Justice involved or criminal legal system involved populations
Tobacco use and associated morbidity and mortality
- Millions of individuals in the United States have experienced incarceration since mass incarceration started 50 years ago. Nearly 80 million individuals have a criminal record and are facing the life-long consequences of conviction including decreased opportunities for housing and employment. 1 These adverse conditions associated with incarceration increase risk of tobacco use.
- Black Americans are disproportionately impacted. One in three Black men have a history of incarceration, and nearly 25% of Black Americans have three or more family members who have been incarcerated during their life.2
- The prevalence of smoking among individuals who have experienced incarceration ranges from 50% to 80%.3,4 Involvement in the justice system is associated with current smoking, and juvenile smoking while in detention is a strong predictor of smoking during adulthood.5 Mass incarceration is independently associated with current tobacco use, which is much higher among Black men and women compared to other racial/ethnic groups in the U.S.6 This is in contrast to the prevalence of smoking in the general population, which is at 11%.7
- People experiencing incarceration have a high burden of chronic disease including tobacco-related cardiovascular disease and cancer,8,9 and incarceration is an independent risk factor for mortality, particularly tobacco-related disease and death.4,10-12
Patterns of tobacco use
- In a study of 5,289 men admitted to a correctional facility in the Midwest between 2012 and 2020, most had used tobacco at some point in their lives (84%-91%). Of those who had ever used tobacco, over 90% were daily users of tobacco products and most had started at a young age (mean age 13 years) prior to incarceration.13 Smoking prevalence across 10 years among this population remained at a high of over 80% even as prevalence had declined in these locales in the general population. Many participants reported no longer being addicted to nicotine and tobacco use while incarcerated.
- There is a high rate of relapse among people re-entering the community from correctional settings, with only 3% of the population released reporting sustained abstinence at 6-months follow-up.14 Prison and jail smokefree policies lead to periods of forced abstinence; however, 60% to 90% resume tobacco use upon release.15-17
Reasons for high rates of tobacco use
- Justice-involved populations have the same risk factors that increase tobacco use in the general population: a high prevalence of substance use and/or other behavioral health conditions, lower education, lower income levels, and identifiying as racial/ethnic minorities.18,19
- Stress and community norms associated with smoking are strong predictors of current tobacco use and these factors also apply to justice-involved populations.20-22 Moreover, longer exposure to chronic stress due to incarceration in an environment where tobacco use is normalized increases likelihood of relapse to smoking even after a period of prolonged forced abstinence.19
- Increased exposure to triggers to smoking after re-entry, such as experiences of homelessness and/or entering a household with other smokers, may further increase risk of relapse after transitioning back to the community.13,23
Barriers to quitting
- Tobacco use was long rooted in the culture of correctional systems, where tobacco was considered a “currency” to exchange for other goods, pay debts, or for gambling. Tobacco was also used as a coping mechanism for stressful conditions in prison systems including abrupt transfers, court hearings, prison visits and lack of family support.24,25
- However, the Federal Bureau of Prisons decided to implement smokefree policies in federal and state prison systems after requests from nonsmoking inmates to live in smokefree environments and increasing healthcare costs among people involved with the justice system.26 Between 1986 and 2007, the proportion of prisons that implemented smokefree policies increased and the proportion that distributed free tobacco decreased. By 2007, 96% of federal prisons systems had put into effect smokefree living areas and 60% had campus-wide bans.26 Policies were enforced successfully when access to contraband tobacco was limited.27
- Policies were associated with reductions in secondhand smoke exposure 27 and reduction in mortality from smoking-related causes including cancer and cardiovascular disease.4
- While establishing policies around tobacco use was a necessary step in the right direction to reduce the pervasiveness of smoking in correctional systems, it was not nearly enough to reduce tobacco use among justice involved populations.
