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Issue. The prevalence of smoking among prisoners is exceptionally high and is often comorbid with alcohol and drug problems, mental illness and other health problems. This review paper summarises the literature and available research related to smoking prevalence and smoking cessation initiatives among prisoners and identifies areas of need for further research and intervention. Approach. This paper highlights three studies conducted in the New South Wales prison system which attempt to address these high rates of smoking including a feasibility study, a focus group study and a randomised controlled trial. Key Findings. The challenges of making systems-level changes to address these high rates of smoking are discussed including a recent National Summit on Tobacco Smoking in Prisons. Implications. Dissemination of research findings has assisted in highlighting the importance of tobacco smoking among prisoners and the need to develop culturally and setting appropriate smoking cessation initiatives for prisoners. Conclusions. As one of the most marginalised and socially disadvantaged populations in Australia, prisoners represent an important population to target for smoking cessation programs and interventions. This paper highlights a number of initiatives undertaken to address this problem and suggests directions for the future.[Richmond RL, Butler TG, Indig D, Wilhelm KA, Archer VA, Wodak AD. The challenges of reducing tobacco use among prisoners. Drug Alcohol Rev 2012;31:625-630] [ABSTRACT FROM AUTHOR]

Objectives: To ascertain the proportion of councils with smoke-free outdoor areas (SFOA) policies in New South Wales (NSW), Australia and to explore the enablers and barriers to local governments introducing such policies., Methods: A structured survey of council staff at NSW councils was conducted by telephone in 2011. Participants were asked about the existence of any SFOA policy, and enablers and barriers of the policy., Results: The study was completed by 148 of 152 NSW councils. Eighty five (57%) councils had an SFOA policy, with playgrounds most likely to be covered by the policy. The most frequently cited enabler for the introduction of SFOA policy was direct advocacy letters, while the most commonly mentioned barrier was a lack of resources., Conclusion and Implications: In the absence of state or federal legislation, local government or councils may respond to community expectations for smoke-free outdoor areas by introducing policy. Advocacy and support from non-government health organisations can increase the likelihood of this occurring and address barriers facing councils, with rural councils most likely to benefit from such support. Interest from councils can influence the adoption of state-wide smoke-free outdoor areas legislation., (© 2014 Public Health Association of Australia.)

Background: Cardiovascular risk factors (CVRF) were collected as part of a randomised controlled trial of a multi-component intervention to reduce smoking among male prisoners. Cross-sectional baseline data on CVRF were compared among smoking male prisoners and males of similar age in the general population., Methods: 425 smoking prisoners were recruited (n = 407 in New South Wales; 18 in Queensland), including 15% of Aboriginal descent (mean age 33 years; median sentence length 3.6 years). We measured CVRF such as smoking, physical activity, blood pressure, risky alcohol use, symptoms of depression, and low socioeconomic status., Results: We found that 39% of prisoners had 3+ CVRF, compared to 10% in a general community sample of most disadvantaged men of a similar age. Significantly more Aboriginal prisoners had 3+ CVRF than non-Aboriginal prisoners (55% vs 36%, p < 0.01) and were twice as likely to have 4+ CVRF (27% vs 12%). In addition to all prisoners in this study being a current smoker (with 70% smoking 20+ cigarettes per day), the prevalence of other CVRF was very high: insufficient physical activity (23%); hypertension (4%), risky drinking (52%), symptoms of depression (14%) and low socioeconomic status (SES) (44%). Aboriginal prisoners had higher levels of risky alcohol use, symptoms of depression, and were more likely to be of low SES., Conclusion: Prisoners are at high risk for developing cardiovascular disease compared to even the most disadvantaged in their community and should be the focus of specific public health interventions., Trial Registration: This trial is registered with the Australian New Zealand Clinical Trials Registry ACTRN#12606000229572.

