Correspondence to: Douglas Eadie, Institute for Social Marketing, University of Stirling and Open University, Stirling FK9 4LA, UK. E-mail: email@example.com
To examine the barriers and facilitators to effective operation of a regional tobacco control coordinator working within and across criminal justice and public health, whose goal was to raise tobacco control awareness and support the development of smoking cessation treatment for offenders.
A reflexive, mixed-methods case study approach using in-depth interviews, project reports and observation of advisory board meetings.
The coordinator worked with prisons, probation and police custody, where there are high levels of social disadvantage and smoking.
Interviews (n = 34) at different stages of project with the coordinator, project advisers and local stakeholders from criminal justice and public health.
Analysis of facilitators and barriers and the coordinator role from different perspectives.
Readiness to develop cessation services was a critical predictor of different criminal justice settings' engagement with the coordinator role. The coordinator enhanced cessation service delivery in individual prisons where there was a requirement and infrastructure in place to provide such services. In police custody, where there was no central guidance or pre-existing requirements, efforts to establish smoking cessation on the local agenda proved ineffective. In probation settings, the coordinator documented examples of good practice and supported brief intervention training. Variability in willingness to engage limited the project's ability to create joined-up working across criminal justice settings.
In the English criminal justice system, the prison service appears to provide a favourable context for development of smoking cessation support and a means of accessing hard-to-reach groups. Other criminal justice settings, most specifically police custody, appear less responsive to such activity. A coordinator role can improve smoking cessation support in the prison setting, and develop local improvements in tobacco control interventions in other settings such as probation, but as configured here, does not have the capacity to effect change across the criminal justice system.
In England and Wales, smoking rates among prisoners are nearly four times higher than in the general population at approximately 80% [1-3], a level comparable with other countries [4-11]. A similarly high prevalence has also been found in police custody and probation [12, 13], although the evidence is less well developed. High smoking prevalence is reflected in high levels of exposure to second-hand smoke, with associated risks for prisoners and prison staff who are typically confined to, or working within, enclosed spaces [14-16]. There appears to be an absence of reliable data on tobacco exposure in other criminal justice settings (CJS).
Studies have found that offender populations are predominantly from more disadvantaged backgrounds and, together with their families, represent one of the most socially excluded groups, experiencing considerable health needs compared to the general population [17, 18]. Similarly, offenders' problems are often complex and inter-related, as many have poor life and coping skills and have also experienced long-term disengagement from services (including health) and a lack of education, training and employment. Importantly, the prison setting is both a home for offenders and a work-place for staff and external service providers. Addressing smoking cessation and other tobacco control issues in prisons and wider CJS therefore represents a major opportunity to engage with those normally considered ‘hard to reach’. This has had increasing policy recognition [19, 20], and offers additional positive benefits in addressing wider health inequalities, not least of which are the health benefits brought about by reducing smoking prevalence among offender groups and the importance of providing cessation support to establishing effective smoke-free policies . Recent studies have shown prison populations to be receptive to smoking cessation interventions, leading to calls for continued cessation support on release from prison to maintain quit attempts and address relapse [21-23].
Offenders are a transient population, and the ‘offender pathway’ within and across CJS incorporates many organizational structures, including police custody, courts, prisons (often with movement between institutions) and probation services, as well as numerous community-based health and social care agencies. In addition, many offenders have short sentences of 6–12 weeks, resulting in little time to initiate cessation support in the prison setting. Consequently, stop smoking support for offenders requires joined-up working, taking a whole systems approach  across CJS to ensure continuity of cessation support at all stages along the offender pathway.
This project aimed to enhance tobacco control awareness, and support the development and utilization of smoking cessation services, within and across all the CJS. The intervention involved the appointment of a tobacco coordinator working across all of the North West region of England.
The organizational structures of prisons and the wider CJS are diverse and require a holistic, multi-faceted and multi-disciplinary approach to support health-related behaviour change such as stopping smoking [24, 25]. These requirements are conceptualized in the settings approach, which was recognized in the World Health Organization's (WHO) ‘Health for All’ strategy  and the subsequent Ottawa Charter for Health Promotion . WHO define settings for health as ‘the place or social context in which people engage in daily activities and in which environmental, organisational and personal factors interact to affect health and wellbeing’ (cited in ). However, while the value of holistic approaches to promoting health has been widely recognized, this tends to be reflected inconsistently in institutional structures, organizational decision-making and policy actions which often fail to address complex inter-relationships among sectors [24, 25].