- Most people continued to smoke under a prison smokefree policy although at a reduced rate compared to before the ban.28-31 However, people who continued to smoke after the ban had a higher sense of cravings and withdrawal symptoms than those who quit smoking during the policy implementation, underscoring the need for effective cessation interventions that accompany smokefree policies in correctional systems.29,31,32
- Re-entry is fraught with challenges. Re-entry is one of the most risky and vulnerable times for people released from jails and prisons given the high rate of overdose and mortality from overdose, particularly in the first 2 weeks after release.12,33 Re-entry is also linked with increased acute care utilization (i.e., emergency room services or hospitalizations).33,34 Health insurance that was replaced by jail or prison healthcare is, in most cases, not immediately re-instated upon release into the community unless individuals are part of a transitions clinic program that allows for seamless transition into primary care after re-entry with intensive case management services and the supports that people need after re-entry.35-37 This lapse in primary care in combination with lacking social supports and structures and being in a high risk situation with increased exposure to tobacco and substance use further poses challenges to quitting smoking.
Promising approaches to quitting
- Because people lose their health insurances when they enter correctional systems, those systems take on the responsibility of providing the necessary medical care that their regular healthcare providers would have otherwise covered. This applies to chronic conditions like HIV, hypertension or diabetes, but it does not apply to tobacco treatment.
- Few jails and prisons offer guideline-recommended tobacco treatment that includes behavioral counseling and pharmacotherapy.38 This is a major disparity in addressing tobacco use among justice involved populations that must be changed.
- Those that do offer such treatments do so in the context of clinical trials, but none of these trials have been translated into policies or programs for tobacco treatment nor have these treatments been standardized across prison and jail systems across the U.S. As a result most people in jails and prisons are forced to quit, and most relapse to smoking upon re-entry.
- However, there are promising approaches that include combinations of counseling and pharmacotherapy. In one study focused on seven state prisons in a Northeastern state, participants in the prison systems who were current, daily smokers had the option to enroll in a program that included group counseling with 6 weeks of pharmacotherapy. Of the 350 individuals screened, 177 enrolled and 102 completed the 6-week program with counseling and pharmacotherapy. Of those, 54 were considered abstinent based on carbon monoxide verification and 123 were continuing smokers.39 This study showed the feasibility of implementing cessation programs with state prison systems and has the potential for scalability.
- Another promising approach is the Trauma Addiction Mental Health and Recovery (TAMAR) model, integrated into several jails and prisons across the US, that provides a tools-focused approach on addressing the complex relationships between tobacco use, substance use and mental health and coping with trauma. The objective is to channel tobacco’s negative coping mechanisms to approaches that allow for recovery, health and wellbeing.40
1. Wang EA, Shavit S. For Health Equity, We Must End Mass Incarceration. JAMA. 2023;330(1):15-16. doi:10.1001/jama.2023.8206
2. Sundaresh R, Yi Y, Harvey TD, et al. Exposure to Family Member Incarceration and Adult Well-being in the United States. JAMA Network Open. 2021;4(5):e2111821-e2111821. doi:10.1001/jamanetworkopen.2021.11821
3. Ahalt C, Buisker T, Myers J, Williams B. Smoking and Smoking Cessation Among Criminal Justice-Involved Older Adults. Tob Use Insights. 2019;12:1179173x19833357. doi:10.1177/1179173x19833357
4. Binswanger IA, Carson EA, Krueger PM, Mueller SR, Steiner JF, Sabol WJ. Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis. Bmj. Aug 5 2014;349:g4542. doi:10.1136/bmj.g4542
5. Hassett-Walker C. The Longitudinal Impact of Arrest, Criminal Conviction, and Incarceration on Smoking Classes. Tob Use Insights. 2022;15:1179173x221089710. doi:10.1177/1179173x221089710
6. Bailey ZD, Okechukwu C, Kawachi I, Williams DR. Incarceration and Current Tobacco Smoking Among Black and Caribbean Black Americans in the National Survey of American Life. Am J Public Health. Nov 2015;105(11):2275-82. doi:10.2105/ajph.2015.302772
7. Cornelius ME, Loretan CG, Jamal A, et al. Tobacco Product Use Among Adults - United States, 2021. MMWR Morb Mortal Wkly Rep. May 5 2023;72(18):475-483. doi:10.15585/mmwr.mm7218a1
8. Garcia-Grossman IR, Cenzer I, Steinman MA, Williams BA. History of Incarceration and Its Association With Geriatric and Chronic Health Outcomes in Older Adulthood. JAMA Netw Open. Jan 3 2023;6(1):e2249785. doi:10.1001/jamanetworkopen.2022.49785
9. Olukotun O, Williams JS, Zhou Z, Akinboboye O, Egede LE. The association between history of incarceration and heart disease: Adults from the 1979 National Longitudinal Survey of Youth. Health Place. May 2022;75:102808. doi:10.1016/j.healthplace.2022.102808
10. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison--a high risk of death for former inmates. N Engl J Med. Jan 11 2007;356(2):157-65. doi:356/2/157 [pii]
11. Aldridge RW, Story A, Hwang SW, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet. Jan 20 2018;391(10117):241-250. doi:10.1016/s0140-6736(17)31869-x
12. Binswanger IA. Release from prison - A high risk of death for former inmates (vol 356, pg 157, 2007). New Engl J Med. Feb 1 2007;356(5):536-536.
