Abstract

Tobacco use is a Public Health issue, and the release of its use in the prison system is controversial. Its prevalence in this population is high, including in women’s prisons. The objective of this article is to estimate tobacco use prevalence in women deprived of liberty and its associated factors. Cross-sectional study with 259 participants who answered a questionnaire in a prison in the Brazilian Midwest. The dependent variable was tobacco use, and the independent variables were sociodemographic, life history, legal status, and use of other drugs. Descriptive and bivariate analyses were performed, using prevalence ratios through the Chi-square test and Poisson regression in the multivariate analysis. Tobacco use prevalence was 86.87%. In the final model, the variables: age group, from 18-39 years (PR 1.33; 95%CI 1.10-1.61), alcohol use (PR 1.26; 95%CI 1.00-1.59), marijuana use (PR 1.16; 95%CI 1.03-1.30), and interaction between prison time and cocaine use (PR 1.05; 95%CI 1.00-1.11) remained associated with tobacco use. Tobacco use prevalence was high. The age group 18-39 years, alcohol and marijuana use and interaction between imprisonment length of 36 months or more and cocaine use were associated with tobacco use.

Key words:
Tobacco use; Prison; Women; Risk Factors

Introduction

There are eleven million people in prison worldwide, with prisons operating above capacity in 119 countries where measures to reduce the prison population have been inadequate. Brazil is the third country with the largest prison population (811,707), in absolute numbers, after the United States (2,068,800) and China (1,690,000). In our country, the prison population rate was 381 people deprived of liberty per 100,000 inhabitants, of which 5.1% were women. Brazil stands out in the growth of these rates when comparing the historical series between countries. Women showed an increase of 455% in the incarceration rate between 2000 and 2016, while, for example, a 2% reduction was observed in Russia¹1 Penal Reform International (PRI) and Thailand Institute of Justice (TIJ). Global Prison Trends 2021 [Internet]. Londres: PRI; 2021 [cited 2021 out 16]. Available from: https://www.penalreform.org/global-prison-trends-2021/key-messages-facts-and-figures.. The Penitentiary System of the State of Mato Grosso considered around 17,000 inmates in its custody, 12,460 of which were in physical cells, and the rest in home arrest with electronic monitoring²2 Departamento Penitenciário Nacional (DEPEN). Levantamento Nacional de Informações Penitenciárias, Período de Julho a Dezembro de 2020 [Internet]. Brasília: DEPEN; 2020 [acessado 2021 out 13]. Disponível em: https://www.gov.br/depen/pt-br/servicos/sisdepen..

Notably, tobacco use and the use of illicit drugs or other health issues in the general population are different from the epidemiological profile among individuals in the prison system, significantly how they are distributed, potentiated by overcrowded conditions, an unhealthy structure of cells with humidity, dirt, poor lighting, and ventilation, intense physical contact between prisoners, violence, abuse that directly impact health demands, thus hindering the care and treatment of these individuals in comprehensively and effectively³3 Minayo MCS, Constantino P, organizadoras. Deserdados sociais: condições de vida e saúde dos presos do estado do Rio de Janeiro. Rio de Janeiro: Ed. Fiocruz; 2015..

Tobacco use is a public health issue, a neurobehavioral disease caused by nicotine dependence, and a risk factor for chronic noncommunicable diseases⁴4 Benowitz NL. Pharmacology of nicotine: addiction, smoking-induced disease, and therapeutics. Annu Rev Pharmacol Toxicol 2009; 49:57-71.. The World Health Organization (WHO) points out that tobacco kills more than 8 million people yearly, and about 7 million of these deaths result from the direct use of this product, of which about 1.2 million are non-smokers exposed to secondhand smoke⁵5 Global Burden of Disease (GBD) [Internet]. Washington, D.C.: IHME [cited 2021 out 17]. Available from: https://www.healthdata.org/gbd/2019.
https://www.healthdata.org/gbd/2019... . The WHO also states that about 80% of the world’s 1.3 billion smokers live in low- and middle-income countries, where the burden of tobacco-related disease and death is highest⁶6 World Health Organization (WHO). Report the Global Tobacco Epidemic: addressing new and emerging products [Internet]. 2021 [cited 2021 out 13]. Available from: https://www.who.int/teams/health-promotion/tobacco-control/global-tobacco-report-2021.
https://www.who.int/teams/health-promoti... .

