THE NEW ZEALAND MEDICAL JOURNAL
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THE NEW ZEALAND MEDICAL JOURNAL Journal of the New Zealand Medical Association New Zealand’s smokefree prison policy appears to be working well: one year on A comprehensive smokefree prisons policy was introduced in New Zealand a year ago (1 July 2011). The impression is that this policy appears to have been very successful so far. Initial concerns about the feasibility of establishing smokefree prisons seem to have been overridden by the reported smooth transition, from 67% of the prison population previously being smokers to a situation of a fully smokefree environment.1 The policy was reported to have been met with cooperation and even enthusiasm from many prisoners across the country.2 In this letter, we review evidence from the media, Government departments, the scientific literature, and other sources, to describe how the policy was introduced, it’s likely effect, and explore its implications for public health and tobacco control. We believe New Zealand is the first country in the world to implement a comprehensive country-level smokefree policy for all staff, prisoners and visitors within prison premises, indoors and outdoors (with 8690 prisoners at March 2012).3 Sweden had previously initiated a partial policy, affecting only the indoor prison environment; however, this policy was not sustained after a legal challenge.4 Other smokefree prison policies have been introduced overseas (such as various US states and Canadian jurisdictions), but these have not been country-level policies.5–7 Overseas experience has tended to show poor results for achieving smokefree prisons. Evaluation of an indoor smokefree policy in a Canadian prison reported that 93% of inmates continued to use tobacco products inside.7 A smokefree prison policy in Taiwan was resisted by inmates, with mixed compliance, as staff were permitted to continue to smoke at work.8 The introduction of smokefree prisons overseas have also regularly been met with the emergence of a black market for tobacco.9–11 There was an initial rise in tobacco contraband in the first 2 months following the introduction of the New Zealand policy and the black market price of tobacco doubled;12 however prisons enhanced their methods for checking and stopping contraband entering, and no further tobacco related problems have been reported since. Another initial reported problem was allegation of some prisoners attempting to smoke their nicotine patches mixed with tea leaves.13 However, there have been no further reports of this nature, and it is unclear if this is an ongoing issue. Three factors were likely to have contributed to the widespread acceptance of smokefree prisons in New Zealand. First, the comprehensive preparation provided by both the Department of Corrections and individual correction facilities; second, the availability, range and standard of smoking cessation support services; and third, the opportunity to learn from overseas experience and enact a comprehensive policy (covering both indoors and outdoors) as opposed to a partial policy. NZMJ 29 June 2012, Vol 125 No 1357; ISSN 1175 8716 Page 164 http://journal.nzma.org.nz/journal/125-1357/5247/ ©NZMA
Preparation for the smokefree policy consisted of a year-long lead-in period.14 During this time, prisoners were provided with educational materials which outlined the health risks of smoking along with advice on how best to quit. After the proposed smokefree policy was announced and prior to its implementation, 2000 prisoners started nicotine replacement therapy (NRT).15 Six voluntary smokefree units were established across the country up to 9 months before the policy was enforced, receiving unexpected support from inmates.16 Tobacco sales were outlawed in prisons a month before the full smokefree prison policy came into effect.17 Police stations also promoted the smokefree prisons policy in advance.1 Smoking cessation services available to inmates have consisted of both pharmacological and behavioural support. These have included NRT, access to a national free-phone service (Quitline), access to cessation guidance books and assistance from health care staff trained in smoking cessation support.15,18 While there were initial concerns over the level of cessation support available for prisoners prior to the policy implementation,19 extra activities were provided as part of the smoking cessation programme including: sporting events, exercise initiatives,20 cultural activities and art classes.15,21 In one correctional facility, prisoners were provided with healthy snacks (carrot sticks) to assist with withdrawal symptoms.22 An important observation, noted from other studies, is that policies that have enforced a 100 percent smokefree environment tended to face fewer problems than “indoor only” policies.23 The smokefree prison policy introduced in New Zealand prohibits smoking within the entire prison premises (both indoors and outside), thus making the policy easier to enforce. Evidence from the