BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

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Research

RESEARCH
Prison tobacco control policies and deaths from
smoking in United States prisons: population based
retrospective analysis
OPEN ACCESS
1

2

Ingrid A Binswanger associate professor , E Ann Carson statistician , Patrick M Krueger assistant
3
1
4
professor , Shane R Mueller professional research assistant , John F Steiner senior director ,
2
William J Sabol acting director
Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Mail Stop B180, 12631 E 17th Avenue,
Aurora, CO 80045, USA; 2Bureau of Justice Statistics, Department of Justice, 810 Seventh Street, NW, Washington, DC 20531, USA; 3Department
of Health and Behavioral Sciences, University of Colorado Denver, Campus Box 188, PO Box 173364, Denver, CO 80217, USA; 4Institute for Health
Research, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237, USA
1

Abstract
Objective To determine the mortality attributable to smoking and years
of potential life lost from smoking among people in prison and whether
bans on smoking in prison are associated with reductions in smoking
related deaths.
Design Analysis of cross sectional survey data with the smoking
attributable mortality, morbidity, and economic costs system; population
based time series analysis.
Setting All state prisons in the United States.
Main outcome measures Prevalence of smoking from cross sectional
survey of inmates in state correctional facilities. Data on state prison
tobacco policies from web based searches of state policies and
legislation. Deaths and causes of death in US state prisons from the
deaths in custody reporting program of the Bureau of Justice Statistics
for 2001-11. Smoking attributable mortality and years of potential life
lost was assessed from the smoking attributable mortality, morbidity,
and economic costs system of the Centers for Disease Control and
Prevention. Multivariate Poisson models quantified the association
between bans and smoking related cancer, cardiovascular and pulmonary
deaths.
Results The most common causes of deaths related to smoking among
people in prison were lung cancer, ischemic heart disease, other heart
disease, cerebrovascular disease, and chronic airways obstruction. The
age adjusted smoking attributable mortality and years of potential life
lost rates were 360 and 5149 per 100 000, respectively; these figures
are higher than rates in the general US population (248 and 3501,

respectively). The number of states with any smoking ban increased
from 25 in 2001 to 48 by 2011. In prisons the mortality rate from smoking
related causes was lower during years with a ban than during years
without a ban (110.4/100 000 v 128.9/100 000). Prisons that implemented
smoking bans had a 9% reduction (adjusted incidence rate ratio 0.91,
95% confidence interval 0.88 to 0.95) in smoking related deaths. Bans
in place for longer than nine years were associated with reductions in
cancer mortality (adjusted incidence rate ratio 0.81, 95% confidence
interval 0.74 to 0.90).
Conclusions Smoking contributes to substantial mortality in prison, and
prison tobacco control policies are associated with reduced mortality.
These findings suggest that smoking bans have health benefits for people
in prison, despite the limits they impose on individual autonomy and the
risks of relapse after release.

Introduction
Smoking tobacco significantly contributes to premature death
and accounts for about six million deaths worldwide each year,1
including deaths from lung cancer, ischemic heart disease,
chronic obstructive pulmonary disease, and cerebrovascular
disease. In the United States at year end 2011, there were 1.4
million people in state prisons.2 The prison population includes
many smokers,3-6 with estimates of prevalence of smoking
ranging from 50% to 83%,7-9 substantially higher than the general
population outside prison.9 Among people formerly in prison,
smoking is an important contributor to mortality.10 11 Little is
known, however, about the cumulative effects of smoking,

Correspondence to: I A Binswanger ingrid.binswanger@ucdenver.edu
Extra material supplied by the author (see http://www.bmj.com/content/349/bmj.g4542?tab=related#datasupp)
Appendix 1: Supplementary tables.
Appendix 2: Crude smoking related and other cause mortality rates (deaths per 100 000) in prisons in states with and without smoking bans, by
year
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BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

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including past and current exposure, among individuals in
prisons. We therefore first determined the smoking attributable
mortality and years of potential life lost from smoking in US
prisons.

A recent report by the US surgeon general suggested the need
for more focus on smoking in low socioeconomic and other
disparity groups.12 People in prisons are disadvantaged on a
number of social and economic indicators that put them at risk
for poor health outcomes13 14 and are thus an important target
population to reduce the harms of smoking. Prisons have several
features that make them unique with regard to both the health
effects of tobacco use and potential strategies to mitigate the
risks. First, smoke exposure for people who smoke, as well as
people who do not smoke, is likely to be more intense in prisons
than in non-institutional settings. People in prisons live and
work in confined indoor spaces that can be crowded and poorly
ventilated. They also have limited movement options and
restricted opportunities for outside air to avoid smoke exposure
even if they do not smoke.

