Smoking bans in prison: time for a breather?

Tony G Butler and Lorraine Yap
Med J Aust 2015; 203 (8): 313. || doi: 10.5694/mja15.00688
Published online: 19 October 2015

Introducing a total smoke-free policy in prisons is not without problems

Successful public health campaigns have contributed to reducing daily smoking rates in the general Australian population from 24% in 1991 to 13% in 2013.1 However, this reduction has not been mirrored in prisons, where no downward trend is apparent and the rate remains stubbornly high at around 84%.2 High rates of community smoking persist in groups over-represented in the criminal justice system — the mentally ill (32% of current smokers had a 12-month mental disorder, compared with 16% of non-smokers),3 Indigenous people (44% of Indigenous v 16% of non-Indigenous Australians)4 and illicit drug users (37%).1

Smoking bans are becoming the norm in Australian prisons, driven mostly by concerns about the effects of second-hand smoke on non-smokers and potential legal action by non-smoking prison staff and prisoners. On 1 July 2013, the Northern Territory was the first Australian jurisdiction to implement a total smoking ban in prisons. Queensland followed suit with a total ban in May 2014, Tasmania from February 2015, and Victoria from July 2015. New South Wales implemented a full smoking ban in its prisons in August 2015; South Australia, Western Australia and the Australian Capital Territory will probably follow suit in the near future. Implementation of smoke-free polices in combination with smoking cessation interventions benefit prisoner health by reducing active smoking and second-hand smoke levels.5

Nevertheless, introducing a total smoke-free policy in prisons is not without problems. There is evidence that enforced prison smoking bans result in black markets in tobacco and other smokable substances.5,6 In one study, researchers reported that a smoking ban was unsuccessful because of low compliance; three-quarters of prisoners continued to smoke illicitly in prison after introduction of the ban.6 Despite imposing ever more severe penalties on the use of contraband goods and spending increasing sums of money on prohibition, very few jails and prisons in the United States, Australia and elsewhere have achieved completely drug-free (including tobacco-free) environments.

Further, fears have been raised that enforced smoking bans in prisons could lead to an escalation of violence. The recent riot at the Melbourne Remand Centre is believed to have been caused by the imminent ban on smoking.7 However, a literature review found little or no evidence of increased violence following the implementation of smoke-free policies in US jails and prisons.5

While banning smoking outright undoubtedly improves air quality8 and avoids possible litigation, another aim must be addressed if we are to tackle tobacco smoking in this population: sustained abstinence from tobacco use after leaving prison. Total smoking bans alone have been ineffective in reducing smoking rates in this population. Follow-up studies of prisoners after their release have found that 56% reported resuming smoking on their first day of release;9 84% had relapsed within 3 weeks,10,11 and 39% by a month after release.12 Another follow-up study found that 63% of former prisoners had relapsed on the first day of release, 82% by 1 week, 86% by 1 month, and 97% at 6 months.13

These findings indicate that this population is in need of interventions both inside prison and after their release to reduce their high rate of tobacco smoking. Few studies on smoking cessation interventions for this population during incarceration have been published. We are unaware of any published studies in Australia that have examined post-release smoking behaviours following a prison smoking ban, or of any post-release smoking cessation interventions for this population. However, a US study found that interventions can be effective in preventing smoking relapse after release from prison.14

Paradoxically, while public health professionals deplore tobacco smoking in the community, many have sympathy for those in prisons who smoke. This sentiment was expressed in 2010 at the National Summit on Tobacco Smoking in Prisons held by Public Health Association Australia. While smoking bans in prisons in Australia are inevitable, a targeted approach that recognises the unique characteristics of this population group is needed, and must involve support both in prison and in the community, recognising that imprisonment for most is only temporary.

Provenance: Commissioned; externally peer reviewed.

  • Tony G Butler
  • Lorraine Yap

  • University of New South Wales, Sydney, NSW


Competing interests:

No relevant disclosures.