Prisons have been the major focus of development of health promotion and smoking cessation within CJS in England and Wales. Following the transfer of commissioning responsibility for prisoner health to the National Health Service (NHS) in 1995, health-care provision, of which stop smoking services are a part, requires prisoners to have access to the same range and quality of health-care services as the public receives in the wider community . Opportunities and requirements for integrating approaches to health promotion in prisons were highlighted in 2002 in the strategy ‘Health Promoting Prisons’, which advocated for a whole prison approach. This was incorporated subsequently into the Prison Service Order 3200 (Health Promotion) in 2003, where smoking was identified as one of five areas for action [30, 31]. In this way the prison service in England and Wales aims to meet its duty of care for those it detains, which covers the promotion and provision of smoking cessation support, as well as protecting prisoners, staff and visitors from exposure to second-hand smoke. At the time of this project, stop smoking support delivered in prison settings was commissioned typically by agencies responsible for primary care, but might be delivered either through specialists going into prisons or through prison health-care staff trained and supported by community stop smoking services. These arrangements have shown some successes, with 4-week quit rates higher in prisons than for any other setting apart from military bases [55% (6577 quitters): 2010–11] . However, numbers are small relative to the throughput of prisoners (approximately 132 000 in 2010 with approximately 85 000 in prison at any one time ), and therefore there is considerable scope for improvement in reach.
Looking beyond prisons, a recent government policy, ‘Improving Health, Supporting Justice’ , advocates for greater integration to improve the health and wellbeing of all those in contact with CJS through, for example, the development of more effective pathways and improved signposting. The report identifies smoking as a risk behaviour worthy of attention. However, there are complex issues at play in each of the major settings, most notably the often conflicting priorities of punishment and the need to support reparation and rehabilitation . For example, prisons exist to punish criminals by separating them from society, correcting and in due course rehabilitating them into the community . In this environment, issues of health and wellbeing often have a lower priority [36-39]. Similarly, probation services focus on reducing re-offending, with mental health, substance misuse and employment taking greater prominence over smoking cessation. Thus, while the importance of tobacco control and smoking cessation may be recognized by CJS authorities, the level of service provision can vary considerably in the face of competing priorities and limited resources, and can be dependent upon the personality and commitment of individual managers and resource allocation. Arguably, however, quitting can provide many benefits in addition to improved health, such as improved self-worth, making positive steps towards improving quality of life and planning for the future .
Tobacco control coordinator posts have, until recently, been in place in most English regions, involving a variety of local services. However, a coordinator role offers a new and innovative approach to providing stop smoking support in an integrated way across CJS. Literature is sparse on the role and its value; studies are reported in other health settings such as long-term care for the elderly , school health  and mental health care , but despite promising outcomes, supporting evidence on impact and effectiveness is limited [40, 41]. This project adapted best practice guidance for effective community engagement , which aims to promote health improvement in the NHS and other sectors using area-based partnership and coordination activities. The approach adopted a model of practical, experiential learning and knowledge transfer within the intervention settings.
The intervention was established to examine the potential benefits of employing a tobacco control coordinator to work across prisons, probation and police custody, where coordination activities are critical to improving continuity of care and access to stop smoking services. The North West region of England provided opportunities for learning across a range of organizational structures and commissioner–provider models. It incorporates: 16 prisons, representing the full range of prisoner categories, ranging from maximum security to open conditions; five probation authorities which commission services, overseeing offenders released from prison on licence and managing approved premises and community hostels; five police constabularies which manage police custody cells; 24 primary care authorities with responsibility for commissioning primary care and community health services, including stop smoking services; and various local government departments, both urban and rural. The intervention period ran for 12 months from December 2010.
The post was hosted by the University of Central Lancashire, in a unit which had expertise in healthy settings research and development in the CJS, and established links with: the local Regional Offender Health Team; local non-governmental organizations (NGOs) responsible for smoke-free policies and supporting cessation; and primary care authorities across the region. The intervention manager was lead for the prisons and criminal justice programme within the university and had established links with key stakeholders in the intervention area. A project advisory group (PAG) was established which incorporated representation from regional and national stakeholders in offender health and tobacco control. The project budget covered staff costs for a full-time coordinator and part-time administrative support, as well as costs for travel, information technology (IT) and hosting local networking events. The coordinator worked within existing resources available in partner organizations.
