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The effects of a prison smoking ban on smoking behavior and withdrawal symptoms
Addictive Behaviors 30 (2005) 589 – 594
Short communication
The effects of a prison smoking ban on smoking behavior and withdrawal symptoms Karen L. Cropseya,*, Jean L. Kristellerb a
Department of Psychiatry, Virginia Commonwealth University, P.O. Box 980109, Richmond, VA 23298, United States b Indiana State University, United States
Abstract This study investigated symptoms of distress and nicotine dependence as predictors of nicotine withdrawal symptoms among 188 incarcerated male smokers during a mandated smoking ban. Participants completed a smoking history questionnaire and measures of nicotine dependence, withdrawal, cravings, and distress before the ban and two follow-up times. The majority of smokers (76%) continued to smoke following the smoking ban. Smokers after the ban were more nicotine dependent than were the participants who reported quitting. Smokers also reported more withdrawal symptoms than did participants who quit, even when accounting for nicotine dependence and baseline withdrawal scores. An interaction was found such that distressed smokers had the highest level of nicotine withdrawal. These results have implications for how smoking bans are instituted in prison settings. D 2004 Elsevier Ltd. All rights reserved. Keywords: Smoking bans; Nicotine withdrawal; Prison
1. Introduction Nicotine withdrawal has received increased attention over the last several years, as smoking has come to be recognized as an addictive disorder (Hughes & Hatsukami, 1986). While several studies have established the effects of nicotine withdrawal in controlled
* Corresponding author. Tel.: +1 804 8271706; fax: +1 804 8289906. E-mail address: [email protected] (K.L. Cropsey). 0306-4603/$ - see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.07.003
590
K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
laboratory conditions (Hatsukami, Hughes, Pickens, & Svikis, 1984; Niaura, Shadel, Goldstein, Hutchinson, & Abrams, 2001), little research has investigated the symptoms of nicotine withdrawal in a naturalistic setting. The implementation of a smoking ban in a prison setting was a unique opportunity to investigate these physiological and psychological variables in a controlled environment. No previous study in the literature has systematically studied nicotine withdrawal, dependence, and depression with an incarcerated population. Furthermore, this study provided an opportunity to investigate these effects with participants who were not seeking to quit smoking but who were being forced to quit due to a statewide smoking ban.
2. Method 2.1. Design and overview of general study A description of the smoking ban has been reported previously (Cropsey & Kristeller, 2003). Participants were assessed at three time periods: baseline (1 week prior to the smoking ban), Time 2 (4 days after the smoking ban), and Time 3 (1 month after the smoking ban). Smoking history information was collected at baseline along with the Fagerstrfm Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstro¨m, 1991), the Hughes–Hatsukami Withdrawal Scale (HHWS; Hughes & Hatsukami, 1986), and the Center for Epidemiological Studies on Depression (CES-D) scale (Radloff, 1977). At both follow-up points, the CES-D, HHWS and the Questionnaire of Smoking Urges-Brief Form (Tiffany & Drobes, 1991) were administered. Three hundred and fourteen inmates identified themselves as current smokers. Smokers who completed the first questionnaire then completed the remaining two questionnaires at the two follow-up time periods. Due to a change in the security level at the prison described previously (Cropsey & Kristeller, 2003), many of the inmates who participated at baseline were not available for follow-up. However, no significant baseline differences were found on the outcome measures when comparing participants who were transferred to participants who completed the study. A total of 188 participants completed all three assessment times and were retained for the following analyses.
