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.