Justice-Involved Individuals

Why it Matters

  • While 16.8% of the adult population in the U.S. smokes cigarettes, the smoking rate for justice-involved (JI) populations is estimated to be between 70%-80%.1 This varies significantly by population, with accurate data difficult to obtain.
  • Incarcerated persons and parolees who use tobacco products are more likely to develop chronic health conditions that are expensive to manage and put financial strain on taxpayer-funded criminal justice and healthcare programs.2
  • In 2018 tobacco-related illnesses accounted for one-third of prisoner deaths in Pennsylvania.3
  • Lung cancer is the leading cause of cancer death among incarcerated persons, accounting for one in three of all cancer deaths in state prisons.4
  • In a study of incarcerated people who are male there was a strong interest in quitting tobacco—72% among those who are Black and 69.5% among those who are non-Black.5
  • Older adults (>55) account for approximately 10% of the population in U.S. jails and prisons. A recent survey found that among adults aged 55 years or older, 70% reported being current smokers, despite strong knowledge (95%) of the health risks. More than half of current smokers (62%) reported a failed quit attempt and/or a desire to quit.6
  • People who are incarcerated have disproportionately high-risk factors for tobacco use, including:
    • Lower education
    • Socioeconomic vulnerability
    • High rates of mental illness and substance abuse disorders
  • The Social Security Act, Sec. 1905(a)(A) prohibits the use of federal funds and services for medical care provided to “inmates of a public institution.” This language does not differentiate between people who are convicted and people in local jails who are in pretrial status or awaiting disposition.7
    • In 2016 jails incarcerated 10.6 million people, whereas prisons incarcerated 602,000.
    • The average length of jail stay was 25 days
    • The discontinuity of care, including stopping prescriptions for tobacco cessation medications, has negative health and economic consequences
    • States have the option of terminating enrollment or suspending enrollment; termination creates significant coverage gaps upon release.
  • Only 15% of persons who are incarcerated are estimated to have health insurance in the year before or after incarceration.8
  • Federal Bureau of Prisons banned smoking and possession of tobacco by any person in prison effective January 2015 (tobacco use and purchase were banned in 2006).
  • People who are incarcerated and employees are allowed to use non-refillable e-cigarettes within designated areas.
    • People who are incarcerated must purchase their own NRT or other cessation aids.

What We Know About What Works

  • Evidence-based smoking cessation interventions have produced cessation rates comparable to community rates.  This includes behavioral interventions and NRT.9
  • In the absence of an intervention other than a tobacco ban, smoking rapidly reverts to baseline levels after release.10
  • In a study of people who smoke and who were recently released from prison, of those who had quit smoking due to tobacco-free prison policies, 98% reporting relapsing after release. After adjusting for independent variables such as employment, housing etc., trying to quit smoking was associated with the absence of risky drinking behaviors on the past 30 days.11
  • Despite high relapse rates, prison tobacco control policies are associated with reduced smoking-related mortality while in prison. Prisons with a smoking ban had a 9% reduction in smoking-related deaths. Bans in place for longer than nine years were associated with reductions in cancer mortality.12
  • Though there are few peer-reviewed evidence-based practices, several themes emerge:13
    • Remove barriers to accessing federal healthcare coverage programs such as Medicaid, Medicare, and CHIP
    • Provide information on tobacco cessation support services in the community for family members and people released from prison
    • Facilitate enrollment or re-enrollment in Medicaid before discharge to provide or maintain access to evidence based cessation support
    • Pre-release planning to prepare for the challenges and triggers associated with returning to homes or communities where tobacco use is prevalent
    • Include family outreach to reduce relapse upon release.
    • Individuals may enroll in Medicaid while still incarcerated but services will not be paid for until discharge; early enrollment can reduce the gaps in coverage that impact access to cessation support under Medicaid
  • Under the Affordable Care Act, discharge from jail or prison triggers a special enrollment period for enrolling in a plan on the Marketplace. If a person is not eligible for Medicaid this may be a good option and one which discharged individuals may not be aware of.14