In 1993, a US Supreme Court ruling suggested that the exposure
of prisoners to environmental smoke can be considered “cruel
and unusual punishment” in violation of the Eighth
Amendment.15 Since then, states have increasingly enacted
various prison tobacco control policies. These include
prohibiting smoking cigarettes (smoking bans) and/or all tobacco
products, including smokeless tobacco (tobacco bans). These
bans can be applied to indoor or outdoor environments, or
both.16-18 England and Wales are also implementing or
considering complete bans on smoking in prison.19 Unlike
smoking restrictions in workplaces and restaurants outside
institutions, complete smoking bans in prison restrict autonomy
by preventing people from smoking anywhere, including living
areas. Thus, we also determined whether state prison bans were
associated with reductions in the rates of smoking related deaths,
including from cancer, cardiovascular disease, and pulmonary
disease. Given that smoking causes both immediate and longer
term health effects, we also sought to understand whether the
length of time a ban was in place was associated with greater
reductions in mortality.

Methods

Study design
We first analyzed cross sectional survey data using the smoking
attributable mortality, morbidity, and economic costs system
and then conducted a population based time series analysis.

Setting
We included data from all US state prisons from 2001 to 2011.
At year end 2006, midway through our observation period, the
median length of time already served in prison was 21 months
(interquartile range 7-64 months) and the median length of
sentence was 84 months (42-180 months). Forty seven percent
of sentences were 10 years or more.20 Nearly half of people
released from prisons were in prison again by three years.21

Data sources
We used several sources of data for our analyses (table 1).⇓

First, we obtained data on self reported smoking from the most
recent cross sectional nationally representative survey of
individuals in state prisons, the Bureau of Justice Statistics
survey of inmates in state correctional facilities, 2004. Of 297
prisons selected by the Bureau of Justice Statistics for its survey,
two refused and 12 were out of scope. Four reserve female
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prisons were added for a total of 287 participating state prisons,
and 14 499 individuals participated.22 Survey participants had
been told verbally and in writing that participation was
voluntary, answers were confidential, the purpose of the survey
was statistical, and individuals would not be identified.22 The
individual level data from this existing survey allowed us to
calculate the prevalence of current, former, and never smoking
in 2004. Using standard classifications,23 24 we coded never
smokers as individuals who had never smoked at least 100
cigarettes in their lives. Current smokers had smoked at least
100 cigarettes in their lifetimes and smoked every day or some
days at the time of the interview. Former smokers had ever
smoked at least 100 cigarettes but did not smoke when
interviewed. We also used age and sex from the survey of
inmates in state correctional facilities to provide age (35-64 and
≥65) and sex specific prevalence rates of the smoking statuses
for our analyses on smoking attributable mortality and years of
potential life lost. For descriptive purposes, we also examined
responses to questions about use of smokeless tobacco (chewing
tobacco and snuff).

Second, data on deaths (outcome of interest) from 2001 to 2011
and all 50 states was drawn from the Bureau of Justice Statistics
deaths in custody reporting program, stratified by sex and age
(35-39, 40-44, 45-49, 50-54, 60-64, 70-74, 75-79, 80-84, and
≥85). These population based data did not include deaths in
local (county) jails (collected in a separate Bureau of Justice
Statistics program), federal prisons, or the District of Columbia.
The Bureau of Justice Statistics has collected mortality data on
people in state prisons for statistical analysis since 2001. State
prisons report deaths among people in their custody, including
deaths in private prisons, hospitals, or during transit. Cause of
death is converted to ICD-10 (international classification of
diseases, 10th revision) codes by a professional nosologist. In
66.2% of deaths from 2001 to 2011, an autopsy was performed.
We examined deaths in 19 adult disease categories classified
as related to smoking by the Centers for Disease Control and
Prevention.25 We refer to all deaths within these disease
categories as “smoking related” deaths. In sensitivity analyses,
we also examined all other causes of death, referred to as “other
causes.”
Third, we obtained data from the Bureau of Justice Statistics
national prisoner statistics program for year end state prison
population estimates by sex and age group (denominator data).

Fourth, we collected data on tobacco control policies in the 50
states in each year from 2001 to 2011 (primary exposure of
interest). We searched public websites about smoking policies
and dates enacted, including Departments of Corrections
websites, the American Nonsmokers’ Rights Foundation,17
legislative websites, reports,26 and media reports. Inconsistencies
between sources were resolved by favoring adopted legislation
or official Department of Corrections’ policies. Each state was
categorized by type of ban and location (indoor/outdoor) in each
year by using existing classifications.17 For instance, Arizona
adopted an indoor smoke-free ban in 2007.27 Idaho had the most
restrictive type of ban, which banned smoking and tobacco use
indoor and outdoor from 1996.28 If no data were available for a
given ban category it was coded as missing.
Finally, to assess potential confounding, we collected data on
the prevalence of smoking in adults in the general population
outside prison of each state by year from the behavioral risk
factor surveillance system.29 We also obtained data from the
Centers for Disease Control and Prevention’s wide-ranging
online data for epidemiologic research database for state, year,
and sex specific estimates of deaths in the general population.
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BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

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RESEARCH

We extrapolated available data (2001-10) to 2011 using Poisson
regression.