US suggests that poor compliance with a smokefree prison policy is associated with a lack of strict enforcement from staff who object to the rules.24 Fortunately, in New Zealand, Corrections staff have been co-operative with the policy. This may partly be explained by the Department of Corrections having sponsored the development of “Workplace Champions”, a voluntary designated staff member, who was provided with smoking cessation training, with the intention of supporting colleagues and prisoners to quit, both before and after the policy was introduced.25 The aims of the New Zealand smokefree prison policy are to make prisons both healthier and safer, primarily to reduce secondhand smoke exposure and risk of fires.26 Staff working in prisons without smokefree policies are exposed to high levels of secondhand smoke exposure. An Irish study showed that 44% of non-smoking prison workers had carbon monoxide levels in respired breath equivalent to those of a light to heavy smoker.27 Studies of indoor air quality in prisons before and after smokefree policies have shown a significant decrease in nicotine concentrations in ambient air.28 Indeed, recent evaluation work in an Auckland prison showed indoor air pollution levels (of fine particulates associated with second-hand smoke) to have halved as a result of the new policy.17 The smokefree prisons policy appears to have reduced the risk of fires. Within a month of the introduction of the policy, the number of arson-related incidents in NZMJ 29 June 2012, Vol 125 No 1357; ISSN 1175 8716 Page 165 http://journal.nzma.org.nz/journal/125-1357/5247/ ©NZMA
prisons dropped. The month before the policy was introduced 18 fires and arson- related incidents occurred compared to only four in the month after the policy was introduced, and only one the following month.29 This was likely to result from the prohibition placed on cigarette lighters, which accompanied the tobacco ban. Smokefree prisons policies have occasionally been associated with riots30,31 and an increase in inmate violence.32 One New Zealand prison was reported to have an increase in violence between prisoners in the month following the introduction of the policy.33 The number of serious assaults in prisons since the implementation of the policy are yet to be reported. International evidence suggests that the re-uptake of smoking once leaving a smokefree prison is high.34 Fortunately in New Zealand, relapsed smokers can get quitting support from the Quitline and many other health service providers. Relapse risk in the community will also be lowered as the price of tobacco continues to rise (with multiple tobacco tax rises planned by the current Government). There are also other supportive environmental measures being planned on the country’s path towards achieving the “Smokefree Nation 2025” goal, such as the requirement for plain (or standard) packaging, being introduced in Australia. However, we believe the smoking relapse rate for released prisoners should be quantified and their needs for services to support them remaining smokefree assessed. Such evidence would help evaluate whether current quit support for prisoners on leaving prison is adequate, and help identify areas where further assistance may be needed. The World Health Organization Framework Convention on Tobacco Control introduced Article 8 in 2007 for countries to protect their citizens from secondhand smoke in indoor public places and workplaces.23 Five years on, it appears that New Zealand is the first country to have successfully addressed these issues in all their prisons. The available evidence suggests that the policy has been successfully introduced, with no evidence of the problems reported in other jurisdictions. Objective indicators have shown both improved indoor air quality17 and reduced incidence of fires29 after the policy was introduced. Nevertheless, we believe that a more in-depth evaluation of this policy is now desirable to inform other smokefree developments in New Zealand, but also to assist the introduction of national smokefree prison policies in other countries. A systematic evaluation of this tobacco control intervention could include a more comprehensive assessment of air quality expanding the previous assessment beyond a single prison, surveying staff and prisoners, measuring health indicators amongst staff and inmates, further determining trends in fires, and assessing whether smokefree prisoners remain so after their release back to their communities. Lucie Collinson1*; Nick Wilson1; Richard Edwards1; George Thomson1; Simon Thornley2 1 Department of Public Health, University of Otago, Wellington 2 School of Population Health, The University of Auckland *Corresponding author, Dr L Collinson: lucie.collinson@otago.ac.nz NZMJ 29 June 2012, Vol 125 No 1357; ISSN 1175 8716 Page 166 http://journal.nzma.org.nz/journal/125-1357/5247/ ©NZMA
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NZMJ 29 June 2012, Vol 125 No 1357; ISSN 1175 8716 Page 168
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