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Banning smoking in prisons reduced medications for smoking-related diseases and improved people's general health. New research found that the ban was accepted more readily than anticipated. Both staff and people in custody said they felt generally better after the ban was introduced.

Smoking affects the health of both smokers and those who share their spaces. It increases the likelihood of more than 50 serious illnesses, including cancer, heart disease and stroke.

The ban on smoking in public places has reduced smoking-related diseases since it was rolled out across the UK in 2006. But many people in prison smoke, and the ban has only recently (2018) been applied to prisons in Scotland.

Before this study, there was little research on the impact of the smoking ban in prisons. Researchers therefore explored whether the smoking ban in Scottish prisons influenced the medication dispensed for smoking-related diseases. They looked at medications for depression (antidepressants) to see if the ban affected mental health. They then asked both staff and people in custody about their experiences of the ban.

What’s the issue?

Smoking kills almost 80,000 people each year in the UK. Many more live with debilitating smoking-related illnesses, including cancer, heart disease and stroke. Non-smokers who live or work in enclosed areas where people are smoking are also at increased risk of these conditions.

Smoking has been common in prisons. In Scotland in 2017, before the ban was introduced, 68% of people in custody were smokers, compared with 18% of the general adult population. Levels of second-hand smoke in prison were typical of those in a house where someone smokes.

Smoke-free policies in public spaces can improve air quality and with it, people's heart and lung health. Bans have been linked to reduced dispensing of medications for respiratory conditions (of the lungs and breathing).

The UK national smoking ban was extended to prisons in Scotland in 2018. This research team wanted to see if the policy led to people in Scottish prisons taking less medication. Their study looked at medicines dispensed for a range of relevant conditions, including dependence on nicotine, mental health, respiratory diseases such as asthma, and angina (chest pain from reduced blood flow to heart muscles).

In another part of the study, staff and people in custody were interviewed about the impact the ban had on them.

What’s new?

Pharmacy data was collected for 44,660 people detained in 14 of the 15 closed prisons (with no access to the community) in Scotland. The data covered medicines dispensed over a period of 5 years, before and after the ban was put in place.

After the smoking ban was put in place, researchers found:

  • a 42% increase in dispensing of nicotine replacement therapy, showing that more people in custody were seeking help to quit smoking
  • a 9% decrease in dispensing for smoking-related illnesses; this was largely accounted for by respiratory diseases, with small decreases in other conditions
  • no changes in antidepressant dispensing.

The research team also conducted interviews with staff (99) and with people in custody (23) after the smoking ban was put in place. They found the smoking ban was accepted more readily than expected.

People in both groups reported positive experiences:

  • The reduction in second-hand smoke led a prison officer to describe: ‘A great improvement to our working life because the halls [residential areas] are quite enclosed, so, you know, you [would] smell it off your clothing when you went home.’ Someone in custody said: “Before you would have to, sort of, clean the walls and things like that when you went in. Like, you’d spray cleaning stuff on the walls and it would just run, like, yellow, see with the nicotine... Whereas, like, it’s a lot fresher. It’s a lot nicer.’
  • Health benefits were described, for example by one person in custody:  “Well to start off with I thought it [smokefree policy] was a joke. But obviously after a couple of weeks you adjust to a life without cigarettes. . .you start to feel a bit better. . .with your breathing. Your lung capacity, your fitness, everything starts picking up.”

However, some people in custody described negative consequences:

  • Increased anxiety was felt by some. One person in custody said: “I did enjoy smoking when I was in prison, it’s one of the small things that I had… was having a smoke, and a coffee… just to kind of, de-stress, kind of… relax. And now it’s been taken away, I feel like my anxiety has increased a lot.”
  • A link with violence was suggested by another: “Because tobacco is not around… it’s causing a lot of aggro, as well… a lot of more fights now, than what there used to be, and more arguments… more tension

Some people in custody said they would have liked earlier access to e-cigarettes.

Why is this important?