3. Results 3.1. Demographic and baseline predictors of smoking status One month after the smoking ban, 24% of the smokers reported quitting smoking (n=45). The majority of the participants reported smoking at some level during the month of the smoking ban (n=143). These groups were reclassified as bquittersQ and bsmokersQ, respectively. Table 1 shows the demographic characteristics for smokers and quitters identified at 1 month. Caucasians and persons serving longer prison sentences were most
K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
591
Table 1 Demographics of participants who continued to smoke versus quit at 1 month Characteristics
Smokers n
Ethnicity*** Caucasian 124 African-American 20 Hispanic-American 3 Marital status Single 71 Married 29 Divorced 38 Separated 5 Widowed 3 Age Mean=34.1 Length of sentence (years)* Mean=23.7 Completion rate All three times 126 Less than three 21 Cigarettes per day** b11 24 11–20 54 21–30 42 N30 23 Age of first smoke** b10 20 10–15 73 16–20 39 N20 10 Other tobacco products (with cigarettes) Snuff 8 Cigars 26 Chew 23 Cigarettes only 86
Quitters (%)
n
(%)
(84.4) (13.6) (2.0)
25 15 1
(61.0) (36.6) (2.4)
(48.6) (19.9) (26.0) (3.4) (2.1) S.D.=9.5 S.D.=22.9
27 6 8 – – Mean=31.54 Mean=14.7
(65.9) (14.6) (19.5) – – S.D.=9.5 S.D.=16.2
(85.7) (14.3)
35 6
(85.4) (14.6)
(16.8) (37.8) (29.4) (16.0)
18 14 1 6
(46.2) (35.9) (2.6) (15.3)
(14.1) (51.4) (27.5) (7.0)
5 12 16 6
(12.8) (30.8) (41.0) (15.4)
(5.6) (18.2) (16.1) (60.1)
– 5 6 24
– (14.3) (17.1) (68.6)
* pb.05. ** pb.01. *** pb.001.
likely to report continuing to smoke following the ban. Furthermore, participants who reported initiating smoking at younger ages and who were smoking more cigarettes per day (cpd) at baseline were more likely to continue smoking. 3.2. Smoking variables and smoking status at 1 month 3.2.1. Nicotine dependence Significant differences were found between the two groups on baseline levels of nicotine dependence using one-way ANOVA [ F(1,180)=15.54, pb.001]. Participants who continued
592
K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
to smoke had higher scores on the FTND (M=6.0; S.D.=2.3) compared with participants who quit (M=4.3; S.D.=2.7) at 1 month. 3.2.2. Nicotine withdrawal A repeated-measures analysis of covariance (ANCOVA) was performed to determine if nicotine withdrawal changed over time between quitters and smokers during the course of the smoking ban. Baseline nicotine withdrawal and FTND were entered as covariates. A significant covariate effect was found for baseline withdrawal symptoms [ F(1,139)=56.55, pb.001] and baseline nicotine dependence, [ F(1,139)=13.33, pb.001]. Even when accounting for the effects of baseline withdrawal and nicotine dependence, smoking status was a significant predictor of withdrawal at follow-up [ F(1,139)=7.61, pb.01], with participants who continued to smoke reporting higher levels of withdrawal compared with participants who reported quitting 1 month after the smoking ban. No significant effect was found for withdrawal across time [ F(1,139)=0.40, p=.53]. 3.2.3. Withdrawal, smoking status, and distress A repeated-measures 22 ANCOVA was performed to examine the relationship between symptoms of distress, smoking status, and withdrawal symptoms across time. Distress was determined by using the clinical cutoff of 16 on the CES-D measured at baseline, and participants were categorized as bdistressedQ (n=83) or bnot distressedQ (n=54). Baseline withdrawal symptoms and nicotine dependence were added as covariates. A significant covariate effect was found for baseline withdrawal [ F(1,130)=27.47, pb.001] and nicotine dependence [ F(1,130)=14.20, pb.001]. Even when accounting for the baseline withdrawal and dependence, a significant interaction was found between smoking status groups and distress for withdrawal [ F(1,130)=4.76, pb.05]. Participants who reported less distress and who successfully quit after the smoking ban showed the lowest level of withdrawal symptoms. Participants who reported the highest levels of distress at baseline and who continued to smoke following the ban reported the highest level of withdrawal. Participants who were high in distress at baseline but who reported quitting smoking after the ban also reported higher levels of withdrawal at follow-up.