  • 1. Australian Institute of Health and Welfare. National Drug Strategy Household Survey: detailed report, 2013. Canberra: AIHW, 2014. (Drug statistics series No. 28. Cat. No. PHE 183.) (accessed Jul 2015).
  • 2. Australian Institute of Health and Welfare. The health of Australia’s prisoners 2012. Smoking. Canberra: AIHW, 2013. (accessed Jul 2015).
  • 3. Australian Bureau of Statistics. 4326.0 National Survey of Mental Health and Wellbeing: summary of results, 2007. Canberra: ABS, 2008.$File/43260_2007.pdf (accessed Aug 2015).
  • 4. Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014. (Australia’s health series No. 14. Cat. No. AUS 178.) (accessed Aug 2015).
  • 5. Kennedy SM, Davis SP, Thorne SL. Smoke-free policies in US prisons and jails: a review of the literature. Nicotine Tob Res 2015; 17: 629-635.
  • 6. Cropsey KL, Kristeller JL. The effects of a prison smoking ban on smoking behavior and withdrawal symptoms. Addict Behav 2005; 30: 589-594.
  • 7. Lord K. Prison riot: “Significant damage” done to Melbourne jail; inquiry ordered, Premier Daniel Andrews says. ABC News 2015; 1 Jul. (accessed Jul 2015).
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  • 9. Pezzino G, Remington PL, Anderson H, et al. Impact of a smoke-free policy on prisoners in Wisconsin, United States. Tob Control 1992; 1: 180-184.
  • 10. Bock B, Lopes CE, van den Berg JJ, et al. Social support and smoking abstinence among incarcerated adults in the United States: a longitudinal study. BMC Public Health 2013; 13: 859.
  • 11. van den Berg JJ, Bock B, Roberts MB, et al. Cigarette smoking as an expression of independence and freedom among inmates in a tobacco-free prison in the United States. Nicotine Tob Res 2014; 16: 238-242.
  • 12. Thibodeau L, Jorenby DE, Seal DW, et al. Prerelease intent predicts smoking behavior postrelease following a prison smoking ban. Nicotine Tob Res 2010; 12: 152-158.
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  • 14. Clarke JG, Stein LA, Martin RA, et al. Forced smoking abstinence: not enough for smoking cessation. JAMA Intern Med 2013; 173: 789-794.


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access_time 09:06, 19 October 2015
Robert Granger

It is worth asking why bans in certain locations have been successful, and why there is little success in others. I recall those not-so-long-ago days in which I would endure those long hours on international flight in the "non-smoking section". If only the cigarette smoke respected those same boundaries! Almost with the flick of a switch, the industry changed its rules about smoking for the safety of the plane and its occupants.

On the ground, the gains have not been so impressive. One of the more woeful examples is to be seen on our hospital campuses. Despite the numerous placards proclaiming to be a smoke-free campus, the reality shows otherwise. Often standing at the entry to the main buildings, smokers defy those warnings as they know that they can get away with it.

It is time to turn the switch in our prisons like the airlines have done. I appreciate that when travelling the demand for cessation is temporary. But when one becomes a prisoner, they lose certain rights. And one of those rights should surely be access to drugs such as cigarettes. Sure, there may be riots initially. And yes, there will be an increase in the need to ensure appropriate surveillance of contraband. So for the sake of the safety of the prison buildings, the employees and the inmates, smoking must be banned as it was for the airlines!

Competing Interests: No relevant disclosures

Dr Robert Granger
Preventive Dermatology

access_time 09:49, 22 October 2015
Umberto Boffa

Drs Butler and Yap have thrown down the gauntlet for the medical profession. (Smoking bans in prison: time for a breather? MJA 203(8) 19/10/15).

They point out that while public health professionals deplore tobacco smoking in the community, many have sympathy for those in prisons who smoke.

There are thousands of prison workers in Australia and an alarming 85% of their charges are tobacco smokers1

The authors advocate a targeted approach to smoking prisoners’ health that recognises the unique characteristics of this population group.

As laudable as these sentiments are, they widely miss the point about the health effects of environmental tobacco smoke (ETS) on prison workers.

The evidence that ETS increases risk of ischaemic heart disease is well established.

There are a large number of epidemiological studies, conducted in a variety of locations reflecting a 30% increase in risk of death from ischemic heart disease among nonsmokers living with smokers,2,3,4.

In every jurisdiction in Australia there are laws obliging employers to maintain a safe workplace that is without risks to health5.

The Australasian Faculty of Occupational and Environmental Medicine (AFOEM) of The Royal Australasian College of Physicians (RACP) recently released a Consensus Statement on the Health Benefits of Work presenting compelling international and Australasian evidence that work is generally good for health and wellbeing.6

Tolerance of ETS in prisons is a violation of prison workers’ rights to a safe workplace in Australian jurisdictions and makes a travesty of the RACP policy toward the health benefits of work.

