown of costs for the base-case results is presented in Table 23. Total costs were lower with the smoke-free policy (post implementation) than without it for both PiC (£32,848 vs. £33,749) and staff (£10,462 vs. £11,183). For both PiC and staff, the largest portion of total costs related to personal costs of tobacco and e-cigarette products (89% and ≈ 60%, respectively); implementation costs (here, costs of providing e-cigarette starter packs) were minimal.

Base-case analysis results are presented in Table 24. As well as costs being lower with the smoke-free policy than without, QALYs were higher in the smoke-free comparator for PiC and staff, suggesting that both cohorts benefit from an increase in quality of life with a smoke-free policy. PiC benefit from a greater increase in QALYs than staff (0.126 vs. 0.094).

For both PiC and staff, ‘with the smoke-free’ policy dominates the ‘without smoke-free’ policy comparator, meaning that mean lifetime costs were lower and quality of life was higher with the smoke-free policy than without it. For completeness, the resulting negative ICERs are presented. No 95% CIs cross zero, indicating that there was little uncertainty in the dominance of the ‘with smoke-free’ comparator.

The cost-effectiveness plane is presented in Figure 9. Plots represent the 1000 bootstrap iterations in each cohort; the triangles represent the respective PSA mean point estimates and the red line represents the £20,000 cost-effectiveness threshold; all estimates below this line are considered cost-effective compared with the £20,000 willingness-to-pay threshold.

FIGURE 9.

Cost-effectiveness plane.

Nearly all estimates were in the south-east quadrant of the cost-effectiveness plane, where the ‘with smoke-free policy’ is less costly and more effective than without, for both PiC and staff. At the £20,000 willingness-to-pay threshold, the smoke-free policy for both cohorts would be considered cost-effective compared with not having the smoke-free policy.

Scenario analyses results

The results for the scenario analyses are presented in Table 25; the results for scenarios 1–9 apply to PiC only. ICERs varied from –£25,215, when applying the resumption of smoking on release rate reported in the TIPs PiC questionnaire (scenario 1), to –£2089, when canteen tobacco spend while in prison was applied to tobacco smokers after release (scenario 9). None of the scenario analyses resulted in a positive ICER.

Two scenarios resulted in lower incremental costs than the base-case analysis: scenario 3 (PiC time in prison: 1 year) and scenario 9 ‘post-prison’ tobacco spend: canteen ‘in-prison’ data. Scenario 3 resulted in lower incremental cost for personal spend as a result of less time in prison with lower tobacco costs applied, and scenario 9 resulted in lower incremental costs as a result of similar tobacco costs in both the ‘in-prison’ and ‘post-prison’ periods. The remaining scenarios had higher or similar incremental costs to the base-case scenario. The two scenarios with the largest incremental costs were the ones exploring the effects of varying assumptions about the resumption of tobacco smoking following release; these showed greater savings because of lower personal spending on tobacco following release.

One scenario, scenario 3 (PiC time in prison: 1 year) resulted in lower incremental QALYs than the base-case scenario (0.056 vs. 0.126, respectively).

In two scenarios, only costs were affected: scenarios 8 and 9 had the same incremental QALYs as the base-case, and the remaining scenarios estimated an increase in incremental QALYs. The scenarios with the greatest increase in QALYs were scenario 1 [PiC smoking resumption on release: TIPs questionnaire (0.352)], scenario 4 [PiC time in prison: 10 years (0.338)] and scenario 5 [PiC time in prison: 17 years (0.503)].

Overall impact of policy

Total cohort costs and QALYs are presented in Table 26 for PiC, staff, and PiC and staff combined. Cost reductions related to morbidity costs and personal tobacco costs with the smoke-free policy equated to approximately £6.7M in the PiC cohort, £2.3M in the staff cohort and £9.0M overall. The number of QALYs gained with the smoke-free policy equate to 947 in the PiC cohort, 304 in the staff cohort and 1251 overall.

Phase 1

Semple S, Sweeting H, Demou E, Logan G, O’Donnell R, Hunt K, on behalf of the Tobacco in Prisons (TIPs) Research Team (2017). Characterising the exposure of prison staff to second-hand tobacco smoke. Ann Work Expo Health 2017;61:809–21.

Semple S, Sweeting H, Demou E, Logan G, O’Donnell R, Hunt K, on behalf of the Tobacco in Prisons (TIPs) Research Team) (2017). Staff Exposure to Second-hand Tobacco Smoke in Scotland’s Prisons. Edinburgh: Scottish Prison Service; 2017.