13. Ives K, Christiansen B, Nolan M, Kaye JT, Fiore MC. Nine years of smoking data from incarcerated men: A call to action for tobacco dependence interventions. Prev Med Rep. Oct 2022;29:101921. doi:10.1016/j.pmedr.2022.101921
14. Lincoln T, Tuthill RW, Roberts CA, et al. Resumption of Smoking After Release From a Tobacco-Free Correctional Facility. J Correct Health Care. Apr 29 2009;
15. Frank MR, Blumhagen R, Weitzenkamp D, et al. Tobacco Use Among People Who Have Been in Prison: Relapse and Factors Associated with Trying to Quit. J Smok Cess. Jun 2017;12(2):76-85. doi:10.1017/jsc.2016.3
16. Puljević C, de Andrade D, Coomber R, Kinner SA. Relapse to smoking following release from smoke-free correctional facilities in Queensland, Australia. Drug Alcohol Depend. Jun 1 2018;187:127-133. doi:10.1016/j.drugalcdep.2018.02.028
17. Lincoln T, Tuthill RW, Roberts CA, et al. Resumption of smoking after release from a tobacco-free correctional facility. J Correct Health Care. Jul 2009;15(3):190-6. doi:10.1177/1078345809333388
18. Papadodima SA, Sakelliadis EI, Sergentanis TN, Giotakos O, Sergentanis IN, Spiliopoulou CA. Smoking in prison: a hierarchical approach at the crossroad of personality and childhood events. Eur J Public Health. Aug 2010;20(4):470-4. doi:10.1093/eurpub/ckp209
19. Howell BA, Guydish J, Kral AH, Comfort M. Prevalence and factors associated with smoking tobacco among men recently released from prison in California: A cross-sectional study. Addict Behav. Nov 2015;50:157-60. doi:10.1016/j.addbeh.2015.06.017
20. Niaura R, Shadel WG, Britt DM, Abrams DB. Response to social stress, urge to smoke, and smoking cessation. Addict Behav. Mar-Apr 2002;27(2):241-50. doi:10.1016/s0306-4603(00)00180-5
21. Ahern J, Galea S, Hubbard A, Syme SL. Neighborhood smoking norms modify the relation between collective efficacy and smoking behavior. Drug Alcohol Depend. Feb 1 2009;100(1-2):138-45. doi:10.1016/j.drugalcdep.2008.09.012
22. Karasek D, Ahern J, Galea S. Social norms, collective efficacy, and smoking cessation in urban neighborhoods. Am J Public Health. Feb 2012;102(2):343-51. doi:10.2105/AJPH.2011.300364
23. Miller J, Cuby J, Hall SM, et al. Tobacco use behaviors and views on engaging in clinical trials for tobacco cessation among individuals who experience homelessness. Contemp Clin Trials Commun. Apr 2023;32:101094. doi:10.1016/j.conctc.2023.101094
24. Richmond R, Butler T, Wilhelm K, Wodak A, Cunningham M, Anderson I. Tobacco in prisons: a focus group study. Tob Control. Jun 2009;18(3):176-82. doi:tc.2008.026393 [pii]
25. Lankenau SE. Smoke 'Em If You Got 'Em: Cigarette Black Markets in U.S. Prisons and Jails. Prison J. 2001;81(2):142-161.