I thank the authors for pointing out the prevalence of smoking in our prisons but I disagree any sanctions should be made.

ETS is the burning issue in the Australian prison system and the medical profession needs to bring its unacceptability urgently to public and judicial attention.

Competing Interests: No relevant disclosures

Dr Umberto Boffa
Monash University

access_time 04:53, 26 October 2015
Deborah Zador

We are surprised by the less than full support of Butler and Yap1 for the laudable introduction of a smoke free policy in custodial settings in NSW. The most recent NSW Inmate Health Survey2 indicated that incarcerated persons have high rates of chronic disease2 consistent with their high smoking rates (76%). Furthermore, this survey2 found 85% of smokers expressed a desire to quit. Exposure to second hand smoke is an unacceptable health risk, and both prisoners and corrections staff should no longer be excluded from access to a smoke-free environment.

In this state, CSNSW and Justice Health & Forensic Mental Health Network carefully planned the introduction of smoking cessation for 2 years. Tested clinical support programs have been established and will continue to assist individuals in custody with withdrawal from nicotine. As a result, the implementation of this policy in a custodial population of over 12, 0003 has been remarkably smooth.

Yet Butler and Yap1 diminish this impressive achievement of a smoke free custodial environment by focusing on the likelihood of released prisoners resuming smoking in the community. Relapse to drug use is a well known characteristic of dependence and supports for individuals to remain abstinent from smoking after release are being addressed as part of a current internal evaluation of the smoke free initiative.

The Smoke-Free Prisons policy provides an enduring opportunity to improve the health of prisoners and those working in correctional facilities. The move to smoke free prisons should be embraced as a public health triumph.

1.Butler TG and Yap L. Smoking bans in prison: time for a breather? Med J Aust 2015; 203 (8): 313.
2.Indig D, Topp L, Ross B, et al. 2009 NSW Inmate Health Survey: Key Findings Report. Justice Health. Sydney, 2010.

Competing Interests: No relevant disclosures

Dr Deborah Zador
Justice Health & Forensic Mental Health Network

access_time 01:31, 4 November 2015
David CCurrow

Butler and Yap’s (1) assertion that “introducing a total smoke-free policy in prisons is not without problems” undermines the significance of a tobacco control initiative aimed at closing the gap in health disparities in, arguably, our most marginalised population.

Smoking prevalence among prison inmates has remained astronomically high at 84% (2), while among the general population there continues a year-on-year reduction. No other lifestyle habit causes greater disease burden with two out of three smokers dying prematurely (3).

What Butler and Yap fail to acknowledge is that in 2012, nearly half of prisoners wanted to quit smoking (2). Smoke free prisons are not a punitive initiative, but support the wishes of prisoners who want to quit. Of prisoners wanting to quit, more than a third did not want cessation support, 30% wanted nicotine replacement therapy (NRT), 21% a quit program and 13% counseling (2). As prisons in NSW went smoke free in August 2015, Justice Health & Forensic Health Network provided cessation support to inmates and staff, providing NRT, cessation resources and access to the NSW Quitline (4).

What is concerning in the approach of Butler and Yap is their bundling together of the significant progress of smoke free prisons and the challenges we still face in supporting continued abstinence after release. Challenges in the latter should not diminish the achievement in the former. Smoke free prisons will make inroads into health disparities. How can Butler and Yap assert it is time for a breather?

1. Butler T, Yap L. Smoking bans in prison: time for a breather? Med J Aust. 2015;203(8):313.
2. AIHW. The health of Australia's prisoners 2012. Canberra: AIHW, 2013 196p. Cat. no. PHE 170.
3. Banks E, Joshy G, Weber MF, et al. Tobacco smoking and all-cause mortality in a large Australian cohort study: findings from a mature epidemic with current low smoking prevalence. BMC Med. 2015;13(1):281.
4. Justice [Internet] Sydney: Corrective Services NSW; 2015. Smoke Free Project; 17 August 2015 [cited 2015, Nov 1]; [2 screens]. Available from:

Competing Interests: The Cancer Institute NSW funds the NSW Quitline.

Prof David CCurrow
Cancer Institute NSW

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