Brown A, Sweeting H, Logan G, Demou E, Hunt K. Prison staff and prisoner views on a prison smoking ban: evidence from the Tobacco in Prisons study. Nicotine Tob Res 2019;21:1027–35.

Brown A, Sweeting H, Semple S, Bauld L, Logan G, Hunt K. Views of prison staff in Scotland on the potential benefits and risks of e-cigarettes in smoke-free prisons: a qualitative focus group study. BMJ Open 2019;9:e027799.

Sweeting H, Semple S, Demou E, Brown A, Hunt K. Predictors of opinions on prison smoking bans: analyses of survey data from Scottish staff and prisoners. Tob Induc Dis 2019;17:47.

Phase 2

Brown A, Eadie D, Purves R, Mohan A, Hunt K. Perspectives on smokefree prison policy among people in custody in Scotland. Int J Prison Health 2020;16:389–402.

Semple S, Dobson R, Sweeting H, Brown A, Hunt K, on behalf of the Tobacco in Prisons (TIPs) research team. The impact of implementation of a national smoke-free prisons policy on indoor air quality: results from the Tobacco in Prisons study. Tob Control 2020;29:234–6.

Phase 3

Demou E, Dobson R, Sweeting H, Brown A, Sidwell S, O’Donnell R, et al. From smoking-permitted to smokefree prisons: a 3-year evaluation of the changes in occupational exposure to second-hand smoke across a national prison system. Ann Work Expo Health 2020;64:959–69.

Sweeting H, Brown A, Demou E, Hunt K. Prisoners and prison staff express increased support for prison smoking bans following implementation across Scotland: results from the Tobacco in Prisons Study (letter). Tobacco Control 2020.

Tweed E, Mackay DF, Boyd K, Brown A, Byrne T, Conaglen P, et al. Evaluation of a national smoke-free prisons policy using medication dispensing: an interrupted time-series analysis. Lancet Public Health 2021;6:E795–804.

Brown A. Understanding the Perspectives of People in Custody and Prison Staff through the Process of a Major Policy Change: The Introduction of Smokefree Prisons in Scotland. PhD thesis. Stirling: University of Stirling; 2021.

Related publications to which the authors of this report contributed

Sweeting H, Hunt K. Evidence on Smoking and Smoking Restrictions in Prisons: A Scoping Review for the Scottish Prison Service’s Tobacco Strategy Group. MRC/CSO Social and Public Health Sciences Unit occasional paper 25 Glasgow: MRC CSO Social and Public Health Sciences Unit; 2015.

Robinson A, Sweeting H, Hunt K. UK news media representations of smoking, smoking policies and tobacco bans in prisons. Tob Cont 2018;27:622–30.

Brown A, O’Donnell R, Eadie D, Purves R, Sweeting H, Ford A, et al. Initial views and experiences of vaping in prison: a qualitative study with people in custody preparing for the imminent implementation of Scotland’s prison smokefree policy. Nicotine Tob Res 2021;23:543–9.

Brown A, O’Donnell R, Eadie D, Ford A, Mitchell D, Hackett A, et al. E-cigarette use in prisons with recently established smokefree policies: a qualitative interview study with people in custody in Scotland. Nicotine Tob Res 2021;23:939–46.

Brown A, Mitchell D, Hunt K. Post-implementation perspectives on smokefree prison policy: a qualitative study with staff and people in custody [published online ahead of print August 27 2021]. Eur J Public Health 2021.

Future publications related to this work can be expected.

Introduction and background

Overview of participant roles and responsibilities: (in general and in relation to smoke-free prisons), time in role/organisation and smoking status. Description of their prison/wider estate: function/category, public/private, prisoner population, and successes and challenges facing the prison – staffing, disruption, time out of cells, etc.

Current and historic smoking restrictions

Current smoking arrangements for PiC and staff: when introduced, where smoking can take place for PiC and staff, whether/what circumstances e-cigarettes can be used for PiC and staff, type/model(s) permitted and how smoking restrictions vary across the prison estate. Process for admission of incoming PiC who smoke: whether or not they are aware they are entering a prison with a smoking ban and views on adequacy of process. Description of pre-ban policies in prison: smoking arrangements for PiC and staff.