What’s Relevant in Pennsylvania

  • Effective July 1, 2019, Pennsylvania banned all tobacco products inside every prison facility’s secure perimeter for employees and inmates. Prior to that PA prisons were smoke-free indoors but not tobacco-free.
    • Tobacco products are not banned on all grounds
  • In 2012, Pennsylvania served 51,125 individuals in state or federal prisons, had an average daily jail census of 36,290, and 279,100 adults under community supervision.15 If 60%-80% of these individuals use tobacco, the numbers are significant.
  • In 2015 a trial initiative was put in place at SCI Muncy in Lycoming County PA. SCI Muncy houses over 1,400 offenders who are female, including all of the state’s females incarcerated for capital cases. The Quitline provided dedicated counselors, a fixed call calendar, and NRT patches to women who chose to participate.  Focus groups with nine participants found the following:
    • One quit (after 62 years of use)
    • Three reduced their use
    • Five returned to prior levels of use (attributed to stress, anxiety and prison commissary as a barter system for other benefits)
    • ALL would participate again, reviewed counseling favorably, and stated intention to call 1-800-QUITNOW after release
  • There was a waiting list to participate in the program and researchers recommended the following for similar initiatives:
    • Peer support and support groups similar to Alcoholics/Narcotics Anonymous on an ongoing basis for those participating or attempting to quit tobacco
    • Improved enforcement of existing smoke free policies
    • Review of products sold in commissary to ensure cessation aids are available
    • Provide contact information for PA Free Quitline in packets given to all people who are incarcerated prior to release
    • Expand NRT protocol to 12 weeks
    • Consider a bonus counseling session post NRT
  • This pilot led to the creation of a toolkit and a series of tobacco cessation classes to incarcerated individuals during SFY 2018/2019 in advance of the 7/1/2019 tobacco free policy. The program is currently being evaluated.16
    • For FY 2018-2019, regional primary contractors (RPCs) worked with 16 state correctional institutions (SCI) in quarter 4 to provide cessation services to 207 people who were incarcerated.
  • People who are incarcerated in Pennsylvania spent $8 million on tobacco products in 2018 and tobacco-related illnesses account for one-third of deaths among people who are incarcerated.17
  • Pennsylvania suspends (as opposed to terminates) Medicaid eligibility for individuals in state and local prisons. This creates an opportunity to reinstate eligibility before discharge.

What Other States Are Doing

  • In Ohio, a policy effective 2/15/16 established Voluntary (participation) Tobacco Cessation programs in all institutions where a Recovery Services Program exists. The goal is to provide support and services to people who are incarcerated and who are discontinuing the use of tobacco.18
  • The Behavioral Health & Wellness Program at the University of Colorado is assisting the Arizona (AZ) Department of Health Services Bureau of Tobacco and Chronic Disease to meet the needs of individuals involved with AZ’s criminal justice system. They are working with the state, counties, public service institutions, and other stakeholders to articulate high-utility, realistic plans for creating tobacco cessation continuity of care that is both scalable and sustainable. https://www.bhwellness.org/projects/adhs/
  • Health districts in Idaho offer tobacco cessation programming for inmates using specially-adapted curriculum to meet the needs of these individuals including pre-release planning and scenerio work designed to help them prepare for challenges and triggers unique to this population. Inmates have the option to request follow-up upon release and can be connected to additional services or programs as needed. They are also provided with information on how to access the Quitline and find no-cost cessation groups.
  • Arkansas demonstrated that a train-the-trainer model for tobacco cessation groups could be scaled up across a state community corrections system. Sustainability is suggested by the fact that since the program’s inception, current corrections staff have continuously administered groups within 33 existing substance use programs. In the first two years of this statewide, evidence-based program, over 1,100 individuals from 33 ACC Area Office locations attended tobacco free groups and provided data that tracked tobacco use and readiness to quit.  Results demonstrated a significant reduction in tobacco use among participants, as well as increased knowledge, confidence, and intent to quit.19
  • There is currently a study under way in Rhode Island assessing a protocol to prevent return to smoking upon release from a smoke free prison. Lead researcher: Jennifer Clarke, Brown University Center for Primary Care and Prevention.