4. Discussion Results from this study indicated that 76% of participants continued to smoke following the implementation of the smoking ban. This low compliance with the smoking ban was surprising and unanticipated. In addition, the fact that more than three-quarters of the smokers admitted to engaging in a behavior that was declared prohibited is also surprising. The low rate of compliance and high disclosure was likely due to the way the smoking ban was enforced. Given that the smoking ban affected employees at the prison who were also prohibited from smoking, employees who were not in favor of the ban, or who were directly affected by the ban (i.e., employees who smoke) may not have been motivated to enforce the
K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
593
smoking ban. While we did not survey employees, Carpenter, Hughes, Solomon, and Powell (2001) found that only 15% of employees who smoked favored a complete ban for inmate smoking at their institution. Even among nonsmoking and ex-smoking employees, a large percentage did not favor a complete ban on smoking for inmates (56% and 49%, respectively; Carpenter et al., 2001). Thus, it appears that the smoking ban was not well enforced and may reflect the overall low support for such a policy. Findings from this study support previous literature demonstrating the link between depression, nicotine addiction, and nicotine withdrawal (Hall, Munoz, Reus, & Sees, 1993; Lerman et al., 1996; etc.). This study was also important for its contribution in studying smoking behavior following a smoking ban. This is a particularly relevant issue because many work sites, hospitals, and state/federal prison facilities are interested in implementing smoking bans to decrease the medical costs of their employees and patients. Currently, 90% of prisons have instituted some limitations on smoking behavior (Vaughn & del Carmen, 1993), and 10 states have banned smoking entirely in their facilities (Smuck, 2002). Thus, it is important to understand the ramifications and withdrawal effects that inmates would suffer in response to smoking bans to better implement and increase compliance with these policies.
Acknowledgement Preparation of this manuscript was supported by NIH K23DA15774.
References Carpenter, M. J., Hughes, J. R., Solomon, L. J., & Powell, T. A. (2001). Smoking in correctional facilities: A survey of employees. Tobacco Control, 10, 38 – 42. Cropsey, K. L., & Kristeller, J. L. (2003). Motivational factors related to quitting smoking among prisoners during a smoking ban. Addictive Behaviors, 28, 1081 – 1093. Hall, S. M., Munoz, R. F., Reus, V. I., & Sees, K. L. (1993). Nicotine, negative affect, and depression. Journal of Consulting and Clinical Psychology, 61(5), 761 – 767. Hatsukami, D. K., Hughes, J. R., Pickens, R. W., & Svikis, D. (1984). Tobacco withdrawal symptoms: An experimental analysis. Psychopharmacology, 84, 231 – 236. Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., & Fagerstrfm, K. O. (1991). The Fagerstrfm Test for Nicotine Dependence: A revision of the Fagerstrfm Tolerance Questionnaire. British Journal of Addiction, 86, 1119 – 1127. Hughes, J. R., & Hatsukami, D. K. (1986). Signs and symptoms of tobacco withdrawal. Archives of General Psychiatry, 43, 289 – 294. Lerman, C., Audrain, J., Orleans, C. T., Boyd, R., Gold, K., Main, D., et al. (1996). Investigation of mechanisms linking depressed mood to nicotine dependence. Addictive Behaviors, 21(1), 9 – 19. Niaura, R., Shadel, W. G., Goldstein, M. G., Hutchinson, K. E., & Abrams, D. B. (2001). Individual differences in response to the first cigarettes following overnight abstinence in regular smokers. Nicotine and Tobacco Research, 3, 37 – 44. Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385 – 401.
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K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
Smuck, B. (2002, February 5). Smoking ban goes into effect for state prisons. Daily Nebraskan. Retrieved March 6, 2002, from http://www.tobaccowars.com/tw3_3news.asp?article=2704. Tiffany, S. T., & Drobes, D. J. (1991). The development and initial validation of a questionnaire on smoking urges. British Journal of Addictions, 86, 1467 – 1476. Vaughn, M. S., & del Carmen, R. V. (1993). Research note: Smoking in prisons—A national survey of correctional administrators in the United States. Crime and Delinquency, 39(2), 225 – 239.