It was envisaged that the coordinator role would develop and share knowledge about tobacco control and stop smoking provision across the system, with the aim of enhancing existing stop smoking services and improving access to and utilization of these services by offender groups. Approaches included working with individual prisons or interventions, and networking with key groups such as service commissioners and primary care alliances to achieve these aims. The work of the coordinator was not specified in advance, but evolved based on assessment of need and a responsive approach to opportunities that emerged to support stop smoking service delivery and to raise awareness of tobacco issues and delivery possibilities. It was not intended that the coordinator would provide services to offenders directly, but instead would support those organizations responsible for offender welfare.
Following an initial information-gathering phase, which included mapping provision in prisons and other sectors, the coordinator found considerable variability of cessation support within the system and at a number of levels. Notably, there was marked variation in understanding and priority given to smoking cessation and tobacco control across agencies. For example, there was no provision of smoking cessation support in police custody suites, whereas smoking was a defined health promotion activity in prison settings. However, there was also variation within sectors such as prisons; individual prisons delivered services differently, and there was considerable variation in aspects such as record-keeping and staff training.
This variability influenced both the reach of the project, in terms of what parts of the system with which it was able to work directly, and the roles assumed by the coordinator. The coordinator aimed to increase awareness and the accessibility of cessation support through two linked areas of activity; first, the use of enabling strategies, such as networking and partnership working, to drive change in individual parts of the system; and secondly, the development and dissemination of a series of guidance documents to prompt changes in practice across the system and to introduce consistency. Chronologically, the project moved from initial information-gathering and identification of needs towards agenda-setting, in conjunction with project advisers, and developing and disseminating project outputs designed to address identified need (see Fig. 1).
Alongside these developments the project also used its links with frontline workers to develop a series of setting-specific case studies. These were designed to address variability and gaps in provision by illustrating examples of good practice and sharing new learning and, similar to the guidance documents, were disseminated to local stakeholders via the e-newsletter and project website (http://www.uclan.ac.uk/schools/school_of_health/research_projects/hsu/tobacco_in_prisons.php).
This paper examines the barriers and facilitators to the work of the regional tobacco control coordinator within the different sectors that make up the CJS, to enhance tobacco control awareness, and support the development and utilization of smoking cessation services, within and across all the CJS.
Evaluating programmes which are non-prescriptive or needs-led and which result in unpredictable and diverse outcomes requires an adaptive approach . More prescriptive evaluation approaches, such as randomized controlled trials, have limited relevance to the many processes used in health promotion programmes and are often impossible to set up in ‘real-world’ situations . A reflexive, mixed-methods case study approach was therefore used to examine barriers and facilitators to coordinator activities. The evaluation tracked and documented progress in relation to primary outputs and engagement strategies, rather than evaluating delivery against a predetermined set of outcomes. The evaluation was conducted by a team specializing in tobacco control research based at Stirling University, which was located outside the intervention area and not part of the local networks used to support the project.
The primary data collection method was the qualitative in-depth interview, supplemented by observation of PAG meetings and review of project documentation and monthly project reports. Views and experiences of the project were elicited from: the actor responsible for delivering the project, the coordinator (n = 1); regular members of the PAG and the intervention manager responsible for guiding the project (n = 5); and professional stakeholders from criminal justice and health sectors who were recipients of, and/or actively contributed to, the development of project outputs (n = 19). In the latter instance, participants for interview were sampled purposively in consultation with the coordinator and intervention manager to obtain a range of perspectives on programme development and delivery. This sample group included professionals working in the three criminal justice settings of interest as well as from public health, stop smoking services and local Youth Offending and Alcohol and Drug Action Teams.
Five bi-monthly interviews were undertaken with the coordinator to map the development of the project, to provide insight into the delivery process and to identify local stakeholders. Members of the PAG were interviewed on two occasions at the beginning and end of the project to review expectations and project delivery, and interviews with professional stakeholders were conducted in the latter stages of the project to provide a retrospective assessment. In total, n = 34 interviews were undertaken.
All prospective participants were approached by e-mail in the first instance from a member of the evaluation team to invite participation and obtain written consent. Initial interviews were guided by topic guides designed for specific interview groups, which were adapted as interviewing progressed, and new themes emerged. Interviews with the coordinator focused on project activities and experiences of opportunities and challenges in delivering the project. Interviews with advisory group members and other professionals explored their experiences of the project and perspectives on its operation.
