In American prisons, tobacco is a way of life; smoking rates are more than triple the figure for the country as a whole. As a result, millions of prisoners risk smoking-related heart and lung diseases, liver problems and diabetes.
With the prison population swelling to more than 2.3 million, or roughly 1 percent of U.S. adults, such dangers are threatening more people than ever before.
Some correctional facilities have tried to ban tobacco, with mixed success. But new research describes a treatment that could help prisoners stop smoking: a program similar to those offered to people in the general population.
During the past half-century, anti-smoking campaigns and innovations like nicotine replacement patches helped bring American tobacco usage rates down to about 20 percent.
“In the general population, people are getting the message that smoking is bad for you,” said study author Karen Cropsey of the University of Alabama, Birmingham’s psychiatry department. “You’d have to be living under a rock not to have heard.”
In prison, though, non-smokers are still in the minority — between 70 and 85 percent of prisoners smoke. That’s partly an unintended consequence of a practice once thought humane: Until the mid-1980s, many facilities provided prisoners with free cigarettes. They often became the currency in the lockups’ barter-based economies.
“Tobacco is integrated into the prison culture,” said Ross Kauffman, a doctoral candidate at The Ohio State University, whose dissertation explores policies addressing prison tobacco use.
Despite their addiction, roughly 70 percent of smoking prisoners say they want to quit, about the same as in the general population.
“There’s this myth that it’s the only thing they have left. People ask: ‘Why take away smoking?’ But they want to quit, too,” Cropsey said.
Most prisoners smoke hand-rolled, unfiltered cigarettes, increasing the risks to their health. For non-smokers, crowded living quarters and long hours indoors exacerbate the effects of secondhand smoke — in one study, the nicotine concentration in a prison living area was 12 times the amount in an average smoker’s home.
For prisoners, that leads to high rates of serious illness and even death. For the rest of us, it means paying for massive cumulative doctor bills from prisons because prisoners receive constitutionally mandated medical treatment. One study predicted that medical care, which already accounts for about 11 percent of correctional budgets, will double in the next 10 years.
As states became aware of the health and economic effects of smoking — sometimes via lawsuits by non-smoking prisoners and facility staff — many instituted smoke-free policies, at least in some rooms. The changes were swift: Between the mid-1990s and 2007, the percentage of prisons with a total smoking ban jumped from 13.5 percent to 60 percent, according to Kauffman. In the early 1990s, only 1 in 4 prisons offered residents smoke-free living areas; now, nearly all do.
When they banned cigarettes, prisons generally offered only limited programs to help prisoners quit, so the vast majority of prisoners kept on smoking, finding ways to illegally procure tobacco.
The incarcerated population is filled with those who are already likely to smoke and suffer from related illnesses: the poor, people of color, high school dropouts and the mentally ill. And while governments and anti-tobacco advocates have poured millions of dollars into new research, they’ve directed little toward smokers in prison. As a result, even a modestly successful anti-smoking program would help a huge number of prisoners.
“When you look at the concentration of smokers in this setting, it’s an ideal opportunity for public health intervention that is currently being missed,” Kauffman said.
There are several correctional anti-smoking programs, including an education curriculum developed by the National Network on Tobacco Prevention and Poverty and the National Commission on Correctional Health Care. It’s used in several states, including Virginia and Michigan. Yet like many others, its results haven’t been tested, though NCCHC is looking for funding to examine how much it helps participants.
Beginning in 2004, Cropsey’s team built a smoking cessation experiment around techniques proven most helpful in the general population: nicotine replacement therapy patches, combined with group therapy. The patches help people deal with physiological cravings; the therapy teaches them mood management. The offenders were residents of a large, women-only prison.
At the end of treatment, 18 percent had quit, and almost 12 percent were still abstinent at the 12-month follow-up. The 1-in-5 quit rate might seem low, but it’s in line with interventions with non-prisoners. Cropsey’s study also set a high standard for success — defining “quitters” as those whose breath contained only tiny amounts of carbon monoxide, a chemical elevated in smokers’ bloodstreams.
According to Cropsey, however, several issues remain: A large number of subjects left the program; group therapy and individual therapy may produce different results; men or juvenile prisoners may not respond as well as women.
Finances are likely the chief obstacle. Nicotine replacement therapy for hundreds of thousands, while ideal for prisoners’ health, would require large-scale public spending. “That’s not going to be politically realistic; it’s just not pragmatic,” said R. Scott Chavez, vice president of the National Commission on Correctional Health Care.
In the long term, though, such expenses might eventually pay for themselves, Cropsey said.
“If you take away (concerns over) the person’s quality of life, whether this is the right thing to do, and all the moral and ethical issues,” she said, “I still think it’s cheaper to do prevention and help people quit.”