Statistical analyses
Smoking attributable mortality and years of
potential life lost

We used the smoking attributable mortality, morbidity, and
economic costs system of the Centers for Disease Control and
Prevention to calculate smoking attributable mortality, years of
potential life lost, and the age adjusted smoking attributable
mortality and years of potential life lost rates per 100 000
population.25 We entered smoking prevalence based on the
individual level data from the survey of inmates in state
correctional facilities, mortality data from the deaths in custody
reporting program for individuals aged ≥35, and prison
populations from the national prisoner statistics program. The
Centers for Disease Control and Prevention’s smoking
attributable mortality, morbidity, and economic costs system
calculated smoking attributable mortality and years of potential
life lost by multiplying the number of deaths from each of the
19 causes by estimates of the smoking attributable fraction of
preventable deaths. The smoking attributable fraction estimates
the public health burden of each risk factor and the relative
importance of risk factors for multifactorial diseases. The
external validity of smoking attributable mortality estimates
with the smoking attributable mortality, morbidity, and
economic costs system has previously been established.30 31 For
years of potential life lost, we used 2004 US population
estimates of life expectancy. To compare to estimates of
smoking attributable mortality and years of potential life lost
for the US as whole (which includes deaths among people in
prisons), we used the 2004 resident population and the 2004
smoking rates provided in the smoking attributable mortality,
morbidity, and economic costs system, the most recent year for
which these data are available.

Sensitivity analysis for smoking attributable
mortality and years of potential life lost

Estimates from the smoking attributable mortality, morbidity,
and economic costs system excluded deaths from burns and
secondhand smoke, and this system does not provide confidence
intervals. Further, the small numbers of individuals aged ≥65
in the prison survey could result in imprecise estimates of
smoking status. Thus, we used two age strata (rather than four)
for our calculations and conducted sensitivity analyses that
assigned inmates aged ≥65 the same smoking prevalence as
inmates aged 35-64 (assumption 2). In addition, given the
presence of smoking bans in some prisons in 2004, survey
estimates of current smoking were lower in prison than before
arrest. We therefore also calculated smoking attributable
mortality and years of potential life lost using estimates of
current and former smoking before arrest for the age groups of
34-64 and ≥65 (assumption 3).

Association between smoking bans and smoking
related deaths

To assess the association between states implementing prison
bans and smoking related deaths in prisons, we first calculated
crude death rates for all smoking related causes of death by year
and state, and then for mortality from smoking related cancers,
cardiovascular diseases, and pulmonary diseases. States were
selected as the unit of analysis as smoking bans are implemented
at the state level. We estimated Poisson regression models
(n=1100) to predict the number of deaths in each state (i) and
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each year (j) between 2001 and 2011, with the number of
inmates in each state and year serving as the exposure, and
including separate dummy variables that indicated whether state
i in year j had a smoking ban of a given type in place. All models
included all ages and were adjusted for sex. We adjusted for
calendar year to account for secular trends in mortality. We also
adjusted for the prevalence of current smoking in the general
population in each state and year to account for the potential
confounding effect of state variation in smoking prevalence
(outside prison).

We estimated a model for all smoking related deaths combined
and then separate models for deaths from cancer, cardiovascular
disease, and pulmonary disease. We expected differences in the
association between bans and mortality based on the disease
process.32 To assess whether the length of time a ban was in
place was influential, subsequent models categorized time since
implementation of bans with cut points at the 25th centile (0
years), 50th centile (4 years), and 75th centile (9 years) and
adjusted for sex, calendar year, and state smoking rates. For
instance, we expected a minimal time lag to affect mortality
from cardiovascular diseases, such as ischemic heart disease,
because tobacco can have immediate physiologic effects on
platelet aggregation.32 Studies have also shown a reduction in
acute myocardial infarction with the implementation of
restaurant, bar, and workplace bans, without a change in the
effect over time since the ban.33 Similarly, we expected both
short and long term effects on pulmonary deaths, as smoking
and smoke exposure can trigger an acute disease exacerbation
and contribute to the development of chronic disease (such as
chronic obstructive pulmonary disease). On the other hand, we
expected that benefits on cancer mortality might become
apparent over only a longer time period.34

Sensitivity analysis for association between
smoking bans and smoking related deaths

We conducted sensitivity analyses adjusting for general
population rates of all smoking related deaths, cancer, and
cardiovascular and pulmonary diseases. In these models, we
did not adjust for state smoking prevalence because of
correlation between those variables. To determine if our results
were also applicable to causes of death that have not been as
strongly linked to smoking, we also modeled the association
between tobacco and other causes of death, adjusting for state
prevalence of smoking.
All analyses were conducted with Stata/SE 13.0 (College
Station, TX).

