A two-arm parallel-group individually randomised prison pilot study of a male remand alcohol intervention for self-efficacy enhancement:The APPRAISE study protocol

Introduction The prevalence of at-risk drinking is far higher among those in contact with the criminal justice system (73%) than the general population (35%). However, there is little evidence on the effectiveness of alcohol brief interventions (ABIs) in reducing risky drinking among those in the criminal justice system, including the prison system and, in particular, those on remand. Building on earlier work, A two-arm parallel group individually randomised Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement (APPRAISE) is a pilot study designed to assess the feasibility and acceptability of an ABI, delivered to male prisoners on remand. The findings of APPRAISE should provide the information required to design a future definitive randomised controlled trial (RCT). Methods and analysis APPRAISE will use mixed methods, with two linked phases, across two prisons in the UK, recruiting 180 adult men on remand: 90 from Scotland and 90 from England. Phase I will involve a two-arm, parallel-group, individually randomised pilot study. The pilot evaluation will provide data on the likely impact of A two-arm parallel group individually randomised Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement (APPRAISE), which will be used to inform a future definitive multicentre RCT. Phase II will be a process evaluation assessing how the ABI has been implemented to explore the change mechanisms underpinning the ABI (figure 1) and to assess the context within which the ABI is delivered. Ethics and dissemination The APPRAISE protocol has been approved by the East of Scotland Research Ethics Committee (19/ES/0068), National Offender Management System (2019-240), Health Board Research and Development (2019/0268), Scottish Prison Service research and ethics committee, and by the University of Edinburgh’s internal ethics department. The findings will be disseminated via peer-reviewed journal publications, presentations at local, national and international conferences, infographics and shared with relevant stakeholders through meetings and events.Additional co-authors: Jeremy Bray, Jennifer Ferguson, Arun Sondhi, Kieran Lynch, Jessica Rees, Dorothy Newbury-Birc

Smoke-free prison policy development, implementation, and impact across the entire national prison service in Scotland (TIPs study): a three-phase, mixed methods natural experimental evaluation

Background: Prisons had partial exemption from UK 2006–07 policies banning smoking in enclosed public spaces, becoming one of few workplaces with continued exposure to second-hand smoke (SHS). Although bans have been introduced elsewhere, evidence of the process and impact of implementing smoke-free prisons is sparse. We aimed to provide evidence on the process and impact of implementation of smoke-free policy across the national prison service in Scotland. Methods: The Tobacco in Prisons study (TIPs) is a three-phase, mixed-methods study exploring the periods before policy formulation (phase 1; September 2016–July 2017), during preparation for implementation (phase 2; August 2017–November 2018), and after implementation (phase 3; December 2018–May 2020). Data on SHS, health, smoking, beliefs (eg, smoking or e-cigarettes, desirability, benefits, and challenges of smoke-free policy) were gathered across all 15 Scottish prisons through: (1) staff and prisoner surveys, staff focus groups (phases 1 and 3), and cessation provider interviews; (2) SHS measures (fine particulate matter, PM2·5, using Dylos DC1700 monitors) before, during (week commencing Nov 28, 2018), and 6 months after (week commencing May 27, 2019) implementation on Nov 30, 2018. In six case-study prisons, in-depth interviews were carried out with prisoners, staff, and smoking cessation providers. We also accessed routine data (eg, sickness absence, “canteen” purchases of tobacco and other products) to assess policy impacts. Ethics approval was granted by SPS Research Access and Ethics Committee and University of Glasgow. Participants provided written informed consent. Findings: Phase 1 data showed high prisoner smoking rates (1858 [74%] of 2505 responders), confirmed by SHS measures (128 431 min of PM2.5 data, median 31·7 μg/m3), and concerns about the challenges of smoke-free policy (eg, 1954 [81%] of 2407 prisoners and 737 [58%] of 1269 staff thought smoking bans caused “trouble”). Compared with 2016, air quality improved in all prisons in 2018 (114 303 min of PM2.5 data) with an overall median reduction on the first full working weekday after implementation (Dec 3, 2018) of –81% (IQR –76 to –91). SHS measures collected 6 months after implementation (126 777 min of PM2·5 data) showed sustained improvement (median 3·1 μg/m3, overall median reduction –91% (IQR –88 to –93%)). Reasons for success and continuing challenges of smoke-free prison policy will be discussed. Interpretation: This evaluation of the development, planning, implementation, and impact of smoke-free prison policy demonstrates the importance of research evidence during policy implementation and, as a study of an entire national prison service, provides new evidence for other jurisdictions contemplating bans on smoking in prisons

