Implementing an indoor smoking ban in prison: enforcement issues and effects on tobacco use, exposure to second-hand smoke and health of inmates.
Lasnier, Benoit ; Cantinotti, Michael ; Guyon, Louise 等
Smoking is an important health issue in correctional environments.
Smoking prevalence is reported to be high in penitentiaries, yet the
last study to measure tobacco use in Canadian correctional facilities
dates back to 1995. At the time, 72% of the inmates held in Canadian
federal penitentiaries were smokers, (1) compared to 31% of the general
population aged 15 and over. (2) To our knowledge, no empirical study
has investigated the prevalence of smoking in provincial correctional
facilities. However, in a recent study carried out in three Quebec
correctional facilities, health care staff members estimated that about
three quarters of the inmates were smokers. (3)
As a consequence of the high level of tobacco use in correctional
facilities, both inmates and staff members are exposed to very high
levels of second-hand smoke (SHS)4-6 and therefore are more likely than
the general population to develop tobacco-related forms of cancer and
disease. (7) According to the World Health Organization (WHO), one of
the most efficient means to preserve the health of both the inmates and
the staff members is the implementation of regulations banning tobacco
use inside correctional facilities. (8)
Implementing smoking bans in correctional facilities has proven to
be difficult: inmates tend to keep on smoking and smokers among the
staff tend not to enforce the bans. (9) Also, staff members believe the
bans will increase the inmates' irritability and get in the way of
the former's surveillance duties. (10,11) When asked about
implementing a smoking ban in correctional facilities, US prison
administrators stated their concerns about a possible increase in the
number of violent events and tobacco smuggling activities. (11) In
Quebec, a study conducted by Royer & Cantinotti (2008) reported
similar concerns, as 85% of the health care staff interviewed considered
that a complete smoking ban would have negative repercussions on the
inmates' behaviour, such as increasing their aggressiveness. (3)
On February 5, 2008, the Quebec Department of Public Security
implemented a regulation that completely banned tobacco use in all its
correctional facilities. Three days later, the regulation was amended to
allow inmates to smoke outdoors (during their allocated period in the
outside courtyard). This amendment was introduced in order to
"facilitate the application of the smoking ban for tobacco
users". (12) As of December 2010, this regulation was still in
effect in all Quebec provincial correctional facilities.
The main objective of this article is to describe the issues
encountered during the implementation of an indoor smoking ban and its
effects on tobacco use, exposure to SHS and health status of inmates in
Quebec's provincial correctional facilities, based on the
perceptions of both inmates and staff. Following the indoor ban, it was
hypothesized that tobacco use and consequently SHS exposure would
decrease as inmates could no longer smoke indoors and could only smoke
for about an hour a day in the outside courtyard. It was also expected
that the reduced tobacco use and SHS exposure would improve the
inmates' perceived state of health. In order to account for
possible paradoxical effects coming from the implementation of the ban,
the antithesis stating that the indoor smoking ban would result in an
increase of smoking and SHS exposure inside the correctional facilities
was also considered for the purpose of analysis (two-tailed testing).
METHODS
Design of study
The study was conducted in three correctional facilities in the
province of Quebec's largest urban centres: two in the region of
Montreal and one in the Quebec City area. The three correctional
facilities are provincial prisons for individuals incarcerated for a
maximum of two years less a day, as well as for defendants awaiting
trial. Each facility has particular characteristics; the Etablissement
de detention de Montreal (Bordeaux) is a detention centre for men that
can hold over 1,000 inmates, while Maison Tanguay is a smaller
institution for women (less than 200 inmates at the time of the study).
By comparison, the Etablissement de detention de Quebec is an average
size detention centre (around 750 inmates at the time of the study) that
includes both men and women.
Data were collected from August to September 2008, i.e., six months
after the implementation of the indoor smoking ban. The study was
approved by the ethics approval boards of the University of Montreal and
the Centre de sante et de services sociaux de la Vieille-Capitale.
Participants
Respondents were recruited through a self-selection process.
Notices were put up at various locations in the correctional facilities
to inform both inmates and staff about the study and to ask for their
participation. Those who wished to participate were referred to the
interviewer via a pre-identified staff contact-person. The only inmates
not eligible to participate were those detained in psychiatric and
secured detention wings. Overall, the sample of 113 inmates was composed
of detainees (69%), defendants (26%) and offenders waiting for transfer
to a federal facility (5%). Two thirds of the sample were men (65%). Of
all inmates participating in the study, 80% were smokers (men: 71%,
women: 95%; [chi sqaure] = 9.00, p<0.01). A vast majority of smokers
(95%) reported smoking on a daily basis. Characteristics of participants
are detailed in Table 1.