Short communication
The effects of a prison smoking ban on smoking behavior and withdrawal symptoms Karen L. Cropseya,*, Jean L. Kristellerb a
Department of Psychiatry, Virginia Commonwealth University, P.O. Box 980109, Richmond, VA 23298, United States b Indiana State University, United States
Abstract This study investigated symptoms of distress and nicotine dependence as predictors of nicotine withdrawal symptoms among 188 incarcerated male smokers during a mandated smoking ban. Participants completed a smoking history questionnaire and measures of nicotine dependence, withdrawal, cravings, and distress before the ban and two follow-up times. The majority of smokers (76%) continued to smoke following the smoking ban. Smokers after the ban were more nicotine dependent than were the participants who reported quitting. Smokers also reported more withdrawal symptoms than did participants who quit, even when accounting for nicotine dependence and baseline withdrawal scores. An interaction was found such that distressed smokers had the highest level of nicotine withdrawal. These results have implications for how smoking bans are instituted in prison settings. D 2004 Elsevier Ltd. All rights reserved. Keywords: Smoking bans; Nicotine withdrawal; Prison
1. Introduction Nicotine withdrawal has received increased attention over the last several years, as smoking has come to be recognized as an addictive disorder (Hughes & Hatsukami, 1986). While several studies have established the effects of nicotine withdrawal in controlled
* Corresponding author. Tel.: +1 804 8271706; fax: +1 804 8289906. E-mail address: [email protected] (K.L. Cropsey). 0306-4603/$ - see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.07.003
590
K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
laboratory conditions (Hatsukami, Hughes, Pickens, & Svikis, 1984; Niaura, Shadel, Goldstein, Hutchinson, & Abrams, 2001), little research has investigated the symptoms of nicotine withdrawal in a naturalistic setting. The implementation of a smoking ban in a prison setting was a unique opportunity to investigate these physiological and psychological variables in a controlled environment. No previous study in the literature has systematically studied nicotine withdrawal, dependence, and depression with an incarcerated population. Furthermore, this study provided an opportunity to investigate these effects with participants who were not seeking to quit smoking but who were being forced to quit due to a statewide smoking ban.
2. Method 2.1. Design and overview of general study A description of the smoking ban has been reported previously (Cropsey & Kristeller, 2003). Participants were assessed at three time periods: baseline (1 week prior to the smoking ban), Time 2 (4 days after the smoking ban), and Time 3 (1 month after the smoking ban). Smoking history information was collected at baseline along with the Fagerstrfm Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstro¨m, 1991), the Hughes–Hatsukami Withdrawal Scale (HHWS; Hughes & Hatsukami, 1986), and the Center for Epidemiological Studies on Depression (CES-D) scale (Radloff, 1977). At both follow-up points, the CES-D, HHWS and the Questionnaire of Smoking Urges-Brief Form (Tiffany & Drobes, 1991) were administered. Three hundred and fourteen inmates identified themselves as current smokers. Smokers who completed the first questionnaire then completed the remaining two questionnaires at the two follow-up time periods. Due to a change in the security level at the prison described previously (Cropsey & Kristeller, 2003), many of the inmates who participated at baseline were not available for follow-up. However, no significant baseline differences were found on the outcome measures when comparing participants who were transferred to participants who completed the study. A total of 188 participants completed all three assessment times and were retained for the following analyses.