Pre-implementation (lead-up to smoking ban)

Trigger(s)/rationale for ban (including drivers at national and local level). Process for communicating ban to prisons/staff/PiC: how prisons were selected to become smoke free; whether voluntary/mandated, piloted/staged; when/how ban was communicated to prisons, staff and PiC; (adequacy of) time to prepare for implementation; initial support for ban from PiC and staff and changes over time; expectations of PiC and staff; and key anticipated risks and benefits. Key measures at national/local level to prepare: who was involved and measures/actions (e.g. communication/engagement with staff, PiC, families, communities; staff training, guidance and support; staffing levels; PiC transfers; provision of ‘smoke-free champions’/peer support, purposeful/other activities (including in-cell activities), and smoking cessation services and support). Key services offered: NRT, whether services available for staff, who delivers cessation service/support, scale of provision, funding, care pathways, whether or not steps taken to harmonise provision across estate, specific measures/support for PiC in vulnerable circumstances and other. Views on effectiveness/success of measures taken in the lead-up: whether or not prison service/staff/PiC felt well prepared for ban (and reasons); what worked well/less well; factors influencing success (including contextual/environmental factors – staffing levels, regime stability); and what, if anything, they would do differently.

Implementation and impacts of smoke-free prisons

Views and experiences of implementation: what it was like in headquarters/prison in days/weeks/months after the ban was introduced; prison staff role in implementing the ban and how well arrangements are working (enforcement, cessation support/interventions, informal guidance/support); what worked well/less well and whether or not this has changed over time; (whether PiC tried to manipulate allocations/transfers to enter/exit smoke-free prisons, what proportion sought NHS support, use of e-cigarettes – how any risks managed; support for most vulnerable/difficult to manage, role of smoke-free champions/peer supporters); factors influencing success; what, if anything, they would do differently. ‘Impacts’ of ban: what ‘success’ means to staff/PiC/prison service; whether/why ban has achieved intended outcomes; variation among prisons, staff, PiC and over time; whether or not there have been any intended consequences of smoking ban; change over time (prevalence of tobacco smoking e-cigarette use before and after ban; use of alternative smoking items; longer-term cessation rates: health for PiC and staff, SHS exposure; physical health; organisational/cultural implications for staff: workload, remit/responsibilities, job satisfaction; incidents of violence/disruption, fires, self-harm and drug use; social/cultural value of tobacco; tobacco/illegal substance black markets; litigation/arguments re rights; economic impacts).

Concluding comments/summary

What measures/actions are most important for successful implementation and what, if anything, they would do differently (any unnecessary measures, any measures that would have been helpful).

Background

How long (each participant) working in this prison, whether or not worked in other prisons, and general atmosphere and relationship in the prison.

Smoking

Smoking status/history of participants: whether or not smoking patterns changed since starting work at this prison and what is it like being a non-smoker working in this prison. Prison context and smoking: how common/’normal’ smoking is in this prison with PiC and staff here; how smoking fits into day-to-day life of this prison; whether or not smoking is more common in this prison than others; extent of ‘trade’ in tobacco between PiC in this prison; when/where PiC usually smoke; exactly where and when are they allowed to smoke; what PiC and staff colleagues think about the current rules around smoking in this prison; when/where do smoking staff smoke usually; how well are smoking rules adhered by staff and PiC; in what ways, if any, are the rules broken; and how colleagues view smoking and PiC who smoke in the prison. Smoking cessation: what might make PiC want to stop smoking while in prison, what might make them not want to stop smoking, what sort of help/support do they (and smoking staff) need to stop smoking, who is best placed to give this support, are different kinds of support needed to give up smoking compared with outside prison, any past experience of smoking cessation services, and what do you think of the support that is available for PiC (and prison staff) who want to stop smoking while in prison.

E-cigarettes

Have you/others you know people used e-cigarettes, what do you think about e-cigarettes, should PiC/staff be allowed to use e-cigarettes in prisons (in what ways would it be a good/bad thing) and what issues could be raised by allowing use of e-cigarettes in prisons?

Experience or threats of violence

Since coming to this prison, any experience of threats of violence or bullying that were so serious that you became afraid, or violence in the past year in this/another prison; were any of these related to tobacco or smoking?

Smoking bans

What did you think when the smoking ban was introduced in Scotland in 2006 (in what ways was it a good/bad thing) and the decision to exempt prisons from the legislation; have you heard about some prisons in Wales and in England going smoke free (what do you think about how this has happened); do people talk about increased smoking restrictions (in prisons) in other countries; what do you/PiC/other prison staff think about introducing smoking bans in prisons; what should Scotland do; how might introducing more smoke-free areas in prisons in Scotland be a good/bad thing and change prison life (for PiC/staff who smoke/do not smoke); what would make it easier/harder to extend smoke-free areas in prisons; and what would make it easier/harder to ban smoking altogether.

Background

Roles and responsibilities: in general and in relation to implementation of the ban, time in current role and experience of working in other prisons in Scotland/UK. Prison context: size, prisoner population, regime, accommodation, strengths and any limitations; what it is like to work in the prison on a typical week/weekend day (atmosphere, prisoner–staff and management–staff relationships). Smoking history: their current and past status and what it is like to work in the prison as a smoker/non-smoker.