The smoke-free policy in prisons has been in place since 2018. This is the first study to look at its impact, and it shows the generally positive effect on prisoners and staff.

The study found that the smoking ban did not affect dispensing for mental health conditions which suggests that it did not increase levels of depression. However, the researchers caution that there may have been an impact on mental health since, in the interviews, some prisoners reported raised anxiety levels.

Improvements in respiratory health were especially marked. Removing second-hand smoke from prisons also improved working conditions for staff.

What’s next?

The ban was accompanied by more smoking cessation support in prisons. This included medicines such as nicotine replacement therapy and other drugs to help with nicotine dependence (such as varenicline or bupropion). E-cigarettes were available and there was behavioural therapy to help people quit.

In the short term, providing such smoking-cessation support increased costs. However, an economic analysis (part of the wider Tobacco in Prisons study) showed that the policy is cost-effective over the longer term, partly because of the reduction in medications for smoking-related illnesses.

The smoking ban in prisons has been in effect in most of the UK for some time. Elsewhere, Northern Ireland and other countries such as in Scandinavia, are yet to adopt it. This research provides support for the ban, showing that it improves the health of people in custody, as well as working conditions for staff.

You may be interested to read

This NIHR Alert is based on: Tweed EJ, and others. Evaluation of a national smoke-free prisons policy using medication dispensing: an interrupted time-series analysis. Lancet Public Health 2021;6:11

The full Tobacco in Prisons study (including economic analysis): Hunt K, and others. Process and impact of implementing a smoke-free policy in prisons in Scotland: TIPs mixed-methods study. Public Health Research 2022;10:1

A plain language briefing from the University of Glasgow: How did a complete smoke-free policy affect the health of people in prison in Scotland? Findings from the Tobacco in Prisons study: .

Further research from the Tobacco in Prisons study:

Semple S, Dobson R, Sweeting H, and others. The impact of implementation of a national smoke-free prisons policy on indoor air quality: results from the Tobacco in Prisons study. Tobacco Control 2020;29:234–36

Brown A, and others. Post-implementation perspectives on smokefree prison policy: a qualitative study with staff and people in custody. European Journal of Public Health 2022;32:1

McMeekin N, and others. Implementation of a national smoke-free prison policy: an economic evaluation within the Tobacco in Prisons (TIPs) study. Tobacco Control 2022;1–8


Funding: This study was funded by the NIHR Public Health Research programme, the Scottish Government Chief Scientist Office and the UK Medical Research Council.

Conflicts of Interest: None declared.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

This study was part of a much larger one, called TIPS (Tobacco in Prisons study) that is looking at the impact of the smoking ban in prisons. A previous publication from this study showed that the smoking ban was linked with improvements in air quality in prisons.

We have now confirmed that air quality improvements led to reductions in the medications required for smoking-related illnesses, particularly respiratory conditions. This suggests that smoke-free prison policies can be beneficial for the health of people in prison, which may be useful evidence for other countries considering similar policies.

Emily Tweed, Clinical Lecturer, Medical Research Council and Chief Scientist, Office of Social & Public Health Sciences Unit, University of Glasgow 

Researcher 

I have conducted research in prisons for many years and know that it was both unpopular and difficult to make prisons smoke free. As such, this paper is important and the findings should be well-received.

Prisoners are a socially disadvantaged group with excess mental and physical health problems. It is therefore important to show the impact of a large-scale public health measure in this group. The findings should have implications for other socially disadvantaged groups and for similar groups internationally.

Smoking is banned in prison but to enable the findings to impact on other socially disadvantaged groups, these findings should be disseminated to policy makers, particularly in health.

Jennifer Shaw, Researcher, University of Manchester 

Member of the public

This research could encourage other prisons to roll out smoke free policies. Smoking bans could have positive health impacts but I doubt they would be well received by the prison population.

It will be important to work alongside people in prison to make sure they are aware of the health benefits, the support available and the low instance of adverse effects.

Robert White, Public Contributor, Newcastle-upon-Tyne 

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