Results

Smoking attributable mortality and years of
potential life lost
About half (49.6%) of people in state prisons at year end 2004
(unweighted n=14 499; weighted n=1 226 171) were aged ≥35,
and 6.8% (83 078) were women (table 2).⇓ Among people of
all ages in state prisons, 75.8% had ever smoked, 38.9% were
current smokers, and 37.0% were former smokers. More than
half (56%) reported smoking daily before their arrest, with
another 7.6% reporting smoking some days before arrest. The
prevalence of current (former) smoking among people aged
35-64 and ≥65 was 38.5% (39.6%) and 17.7% (48.2%),
respectively, for men and 46.7% (33.6%) and 5.9% (38.0%),
respectively, for women. Compared with smoking, a much
smaller proportion had ever used smokeless forms of tobacco
(22.4%) or currently used them (1.9% used every day and 2.5%
used some days).
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BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

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In all age groups of people in state prisons in 2001-11, there
were 16 024 deaths attributable to the 19 smoking related causes
of death (table 3).⇓ Of these, 15 289 (95.4%) were among
individuals aged ≥35; 44.6% (n=7152) of which attributable to
smoking. At the time of death, the mean age was 56.6 (SD=12.8)
and the median length of incarceration was 6.1 years
(interquartile range 1.8-14.7 years). Of smoking attributable
deaths, 237 (3.3%) were among women. The largest categories
of these deaths were tracheal, lung, and bronchial cancer
(smoking attributable mortality n=2573), ischemic heart disease
(n=1554), other heart disease (n=1213), cerebrovascular disease
(n=359), chronic obstructive pulmonary disease (n=288), and
pneumonia/influenza (n=174).
In 2001-11, the age adjusted rate of smoking attributable
mortality was 360 per 100 000. The number of age adjusted
years of potential life lost was 5149 per 100 000 (table 4,
assumption 1).⇓ In sensitivity analyses that either assumed a
constant prevalence of smoking for individuals ≥35 (assumption
2) or used the pre-arrest prevalence of smoking (assumption 3),
the age adjusted smoking attributable mortality and years of
potential life lost rates were increased compared with analyses
that used prison smoking prevalences for age groups 34-64 and
≥65 (assumption 1) (for assumption 2 the smoking attributable
mortality rate was 411 per 100 000 and years of potential life
lost rate 5667 per 100 000; for assumption 3 the
smoking-attributable mortality rate was 418 per 100 000 and
years of potential life lost rate 5924 per 100 000, respectively).
For the US population as a whole in 2004, the smoking
attributable mortality rate was 248 per 100 000 and the years
of potential life lost was 3501 per 100 000.

Association between smoking bans and
smoking related deaths
In 2001, half of all states had any smoking ban (n=25; table A,
appendix 1). By 2011, 48 states had implemented a ban on
smoking in prisons. All states with a ban had a ban on smoking
indoors. By 2011, 44 states banned tobacco indoors and 39
states banned smoking or tobacco outdoors. Crude mortality
rates in states in years with any ban were lower than in those
without a ban (incidence rate ratio 0.86 (110.4/128.9), 95%
confidence interval 0.83 to 0.89; figure).⇓ States with the most
restrictive bans (outdoor and indoor bans) had the lowest
mortality rates (incidence rate ratio 0.85, 95% confidence
interval 0.82, 0.87).

Adjustment for sex, calendar year, and smoking prevalence in
the general population in the state (table 5, model 1),⇓ any ban
was associated with a reduced incidence of any smoking related
death (adjusted incidence rate ratio 0.91, 0.88 to 0.95), including
significant reductions in cardiovascular deaths (0.91, 0.87 to
0.96) and pulmonary deaths (0.71, 0.61 to 0.82). Men had
significantly higher rates of death than women for all smoking
related causes, cancer, and cardiovascular disease. In categorical
analyses (table 5, model 2),⇓ bans in place for more than nine
years were associated with reductions in all smoking related
deaths (0.89, 0.85 to 0.94), cancer deaths (0.81, 0.74 to 0.90),
and pulmonary deaths (0.66, 0.54 to 0.80) compared with places
with no ban.
In sensitivity analyses, we adjusted for rates of death from
smoking related causes in the general population by state and
found little substantive change in the point estimates, although
the 95% confidence intervals were marginally wider (table B,
appendix 1). To further confirm the robustness of our results,
we examined deaths from causes other than tobacco from
2001-11 (table C, appendix 1). No similar reductions in mortality
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were associated with smoking bans for deaths from other causes
(adjusted incidence rate ratio 1.05, 95% confidence interval
1.00 to 1.09; appendix 2).

Discussion

Main findings
Smoking contributes to substantial excess mortality in prisons.
Our study suggests that the implementation of smoking bans in
prison is associated with reductions in smoking related mortality
among people in prisons, particularly cardiovascular and
pulmonary deaths. These findings are likely related to reductions
in smoking and exposure to secondhand smoke among people
in prisons. Bans in place for nine or more years were also
associated with reduced cancer mortality.