Awareness and opinions about impending introduction of smoke-free policies in November 2018: level of awareness that Scottish prisons will become smoke free; whether (why) they agree with plans to make prisons smoke free; what might be good/bad about prisons being smoke-free and whether/why their views on smoke-free prisons have changed over time. Views on smoke-free prison policies in England and Wales (and wider society): extent of knowledge; what they think about prisons in Wales and England going smoke-free; and what, if anything, they have heard about how successful they think the policy has been.

Life in prison in anticipation of going smoke free

Experience of working in the prison in the lead-up to the introduction the ban: smoking culture and prisoner/staff smoking habits – how smoking fits into the day-to-day life of the prison (‘normality’ of smoking among PiC and staff); importance and role of tobacco in prisons, including trade; how PiC who smoke are seen by other PiC and staff; how interested PiC are in quitting; how much tobacco PiC buy from canteen; how much PiC usually smoke; how well rules around smoking are followed by PiC and staff; consequences of breaking smoking rules; and any changes in smoking within prisons since July/August 2017 (and if so whether or not related to impending ban from November 2018/introduction of the minimum pack size for cigarettes/other factors). Communication and engagement: whether/when/how plans to make prisons smoke free were communicated to staff, PiC and families – what worked well/less well; whether/what staff and PiC have been talking about in relation to the smoke-free policy; and whether or not staff/PiC have been involved in getting the prison ready to become smoke free (what works well/less well). Stop-smoking support: how easy/difficult for PiC to quit in prison and why; what they think about the help currently available to PiC; what works well/less well; whether or not stop-smoking support is good enough for the prison to become smoke-free; whether/how it has changed since July/August 2017; and what, if anything, could be done to make prisoner stop-smoking support better. E-cigarettes: how much do they know about e-cigarettes and different types of devices/e-flavours/levels of nicotine; whether they have used e-cigarettes outside/inside prison; whether/why PiC should be allowed to use e-cigarettes in prisons in the lead-up to and/or after prisons become smoke free; and any problems related to introducing e-cigarettes in prisons, and ways to resolve any issues. Other aspects of prison life in the lead-up to ban: any other changes in the prison in the lead-up to ban (how well rules are followed by PiC, prison day/regime, atmosphere, how staff/PiC are feeling/behaving, prisoner–prisoner and prisoner–staff relationships).

Implementing the smoke-free policy

What could facilitate a smoke-free environment for staff/PiC from November 2018: how easy/difficult will staff/PiC find it when prisons become smoke free; which groups of staff/PiC might find smoke free easier/harder; what actions could make it easier for staff/PiC; what actions should be taken in the lead-up; and what actions should be taken after the prison has become smoke free. What actions are being taken to implement a smoke-free policy in this prison: before/planned for after the policy is introduced; what is working well/less well; what could be improved; and what actions will be taken in the post-implementation phase to help ensure continued success. Successes, challenges and lessons learned to date in respect of the implementation of smoke-free prisons.

Background

What it is like in the prison on a typical week/weekend day: how they spend their time; what, if anything, is good/bad about the prison; how well prisoners and staff get along; and what the atmosphere is like. How long they have been in prison and when they expect to get out; whether or not they have been in prison before – roughly how many times and for how long.

Smoking history

For smokers: whether or not they smoked before they came to prison and whether and how their smoking habits have changed since coming to prison, and whether or not they are interested in giving up smoking while in prison. For ex-smokers: when did they quit smoking and what it was like, and what it is like to be an ex-smoker in a prison. For never smoker: what it is like being a non-smoker in a prison.

Awareness of and opinions on prison smoke-free policies

Explore opinions about the introduction of smoke-free policies in Scottish prisons from late November 2018: whether or not they have heard that Scottish prisons will become smoke-free, whether or not they agree with plans to make prisons smoke free, what might be good and bad about prisons being smoke free, and have their views on smoke-free prisons changed over time and reasons for this. Explore views on smoke-free prison policies in England and Wales: what they think about prisons in Wales and England going smoke-free; and what, if anything, they have heard about what life is like in these prisons since they became smoke-free.

Background

Age, when (month/year) they entered prison (did they enter prison on their current sentence before or after 30 November 2018), sentence type, sentence length and whether or not this is the first time they have been in prison.