All interviews and selected PAG meetings were recorded digitally with the participants' permission and were transcribed in full, with identifying details of participants anonymized in accordance with governance requirements. Analysis themes were identified relating to the study aims and additional emergent areas of inquiry. As the analysis progressed, reliability of themes was established via cross-examination between the two members of the evaluation team responsible for conducting the interviews. This allowed areas of interpretative disagreement to be identified and addressed through redefinition of key concepts. The analysis of all qualitative data was supported by QSR Nvivo version 9.0 software.
Analysis of stakeholder narratives revealed several factors which influenced the progress of the project and its ability to engage and support local stakeholders from across criminal justice and primary care. These factors were grouped under four broad themes, each of which included both barriers and enablers to project delivery. The themes covered internal factors such as programme design and implementation, over which the project had direct control, as well as external factors which related to the intervention settings and wider environmental influences. Quotes drawn from the interviews and advisory meetings are used to illustrate the study findings and are identified by interview and meeting number to ensure anonymity of participants.
The experience, skills and personality of the coordinator emerged as critical factors influencing implementation, reflecting the dependence on a single individual to implement the intervention. In particular, the postholder's networking skills acquired through previous health coordinator positions, coupled with his ability to exploit existing links with local public health communities, were important enabling factors.
He's able to understand, you know, the public health issues that are involved and really sort of approach it from a patient perspective as well, and to evaluate what would be practical and not practical (interview 23).
These qualities were regarded as critical assets which enabled the project to progress more rapidly and to establish a wider network of support than might otherwise have been possible. For example, the coordinator had an existing understanding of public health infrastructures in the North West and contacts he could approach. Nevertheless, some gaps were judged to act as limiting factors, most specifically the postholder's lack of tobacco control experience and limited links with parts of the criminal justice system, which were addressed by additional support from the intervention manager and project advisers. For example, the intervention manager provided access to the local prison health network of which she was a member, and a PAG member worked closely with the coordinator to develop a data collection guidance document to assess cessation outcomes in prisons, an area in which the member had considerable technical expertise.
Three programme elements emerged as factors influencing delivery: management support, hosting arrangements and length of delivery period.
The existence of established links with, and strong understanding of, local criminal justice and primary care structures by the intervention manager and members of the advisory group had an important influence on the reach and scope of the project, as described above. These links were important to facilitating access to relevant institutions and bodies and were responsible for initiating much of the development work undertaken within the prison setting and establishing advocates and training partnerships in the probation sector.
Because of [the intervention manager's] work we had a fairly extensive list of contacts for the prisons in terms of health care leads so the starting point was really quite simple. So the prisons bit has been really quite easy (interview 30).
Conversely, in those areas of the system where links with the project were absent or less well developed, notably police custody (see Box 1), the coordinator was able to establish some initial contacts but typically struggled to influence engagement with tobacco control issues in the face of other priorities in this setting.
Police custody is the first stage of the offender journey following arrest or detention. Stays typically last 6–8 hours and the setting is covered by smoke-free legislation. This has significant implications for managing the effects of nicotine withdrawal, especially given that smoking prevalence is similar to other criminal justice settings . Custody suites are well positioned to support enforced abstinence and to act as a gateway to stop smoking and other health-care services .
The project aimed to promote the provision of NRT in police custody suites across the intervention area. Initially, the coordinator conducted a search for relevant national policies and a country-wide review of police custody smoking policies available online (n = 20). This exercise provided useful examples of area smoking policies and some general indicators of national support of NRT in custody suites. The coordinator then undertook a local fact-finding exercise with a senior police officer to assess existing practice and to explore the potential for establishing local alliances.
The coordinator was unable to gain the necessary support to raise the issue at the region's police custody forum, as tobacco control was regarded as a low priority area. In view of this, the coordinator then sought to gain a voice at the forum by exploiting his links with senior public health officials and to work with the regional offender health team in reviewing new police custody health-care contracts. These efforts again proved unsuccessful, although the project did succeed in influencing routine collection of detainee smoking data as part of a local health pilot.
