A Call for Health Equity in Tobacco Control and Treatment for the Justice-Involved Population

"The objectives of a health and medical services program for prisoners must include the promotion of health, the prevention of disease and disability, the cure or mitigation of disease, and the rehabilitation of the patient…To achieve the goals set down above, medical care programs for prisoners must be equivalent to the care which is available in the community."- American Correctional Association, Manual of Correctional Standards, 1966 1 Tobacco-related disparities in the justice-involved population represent a largely ignored health equity and human rights issue.2 Estimated cigarette smoking prevalence rates among the justice-involved range from 50-83%,3 a rate that has remained high and unchanged compared to declining smoking rates among U.S. adults (11.5% prevalence in 2021).4 The high smoking prevalence among the justice-involved is an outcome of larger social and economic inequities that have concentrated risk factors for smoking (e.g. poverty, housing instability, unemployment) in certain groups overrepresented in the criminal justice system.5 These groups include but are not limited to racial and ethnic minorities, individuals with lower socioeconomic status, and those with a co-occurring mental illness and substance use disorders.5 The carceral environment is a risk factor for smoking during incarceration and after release. The stress of incarceration, stigma related to justice-involvement, and the many challenges of reentry increase the risk of adopting coping behavior, such as smoking, that may have negative consequences after release.6 In the absence of tobacco dependence treatment during incarceration or upon release, as many as 90% of individuals who smoked prior to incarceration will resume smoking once out of prison or jail.7 Additional risk factors for smoking relapse during reentry into the community are barriers to accessing health care and returning to communities with a high tobacco retail density as a result of discriminatory targeting by the tobacco industry.5 Effective tobacco control strategies and treatments exist but are not reaching the justice-involved, a population already burdened by morbidity and mortality from a high prevalence of chronic and communicable disease.8 Neglecting to provide an essential preventive addiction treatment service for tobacco dependence contributes to worse health outcomes, premature mortality, and shifts the cost burden on to justice-involved individuals and the community health care facilities where they access care after release.8 Thus, tobacco-related disparities are an important health equity issue and a public health problem because they put a population that is already at risk for poor health at further disadvantage with respect to health. This review examines the existing tobacco control landscape in prisons and jails and recommends providing tobacco treatment as a standard of correctional health care within a supportive, tobacco-free environment. Cross-sector collaborations between public health, community behavioral health, and correctional systems are needed to achieve more equitable reach of tobacco control strategies to the justice-involved population. Tobacco use has long been embedded in prison and jail culture, for both correctional staff and incarcerated individuals.9 Over the last few decades, however, there have been efforts to implement smoke-free policies in prison and jails, largely driven by the recognition of the risks of second-hand smoke exposure and the threat of litigation.9 By 2007, 60% of prison systems had implemented a comprehensive smoke-free policy prohibiting smoking indoors and throughout the grounds, while 27% of prisons had implemented a policy prohibiting smoking only indoors. Over half (55%) of jails had implemented comprehensive indoor/outdoor smoke-free policies by 1998.9 Despite the increase in tobacco-free carceral settings, inconsistent adoption and enforcement of comprehensive tobacco policies have left gaps in protection from second-hand smoke or e-cigarette vapor exposure. For example, the American Correctional Association, the National Commission on Correctional Health Care (NCCHC), and the American Jail Association recommend, but do not mandate, adoption of smoke-free policies.10 Currently, many jails explicitly allow and profit from the purchase of electronic nicotine delivery devices, (e.g. e-cigarettes or vapes).11 Consequently, even when policies exist, the prevalence of smoking and tobacco use during incarceration persists, with estimates between 20% to 76%.9 The security level of the facility, the severity of penalties for violations, and prevalence of illicit market trade are additional factors implicated in tobacco use.12 While implementation of tobacco-free policies varies widely by the type of carceral setting, best practices for the prevention, management, and treatment of tobacco use in jails and prisons across these settings remain the same. Tobacco control encompasses the policy itself, staff support, and treatment for individuals during incarceration and reentry. Table 1, Table 2 provide detailed, step-by-step strategies to implement comprehensive tobacco-free policies and tobacco dependence treatment.Table 1Health Systems Change Strategies for Comprehensive Tobacco-Free Policies14Health Systems Change StrategyAction StepsAssemble a workgroupDevelop a tobacco policy.Set milestones and implementation timeline.Build stakeholder support and buy-in (e.g., leadership, staff, people who are incarcerated).Provide resources and support to staff and people who are incarcerated.Implement and enforce the policy.Address staff questions and concernsProactively solicit feedback and provide a barrier-free mechanism for Q&A.Note: Tobacco- free policies are legal and do not discriminate against people who smoke. A tobacco-free environment policy prohibits the use of tobacco products in the same manner as other substance use policies, by setting a rule for activities prohibited on the property.Develop a comprehensive policyInclude all commercial tobacco products (e.g., cigarettes, smokeless, e-cigarettes/vaping devices).Ban tobacco