摘要：Objectives. We tested the efficacy of a combined pharmacologic and behavioral smoking cessation intervention among women in a state prison in the southern United States. Methods. The study design was a randomized controlled trial with a 6-month waitlist control group. The intervention was a 10-week group intervention combined with nicotine replacement therapy. Two hundred and fifty participants received the intervention, and 289 were in the control group. Assessments occurred at baseline; end of treatment; 3, 6, and 12 months after treatment; and at weekly sessions for participants in the intervention group. Results. The intervention was efficacious compared with the waitlist control group. Point prevalence quit rates for the intervention group were 18% at end of treatment, 17% at 3-month follow-up, 14% at 6-month follow-up, and 12% at 12-month follow-up, quit rates that are consistent with outcomes from community smoking-cessation interventions. Conclusions. Female prisoners are interested in smoking cessation interventions and achieved point-prevalence quit rates similar to community samples. Augmenting tobacco control policies in prison with smoking cessation interventions has the potential to address a significant public health need. Smoking is the leading preventable cause of death in the United States. 1 Smoking prevalence and associated morbidity and mortality have decreased in the general US population; however, smoking prevalence remains 3 to 4 times higher among prisoners than in the nonincarcerated adult population. 2 The most common medical problems of prisoners are smoking related, including heart, circulatory, respiratory, kidney, and liver problems and diabetes. 3 Medical care for prisoners consumes 11% of correctional budgets and is expected to double in 10 years, in part because of high rates of smoking and associated medical conditions. 4 The continued high prevalence of smoking among prisoners has important public health implications because of the increasing incarceration rate in the United States, 5 high prevalence of comorbid psychiatric and substance abuse disorders associated with nicotine dependence, and low natural rates of smoking cessation among prisoners. Among incarcerated men, 70%–80% are current smokers. 2 , 6 – 11 Smoking prevalence among incarcerated women ranges from 42% to 91%, 2 to 4 times higher than among women in the general population. 2 , 12 , 13 Prisoners are also more likely to have comorbid conditions—psychiatric disorders and substance dependence—associated with greater nicotine dependence and less likelihood of smoking cessation in the absence of intensive interventions. 14 Over the past 10 years, because of concerns about secondhand smoke, threats of litigation, and desires to protect employee and prisoner health, reduce prison health care expenditures, and limit prisoner amenities, correctional facilities have implemented smoking bans and restrictions. Smoking bans in prisons differ from smoking bans in other settings. Prisoners are confined and have no legitimate opportunities to smoke for the duration of their sentence. Hence, they have no recourse except to quit smoking—usually “cold turkey” and without smoking cessation treatment or nicotine replacement—or to obtain cigarettes or tobacco from the underground prison economy. Prison smoking bans often have unintended consequences: prisoners continue to smoke, and a thriving contraband economy grows to meet the demand for cigarettes. 8 , 9 , 15 , 16 From a public health perspective, temporary cessation of smoking because of punitive smoking restrictions is different from “quitting” smoking. 17 Indeed, 97% of people in a smoke-free jail returned to smoking within 6 months of release, suggesting that smoking bans or restrictions during incarceration are unlikely to have a marked effect on the lifetime prevalence of smoking. 18 The National Commission on Correctional Health Care, in its 2002 report on the health status of soon-to-be-released inmates, recommended that all inmates be provided with a smoke-free environment and that smoking cessation programs be offered to staff members and inmates. Offering smoking cessation programs along with smoking restrictions might increase the likelihood of tobacco control in the prison environment and sustained smoking cessation after release. 19 However, the need for smoking cessation interventions shown to be effective in correctional settings remains virtually ignored, despite the enormous human, health, and economic costs of smoking among prisoners. 13 , 19 , 20 Among the burgeoning literature on smoking cessation with other populations, we could locate only 2 published papers of smoking cessation interventions with prisoners. Edinger et al. conducted 2 small studies of self-control procedures for smoking cessation among male prisoners. 21 Their studies had methodological limitations, including small sample sizes (N = 14 and N = 28), significant treatment attrition, and lack of biological verification of treatment outcomes. Richmond et al. reported a pilot study with 30 male prisoners who received 2 sessions of cognitive–behavioral counseling, nicotine replacement therapy, buproprion, and self-help materials. 22 Self-reported smoking verified through levels of expired carbon monoxide (CO) was assessed 6-months after intervention. At 6 months, 26% had verified point-prevalence abstinence, and 22% had continuous abstinence. Overall, these studies are notable for their small sample sizes and focus on male prisoners. To our knowledge, our study is the first-ever randomized clinical trial of smoking cessation with female prisoners. We examined the efficacy of a combined behavioral and pharmacologic intervention compared with a waitlist control group. The study was designed to overcome the limitations of previous studies and to focus on female prisoners. We anticipated that the group exposed to the intervention would have superior quit rates at all time points compared with the waitlist control group.