A number of useful learning points emerged from the analysis:
Custody suites are not considered conducive to delivering cessation support, as detainees are often in crisis and there is limited capacity for structured intervention
A minority of smoking policies permit detainees to smoke in ‘exceptional circumstances’ in exercise yards and custody cells
Current local variability highlights scope to explore routine provision of NRT to counteract nicotine withdrawal and to motivate detainees to consider stopping. Routine assessment of detainees for risk of harm provides an ideal opportunity to screen for smoking
Nationally, requirements to provide pharmacotherapies are unclear. However, ‘Expectations Criteria’ for assessing health provision requires inspectors to assess routinely the availability of NRT  and the Faculty of Forensic and Legal Medicine  provides special grounds to support temporary abstinence
Positioning NRT provision as addressing the more severe effects of nicotine withdrawal such as depressive symptoms and aggression  is likely to be of greater relevance to police authorities than highlighting health benefits of quitting
Additional advantages include avoidance of exposure to second-hand smoke by staff and other detainees, and reduced need for security measures linked with escorting detainees to outside areas
Appropriate pharmacotherapies include micro tablets or mini lozenges because of rapid effect, ease of administration and lower security and choking risks
Greater clarity is needed on national policy for the provision of pharmacotherapies in police custody that takes cognisance of smoke-free environments and staff and detainee rights to be protected from second-hand smoke. There is an opportunity for the proposed national commissioning body to establish provision of NRT as a priority area as police forces review their health-care contracts. There is also a need for pilot work to evaluate temporary abstinence supported by NRT as a trigger for a sustained quit attempt.
The choice of host institution, a health research unit located within a local university, also had an impact on how the project was perceived and the way in which stakeholders engaged with it. Keeping the project organizationally separate from the criminal justice system was considered to give it the independence to respond flexibly and the ability to work across the range of stakeholder agendas necessary to the coordinator role.
Because [the coordinator's] not employed by health, not employed by the prison service, the constraints are completely different. There is more flexibility there (interview 32).
I think it helped being based within a university—it helped to give credibility and kept it separate from day to day business (interview 12).
However, there was no clear consensus on the ideal location. Some stakeholders were ambivalent about the hosting arrangements while others, particularly those in the prison sector, expressed unease, or as one stakeholder put it, were ‘a little twitchy’ about engaging in an initiative that, by virtue of its location, could be seen as part of a research project.
Finally, the prescribed delivery period of 12 months was widely considered to be insufficient for a coordination role working at a regional level across both health and criminal justice. As a consequence, the project initially prioritized those areas where it was likely to have greatest impact within the time available, and worked subsequently with those institutions who expressed a willingness to engage, although there was insufficient time to embed individual advances made. As one advocate of the approach explained:
We're not feasibly going to be able to work in a twelve month period with all the people across the system and engage them all to the same level. What we can do is pick out those that (1) show interest and (2) that are in a reasonable position to be able to progress some of what we are saying we want to do, but again that's a coordination role (interview 31).
Similarly, the project outputs developed to share good practice and promote consistency in service delivery were not utilized fully during the project life-time, although the relevant guidance documents were made available on the project website.
Given the project's dependence on working with existing resources available within the wider system, engagement with the project by the various CJS varied in accordance with their readiness to change and the extent to which tobacco control formed part of local operational agendas. These different patterns of response are illustrated by three settings-specific case studies (Boxes 1-3), which describe the engagement strategies adopted and the types of impacts achieved, alongside practice learning to emerge from these experiences and implications for development of cessation support in each setting.
Box 2. Service development in a prison
A large women's prison with accommodation mainly in detached houses and including a smoke-free mother and baby unit. Smoking cessation support was offered, but uptake was negligible at the time of the first coordinator visit. The case study provides an illustration of how a ‘light touch’ approach by the coordinator can facilitate positive change.
The mapping review exercise indicated that while group quit programmes were offered, several factors had contributed to a downturn in provision:
Staff capacity and lack of trained staff
Variable allocation of clinic rooms and session times
Regime issues restricting prisoner movement from cells to sessions
Rapid turn-around of some prisoner categories moving between and from prison
Absence of incentives to quit and involvement of prisoners in service provision
No support for staff to stop smoking
A number of positive developments followed the mapping review. Most notably, a multi-agency development meeting convened by the coordinator with leads from the prison, public health commissioning and the community stop smoking team led to enhanced recognition of past challenges, recent advances and development opportunities.
These initial intervention activities acted as a catalyst for change, resulting in increased attendance at sessions and successful 4-week quits. Access to clinics increased steadily from 12 clinic slots in January 2011 to 104 by May 2011, levelling off thereafter. Numbers setting a quit date also increased over the same period from zero to 16, although there was some drop-off, reflecting a recurrence of previous problems.