3. Results 3.1. Demographic and baseline predictors of smoking status One month after the smoking ban, 24% of the smokers reported quitting smoking (n=45). The majority of the participants reported smoking at some level during the month of the smoking ban (n=143). These groups were reclassified as bquittersQ and bsmokersQ, respectively. Table 1 shows the demographic characteristics for smokers and quitters identified at 1 month. Caucasians and persons serving longer prison sentences were most
K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
591
Table 1 Demographics of participants who continued to smoke versus quit at 1 month Characteristics
Smokers n
Ethnicity*** Caucasian 124 African-American 20 Hispanic-American 3 Marital status Single 71 Married 29 Divorced 38 Separated 5 Widowed 3 Age Mean=34.1 Length of sentence (years)* Mean=23.7 Completion rate All three times 126 Less than three 21 Cigarettes per day** b11 24 11–20 54 21–30 42 N30 23 Age of first smoke** b10 20 10–15 73 16–20 39 N20 10 Other tobacco products (with cigarettes) Snuff 8 Cigars 26 Chew 23 Cigarettes only 86
Quitters (%)
n
(%)
(84.4) (13.6) (2.0)
25 15 1
(61.0) (36.6) (2.4)
(48.6) (19.9) (26.0) (3.4) (2.1) S.D.=9.5 S.D.=22.9
27 6 8 – – Mean=31.54 Mean=14.7
(65.9) (14.6) (19.5) – – S.D.=9.5 S.D.=16.2
(85.7) (14.3)
35 6
(85.4) (14.6)
(16.8) (37.8) (29.4) (16.0)
18 14 1 6
(46.2) (35.9) (2.6) (15.3)
(14.1) (51.4) (27.5) (7.0)
5 12 16 6
(12.8) (30.8) (41.0) (15.4)
(5.6) (18.2) (16.1) (60.1)
– 5 6 24
– (14.3) (17.1) (68.6)
* pb.05. ** pb.01. *** pb.001.
likely to report continuing to smoke following the ban. Furthermore, participants who reported initiating smoking at younger ages and who were smoking more cigarettes per day (cpd) at baseline were more likely to continue smoking. 3.2. Smoking variables and smoking status at 1 month 3.2.1. Nicotine dependence Significant differences were found between the two groups on baseline levels of nicotine dependence using one-way ANOVA [ F(1,180)=15.54, pb.001]. Participants who continued
592
K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
to smoke had higher scores on the FTND (M=6.0; S.D.=2.3) compared with participants who quit (M=4.3; S.D.=2.7) at 1 month. 3.2.2. Nicotine withdrawal A repeated-measures analysis of covariance (ANCOVA) was performed to determine if nicotine withdrawal changed over time between quitters and smokers during the course of the smoking ban. Baseline nicotine withdrawal and FTND were entered as covariates. A significant covariate effect was found for baseline withdrawal symptoms [ F(1,139)=56.55, pb.001] and baseline nicotine dependence, [ F(1,139)=13.33, pb.001]. Even when accounting for the effects of baseline withdrawal and nicotine dependence, smoking status was a significant predictor of withdrawal at follow-up [ F(1,139)=7.61, pb.01], with participants who continued to smoke reporting higher levels of withdrawal compared with participants who reported quitting 1 month after the smoking ban. No significant effect was found for withdrawal across time [ F(1,139)=0.40, p=.53]. 3.2.3. Withdrawal, smoking status, and distress A repeated-measures 22 ANCOVA was performed to examine the relationship between symptoms of distress, smoking status, and withdrawal symptoms across time. Distress was determined by using the clinical cutoff of 16 on the CES-D measured at baseline, and participants were categorized as bdistressedQ (n=83) or bnot distressedQ (n=54). Baseline withdrawal symptoms and nicotine dependence were added as covariates. A significant covariate effect was found for baseline withdrawal [ F(1,130)=27.47, pb.001] and nicotine dependence [ F(1,130)=14.20, pb.001]. Even when accounting for the baseline withdrawal and dependence, a significant interaction was found between smoking status groups and distress for withdrawal [ F(1,130)=4.76, pb.05]. Participants who reported less distress and who successfully quit after the smoking ban showed the lowest level of withdrawal symptoms. Participants who reported the highest levels of distress at baseline and who continued to smoke following the ban reported the highest level of withdrawal. Participants who were high in distress at baseline but who reported quitting smoking after the ban also reported higher levels of withdrawal at follow-up.