Health care in the prison system should be available and provided under conditions similar to health care for the general population. In this regard, several organizations have developed guidelines and standards for providing health care in correctional facilities. In Brazil, the Ministry of Health developed the National Comprehensive Health Care Policy for People Deprived of Liberty in the Prison System (PNAISP), established through Interministerial Ordinance No. 1 of January 2, 2014, whose main objective is assuring the right to health for all persons deprived of their liberty in the Prison System. Moreover, this policy aims to guarantee this population’s access to the Unified Health System (SUS), respecting the precepts of human rights and citizenship⁷7 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Coordenação de Saúde no Sistema Prisional. Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional. 1ª ed. Brasília: MS; 2014., and the National Health Care Policy for Incarcerated and Released Women (PNAMPE)⁸8 Brasil. Ministério da Justiça e Segurança Pública (MJ). Departamento Penitenciário Nacional. Gabinete do Departamento Penitenciário Nacional. Nota Técnica nº 17/2020/DIAMGE/CGCAP/DIRPP/DEPEN/MJ, de 26 de maio de 2020. Consolida a Política Nacional de Atenção às Mulheres em Situação de Privação de Liberdade e Egressas do Sistema Prisional (PNAMPE). Brasília: MJ; 2020..

We should highlight that Brazil has consolidated the National Tobacco Control Program (PNCT) within the SUS, including the Clinical Protocol and Therapeutic Guidelines for Nicotine Dependence⁹9 Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria nº 1.575, de 29 de agosto de 2002. Consolida o Programa Nacional de Controle do Tabagismo. Diário Oficial da União 2002; 3 set.. As a result, the smoker’s cognitive-behavioral approach and drug treatment, with Nicotine and Bupropion Replacement Therapy, started to be provided free of charge to the Brazilian population.

Brazil has stood out worldwide due to the implantation and implementation of tobacco control policies that are progressively more effective, which reduced tobacco use prevalence from 34.8% in 1989 in the adult population¹⁰10 Instituto Nacional de Alimentação e Nutrição (INAN). Pesquisa Nacional sobre Saúde e Nutrição (PNSN) 1989. Brasília: INAN, MS; 1990. to 12.6% in 2019¹¹11 Instituto Brasileiro de Geografia e Estatística (BR). Pesquisa nacional de saúde: 2019: informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2020., although reducing tobacco use among women was lower than among men.

Prison tobacco use has been seen as a stress coping mechanism¹²12 Turan O, Turan PA. Smoking-Related Behaviors and Effectiveness of Smoking Cessation Therapy Among Prisoners and Prison Staff. Respir Care 2016; 61(4):434-438., combined with the lack of smoking cessation treatments, which may contribute to high smoking rates. Women experience separation from family and friends, deprivation of liberty, long periods of boredom in cells, and stress around the personal situation they must address when returning to the community¹³13 Mignon S. Health issues of incarcerated women in the United States. Cien Saude Colet 2016; 21(7):2051-2060.. Furthermore, we observe difficulties interacting with prisoners, correctional officers, and the health team.

Considering tobacco use as a public health problem, besides its higher prevalence in the population deprived of liberty, because this chemical dependence is a risk factor for NCDs, this study aims to estimate tobacco use prevalence and the associated factors in women deprived of liberty in Cuiabá, Mato Grosso, Brazil.

Methods

This cross-sectional epidemiological study was conducted with all 259 adult women deprived of their liberty at the Ana Maria do Couto May Female Penitentiary in Cuiabá, Central West Brazil.

The interviews were held in the prison unit’s ward from October 2020 to March 2021 by the medical researcher who works in public health and tobacco use by order of arrival of the participants. An interview was conducted, and a questionnaire containing questions with the following fields (independent variables) was applied: general information with identification, sociodemographic data, arrest date, life history, criminal history, use of tobacco, alcohol, and other drugs, and questions related to comorbidities.

The dependent variable was tobacco use, defined when the respondent answered that she was smoking and had smoked more than 100 cigarettes in her lifetime.