A number of factors appeared to improve engagement and quit levels:
Providing adviser training for health care and integrated drug treatment service staff helped to address capacity issues
Changing from group to 1 : 1 support counteracted the less productive ‘sociable’ motivation for engagement and was more manageable
Establishing regular clinic sessions and room allocations facilitated an appointment system, which was preferable to ‘drop-in’
Providing nicotine replacement therapy (NRT) on the first visit, following assessment, addressed short-stay issues
Reducing staff restrictions on inmate movements helped to promote attendance
Using the same monitoring software (Quit Manager) as community services facilitated more accurate data collection and monitoring, and local connections on release
Personal appointment cards facilitated ongoing support on transfer and release
Highlighting services at the second health screen rather than prison entry enabled more balanced consideration by inmates and reduced non-attendance
Additional developments contributing to a more positive smoking cessation environment included proposals for expanding smoke-free accommodation and more active engagement with the healthy prisons agenda. Moreover, information on local services and, where appropriate, supply of NRT were included in health promotion release packs.
Recommendations for developing quit services in prisons
Foster partnership working between community stop smoking specialists, prison health-care staff and commissioners, and across the prison environment, to maximize effectiveness
Establish consistent structures which integrate staff rotas, clinic room availability and inmate movement within the prison
Ensure sufficient staff are suitably trained to cover sessions
Review delivery approaches: 1 : 1 may be more suitable than group programmes, especially where inmate turnover is high
Ensure robust and consistent data collection and monitoring, supported by electronic databases
Support development of smoke-free living areas and consider additional incentives to reward quitting
Provide brief intervention training across prison staff, with a setting-specific perspective to raise awareness and support engagement
Box 3. Opportunities in probation settings
Probation provides opportunities for offering stop smoking support in a familiar setting to a group who are normally considered ‘hard to reach’. The primary driver for health interventions in this setting is to tackle risk factors associated with re-offending. Consequently, the project bridged the aims of reducing re-offending and promoting quitting as a positive life-style behaviour change.
The coordinator's initial task was to review an innovative Offender Health Trainer (OHT) project, which was ongoing in the intervention area. Key themes explored include:
Training received to set up and deliver the OHT service, including smoking cessation
Interrogating available data
Client needs and aspirations for the OHT service
Reflecting on service developments needs, including: linking prisoners to the OHT service on release; utilizing the probation induction programme to raise awareness; and signposting the service to ex-offenders
This led to reviews of related activity in two other probation settings: approved premises (formerly bail hostels) and a local women's project. The coordinator approached this through informal telephone and face-to-face meetings (n = 8) with a range of stakeholders across health and justice agencies.
There was considerable value in exploring how stop smoking support in probation settings might serve the wider agenda to reduce re-offending. For example:
The OHT project used peer education principles to promote health behaviour change which can contribute to improved self-esteem, self-worth and increased confidence, all factors associated with reducing re-offending behaviour
The women's project supported women at risk of offending to develop an individual work plan, an integral part of which was a health check incorporating smoking advice
In turn, the coordinator was able to demonstrate:
Opportunities for developing locations for effective delivery of stop smoking services
Good practice initiatives
Key learning to replicate and create linkages across the system
Staff training was identified as a way of changing knowledge, attitudes and practice, and locating stop smoking services within approved premises as a means of delivering structured group or 1 : 1 support to ‘hard-to-reach’ offenders subject to curfew.
Recommendations for developing quit services for offenders in probation settings
Support referral of quitters to an offender health trainer on release from prison to help reduce relapse
Develop offender health trainers as stop smoking advisers to facilitate access to specialist community stop smoking teams
Foster partnership working between community stop smoking specialists, probation, prisons, health service commissioners and wider community agencies to maximize effectiveness of stop smoking services
Explore opportunities for delivering targeted stop smoking interventions in approved premises: as a minimum, establish access to information, protocols and clear pathways into services
Pilot the delivery of stop smoking brief intervention training programme to probation staff
Raise awareness of the impact of second-hand smoke on children as part of training, where appropriate
Offender health trainer programmes are based on longer established community health trainer programmes; namely, trained peers offering one-to-one support, to help identify and make positive health changes and to encourage engagement with other services.
