Social support, key to quitting smoking in prison

A study evaluating a smoking cessation program in Hong Kong prisons highlights factors that facilitate and hinder smoking cessation. Even more so than in other situations, support from family and prison staff appears to be decisive factors in smoking cessation.

Smoking prevalence is significantly higher among prisoners than in the general population in all countries: up to 7.3 times higher for men and up to 62 times higher for women.[1]Smoking bans in prison are currently concentrated in high-income countries.[2], but they do not prevent a high rate of resuming smoking (more than 60 %) upon leaving prison.

Hong Kong prisons are divided into smoking and non-smoking wards, but inmates are not asked to express their choice in this regard. A program called "Quit to Win" (QTW) specifically targets inmates who smoke and volunteer in smoking wards, offering them incentives. These include a small sum of money for completely quitting (HK$1,000, or €120), more visits from family and friends, and a small ceremony recognizing their efforts. A team of researchers conducted a qualitative study to evaluate this program and identify the factors that facilitate and hinder smoking cessation in prison.[3].

Stress and boredom, factors that promote smoking in prison

The smoking status of program participants was verified by exhaled carbon monoxide (CO) or saliva nicotine testing. Of the 59 inmate smokers from the two prisons who participated in the QTW program between 2018 and 2021, 26 were interviewed qualitatively, with response saturation reached by the 23rd interview. Half of the respondents were men, the other half were women, with one of the two pilot facilities being a women's prison. Two additional interviews were conducted with prison staff from these facilities who coordinated the QTW program.

The main barriers to smoking cessation identified were stress, boredom, isolation, and a lack of overall autonomy (loss of freedom, financial limitations), factors also present in the general population but reinforced in detention. Tobacco addiction was often strong, and access to nicotine replacement therapy was difficult. The difficulty of moving to a smoke-free area was an additional barrier. Among the facilitating factors, the cost of tobacco proved to be a strong motivator, as inmates' incomes were particularly low, making the program very attractive. Health concerns were also cited and were reinforced by the awareness-raising interventions contained in the program. The screening of an educational video showing a watermelon turning black after a cigarette was inserted was notably cited as a strong message.

Although financial incentives play a key role in the smoking cessation process, the most important element of the program was maintaining social ties with loved ones. The program not only allowed for more visits, but also allowed for the physical presence of family members during the small closing ceremony. According to the study authors, this social support from family would be even more important in China, where filial devotion is highly developed. The role of this support in quitting was apparently confirmed in 2020, when the Covid-19 pandemic led to the cancellation of the closing ceremony; maintaining quitting proved more difficult for participants who were unable to be congratulated by their families on this occasion. The support of prison staff in the cessation process was also cited as crucial for inmates.

The importance of the social dimension of smoking is once again highlighted

This study has several limitations. It is based on the evaluation of the Quit to Win program and therefore cannot be generalized to all prison situations. Furthermore, participants in this program were highly motivated by the rewards provided for quitting smoking, which introduces a selection bias.

Although the study does not claim to be representative, the fact of giving such a large place to women in the sample can also be questioned: the proportion of women in prison is 14 % in Hong Kong[4], which thus places itself at the top of the world ranking of women's imprisonment; in France, women represent only 3.3 % of prisoners[5]The overrepresentation of women in this study therefore mainly reflects the spread of the QTW program in two establishments. It also has the merit of allowing a better exploration of the factors facilitating and hindering smoking cessation among incarcerated women, in a region where they are more numerous than elsewhere.

The interest of this study remains to highlight some specificities of smoking cessation in prison. It allows to confirm the importance of the social dimension in smoking cessation, and not only at the stages of initiation or maintenance of this addiction. A French study had also highlighted the weight of the relational dimension in smoking cessation of prisoners, whether it comes from the family or the various professionals intervening in the prison environment – guards, caregivers or external[6].

The study also highlights the need to make nicotine replacement therapy accessible, and the value of awareness-raising tools that can actually trigger awareness. Finally, it illustrates the issue of financial incentives in the smoking cessation process in prisons, the value of which has already been highlighted in other studies among pregnant women.[7].

©Generation Without Tobacco

MF

[1] Spaulding AC, Eldridge GD, Chico CE, et al. Smoking in correctional settings worldwide: prevalence, bans, and interventions. Epidemiol Rev. 2018;40(1):82-95.

[2] WHO regional office for Europe, Tobacco use in prisons, 2022.

[3] Weng X, Ma EC, Song CY, et al. Experiences of leaving smoking in prisons: A qualitative study of people in custody. Tobacco Induced Diseases. 2024;22(February):43. doi:10.18332/tid/183604.

[4] Number of persons under CSD management, Government of the Hong Kong Special Administrative Region, accessed March 4, 2024.

[5] Women prisoners, International Prison Observatory, accessed March 4, 2024.

[6] Picot-Ngo C, Protais C, Michel M, Morel d'Arleux J, Kivits J, Chevreul K, Smoking in French prisons: Factors associated with consumption and cessation, Qualitative Research in Health 4 (2023) 100345.

[7] Berlin I, Berlin N, Malecot M, Breton M, Jusot F, Goldzahl L, Financial incentives for smoking cessation in pregnancy: multicenter randomized controlled trial, BMJ 2021;375:e065217.