Strengths and weaknesses of study
We might have underestimated smoking attributable mortality
for several reasons.12 First, people who do not smoke might
experience a higher intensity of secondhand exposure in cells
and indoor prison spaces with poor ventilation. The smoking
attributable mortality, morbidity, and economic costs system
does not include effects of secondhand smoke in its calculations
of smoking attributable mortality. Second, in prisons, people
who smoke might smoke more than other populations; thus, the
relative risk assumptions used in the system software to calculate
smoking attributable mortality might be inappropriately low for
this population. Third, in addition to the 19 causes of death
thought to be related to smoking in prior reports of smoking
attributable mortality in the general populations,25 additional
causes of death might be related to smoking, such as colon
cancer.12 These were not accounted for in the system software
we used. Fourth, the smoking attributable mortality, morbidity,
and economic costs system does not account for pipe or cigar
smoking. In addition, our estimates of smoking attributable
mortality and years of potential life lost were limited by the
small number of older people in the prison survey. Our estimates
of smoking in older people might be unstable, although the
decline in smoking prevalence among such people observed
mirrors the trend in the general population.
Our analysis of the effects of tobacco control polices on
mortality was based on the best available observational data to
examine this question. A randomized trial of these policies that
is adequately long and of sufficient size to assess mortality
outcomes is unlikely to be conducted. Our data do not include
deaths in local jails or federal prisons, among individuals on
probation or parole, or among people released from prison.
Some individuals with major illness could have been released
from prison on medical parole or compassionate release before
dying from cancer or other illnesses. Our data did not capture
these deaths. Underlying cause of death was determined by state
prisons systems and Bureau of Justice Statistics by using
algorithms that do not necessarily correspond to algorithms used
by the Centers for Disease Control and Prevention to classify
cause of death when multiple causes contribute.
Our findings on the association between smoking bans and
mortality also have limitations. First, as noted by the Institute
of Medicine, it can be difficult to separate the direct effects of
a ban from dissemination of information about the ban,
associated education about secondhand smoke, and associated
efforts at smoking cessation.35 Second, states that implemented
prison bans might also have implemented other workplace or
public bans, which reduced smoking related mortality. Our
sensitivity analyses, however, suggest that our results are robust.
Third, because of limitations of our data we could not adjust
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for differences in the distribution of age across states. The
mortality reductions we observed could have occurred as a result
of reductions in smoking or exposure to secondhand smoke, or
both. Finally, our estimates of the effects of time since the
implementation of bans might have been conservative as people
might not have been exposed to the bans for the whole time,
given transitions in and out of prison.

Strengths and weaknesses in relation to other
studies
The association between smoking bans in prison and mortality
has not been previously reported. In the population outside
prison, smoke-free legislation has been associated with reduced
admission to hospital and mortality from coronary events, other
heart disease, cerebrovascular disease, and respiratory disease.33
More comprehensive laws have been associated with greater
risk reductions.33 The Institute of Medicine also suggested that
reduced exposure to secondhand smoke from smoking bans led
to declines in myocardial infarction.35 Other studies of workplace
and public smoking bans have shown a reduction in visits to
emergency departments and hospital admissions for smoking
related diseases after implementation.36 37 To our knowledge,
this is the first study to show an association between smoking
bans and reduced cancer mortality over time. The long latency
between smoking exposure and the development of cancer might
make this association more challenging to demonstrate through
epidemiologic studies in populations outside prison that are
more mobile and might experience a lower intensity of exposure
to smoke than people in prisons. Fry and colleagues noted,
however, that compared with people who continue to smoke,
those who quit smoking have half the risk of lung cancer 10
years after they quit smoking34—a finding that is consistent with
our results. Previous research, however, has not documented
the effect of smoking bans on cancer mortality; this finding
should therefore be replicated in other settings.

Meaning of the study
Our results suggest that smoking bans in prisons can reduce the
risk of death in prison. Smoking bans do not directly reduce
mortality but act through effects on smoking and exposure to
secondhand smoke. The institution of prison smoking bans has
been associated with a reduction in exposure to secondhand
smoke and improvements in air quality.16 38Smoking bans can
also reduce the initiation of smoking in prison, improve health
among correctional officers and other prison staff, improve fire
safety, and reduce costs associated with liability insurance,
facility maintenance, and healthcare.7

On the other hand, complete (indoor and outdoor) smoking and
tobacco bans in prisons strongly limit individual autonomy and
might not prepare individuals with tobacco use disorders for
life in the community, where they can purchase and consume
tobacco. Internationally, various types of incomplete bans are
being implemented, such as bans that prohibit smoking in public
prison spaces, in cells, or in all spaces except for designated
smoking areas. Some prisons have also prohibited correctional
facilities from forcing people who do not smoke to share cells
with inmates who smoke.19 39 In addition, smoking bans do not
lead to sustained long term cessation. Many people resume
smoking after release from prison,7 and others might be
transferred to or re-incarcerated in jails, halfway houses, and
drug treatment facilities without bans. Finally, some inmates
smoke despite bans,18 which can lead to correctional sanctions
and negative health outcomes for people with tobacco use
disorders. Reduced smoking and smoke exposure, however, can
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have positive health benefits even if there is not complete
adherence with a ban.