Background: This article examines the prevalence of smoking among general practice patients and assesses their stage of readiness to quit., Method: Descriptive study involving eight general practice registrars working in teaching practices in metropolitan Sydney (New South Wales) who surveyed 1069 consecutive patients over 16 years of age to determine their smoking status; and for smokers, their stage of readiness to stop smoking., Results: Of these patients 375 (35%) were current smokers, with smoking more common among men (40%) than women (33%). Proportions of smokers in each stage of change were: 137 in precontemplation (36.5%), 158 in contemplation (42%) and 79 in preparation (21%). The majority of patients in preparation (67%) and contemplation (53%) were assessed as willing to further discuss their smoking, whereas only 16% of those in the contemplation stage were willing., Discussion: Smoking rates among general practice patients were higher than in community samples. Most of the smokers were either contemplating or preparing to quit, and the majority of smokers in these groups were willing to receive advice about smoking cessation.

Objective: To follow-up abstainers from the end of their initial treatment over seven points to 10 years., Methods: In the original study there were 305 smokers who were recruited in a double-blind randomised controlled trial. Those subjects who had remained continuously abstinent to seven years (n=20) were followed up to ascertain continuous smoking prevalence to 10 years. Main outcome measure was continuous abstinence., Results: At 10 years, the active nicotine patch group showed significantly higher continuous abstinence rates that were double those of the placebo group (7.9% vs. 2.6%, respectively). The high rate of relapse declined after six months., Conclusions: The nicotine patch leads to superior continuous abstinence over 10 years when compared with placebo. PUBLIC HEALTH IMPLICATIONS: This is the longest follow-up study of continuous smoking abstinence after cognitive behaviour treatment combined with the nicotine patch.

Despite high rates of smoking among people with psychotic disorders, and the associated health and financial burden, few studies have investigated the characteristics of this group of smokers. This paper reports data from 298 smokers with an ICD-10 psychotic disorder residing in the community (56.7% with schizophrenia or schizoaffective disorder), including an examination of their demographic and clinical characteristics, smoking behaviours, severity of nicotine dependence, stage of change, and reasons for smoking and for quitting. Standardized self-report instruments were used, in conjunction with structured interviews, as part of the first phase of a randomized controlled trial. On average, participants smoked 30 cigarettes per day, commenced smoking daily at about 18 years of age (5 years before illness onset), and had made 2-3 quit attempts in their lifetime. Higher levels of nicotine dependence and concurrent hazardous use of alcohol or cannabis were associated with a younger age at smoking initiation. The present sample was also more likely to report stress reduction, stimulation and addiction as reasons for smoking, compared to a general sample of smokers. Males, precontemplators and participants with concurrent hazardous substance use cited fewer reasons for quitting smoking. These and other subgroup differences in smoking characteristics are used to illustrate potential implications for the nature and timing of smoking interventions among people with a psychotic disorder.

Objective: To conduct a pilot study to determine the feasibility and effectiveness of a multi-component smoking cessation intervention among prison inmates., Methods: A prospective study conducted within a maximum-security prison located near Sydney, New South Wales, and housing around 330 men. Participants received a smoking cessation intervention with six-month follow-up to determine abstinence. The smoking cessation intervention consisted of two brief cognitive behavioural therapy sessions, nicotine replacement therapy, bupropion and self-help resources. Point prevalence and continuous abstinence at follow-up were verified with expired carbon monoxide measures., Results: Thirty male inmates participated in the intervention. At six months, the biochemically validated point prevalence and continuous abstinence rates were 26% and 22% respectively. Reasons for relapse to smoking included: transfers to other prisons without notice, boredom, prolonged periods locked in cells, and stress associated with family or legal concerns. Those inmates who relapsed, or continued to smoke following the intervention, smoked less tobacco than at baseline and 95% stated they were willing to try to quit again using our intervention., Conclusions: Prison inmates are able to quit or reduce tobacco consumption while in prison but any smoking cessation intervention in this setting needs to address prison-specific issues such as boredom, stress, transfers to other prisons, court appearances, and isolation from family and friends., Implications: The prevalence of smoking within Australian prisons is alarmingly high. Further work into how to encourage prisoners to quit smoking is required.