use in both indoor and outdoor spaces.Apply to correctional staff, incarcerated individuals, and visitors.Ban sale of commercial tobacco products, including e-cigarettes.Offer or facilitates access to nicotine replacement therapy to incarcerated individuals.Provide information on tobacco cessation employee benefits offered to correctional staff who use tobacco.Define what is considered a violation of the policy and consequences for non-compliance.Educate about the new policyCommunicate to staff and people who are incarcerated the new policy's content, timeline, enforcement procedure, and rationale for change.Promote how to access tobacco treatment.Implement the policyInstall signage on the grounds and facility.Remove smoking huts, ashtrays, and receptacles in designated smoking areas.Enforce the policySet clear guidelines on what constitutes a violation.Align consequences for tobacco use violations with other prohibited substances. Open table in a new tab Table 2Health Systems Change Strategies for Comprehensive Tobacco Treatment 14Health Systems Change StrategyAction StepsImplement a system-wide tobacco use identification protocol.Ensure every individual entering a prison or jail is screened for tobacco use (regardless of length of stay).Assess level of tobacco dependence/addiction (e.g., Heaviness of Smoking Index).Integrate tobacco use documentation into standardized screening tools that are used to identify other recent, regular, or heavy substance use.Provide tobacco dependence treatment to all people who use tobacco.Treatment should be evidence-based and at minimum adhere to U.S. Public Health Service Clinical Practice Guidelines.14Integrate tobacco treatment into primary care and/or behavioral healthcare services.Provide medication for withdrawal management (nicotine patch, gum, or lozenge) for all individuals who screen positive for tobacco use and dependence.Provide a combination of counseling and medication (e.g., NRT, varenicline, bupropion) for tobacco treatmentBehavioral interventions during incarceration and prior to release should use evidence-based counseling strategies.Integrate tobacco use into the release planTobacco use should be addressed to the same standard of care as other substance use disorders and/or mental health conditions.In-reach care coordination provides referrals to community treatment providers or tobacco dependence treatment resources (e.g., 1800-QUIT-NOW) for continuity of care after release.Provide nicotine replacement therapy prior to release to prevent relapse.Provide education, resources, and feedback to correctional healthcare staffOffer training on tobacco treatments and provide continuing education and/or other incentives for participation.Provide tobacco treatment resources and materials (e.g., QuitLine and self-help materials).Track and report tobacco use screening and the provision of tobacco treatment to accrediting organizations.Monitor and provide feedback on the degree to which correctional health care staff screen, document, and treat individuals who use tobacco. Open table in a new tab Comprehensive tobacco-free policies should be clear and succinct and written at a literacy level comprehensible by both justice-involved individuals and correctional personnel. Such policies should explicitly delineate the range of products prohibited (e.g., cigarettes, vaping products) and detail who must adhere to such policy (e.g., incarcerated individuals, correctional staff, visitors).13 The policy should unequivocally prohibit tobacco use in both enclosed and outdoor spaces, including staff only spaces and facility vehicles. A comprehensive tobacco-free policy should also ban the sale of commercial tobacco products in jails and prisons. Additionally, the US Food and Drug Administration (FDA)-approved medications for tobacco treatment should be accessible by prescription, free of charge, or for purchase at a price comparable to or lower than what is available in the community. The policy would further detail what constitutes a tobacco use violation, the consequences for non-compliance, and provide notification about the availability of treatments for nicotine withdrawal and smoking cessation. Comprehensive tobacco-free policies should support staff who use tobacco. Correctional staff use tobacco at significantly higher rates than the general population, and staff have been a source of illicit tobacco distribution within carceral systems where use is prohibited.13,9 By 2001, 61% of ostensibly "tobacco-free" prisons and jails still permitted staff to smoke.9 Consequently, the efficacy of tobacco-free policies for the justice-involved hinges on also curbing tobacco use among correctional staff. The carceral system should ensure that tobacco use treatment benefits are incorporated into employer-sponsored health insurance plans, accompanied by clear, regular guidance on accessing treatment benefits.9 Institutions should strongly encourage staff to abandon tobacco use, employing a blend of financial incentives, psychosocial motivations, and education regarding the impacts of tobacco use on the health of themselves and others. For example, when staff return to work from smoke-breaks smelling strongly of cigarettes, it exposes incarcerated people to significant triggers that may elicit or exacerbate strong craving to smoke or unpleasant withdrawal symptoms. For staff grappling with tobacco dependence, the provision of nicotine replacement therapy throughout work shifts is recommended to mitigate withdrawal symptoms and support "tobacco-free shifts." Tobacco use disorder treatment should be integrated as a standard of care during incarceration. While comprehensive tobacco policies reinforce tobacco-free norms and support tobacco treatment goals, tobacco policy and treatment implementation are often not concurrent processes. Therefore, regardless of a facility's policy, individuals who smoke should be assessed for nicotine dependence upon intake to jail or prison and provided with evidence-based treatment for withdrawal management during incarceration. A five-step clinical practice guideline can facilitate systematically integrating screening and tobacco treatment as a standard of care: 1) Ask