Prisons were described as ‘the easy bit of the jigsaw’ and emerged as the setting most prepared to engage with the project. This was attributed largely to the fact that there was a statutory requirement to provide cessation support within prisons. Consequently, relatively low-level intervention work, which raised awareness of service issues and brought together local stakeholders, was often sufficient to act as an impetus for change.
In prison it is about making sure that the services that are being delivered are robust enough and are being delivered in the way that they should be. That feels easier, although it's still a big challenge (PAG meeting 4).
… we've had very little input into [named prison which had improved its stop smoking services] other than the initial review … And again, I think it's just that issue about putting a bit of a spotlight on it and somebody's started asking questions, they've looked at what they could do … (interview 34).
Nevertheless, the coordinator's ability to act as a conduit for sharing information and as a catalyst for problem-solving was very beneficial:
If you have somebody come in who says, ‘Well you know, we are actually trying to do this across a number of prisons, it gives everybody a right to say, ‘Yes, we need to do this, we need to solve this’. And I think that helped the prison and I think it helped us [in public health] as well. It re-invigorated us to go and say, ‘Right, what do we need to do, how can we help?’ (interview 24).
I think it's useful because if you are based in a prison, you are very isolated and you do become quite blinkered. So it is good that someone who is not based in the prison, who is going around and seeing all these different ways of working, can keep reminding you of these things. That's hugely useful (interview 14).
In contrast, probation services were not required to provide smoking cessation support, and the focus here was placed upon providing more diverse support promoting brief intervention training, and documenting and sharing examples of good practice as ways of influencing the wider social and health care agenda (see Box 3).
From probation's point of view, when they [offenders] come out on supervision, they haven't really looked at the issues of smoking, because they've got other priorities like trying to prevent re-offending and drugs, alcohol, mental health, employment … (interview 8).
Engagement challenges were greatest in the police custody setting because tobacco control issues rarely featured on their health and safety agenda, and there was a lack of capacity and will to address the issue (Box 1). As a consequence, the approach adopted here was limited ultimately to using existing public health networks and links to try to encourage discussion of nicotine replacement therapy (NRT) provision at the regional police custody forum. These efforts were hampered by the apparent absence of national guidelines on the provision of NRT in police custody. Stakeholder assessments suggest that the project did not have the necessary profile and resources to effect change at the level required in this setting, or as one member of the intervention team commented on attempts to engage police custody management, it was like being up against a ‘solid brick wall’.
On reviewing the different levels of engagement achieved in each setting, the PAG and project management speculated that a higher level strategic approach was required if the project was to establish effective partnerships between the CJS and public health capable of providing continuity in cessation support for offenders as they move through the whole system.
I think we need to engage more strategically, I think the future would be to do that. I think what this project has done [so far] is established ways of doing things on the ground (interview 2).
Two environmental factors acted as significant barriers at the time of delivery. The first involved the economic downturn, which placed constraints on public finances, and the second involved a major reorganization of health services and the way in which patient care was to be delivered, which was responsible for uncertainties about future commissioning arrangements for stop smoking services and commitment to providing cessation support:
We [in the youth offending team] are undergoing audits of where our time can be most effectively spent so I think until that is done I don't think training [for brief interventions] is high on the agenda for us at the moment because we've got bigger priorities (interview 18).
These wider environmental factors and the transitional context not only had an impact on the structures and networks on which the project relied, but also on the management team and individual implementers, through organizational funding cuts, changing job remits and delays on decisions to fill vacant posts. However, it was also speculated that the proposed structural changes could lead to new development opportunities or, as one stakeholder suggested, ‘it depends on what happens with the commissioning of prison health care (and) what the roles are for prison staff’.
A range of factors influenced the progress of the project. The main facilitators were the experience, skills and personality of the postholder, and the complementary support and access to professional networks provided by the intervention manager and project advisers. Important barriers included the difficult operational climate characterized by financial cutbacks and organizational restructuring in potential partner agencies, and insufficient time to roll out and embed the project's guidance documents, which were intended to enhance cessation practice and widen tobacco control activity. However, despite these difficulties the project was able to demonstrate progress in a number of areas, while the proposed restructuring which involved shifting responsibility for public health decision-making to local authority structures  was seen to offer opportunities to address stop smoking provision as part of a wider health and social inequalities agenda.