Pharmacologically supported tobacco cessation treatment and
behavioral interventions are important adjuncts for tobacco use
disorders and need wider dissemination in prisons.40 41 Prevention
of relapse during the transition back to the community is also
critical. People with mental health and substance use disorders,
which are associated with tobacco use,42 might require
specialized interventions to help maintain long term cessation
and manage forced abstinence in prison. Smoking cessation can
lead to secondary health benefits in children and families after
individuals are released from prison. Other healthcare services
that can provide benefit to people with a history of smoking
include vaccination against influenza and pneumococcal disease,
evidence based management of chronic obstructive pulmonary
disease, and primary and secondary prevention of heart and
cerebrovascular disease.

Unanswered questions and future research
Further research is needed on several related issues, such as the
effect of tobacco policies among correctional officers and prison
staff, who also smoke at disproportionately high rates42; public
expenditures because of smoking related illness in prisons and
after release; the costs of tobacco control and cessation
interventions in prisons; whether incarceration in correctional
facilities that permit smoking increase smoking initiation or
consumption; when maximal effects on cancer mortality are
observed (including after release from prison); and the use of
smokeless and electronic cigarettes in prisons. We noted an
overall increase in the 2011 mortality rate, a finding that needs
further investigation if it represents a trend. Whereas death rates
in prisons are often similar to or slightly lower than those in the
general population, for the same age, sex, and race (in part
because of protection from deaths from injury), the risk of death
increases after release from prison. Lung cancer and
cardiovascular mortality are important contributors to death
after release from prison.11 Prison smoking bans could reduce
mortality after release. While we observed significant benefits
of smoking bans on mortality, ongoing research and
implementation efforts are needed to promote effective long
term cessation in prisons and after release as part of a
comprehensive tobacco strategy for this high risk group.
We thank Marc F Stern and Karen Cropsey for their valuable input into
this study.
Preliminary data from portions of this study were presented at the Society
for General Internal Medicine 36th Annual Meeting in Denver, CO, on
24 April 2013 and at the 6th Academic and Health Policy Conference
on Correctional Health, Chicago, IL, on 21 March 2013.
Contributions: IAB, EAC, and WJS designed the study. IAB wrote the
protocol and supervised data collection and analysis. EAC and WJS
participated in data collection, data interpretation, and revisions of the
manuscript. JFS and PMK participated in data interpretation and revising
the manuscript. IAB and SRM conducted literature searches, and SRM
coordinated data collection and approvals. IAB and PMK undertook the
statistical analysis. IAB wrote the first draft of the manuscript. All authors
contributed to and have approved the final manuscript. All authors had
full access to all the data in the study and take responsibility for the
integrity of the data and the accuracy of the data analysis. IAB is
guarantor.
Funding: This study was supported by the Bureau of Justice Statistics
Visiting Fellows Program, US Department of Justice (grant No
2011-BJ-CX-K073). The views and opinions expressed do not

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BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

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What is already known on this topic
People in prisons represent a large and high disparity population with a high prevalence of tobacco use
Prisons have increasingly implemented prison smoking and tobacco bans, but the effects of smoking on mortality and health benefit of
these policies have not been evaluated

What this paper adds
Our national study provides estimates of the rates of smoking attributable mortality and years of potential life lost in prisons, which are
higher than in the general population
Prison smoking bans are associated with reductions in mortality from smoking related causes

necessarily represent the views and opinion of the Bureau of Justice
Statistics or the US Department of Justice.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no
support from any organization for the submitted work; no financial
relationships with any organizations that might have an interest in the
submitted work in the previous three years; no other relationships or
activities that could appear to have influenced the submitted work.
Ethical approval: This study was approved by the Colorado Multiple
Institutional Review Board (protocol 12-0092).
Data sharing: Bureau of Justice Statistics data are archived at the
National Archive of Criminal Justice Data for public download and use
(NACJD; www.icpsr.umich.edu/icpsrweb/NACJD/). Due to the sensitive
nature and individual level records of the Deaths in Custody Reporting
Program (Deaths in Custody Reporting Program; ICPSR 34277), this
collection has been judged by a disclosure review panel to be restricted
and must be used in an enclave setting. Due to the individual level
records of the National Corrections Reporting Program (NCRP; ICPSR
34984), this collection has been judged by a disclosure review panel to
be restricted, but the data can be downloaded to computers outside of
an enclave setting by application to NACJD. Data from the National
Prisoners Statistics Program (National Prisoner Statistics program;
ICPSR 34540) are freely available to the public.
Transparency declaration: The lead author affirms that this manuscript
is an honest, accurate, and transparent account of the study being
reported; that no important aspects of the study have been omitted; and
that any discrepancies from the study as planned have been explained.
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Accepted: 07 July 2014
Cite this as: BMJ 2014;349:g4542
This is an Open Access article distributed in accordance with the Creative Commons
Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute,
remix, adapt, build upon this work non-commercially, and license their derivative works
on different terms, provided the original work is properly cited and the use is
non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/.