about tobacco use, 2) Advise people to stop using tobacco; 3) Assess readiness to quit and level of dependence; 4) Assist people with accessing pharmacotherapy and counseling; and 5) Arrange for follow-up to prevent/address relapse.14 The standard of care for tobacco dependence is the same as standard of care for other substance use disorders, such as opioid and alcohol use disorder; treatment should include both pharmacotherapy and counseling to enhance motivation to quit, intention to quit, and long-term abstinence.14-15 The FDA has approved three types of pharmacotherapies for tobacco dependence: nicotine replacement therapy (NRT; e.g., patch, lozenge, gum), bupropion, and varenicline.14 Effective behavioral treatment approaches include Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), contingency management, and brief and more intensive practice-based advice to quit. Counseling can be delivered in-person (individual or group format), via telephone, text messaging, and/or through internet-based support.14 Tobacco relapse prevention treatment is essential during reentry. Reentry, or the transition to community corrections, is a vulnerable time for smoking relapse due to many health-related needs, psychosocial stressors, stigma and discrimination, increased access to tobacco products, and exposure to many cues/triggers to smoke. This underscores the importance of integrating tobacco treatment within existing policies addressing substance use disorder treatment to ensure abstinence endures post-incarceration. Reentry health care services should be facilitated by well-defined procedures for continuity-of-care, including the seamless transfer of incarcerated individual's health records to designated community treatment providers. When possible, referrals to outside resources like state tobacco quitlines (1-800-QUIT-NOW) are an effective but underutilized treatment extender at time of release.14 Expanding Medicaid coverage for the justice-involved, improving national standards in correctional health care, and increasing tobacco treatment research in carceral settings are opportunities for cross-sector collaboration between public health, community behavioral health, and correctional health systems to facilitate the implementation of tobacco treatments during incarceration and after release. Efforts to address tobacco-related disparities must consider insurance coverage as it is a critical component to bridging gaps in access to health care after release from prison or jail. Medicaid Reentry Section 1115 demonstration waivers are increasing nationwide as a novel enrollment and transitional care initiative, with most states focusing on expanding access to treatment for opioid and other substance use disorders up to 90 days prior to an individual's release.16 Medicaid 1115 demonstration waivers provide states an opportunity to expand access to tobacco treatment within a comprehensive substance use disorder benefit package. Few factors have been more influential in shaping and improving the quality of correctional health care services than voluntary compliance with national standards. Yet the current standards fall short in providing evidence-based guidance.17 In the 2018 NCCHC Standards for Health Services in Prisons and Jails, NCCHC only recommends that prisons and jails provide prevention and cessation education through self-help classes and informational digital media to all incarcerated people who use tobacco.17 Nearly all daily tobacco users are nicotine dependent and should be offered nicotine withdrawal medication management upon intake and engaged in ongoing treatment to support recovery, regardless of length of stay. Aligning tobacco treatment standards with existing standards for other substance use disorder treatment will require increased effort and resources from corrections facilities, but the clinical and cost-effectiveness of treating tobacco dependence is well established.14 Research is needed to guide tobacco treatment implementation in prisons and jails. Despite tobacco use among the justice-involved being a well-documented public health issue, less focus has been placed on understanding how to implement evidence-based tobacco treatments in carceral settings. Several recent small innovative studies in prisons and jails have demonstrated good feasibility and acceptability of a variety of promising and scalable interventions (e.g., peer-led counseling, NRT) that should be evaluated in larger trials.18-20 However, research gaps persist in understanding how to best implement and tailor tobacco treatment during incarceration and reentry, and what factors are likely to increase smoking abstinence following release from incarceration.21 There is an urgent need for more funding and collaboration to prioritize tobacco treatment research in prisons and jails given that tobacco treatments are feasible and effective, 22 there is a desire to engage in tobacco treatment, 19,22 and prisons and jails provide an ideal setting for these interventions.22 Prisons and jails are overdue in making systems changes necessary to support incarcerated individuals who use tobacco. People who are justice-involved deserve tobacco-free policies that eliminate second-hand smoke and e-cigarette vapor exposure while incarcerated. Prisons and jails should provide equal access to tobacco treatment, commensurate with what is offered in the community and in accordance with the standards for other substance use disorder treatment. Treatment ought to encompass routine assessment of tobacco use, medically supervised withdrawal, access to medication and behavioral support during incarceration, with post-release referral to continued treatment. Cross-sector collaboration will be essential to improving the standards of tobacco treatment services during incarceration and facilitating continuity of care after release. A concerted effort to equitably implement effective tobacco control strategies in carceral settings could have a substantial impact on improving the health and wellbeing of incarcerated individuals, significantly reducing the health care costs of continued tobacco use, and closing this health equity gap for the justice-involved population.