Smoking and vaping status and history pre ban or arrival in custody

Smoking history pre ban or arrival in custody. For previous smokers: when did they start smoking; how many cigarettes/roll ups did they smoke per week at that time; how did they feel about smoking at that time; before entering prison (for this sentence)/before smoke-free rules came in did they try to cut down or stop smoking; what were their reasons for doing so; what support did they use to try to help them to cut down or stop smoking, if anything; did they manage to cut down or stop and for how long; how easy or difficult they found it to try to stop smoking and the reasons for this; before entering prison/before smoke-free rules were they considering or planning to try to cut down or stop smoking? For those who were non-smokers before the introduction of smoke-free rules/before entering prisons: have they ever smoked and if so when and why they decided to quit and how they did it. E-cigarette use history: before entering prison/before introduction of the smokefree policy did they ever use e-cigarettes (when did they start using e-cigarettes and why; did the use e-cigarettes regularly at that time; what, if anything, did they like or dislike about using e-cigarettes at that time; did they use e-cigarettes only or did they also smoke tobacco).

Overall experiences, benefits, and challenges of living in a smoke-free prison

Overall, what it is like living in a smoke-free prison: what is good/bad about living in a smoke-free prison; benefits/issues/challenges; impacts on different groups, for example PiC (including new arrivals and vulnerable prisoner groups), staff, prison service and families. Has the introduction of smoke-free rules been like they imagined (if relevant): how does their experience now compare to the first few days/weeks of living in a smoke-free prison. Explore views on other positive/negative consequences of smoke-free prison policy: ‘trouble’ in prisons; working conditions for staff/living conditions for prisoners; physical and/or mental health and well-being of PiC, families and staff; smoking behaviour; and impacts on prison service/life in prison. What things have influenced the level of success of smoke-free rules in this prison: to what extent was preparation good in this prison for the smoking ban, what helped/did not help and why; and what things are helping/not helping with the ongoing operation of smoke-free rules.

Communication of smoke-free prison rules

How did they hear about the introduction of smoke-free rules in Scottish prisons from 30 November: what were they told, by whom and when; and were there any issues/challenges in respect of the information they were given about smoke-free prison rules.

Smoking abstinence/cessation in smoke-free prison

Overall, how easy or difficult are they finding it not to smoke: what kinds of things they do instead of smoking; how/in what way has the ease/difficulty of not smoking in prison changed over time? Reasons for this; how well are other prisoners managing without tobacco? Are some prisoner groups finding it harder than others? Which groups and why? What kind of support in respect of not smoking/quitting nicotine, if any, have they used or tried to access in (smoke-free) prison since the ban: why did they decide to access or try to access support not to smoke; how easy did they find it to access support/how long did they have to wait; what did they do in the interim; what worked well and less well about the support; and how do they think the support available in this prison to help prisoners not to smoke or quit nicotine long term could be improved. If they entered prison from 30 November 2018, explore what it was like as a smoker to enter a smoke-free prison.

Compliance and enforcement of smoke-free prison rules

How well do prisoners in this prison stick to no-smoking rule: how common is smoking in this prison; how easy or difficult would it be for someone to buy tobacco, lighters/matches. How likely it is that smoking will be detected by staff?

E-cigarettes in a smoke-free prison

What are their views on e-cigarettes generally. What is it like to live in an environment in which prisoners are using e-cigarettes. What do they think about the availability of e-cigarettes in smoke-free prison: what, if anything, has been good/bad about the availability of e-cigarettes in smoke-free prison; and how do other staff/prisoners feel about the sale of e-cigarettes in smoke-free prison. How common is it for prisoners to use e-cigarettes in this prison: has the popularity of e-cigarettes among prisoners changed over time, and do e-cigarettes have more value to some groups of prisoners than other. Have they used e-cigarettes while in smoke-free prison? If yes, explore: what are/were their reasons for using e-cigarettes in (smoke-free) prison; what plans, if any, did they have initially in respect of using e-cigarettes in prison and have they ended up using e-cigarettes in this way; how often do/did they use e-cigarettes; what products have they tried and what are their opinions of them. Have they considered reducing/stopping their intake of nicotine? If yes: reasons for this, what stage they are at, what support, if any, did they get to stop vaping and who from, what worked well and less about the support? What made it easier/more difficult to stop using e-cigarettes in prison? Do they intend to continue using e-cigarettes in the future?

Smoking and vaping behaviour during work placement/home leave or after liberation

What plans, if any, do they have regarding smoking after they leave prison/during work placement/home leave: how do they feel about the idea of not smoking after they leave prison/during work placement/home leave, and how easy or difficult do they think it will be to not to smoke after they leave prison/during work placement/home leave. Reasons for this.

What, if anything, they think could be done to help prisoners avoid returning to smoking after liberation/during work placement/home leave?

Lessons learnt and concluding remarks

What lessons do they think could be learnt from Scotland in relation to how to have a smoke-free prison?