4. Discussion Results from this study indicated that 76% of participants continued to smoke following the implementation of the smoking ban. This low compliance with the smoking ban was surprising and unanticipated. In addition, the fact that more than three-quarters of the smokers admitted to engaging in a behavior that was declared prohibited is also surprising. The low rate of compliance and high disclosure was likely due to the way the smoking ban was enforced. Given that the smoking ban affected employees at the prison who were also prohibited from smoking, employees who were not in favor of the ban, or who were directly affected by the ban (i.e., employees who smoke) may not have been motivated to enforce the
K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
593
smoking ban. While we did not survey employees, Carpenter, Hughes, Solomon, and Powell (2001) found that only 15% of employees who smoked favored a complete ban for inmate smoking at their institution. Even among nonsmoking and ex-smoking employees, a large percentage did not favor a complete ban on smoking for inmates (56% and 49%, respectively; Carpenter et al., 2001). Thus, it appears that the smoking ban was not well enforced and may reflect the overall low support for such a policy. Findings from this study support previous literature demonstrating the link between depression, nicotine addiction, and nicotine withdrawal (Hall, Munoz, Reus, & Sees, 1993; Lerman et al., 1996; etc.). This study was also important for its contribution in studying smoking behavior following a smoking ban. This is a particularly relevant issue because many work sites, hospitals, and state/federal prison facilities are interested in implementing smoking bans to decrease the medical costs of their employees and patients. Currently, 90% of prisons have instituted some limitations on smoking behavior (Vaughn & del Carmen, 1993), and 10 states have banned smoking entirely in their facilities (Smuck, 2002). Thus, it is important to understand the ramifications and withdrawal effects that inmates would suffer in response to smoking bans to better implement and increase compliance with these policies.
Acknowledgement Preparation of this manuscript was supported by NIH K23DA15774.
References Carpenter, M. J., Hughes, J. R., Solomon, L. J., & Powell, T. A. (2001). Smoking in correctional facilities: A survey of employees. Tobacco Control, 10, 38 – 42. Cropsey, K. L., & Kristeller, J. L. (2003). Motivational factors related to quitting smoking among prisoners during a smoking ban. Addictive Behaviors, 28, 1081 – 1093. Hall, S. M., Munoz, R. F., Reus, V. I., & Sees, K. L. (1993). Nicotine, negative affect, and depression. Journal of Consulting and Clinical Psychology, 61(5), 761 – 767. Hatsukami, D. K., Hughes, J. R., Pickens, R. W., & Svikis, D. (1984). Tobacco withdrawal symptoms: An experimental analysis. Psychopharmacology, 84, 231 – 236. Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., & Fagerstrfm, K. O. (1991). The Fagerstrfm Test for Nicotine Dependence: A revision of the Fagerstrfm Tolerance Questionnaire. British Journal of Addiction, 86, 1119 – 1127. Hughes, J. R., & Hatsukami, D. K. (1986). Signs and symptoms of tobacco withdrawal. Archives of General Psychiatry, 43, 289 – 294. Lerman, C., Audrain, J., Orleans, C. T., Boyd, R., Gold, K., Main, D., et al. (1996). Investigation of mechanisms linking depressed mood to nicotine dependence. Addictive Behaviors, 21(1), 9 – 19. Niaura, R., Shadel, W. G., Goldstein, M. G., Hutchinson, K. E., & Abrams, D. B. (2001). Individual differences in response to the first cigarettes following overnight abstinence in regular smokers. Nicotine and Tobacco Research, 3, 37 – 44. Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385 – 401.
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K.L. Cropsey, J.L. Kristeller / Addictive Behaviors 30 (2005) 589–594
Smuck, B. (2002, February 5). Smoking ban goes into effect for state prisons. Daily Nebraskan. Retrieved March 6, 2002, from http://www.tobaccowars.com/tw3_3news.asp?article=2704. Tiffany, S. T., & Drobes, D. J. (1991). The development and initial validation of a questionnaire on smoking urges. British Journal of Addictions, 86, 1467 – 1476. Vaughn, M. S., & del Carmen, R. V. (1993). Research note: Smoking in prisons—A national survey of correctional administrators in the United States. Crime and Delinquency, 39(2), 225 – 239.