26. Kauffman RM, Ferketich AK, Wewers ME. Tobacco policy in American prisons, 2007. Tob Control. Oct 2008;17(5):357-60. doi:tc.2007.024448 [pii]
27. Kennedy SM, Davis SP, Thorne SL. Smoke-Free Policies in US Prisons and Jails: A Review of the Literature. Nicotine & Tobacco Research. Jun 2015;17(6):629-635. doi:10.1093/ntr/ntu225
28. Eldridge GD, Cropsey KL. Smoking bans and restrictions in U.S. prisons and jails: consequences for incarcerated women. Am J Prev Med. Aug 2009;37(2 Suppl):S179-80. doi:S0749-3797(09)00290-6 [pii]10.1016/j.amepre.2009.05.009
29. Cropsey KL, Kristeller JL. The effects of a prison smoking ban on smoking behavior and withdrawal symptoms. Addict Behav. Mar 2005;30(3):589-94. doi:S0306-4603(04)00249-7 [pii]
30. Kauffman RM, Ferketich AK, Murray DM, Bellair PE, Wewers ME. Measuring tobacco use in a prison population. Nicotine Tob Res. Jun 12(6):582-8. doi:ntq048 [pii]10.1093/ntr/ntq048
31. Kauffman RM, Ferketich AK, Murray DM, Bellair PE, Wewers ME. Tobacco Use by Male Prisoners Under an Indoor Smoking Ban. Nicotine Tob Res. Mar 29 doi:ntr024 [pii]10.1093/ntr/ntr024
32. Foley KL, Proescholdbell S, Herndon Malek S, Johnson J. Implementation and enforcement of tobacco bans in two prisons in North Carolina: a qualitative inquiry. J Correct Health Care. Apr 2010;16(2):98-105. doi:16/2/98 [pii]
33. Binswanger IA, Blatchford PJ, Mueller SR, Stern MF. Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009. Annals of Internal Medicine. Nov 5 2013;159(9):592-600. doi:10.7326/0003-4819-159-9-201311050-00005
34. Wang EA, Wang YF, Krumholz HM. A High Risk of Hospitalization Following Release From Correctional Facilities in Medicare Beneficiaries A Retrospective Matched Cohort Study, 2002 to 2010. Jama Internal Medicine. Sep 23 2013;173(17):1621-1628. doi:10.1001/jamainternmed.2013.9008
35. Wang EA, Hong CS, Samuels L, Shavit S, Sanders R, Kushel M. Transitions clinic: creating a community-based model of health care for recently released California prisoners. Public Health Rep. Mar-Apr 125(2):171-7.
36. Wang EA, Hong CS, Shavit S, Sanders R, Kessell E, Kushel MB. Engaging individuals recently released from prison into primary care: a randomized trial. Am J Public Health. Sep 2012;102(9):e22-9. doi:10.2105/AJPH.2012.300894
37. Puglisi L. KL, Shavit S. Greifinger R.B., editor. In: Public Health Behind Bars. . Springer Nature; New York, NY, USA: 2021 pp 429–443.
38. Patnode CD, Henderson JT, Coppola EL, Melnikow J, Durbin S, Thomas RG. Interventions for Tobacco Cessation in Adults, Including Pregnant Persons: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. Jan 19 2021;325(3):280-298. doi:10.1001/jama.2020.23541
39. Examining Attitudes, Expectations, and Tobacco Cessation Treatment Outcomes Among Incarcerated Tobacco Smokers. Journal of Correctional Health Care. 2022;28(4):252-259. doi:10.1089/jchc.20.08.0074
40. National Association of State Mental Health Program Directors. Trauma Addiction Mental Health and Recovery. Available at: https://wwwnasmhpdorg/sites/default/files/TAMAR_with_Smoking_Cessationpdf. 2023;Accessed on November 21, 2023.