References and Resources

  1. Cropsey KL, Eldridge GD, Weaver MF, Villalobos GC, Stitzer ML. Expired carbon monoxide levels in self-reported smokers and nonsmokers in prison. Nicotine Tob Res 2006;8:653-9.
  2. Providing Tobacco Cessation Services in Correctional Settings: Frameworks, Feasibility, Effectiveness. The Justice-Involved Tobacco Cessation Project. December 2017. https://www.bhwellness.org/projects/adhs/
  3. https://www.prisonlegalnews.org/news/2019/jul/2/pennsylvania-prisonerscigarette-stashes-go-smoke/
  4. Alberg A. et al., Epidemiology of Lung Cancer: ACCP Evidence-based Clinical Practice Guidelines (2nd ed.), 132 Chest (Suppl.) 29S, 34S-40S
    (2007), available at http://www.ncbi.nlm.nih.gov/pubmed/17873159.
  5. Valera P., Reid A., Acuna N., Mackey D. The Smoking Behaviors of Incarcerated Smokers. Health Psychology Open. January-June 2019:1-11.
  6. Ahalt C., Buisker T., Myers J., Williams B. Smoking and Smoking Cessation Among Criminal Justice-Involved Older Adults. Tobacco Use Insights.  January 2019. https://doi.org/10.1177/1179173X198333
  7. National Association of Counties. Federal Policy Impacts on County Jail Inmate Healthcare & Recidivism. March 2019. https://www.naco.org/sites/default/files/documents/Medicaid%20and%20County%20Jails%20Presentation.pdf
  8. Wang E., et al., Incarceration, Incident Hypertension and Access to Health Care Findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Study, 169 Archives of Internal Medicine 687, 692 (2009)
  9. Cropsey K, Eldridge G, Weaver M, et al. Smoking cessation intervention for female prisoners: addressing an urgent public health need. Am J Public Health. 2008;98(10):1894–1901.
  10. Lincoln T, Tuthill RW, Roberts CA, et al. Resumption of smoking after release from a tobacco-free correctional facility. J Correct Health Care.
    2009;15(3):190–196
  11. Frank M, Blumhagen R, Weitzenkamp D, Mueller S. Tobacco Use Among People Who Have Been in Prison: Relapse and Factors Associated with Trying to Quit. Journal of Smoking Cessation Volume 12, Issue 2. June 2017.
  12. Binswager I., Carson A., Krueger P., Mueller S., Steiner J., Sabol W. Prison Tobacco Control Policies and Deaths from Smoking in United States Prisons: Population Based Retrospective Analysis. The BMJ. August 2014.  doi:10.1136/BMJ.g4542.
  13. Providing Tobacco Cessation Services in Correctional Settings: Frameworks, Feasibility, Effectiveness. The Justice-Involved Tobacco Cessation Project.  December 2017. https://www.bhwellness.org/projects/adhs/
  14. Health Coverage for Incarcerated People. https://www.healthcare.gov/incarcerated-people/
  15. Gates A., Artiga S., Rudowitz R. Health Coverage and Care for the Adult Criminal Justice-Involved Population. Kaiser Family Foundation. September 5, 2014. https://www.kff.org/uninsured/issue-brief/health-coverage-and-carefor-the-adult-criminal-justice-involved-population/
  16. MPower Annual Summary Report State Fiscal Year 2018/2019. Pennsylvania Tobacco Prevention and Control Program. Prepared by Public Health Management Corporation.
  17. https://www.prisonlegalnews.org/news/2019/jul/2/pennsylvania-prisonerscigarette-stashes-go-smoke/
  18. http://www.drc.ohio.gov/Portals/0/Policies/DRC%20Policies/70-RCV-04.pdf?ver=2016-09-01-142053-260
  19. Garver-Apgar C, Young S, Howard B, Udochi B, Morris C. Effects of a Statewide Tobacco Cessation Program Among Individuals Involved With Arkansas Community Correction. J Correct Health Care. 2017;23(3):259-270. doi:10.1177/1078345817709017

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