Tobacco use, cessation, and substitution among people who experience incarceration in Queensland, Australia

Abstract

Smoke-free policies have been introduced in prisons in many jurisdictions, including in Queensland, Australia, in an attempt to reduce high levels of tobacco use and related harms. However, these policies have not resulted in smoking cessation in all cases. One unintended consequence reported in some prisons has been the substitution of cigarettes with “teabacco”—tea leaves infused with nicotine replacement therapy (NRT) patches, wrapped in Bible paper. Second, studies based in the United States (US) have found that the majority of former smokers resume smoking upon release from smoke-free prisons, indicating that correctional smoke-free policies typically result in short-term smoking cessation only. The research presented in this thesis as a series of publications seeks to add to the knowledge base regarding tobacco use, cessation, and substitution among people who experience incarceration. The findings may inform interventions designed to reduce tobacco use and harm among a population with high levels of smoking-related illness. This thesis comprises eight chapters, including eight publications. First, chapter one provides an introduction to the topic, followed by a review of relevant literature. Chapter two is a systematic review of literature describing factors influencing smoking relapse following release from smoke-free prisons. This review identified only 15 relevant publications, most of these methodologically weak, and mostly US-based. Chapter three outlines the methods of the studies included in chapters four, five, and six. Chapter four includes three publications focusing on relapse to tobacco smoking following release from smoke-free prisons in Queensland. The first, based on a quantitative survey with 114 people recently released from smoke-free prisons in Queensland, found that although 94% returned to smoking following release from prison (72% on the day of release), 62% were smoking significantly less per day compared to before prison. The second publication in chapter four is a letter to the editor highlighting the need for interventions promoting smoking cessation for people released from smoke-free prisons. The third publication in chapter four presents findings from a qualitative study exploring the facilitators and barriers of smoking relapse following release from prison, among a subset of 21 participants recruited as a follow-up to the survey. Common barriers to continued smoking abstinence included pre-release intention to resume smoking; situational factors associated with home environments; resuming smoking to celebrate freedom; associating smoking with stress relief; and using tobacco to cope with cravings for illicit substances. Facilitators included an awareness of health and financial benefits of smoking abstinence, intrinsic motivation, distraction from nicotine cravings using alternative activities, and social support from family and peers. Chapter five includes two studies exploring the creation and use of teabacco in Queensland’s smoke-free prisons. The first study found that 57% of participants had smoked teabacco while incarcerated; commonly-reported motivations for teabacco use included craving tobacco, wanting to experience a drug high, and boredom. Building on these findings, forensic scientists analysed the chemical constituents of teabacco made from nicotine lozenges. The analysis found that this form of teabacco is not as harmful as teabacco made from nicotine patches, or normal cigarettes. The results of this analysis are presented in the second publication in chapter five. Chapter six analyses data from a survey of people soon-to-be released from prisons in Queensland, prospectively linked with Pharmaceutical Benefits Scheme (PBS) records, to investigate use of government-subsidised smoking cessation pharmacotherapy (NRT patches, varenicline, and bupropion) following release from prison. This study found that only 8.9% of smokers accessed government-subsidised smoking cessation pharmacotherapy in the two years following release from prison. Chapter seven is a protocol for a randomised controlled trial of an intervention aiming to reduce smoking relapse among people released from smoke-free prisons in Queensland. Chapter eight integrates the findings of all eight studies and proposes future directions for research and policy. Combined, the studies presented within this thesis highlight high rates of smoking relapse among former smokers released from smoke-free prisons, and the lack of smoking cessation strategies aimed at people in and leaving smoke-free prisons. This thesis emphasises the missed public health opportunity that this represents among a marginalised and underserved population. Greater investment in smoking cessation supports for people who cycle through smoke-free prisons has the potential to improve the health of a population with especially poor health outcomes, reduce the cost of treating smoking-related illness, and prevent the use of potentially harmful substitute substances such as teabacco in prison.