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BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

Page 7 of 12

RESEARCH

Tables
Table 1| Sources of data on prison tobacco control policies and deaths from smoking in United States
Data source

Year(s)

Survey of inmates in state correctional facilities

2004

Bureau of Justice Statistics

Agency

Smoking and tobacco use data for smoking attributable
mortality/years of potential life lost analysis and descriptive
purposes

Data elements used

Deaths in custody reporting program

2001-11 Bureau of Justice Statistics

Number of deaths and cause of death among prison inmates
(primary outcome)

National prisoner statistics program

2001-11 Bureau of Justice Statistics

Prison population numbers (denominator)

Smoking attributable mortality, morbidity, and
economic costs

2001-11 Centers for Disease Control and
Prevention

Smoking attributable mortality and years of potential life lost

Departments of Corrections websites, American
2001-11 Various
Nonsmokers’ Rights Foundation, legislative websites,
reports, and media reports

Tobacco control policies in each state correctional
department (exposure)

Behavioral risk factor surveillance system

2001-11 Centers for Disease Control and
Prevention

State general population smoking prevalence for adjustment
purposes

Wide-ranging online data for epidemiologic research 2001-11 Centers for Disease Control and
Prevention

State general population death rates for ages 15-64 by cause
for sensitivity analyses

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BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

Page 8 of 12

RESEARCH

Table 2| Weighted national prevalence of smoking and tobacco use among people of all ages in state prisons in 2004 (n=14 499, weighted

n=1 226 171). Figures are numbers (percentage) of people in prisons
All people in prisons

Men

Women

1 226 171

1 143 093 (93.2)

83 078 (6.8)

<35

618 355 (50.4)

580 932 (50.8)

37 424 (45.1)

35-64

598 305 (48.8)

552 880 (48.4)

45 425 (54.7)

11 688 (1.0)

11 416 (1.0)

272 (0.3)

African American*

496 936 (40.5)

468 998 (41.0)

27 936 (33.6)

White*

431 482 (35.2)

394 013 (34.5)

37 469 (45.1)

Hispanic

222 694 (18.2)

210 941 (18.4)

11 753 (14.1)

American Indian/Alaska Native*

20 696 (1.7)

18 680 (1.6)

2015 (2.4)

Asian/Pacific Islander*

13 080 (1.1)

12 829 (1.1)

250 (0.3)

Other/missing

41 284 (3.4)

37 628 (3.2)

3655 (4.4)

919 054 (75.8)

854 672 (75.6)

64 382 (78.8)

Current

470 925 (38.9)

432 778 (38.3)

38 147 (46.7)

Former

448 129 (37.0)

421 894 (37.3)

26 235 (32.1)

Never†

293 120 (24.2)

275 759 (24.4)

17 362 (21.2)

690 280 (56.3)

637 144 (55.8)

53 136 (64.0)

Total
Age (years):

≥64
Race/ethnicity:

Ever smoked at least 100 cigarettes
Smoking status:

Smoking before arrest:
Every day
Some days

92 954 (7.6)

88 185 (7.7)

4769 (7.7)

441 943 (36.1)

416 805 (36.5)

25 138 (36.5)

271 782 (22.4)

266 137 (23.5)

5599 (6.8)

Every day

23 561 (1.9)

23 433 (2.1)

128 (0.2)

Some days

30 300 (2.5)

30 018 (2.6)

281 (0.3)

1 172 216 (95.6)

1 089 547 (95.3)

82 669 (99.5)

Not at all
Ever used chewing tobacco or snuff
Uses chewing tobacco or snuff:

Not at all
*Not of Hispanic origin.

†Never smokers are defined as individuals who never smoked 100 cigarettes in their lives.