Evaluation of a national smoke-free prisons policy using medication dispensing: an interrupted time-series analysis

Background Internationally, smoking prevalence among people in prison custody (ie, people on remand awaiting trial, awaiting sentencing, or serving a custodial sentence) is high. In Scotland, all prisons implemented a comprehensive smoke-free policy in 2018 after a 16-month anticipatory period. In this study, we aimed to use data on medication dispensing to assess the impact of this policy on cessation support, health outcomes, and potential unintended consequences among people in prison custody. Methods We did an interrupted time-series analysis using dispensing data for 44 660 individuals incarcerated in 14 closed prisons in Scotland between March 30, 2014, and Nov 30, 2019. We estimated changes in dispensing rates associated with the policy announcement (July 17, 2017) and full implementation (Nov 30, 2018) using seasonal autoregressive integrated moving average models. Medication categories of primary interest were treatments for nicotine dependence (as an indicator of smoking cessation or abstinence attempts), acute smoking-associated illnesses, and mental health (antidepressants). We included antiepileptic medications as a negative control. Findings A 44% step increase in dispensing of treatments for nicotine dependence was observed at implementation (2250 items per 1000 people in custody per fortnight, 95% CI 1875 to 2624) due primarily to a 42% increase in dispensing of nicotine replacement therapy (2109 items per 1000 people in custody per fortnight, 1701 to 2516). A 9% step decrease in dispensing for smoking-related illnesses was observed at implementation, largely accounted for by respiratory medications (−646 items per 1000 people in custody per fortnight, −1111 to −181). No changes associated with announcement or implementation were observed for mental health dispensing or antiepileptic medications (control). Interpretation Smoke-free prison policies might improve respiratory health among people in custody and encourage smoking abstinence or cessation without apparent short-term adverse effects on mental health dispensing

Process and impact of implementing a smoke-free policy in prisons in Scotland: TIPs mixed-methods study

Background: Prisons had partial exemption from the UK’s 2006/7 smoking bans in enclosed public spaces. They became one of the few workplaces with continuing exposure to second-hand smoke, given the high levels of smoking among people in custody. Despite the introduction of smoke-free prisons elsewhere, evaluations of such ‘bans’ have been very limited to date. Objective: The objective was to provide evidence on the process and impact of implementing a smoke-free policy across a national prison service. Design: The Tobacco in Prisons study was a three-phase, multimethod study exploring the periods before policy formulation (phase 1: pre announcement), during preparation for implementation (phase 2: preparatory) and after implementation (phase 3: post implementation). Setting: The study was set in Scotland’s prisons. Participants: Participants were people in custody, prison staff and providers/users of prison smoking cessation services. Intervention: Comprehensive smoke-free prison rules were implemented across all of Scotland’s prisons in November 2018. Main outcome measures: The main outcome measures were second-hand smoke levels, health outcomes and perspectives/experiences, including facilitators of successful transitions to smoke-free prisons. Data sources: The study utilised cross-sectional surveys of staff (total, n = 3522) and people in custody (total, n = 5956) in each phase; focus groups and/or one-to-one interviews with staff (n = 237 across 34 focus groups; n = 38 interviews), people in custody (n = 62 interviews), providers (n = 103 interviews) and users (n = 45 interviews) of prison smoking cessation services and stakeholders elsewhere (n = 19); measurements of second-hand smoke exposure (e.g. 369,208 minutes of static measures in residential areas at three time points); and routinely collected data (e.g. medications dispensed, inpatient/outpatient visits). Results: Measures of second-hand smoke were substantially (≈ 90%) reduced post implementation, compared with baseline, largely confirming the views of staff and people in custody that illicit smoking is not a major issue post ban. Several factors that contributed to the successful implementation of the smoke-free policy, now accepted as the ‘new normal’, were identified. E-cigarette use has become common, was recognised (by both staff and people in custody) to have facilitated the transition and raises new issues in prisons. The health economic analysis (lifetime model) demonstrated that costs were lower and the number of quality-adjusted life-years was larger for people in custody and staff in the ‘with smoke-free’ policy period than in the ‘without’ policy period, confirming cost-effectiveness against a £20,000 willingness-to-pay threshold. Limitations: The ability to triangulate between different data sources mitigated limitations with constituent data sets. Conclusions: To our knowledge, this is the first study internationally to analyse the views of prison staff and people in custody; objective measurements of second-hand smoke exposure and routine health and other outcomes before, during and after the implementation of a smoke-free prison policy; and to assess cost-effectiveness. The results are relevant to jurisdictions considering similar legislation, whether or not e-cigarettes are permitted. The study provides a model for partnership working and, as a multidimensional study of a national prison system, adds to a previously sparse evidence base internationally. Future work: Priorities are to understand how to support people in custody in remaining smoke free after release from prison, and whether or not interventions can extend benefits to their families; to evaluate new guidance supporting people wishing to reduce or quit vaping; and to understand how prison vaping practices/cultures may strengthen or weaken long-term reductions in smoking. Study registration: This study is registered as Research Registry 4802. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information