Instruments and variables
Two different instruments were used in the data collection process:
a questionnaire and a semi-structured interview guide, both in French.
The questionnaire used to collect quantitative data was administered to
all 113 inmates willing to participate in the study. Of those, 52
inmates volunteered to participate in the semi-structured interview, as
did 27 staff members (administrators, correctional officers, health care
officers). The semi-structured interview guide used to collect
qualitative data was similar for both inmates and staff. The variables
used in this article describe the inmates' smoking status and
tobacco use, the perceived prevalence of smoking in the correctional
facility, and the perceived effect of the ban on tobacco use, SHS
exposure and general health status.
RESULTS
Prevalence of smoking and number of cigarettes smoked by inmates
Respondents were asked to estimate the prevalence of smoking in
their respective correctional facility (Table 2). On average, inmates
estimated a smoking rate of 85% (SD=10.6). Male smokers reported smoking
more cigarettes per day than did female smokers (14 versus 11
cigarettes; t (78) = 2.10, p<0.05).
Effect of the ban on tobacco use, exposure to SHS and health
Slightly more than half the smokers (58%) felt the regulation had
an effect on their cigarette consumption (Figure 1); of these, a
majority (89%) reported a reduction in their tobacco use. Surprisingly,
11% of smokers reported an increase in their cigarette consumption. An
explanation for these results might lie with the earlier observation
that a vast majority of inmates, at least among those interviewed, kept
on smoking indoors despite the ban.
It also appears that a large proportion of inmates did not perceive
that the ban decreased their level of exposure to SHS (Figure 2). Among
respondents who were incarcerated before the implementation of the
indoor ban, only 34% perceived a reduction of their exposure to SHS.
Nevertheless, 45% of the same respondents felt the ban had improved
their general health. Smoking status had no significant relationship
with the perception of the ban's effect on general health ([chi
square] = 1.78, p=0.18).
Enforcement of the indoor smoking ban
While smoking 11 to 14 cigarettes per day might seem high for
individuals who are allowed only one hour to smoke in the courtyard on a
daily basis, it appears to be consistent with the fact that 93% of
smokers interviewed reported smoking inside their respective
correctional facility despite the indoor smoking ban. The following
quotes * from an inmate and a member of the staff support the previous
observation:
Nobody's waiting to go out in the courtyard to smoke.
(Patrick, inmate, smoker)
The regulation looks good on paper but here we deal with inmates,
and the boys they don't respect the rules outside so they
won't respect them here either. And the cravings go far beyond the
fear of receiving a disciplinary report or any other consequences, so
they smoke in their cell; there are some who even have the guts to smoke
in the common rooms. (Kathryn, staff, non-smoker)
Interestingly, only 46% of smokers declared ever having been caught
smoking inside the facility. Among those, more than half reported no
consequences to their illegal smoking. Furthermore, 83% of non-smokers
and 49% of smokers interviewed reported that the level of enforcement
regarding tobacco use inside correctional facilities was low. To explain
why the regulation was not systematically enforced, the staff pointed to
the lack of clear instructions on the procedures to follow when
confronted with illegal smoking:
We never received any instructions on that [...]. But look, I mean,
I'd go ask the chief and I think even he couldn't tell me for
sure. [...] They tell us to enforce a regulation, but... No, they never
told us to write disciplinary reports; they never told us to ask them to
butt out. (Karen, staff, smoker)
The staff also reported on the complexity of the application of the
indoor smoking ban:
It just can't be applied. They [inmates] come back from the
courtyard and they all bring tobacco in their cell; it's clear that
you can't ask a smoker not to smoke during the next 23 hours by
telling them 'You just have to wait'; c'mon that's
completely. that's ridiculous you know. (Rachel, staff, non-smoker)
Examination of the tobacco supply policies in the three
correctional facilities revealed that although the amount of tobacco
available for purchase per capita was limited, it was still sold in the
canteens. At the time of the study, the policies differed among the
facilities. The number of cigarettes allowed per week varied between 35
to 50 cigarettes in the detention centres for women and 75 cigarettes in
the detention centres for men. This is far below the reported daily
number of cigarettes smoked by the respondents (mean of 77
cigarettes/week for women and 98 for men). This seems to indicate the
presence of a cigarette grey market, which could have made difficult the
enforcement of the indoor smoking ban. (13)
Work overload was also mentioned as a reason why the regulation was
not evenly enforced:
It's because the staff is overwhelmed, because we lack
manpower; they have so much to do that they go like 'No, I have too
much work', and they let it fly. Sometimes they just let it fly.