Despite evidence of high rates of smoking among prisoners, there has been limited research that describes smoking patterns and risk factors associated with smoking in this group. This study describes inmate smokers and identifies factors associated with smoking in prison, using a survey comprising a cross-sectional random sample of inmates stratified by sex, age and Aboriginality. A total of 914 adult inmates (747 men, 167 women) were recruited from 29 New South Wales (Australia) correctional centres. Information on the prevalence of smoking, smoking history, smoking behaviours and other risk factors were collected. Of the participants, 79% were current smokers (78% men, 83% women). Younger inmates were more likely than older inmates to smoke (86% vs. 64%). Most individuals smoked between 11 and 20 cigarettes a day and a median of 50 grams per week. In the previous year, over half (52%) of current smokers had attempted to quit or reduce the amount they smoked. At the time of the survey, 58% of smokers had plans to quit; 21% within 3 months. Independent predictors of current smoking in the multivariate analysis were past use of cannabis and a history of illicit drug use. The prevalence of smoking in prison is extraordinarily high and exceeds that of the general community. Despite this, the majority of prisoners report plans to quit. Readily available smoking cessation advice, support and treatment are needed to assist those wanting to quit in this stressful environment. As the prevalence of smoking within the general community declines, assisting cessation in groups containing a disproportionate number of smokers will become increasingly important. Despite high levels of tobacco dependence, many prisoners intend to quit and health planners and custodial authorities need to encourage and support inmates who do attempt to quit.

In Australia, the prevalence of smoking is higher among certain sub-populations compared to the general population. These sub-populations include Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, as well as people with mental and substance use disorders and prisoners. The aims of this paper are to: describe the high prevalence of smoking among these particular sub-populations and harms associated with smoking; explore possible reasons for such high prevalence of smoking; review the evidence regarding the efficacy of existing smoking cessation interventions; and make recommendations for smoking interventions and further research among these groups. In addition to low socio-economic status, limited education and other factors, there are social, systems and psychobiological features associated with the high prevalence of smoking in these sub-groups. General population-based approaches to reducing smoking prevalence have been pursued for decades with great success and should be continued with further developments that aim specifically to affect Aboriginal and Torres Strait Islander people and some cultural groups. However, increasing attention, more specific targeting and flexible goals and interventions are also required for these and other distinct sub-populations with high smoking prevalence. Recommendations include: more funding and increased resources to examine the most appropriate education and treatment strategies to promote smoking cessation among people from Aboriginal and Torres Strait Islander and some culturally and linguistically diverse backgrounds; larger and better-designed studies evaluating smoking cessation/reduction interventions among distinct sub-groups; and system-wide interventions requiring strong leadership among clients and staff within mental health, drug and alcohol and prison settings.

Despite high rates of comorbid substance use disorders and smoking among people with psychotic disorders, previous studies have not examined differences in socio-demographic, clinical or disability characteristics between psychosis sub-groups with different patterns of substance use. This study compared the characteristics of five groups of people with psychosis and varying patterns of substance use (n=1152), including groups entering treatment studies for substance use or smoking, epidemiological samples of substance users and smokers, and people without such problems. Data were drawn from several recent Australian studies using comparable structured interviews and scales. There were moderate group differences in illness and symptom profiles, with substance users tending to have higher depression and reality distortion scores. Unexpectedly, personal disability was considerably lower among those seeking treatment for their substance use compared with the epidemiological groups, raising concerns about the appropriateness of traditional recruitment approaches in treatment studies and highlighting the need for more assertive treatment engagement and referral strategies in routine clinical settings. As a consequence of uncertainty about links between substance use and everyday functioning, it is suggested that health messages to young people may need to strike a better balance between the potential harms and benefits associated with substance use in pursuing broader harm minimization goals.