All women deprived of their liberty who voluntarily accepted to participate were included, and women who had cognitive or behavioral impairments that hindered their answers to the questionnaire were excluded.

Regarding data analysis, a descriptive analysis was initially performed, followed by bivariate analysis, to associate the dependent variable (tobacco use) and other independent variables, using the Mantel-Haenszel chi-square test and the measure of association with the Prevalence Ratio, with their respective 95% confidence intervals. Possible confounding and interactions were also tested through stratified analysis per the biological plausibility criteria endorsed by the scientific literature. Variables with association test with p<0.20 were tested in Poisson’s multivariate model with robust variance estimation, gradually removing by the backward method, and maintaining the variables with a p-value less than 5% (p<0.05) in the final multivariable model.

Analyses were performed using Epi-Info® 7.2.4 software (Center for Disease Control and Prevention, Atlanta, Georgia, USA), with subsequent use of SPSS® software version 20.0 (SPSS Inc., Chicago, IL, USA) for analysis of the multivariate model. The Research Ethics Committee of the Federal University of Mato Grosso approved the research project under Opinion No. 4.038.796. All participants were informed about the characteristics of the study and signed the Informed Consent Form.

Results

The mean age of the inmates was 32.63 (SD±9.12) years. Table 1 shows the descriptive sociodemographic data, where the most prevalent age group was 18-29 years (46.33%), and being single was the most common marital status, with 51.74%. Regarding schooling, the largest group was incomplete elementary school, with 43.24%. Most were brown (62.93%).

On average, women deprived of their liberty were incarcerated for at least 51.73 months (SD±58.56) or 4.31 years. Table 1 also contains life history, criminal justice status, and substance use data. Notably, most of them were raised without parents (55.21%), had good family relationships (55.60%), and had children younger than 12 years old (45.46%). As for their legal status, most of them were in a temporary situation (57.53%). Concerning substance use, tobacco use prevalence was 86.87%, and the use of other drugs up to imprisonment: alcohol use was 67.18%, and use of illicit drugs (marijuana or cocaine) was 57.92%.

The mean initiation age of smoking was 13.41±1.91 years, alcohol 15.60±3.67 years, marijuana 15.50±2.92 years, and cocaine 16.33±3.30 years (Table not shown).

The measures of association between tobacco use and sociodemographic data are shown in Table 2. Variables associated with tobacco use were the age group 18-39 years (PR 1.44; 95%CI 1.17-1.78) and schooling up to high school (PR 1.17; 95%CI 0.93-1.49).

In Table 3, the bivariate analysis shows the association between tobacco use and having suffered childhood violence (PR 1.12; 95%CI 1.03-1.23), drug-related crime (PR 1.11; 95%CI 1.01-1.23), alcohol use (PR 1.50; 95%CI 1.18-1.90), marijuana use (PR 1.32; 95%CI 1.17-1.28) and cocaine use (PR 1.17; 95%CI 1.07-1.28).

Seeking some associations between cocaine and tobacco use, at first, this use was stratified between the age group from 18-39 years and 40 years and over, where an association of 1.12 times more between cocaine and tobacco use was observed only with a statistically significant association in the age group 18-39 years. Moreover, when stratifying cocaine and tobacco use by prison time, an association was identified only among those who had been in prison for 36 months or longer, with 1.26 times more cocaine use among the latter (Table 4).

In the final multivariable model, Table 5, we observed that the following variables remained associated with tobacco use: age group 18-39 years (PR 1.33; 95%CI 1.10-1.61), alcohol use (PR 1.26; 95%CI 1.00-1.59), marijuana use (PR 1.16; 95%CI 1.03-1.30) and interaction between prison time 36 months and over and marijuana use (PR 1.16; 95%CI 1.03-1.30) and interaction between prison time 36 months and over.