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BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

Page 9 of 12

RESEARCH

Table 3| Deaths in categories of smoking related cause of death and smoking attributable mortality among people in prisons, 2001-11
Deaths
All ages
Cause of death

Men

Age ≥35

Women Overall

Smoking attributable mortality*

Men

Women

Overall

Men

Women

Overall

Malignant neoplasm:
Lip, oral cavity, pharynx

216

3

219

213

3

216

172

2

174

Esophagus

217

4

221

217

4

221

167

4

171

Stomach

207

4

211

195

3

198

67

0

67

Pancreas

438

14

452

431

14

445

144

4

148

Larynx

95

4

99

95

4

99

82

4

86

2748

100

2849

2733

100

2833

2488

85

2573

0

12

12

0

10

10

0

1

1

Kidney and renal pelvis

201

4

205

193

3

196

90

0

90

Urinary bladder

152

1

153

152

1

153

82

0

82

Acute myeloid leukemia

85

4

89

71

4

75

21

0

21

4339

151

4510

4300

146

4446

3313

100

3413

Ischemic heart

3959

105

4064

3836

105

3941

1507

47

1554

Other heart

4993

199

5192

4614

167

4781

1181

32

1213

Cerebrovascular

928

57

985

862

53

915

333

26

359

Atherosclerosis

32

2

34

31

2

33

10

0

10

Aortic aneurysm

122

3

125

117

2

119

82

1

83

Other circulatory

50

4

54

45

4

49

11

0

11

10 084

370

10 454

9505

333

9838

3124

106

3230

612

52

664

565

48

613

158

16

174

Trachea/lung/bronchus
Cervix uteri

Total cancer
Cardiovascular disease (CVD):

Total CVD
Respiratory diseases:
Pneumonia/influenza
Bronchitis/emphysema

49

2

51

47

2

49

45

2

47

Other chronic obstructive pulmonary disease†

331

14

345

329

14

343

275

13

288

Total respiratory

992

68

1060

941

64

1005

478

31

509

15 435

589

16 024

14 746

543

15 289

6915

237

7152

Overall total
*Calculated only for people aged ≥35.
†ICD-10 code J44.

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RESEARCH

Table 4| Annual smoking attributable mortality and years of potential life lost in US state prisons (2001-11) under varying assumptions and

in US general population (2004)

US state prisons (2001-11)
Assumption 1* Assumption 2† Assumption 3‡

US general population (2004)

Smoking attributable mortality

7152

7424

8120

379 727

Smoking attributable mortality rate/100 000

360

411

418

248

170 191

173 202

192 826

5 392 848

5149

5667

5924

3501

Number of years of potential life lost
Years of potential life lost/100 000

*Uses current in prison smoking for prisoners aged 35-65 and ≥65.
†Uses current in prison smoking for prisoners aged ≥35.
‡Uses current smoking before arrest for prisoners aged 35-65 and ≥65.

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BMJ 2014;349:g4542 doi: 10.1136/bmj.g4542 (Published 5 August 2014)

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RESEARCH

Table 5| Association between any state prison smoking ban and smoking related deaths adjusted for sex, calendar year, and state smoking

prevalence in general population (model 1) and between year since ban and smoking related deaths adjusted for sex, calendar year, and
state general population smoking prevalence (model 2). Figures are adjusted incidence rate ratios (95% confidence interval)
Smoking related cause of death
All categories

Cancer

Cardiovascular

Pulmonary

Model 1: any smoking ban
Any ban

0.91 (0.88 to 0.95) 0.96 (0.89 to 1.03) 0.91 (0.87 to 0.96) 0.71 (0.61 to 0.82)

Calendar year

1.04 (1.03 to 1.04) 1.06 (1.05 to 1.07) 1.02 (1.01 to 1.03) 1.05 (1.04 to 1.08)

Men

1.96 (1.80 to 2.12) 2.16 (1.84 to 2.54) 2.03 (1.83 to 2.25) 1.08 (0.84 to 1.39)

State population prevalence of smoking 1.05 (1.05 to 1.07) 1.06 (1.05 to 1.07) 1.06 (1.05 to 1.07) 1.02 (1.00 to 1.04)
Model 2: years since smoking ban implemented
Years since ban:
0

Reference

Reference

Reference

Reference

>0-<4

0.96 (0.92 to 1.01) 0.96 (0.88 to 1.05) 0.99 (0.93 to 1.04) 0.74 (0.62 to 0.88)

≥4-<9

0.93 (0.89 to 0.97) 0.94 (0.86 to 1.02) 0.93 (0.88 to 0.98) 0.83 (0.70 to 0.99)

≥9

0.89 (0.85 to 0.94) 0.81 (0.74 to 0.90) 0.95 (0.89 to 1.02) 0.66 (0.54 to 0.80)

Calendar year

1.04 (1.03 to 1.04) 1.07 (1.06 to 1.08) 1.02 (1.01 to 1.03) 1.07 (1.04 to 1.09)

Men

1.95 (1.80 to 2.12) 2.15 (1.83 to 2.53) 2.03 (1.83 to 2.26) 1.08 (0.84 to 1.38)

State prevalence of smoking

1.06 (1.06 to 1.07) 1.06 (1.05 to 1.07) 1.07 (1.06 to 1.07) 1.02 (1.01 to 1.04)

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RESEARCH

Figure

Crude smoking related mortality rates (deaths per 100 000) in prisons in states with and without smoking bans and in
general (non-prison) population by year. Categories of bans are not mutually exclusive

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