The study design examined delivery processes associated with a tobacco control coordinator role, operating across a range of criminal justice settings and specific localities. While the case study approach limits the generalizability of the results, the multiple perspectives offered by interviewing a cross-section of stakeholders brings internal validity to the findings, as does the review of associated project documentation and observation of PAG meetings. The study, therefore, provides a robust data set for assessing the types of contribution that such a role can make, and the barriers and facilitators to its implementation in CJS. The methodology did not provide an assessment of impact on smoking rates at an individual level, nor of longer-term impact on health outcomes. It had originally been anticipated that routinely collected data on cessation rates in prisons would provide an indication of the project's impact, but data collection in prisons in the intervention area was found to be extremely variable and unreliable, leading to a decision to develop guidance on, and a framework for, record-keeping for prisons to address this gap. The extent to which these and other areas could be addressed underline limitations of the intervention in terms of time and scope.
Of particular relevance to others seeking to deliver cessation support in the CJS is the differential reach and impact the role had in each of the justice settings addressed by the project. As illustrated by the setting-specific case studies, the requirement to work within existing resources meant that developments were restricted mainly to the prison setting, where tobacco control measures were already an established feature of the offender health service (albeit variable in delivery) and where the coordinator role was able to act as a catalyst for change and improvement. At a practice level this divergence highlights important challenges to establishing cessation support for offenders moving across these settings, such as the failure to affect tobacco control policy in the police custody setting meant it was not possible to develop linkages between custody with other parts of the CJS. Only where links in health-care provision were already being developed, such as between a prison and a peer-led health trainer scheme set up by the local probationary service, was the coordinator able to raise the profile of cessation support. There are also useful insights for practitioners wishing to develop cessation support within these settings in terms of the types of approach required, most notably the provision of brief intervention training to frontline staff to promote engagement and awareness of smoking issues. At a policy level, the study findings suggest that there may be benefits in a national commissioning body to promoting greater coherence in the delivery of stop smoking services for offenders  and also highlights a need for clear guidance for NRT to support temporary abstinence for detainees in police custody.
In addition, differences in level of engagement with cessation support by CJS highlight the importance of developing complementary strategies to reflect settings-specific priorities: in probation, promoting stop smoking support as a means of tackling re-offending through enhanced self-esteem; and in police custody, offering NRT as a means of reducing aggression and stress brought about by nicotine withdrawal.
The views expressed by the project management team and advisers based on their experiences of supporting the project suggest that the coordinator role might be more effective if it were extended to operate at a strategic level, as it was believed that this would give the role the necessary authority to establish more formal structures and partnership working across health and criminal justice systems. Such a move away from a reliance on a local needs-led approach, it is believed, has the potential to enhance the role's influence through the formation of a regional tobacco control strategy for criminal justice. The success of incorporating a strategic partnership approach is dependent upon a number of factors, including: a requirement for a higher level appointment; additional resources; a joint commitment from relevant authorities in both health and criminal justice; and a longer time-frame to negotiate and implement an agreed strategy.
In conclusion, this intervention study provides some useful insights into the benefits and limitations of a tobacco control coordinator role working both within and across CJS to raise tobacco control awareness and improve provision of cessation support for offenders. The findings indicate that the role has the potential to change and influence practice in those parts of the CJS where cessation support is an established feature of health-care delivery, but is limited in its ability to promote interagency alliances and establish continuity in the delivery of cessation support across the CJS. These findings contribute to the evidence base regarding the strengths and limitations of health coordinators, and indicate that coordinator roles can be effective in helping to facilitate implementation of accepted policy , but in cases where policy development is weak and there is low readiness to change then establishing a more senior post with clear lines of accountability is critical to effecting organizational change .
The project is part of a portfolio funded by the Department of Health and led by the UK Centre for Tobacco Control Studies (UKCTCS: http://www.ukctcs.org). Stephen Woods, the Project Coordinator, had a central role in delivering the project which forms the focus of this evaluation. He also produced the initial draft case studies, under the direction of the intervention manager. The authors would like to acknowledge the support of the National Offender Management Service's North West office; the Regional Offender Health Team; the Governance Teams; prisons, particularly those participating in the case studies; Greater Manchester Probation Trust; NHS Heywood, Middleton and Rochdale PCT; Tobacco Free Futures and many other participating agencies. Thanks also to Debbie Cocker and Aileen Paton, who provided administrative support.
Declarations of interest
This research was carried out as part of a programme of inequalities projects implemented by the UK Centre for Tobacco Control Studies and funded by the Department of Health. Michelle Baybutt acted as the intervention manager for the project under evaluation. The remaining authors have no interests to declare.