(Valery, staff, smoker) It should also be recognized that some staff
members were upset by the amendment made to the original regulation,
i.e., from complete smoking ban to indoor ban only:
So we just went back to the way it was before. It was like
"They wanna smoke, let them have it, in the end we don't
really care", you know. [...] It's because we all got
frustrated that the ban didn't work as planned, that we all put a
lot of effort into this and that some inmates had already taken on
therapy to quit smoking, and ... Look, it lasted only three days;
it's completely ridiculous. (Anne, staff, non-smoker) Furthermore,
it appears that the correctional officers' reactions to the
amendment were, in part, influenced by their own smoking status: It
certainly has to do with each person's values hey! One who's
smoking and works as an administrator, a correctional officer, any sort
of job, he's gonna be more tolerant towards smoking than the other
who's a non-smoker and hates cigarettes. (Helen, staff, non-smoker)
Finally, some administrators feared that a complete smoking ban would
exacerbate tensions between inmates and that violence would ensue. They
perceived the ban as a threat to the management of day-to-day operations
in the correctional facility. In one instance, a particular
administrator held a negative view of complete smoking bans and
consequently was relieved when the regulation was amended:
Oh my! That situation would've only led to conflicts [.] that
would've been hard to take. [.] That would've been hard for
bosses to manage. This [the complete smoking ban] could have led to
hazardous situations, like riots. (Jessamine, staff, smoker)
Many inmates also reported having a negative perception of smoking
bans, although not for similar reasons. According to some of the smokers
interviewed, the smoking ban goes against their rights because it
prevents them from making choices, including the choice to smoke:
Myself I see it as [...], a sort of repression, like a breach of my
rights. [...] I consider smoking as an acquired right in detention.
(John, inmate, smoker)
Some inmates consider the correctional facility, and more precisely
the prison cell, as their home. Therefore they think that they should be
allowed to smoke cigarettes inside their cell: I find it inconceivable
that they keep us from smoking because, in a sense, our cell's our
home you know. I mean, some girls stay here a whole year. [...] Some
stay here a year, eighteen months, that's a lot for them you know
[...]. (Mary, inmate, smoker)
DISCUSSION
As previously stated, the decision to implement an indoor smoking
ban in provincial correctional facilities was taken by the Quebec
Department of Public Security with the objective of improving the health
of both inmates and staff members. However, the results of this study
tend to demonstrate that, six months after its implementation, the ban
had not yet produced the intended results.
The most likely explanation for this finding is that a large
majority of smokers kept on smoking inside the facility despite the ban.
The period of time allocated for outdoor smoking is extremely limited in
detention centres and most centres only allow inmates to go outside for
one hour per day. Since the majority of inmates are daily smokers with
likely a high level of nicotine dependence14 and since tobacco remains a
legal product that they are allowed to purchase and keep in their
possession at all times, most of them continued to smoke in their cells
or in places out of sight of correctional officers. This continued
smoking inside the correctional facilities most likely generated
important SHS exposure and therefore did not generate the expected
health benefits.
For the staff, organizational and environmental factors made the
enforcement of the ban far too complex to be carried out efficiently. It
should also be recognized that some members of the staff were greatly
disappointed by the amendment made to the original regulation (complete
smoking ban), and were therefore less inclined to enforce the new
regulation (indoor smoking ban).
Despite the numerous issues associated with the implementation of
the indoor smoking ban, one should not conclude that every attempt to
limit tobacco use in correctional environments is doomed to failure or
will raise multiple problems. This study took place in a context where a
complete smoking ban was suddenly reduced to an indoor ban. Therefore,
the present results should be considered in relation to this particular
context and the issues encountered in the process of enforcing the
indoor smoking ban.
This situation outlines the relevance of joining process evaluation
to impact evaluation when studying the implementation of smoking bans,
especially in particular environments such as correctional facilities.
Resorting to impact evaluation only (also called black box evaluation)
(15) could have precluded gaining important insights on several key
factors related to the problems encountered in the implementation of the
ban.
