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Two decades since the WHO Regional Office for Europe outlined and published a report on health promotion in prison, which stimulated further debate on the concept of the ‘health promoting prison’, this paper discusses the extent to which the concept has translated into practice and the extent to which success has been achieved. This paper primarily focuses on why there has been a gap between the strategic philosophy of health promotion in prison and practical implementation, suggesting that factors such as ‘lifestyle drift’ and public and political opinion have played a part. A further argument is made in relation to the overall commitment of European countries and more broadly WHO in their support of settings-based health promotion in this context. It is proposed that there has been a weakening of commitment over time with a worrying ‘negative trajectory’ of support for health promoting prisons. The paper argues that despite these challenges, the opportunities and potential to address the needs of those who are often most vulnerable and excluded is colossal and acting to tackle this should be a greater priority. [ABSTRACT FROM PUBLISHER]