Process and impact of implementing a smoke-free policy in prisons in Scotland: TIPs mixed-methods study

Background: Prisons had partial exemption from the UK’s 2006/7 smoking bans in enclosed public spaces. They became one of the few workplaces with continuing exposure to second-hand smoke, given the high levels of smoking among people in custody. Despite the introduction of smoke-free prisons elsewhere, evaluations of such ‘bans’ have been very limited to date. Objective: The objective was to provide evidence on the process and impact of implementing a smoke-free policy across a national prison service. Design: The Tobacco in Prisons study was a three-phase, multimethod study exploring the periods before policy formulation (phase 1: pre announcement), during preparation for implementation (phase 2: preparatory) and after implementation (phase 3: post implementation). Setting: The study was set in Scotland’s prisons. Participants: Participants were people in custody, prison staff and providers/users of prison smoking cessation services. Intervention: Comprehensive smoke-free prison rules were implemented across all of Scotland’s prisons in November 2018. Main outcome measures: The main outcome measures were second-hand smoke levels, health outcomes and perspectives/experiences, including facilitators of successful transitions to smoke-free prisons. Data sources: The study utilised cross-sectional surveys of staff (total, n = 3522) and people in custody (total, n = 5956) in each phase; focus groups and/or one-to-one interviews with staff (n = 237 across 34 focus groups; n = 38 interviews), people in custody (n = 62 interviews), providers (n = 103 interviews) and users (n = 45 interviews) of prison smoking cessation services and stakeholders elsewhere (n = 19); measurements of second-hand smoke exposure (e.g. 369,208 minutes of static measures in residential areas at three time points); and routinely collected data (e.g. medications dispensed, inpatient/outpatient visits). Results: Measures of second-hand smoke were substantially (≈ 90%) reduced post implementation, compared with baseline, largely confirming the views of staff and people in custody that illicit smoking is not a major issue post ban. Several factors that contributed to the successful implementation of the smoke-free policy, now accepted as the ‘new normal’, were identified. E-cigarette use has become common, was recognised (by both staff and people in custody) to have facilitated the transition and raises new issues in prisons. The health economic analysis (lifetime model) demonstrated that costs were lower and the number of quality-adjusted life-years was larger for people in custody and staff in the ‘with smoke-free’ policy period than in the ‘without’ policy period, confirming cost-effectiveness against a £20,000 willingness-to-pay threshold. Limitations: The ability to triangulate between different data sources mitigated limitations with constituent data sets. Conclusions: To our knowledge, this is the first study internationally to analyse the views of prison staff and people in custody; objective measurements of second-hand smoke exposure and routine health and other outcomes before, during and after the implementation of a smoke-free prison policy; and to assess cost-effectiveness. The results are relevant to jurisdictions considering similar legislation, whether or not e-cigarettes are permitted. The study provides a model for partnership working and, as a multidimensional study of a national prison system, adds to a previously sparse evidence base internationally. Future work: Priorities are to understand how to support people in custody in remaining smoke free after release from prison, and whether or not interventions can extend benefits to their families; to evaluate new guidance supporting people wishing to reduce or quit vaping; and to understand how prison vaping practices/cultures may strengthen or weaken long-term reductions in smoking. Study registration: This study is registered as Research Registry 4802. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information.Additional co-authors: Jill Pell, Emily Tweed, Tom Byrne, Lesley Graham, Helen Sweetin