The results presented in this paper have some limitations; first it
should be noted that only three provincial correctional facilities were
included in the study, and the sample size used was small. Consequently
the results are not necessarily representative of the entire
correctional population in Quebec. Also, the participants were recruited
through a self-selection method; this method could have introduced a
selection bias by keeping out potential respondents who were less
interested to participate in the study while recruiting those whose
feelings towards the smoking ban were stronger. Therefore, the selection
procedure could have contributed to polarizing the respondents'
opinion of the ban. As all data are self-reported and rely on the
perceptions of the respondents, it is possible that they do not
objectively reflect all the particular aspects of the smoking ban as
experienced in Quebec. Because no objective evaluation of SHS exposure
or health status was conducted before and during the study, results
should only be seen as indications of the situation prevailing in Quebec
provincial correctional facilities at the time of the study.
Acknowledgements: This study was funded by the Quebec Department of
Health and Social Services and the Interdisciplinary Capacity
Enhancement (ICE) Program (Small Project Funding). The opinions
expressed in the article do not necessarily reflect those of the Quebec
Department of Health and Social Services and the Quebec Department of
Public Security. During part of this study, Michael Cantinotti was a
postdoctoral fellow with an award from the Transdisciplinary Training
Program in Public and Population Health Research of the Canadian
Institutes of Health Research.
Conflict of Interest: None to declare.
Received: July 13, 2010
Accepted: January 18, 2011
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* All quotes were freely translated from French by the authors.
Correspondence: Benoit Lasnier, Institut national de sante publique
du Quebec, 190 Cremazie Est Blvd, Montreal, QC H2P 1E2, Tel:
514-864-1600, ext. 3514, Fax: 514-864-1616, E-mail:
benoit.lasnier@inspq.qc.ca
Benoit Lasnier, MSc, [1] Michael Cantinotti, PhD, [2] Louise Guyon,
MA, [1] Ann Royer, PhD, [3] Serge Brochu, PhD, [4] Lyne Chayer, MSc [1]
Author Affiliations
[1.] Institut national de sante publique du Quebec, Montreal, QC
[2.] Institut national de sante publique du Quebec, Universite de
Montreal, CSSS de la Vieille-Capitale, CAU, Quebec, QC
[3.] DRSP de la Capitale-Nationale, Universite Laval, CSSS de la
Vieille-Capitale, CAU, Quebec, QC
[4.] Universite de Montreal, Montreal, QC
Table 1. Socio-demographic Characteristics of Participants
(Inmates) According to Smoking Status
Smoking Status
Smokers Non-smokers Total
(n=90) (n=23) (N=113)
Socio-demographic Characteristics
Sex
Male 58 91 65
Female 42 9 35
Age (years)
18-30 21 39 25
31-40 31 22 29
41-50 33 17 30
[greater than 14 22 16
or equal to] 51
Civil status (single) 62 52 60
Primary or secondary 80 83 81
school education
Duration of prison stay (days)
1-100 51 22 45
101-200 13 35 18
201-400 26 35 27
>400 10 9 10
Note: Due to rounding, percentages may not total 100%.
Table 2.Perceived Prevalence of Smoking and Number of Cigarettes
Smoked Daily by Inmates in Provincial Correctional Facilities
According to Sex and Smoking Status
Sex and Smoking Status
Men (n=73) Women (n=40)
Smokers Non-smokers Smokers
(n=52) (n=21) (n=38)
smoking among inmates
Perceived prevalence of
Mean 80% 85% 90%
Standard Deviation 10.6 10.0 8.0
Number of cigarettes
smoked daily *
Mean 14 (n=46) -- 11 (n=34)
Standard Deviation 7.0 -- 7.1
Sex and Smoking Status
Non-smokers
(n=2)
smoking among inmates
Perceived prevalence of
Mean 97%
Standard Deviation 2.8
Number of cigarettes
smoked daily *
Mean --
Standard Deviation --
* Occasional smokers not included.
Figure 1. Perception of smoking inmates regarding the effect
of the indoor ban on their tobacco use
No effect on tobacco use (42%)
effect on tobacco use (58%)
Decrease (89%)
Increase (11%)
Left circle: Respondents who smoked at least 1 cigarette in the
previous 30 days (N=91)
95% confidence intervals: No effect on tobacco use (31%-53%);
Effect on tobacco use (47%-69%)
Right circle: Respondents who identified an effect of the
regulation on their tobacco use (N=53)
95% confidence intervals: Decrease (77%-96%); Increase (4%-23%)
Note: Table made from pie chart.
Figure 2. Perception of SHS exposure since the indoor
smoking ban
Remained
the same (49%)
Decreased (34%)
Increased (17%)
Respondents incarcerated before February 8, 2008 (N=41)
95% confidence intervals: Remained the same (33%-65%);
Increased (7%32%); Decreased (20%-51%)
Note: Table made from pie chart.