Discussion

The tobacco use prevalence found was relatively high in this study (86.9%). This data is similar to that of the international and national literature, which has found high tobacco use rates in people deprived of liberty¹⁴14 Spaulding AC, Eldridge GD, Chico CE, Morisseau N, Drobeniuc A, Fils-Aime R, Day C, Hopkins R, Jin X, Chen J, Dolan KA. Smoking in Correctional Settings Worldwide: Prevalence, Bans, and Interventions. Epidemiol Rev 2018; 40(1):82-95.^,1515 Howell BA, Guydish J, Kral AH, Comfort M. Prevalence and factors associated with smoking tobacco among men recently released from prison in California: A cross- sectional study. Addict Behav 2015; 50:157-160.. A study in the Brazilian Northeast showed that 60.3% of the inmates were smokers¹⁶16 Medeiros MM, Santos AAP, Oliveira KRV, Silva NAS, Silva JKAM, Anunciação BMG. Panorama das condições de saúde de um presídio feminino do nordeste brasileiro. Rev Pesqui (Univ Fed Estado Rio J, Online) 2021; 13:1060-1067.. Another study carried out with women deprived of liberty in the U.S. showed that most inmates (73.9%) were smokers, and 60.6% of them had already attempted to quit smoking at least once in their lifetime. Overall, 64.2% reported interest in participating in the smoking cessation program, but only 24.5% felt very confident¹⁷17 Cropsey K, Eldridge G, Ladner T. Smoking among female prisoners: an ignored public health epidemic. Addict Behav 2004; 29(2):425-431..

Notably, most female smokers in the Penitentiary responded positively that they would like to participate in a cessation program. Possibly, these women felt the importance of the almost daily presence of the principal researcher of this study, who, besides tobacco use, voluntarily performed care for other diseases, with health guidelines, referrals, and more straightforward interventions demanded by the study population.

However, the numbers were much higher when comparing the tobacco use prevalence in this study with the general population. The VIGITEL 2020 (Telephone Survey on Surveillance of Risk and Protection Factors for Chronic Diseases) carried out only in Brazilian capitals identified that the tobacco use prevalence in adults was 9.5% and was higher in males (11.7%) than in females (7.6%). In Cuiabá-MT, this prevalence of female smokers was 8.1%¹⁸18 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2020: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2020. Brasília: MS; 2021..

Some possible explanations can be suggested to understand better this high prevalence rate in women deprived of liberty. First, prison is a hostile environment, leading to worse chronic stress conditions, restrictive norms in these communities, and difficult access to health services¹⁹19 Ahmed R, Angel C, Martel R, Pyne D, Keenan L. Access to healthcare services during incarceration among female inmates. Int J Prison Health 2016; 12(4):204-215.. Other situations, also not evaluated in this study, may be related to imbalances, inequalities, and social violence expressed in the incarceration situation, besides unhealthy conditions such as poorly ventilated cells, the very social marginalization of these women deprived of liberty, and the limited access to health care³3 Minayo MCS, Constantino P, organizadoras. Deserdados sociais: condições de vida e saúde dos presos do estado do Rio de Janeiro. Rio de Janeiro: Ed. Fiocruz; 2015..

In our study, a higher tobacco use prevalence was observed among younger women, and this association was statistically significant in the final model. Similar to other studies that show in young adults the highest tobacco use prevalence among all age groups in most industrialized countries and significant variability in smoking behavior²⁰20 Ghenadenik AE, Gauvin L, Frohlich KL. Smoking in Young Adults: A Study of 4-Year Smoking Behavior Patterns and Residential Presence of Features Facilitating Smoking Using Data From the Interdisciplinary Study of Inequalities in Smoking Cohort. Nicotine Tob Res 2020; 22(11):1997-2005.^,2121 Reid JL, Hammond D, Rynard VL, Madill CL, Burkhalter R. Tobacco Use in Canada: Patterns and Trends, 2017 Edition. Waterloo: Propel Center for Population Health Impact, University of Waterloo; 2017..

Another variable associated with tobacco use in the final model was previous alcohol use, as found in another study²²22 Richmond RL, Indig D, Butler TG, Wilhelm KA, Archer VA, Wodak AD. Smoking and other drug characteristics of aboriginal and non-aboriginal prisoners in australia. J Addict 2013; 2013:516342.. Alcohol and nicotine have interactive pharmacological effects that motivate their combined use, besides a reinforcing and cross-tolerance role in developing consumption, maintenance, and dependence on both substances²³23 Oliver JA, Blank MD, Van Rensburg KJ, MacQueen DA, Brandon TH, Drobes DJ. Nicotine interactions with low-dose alcohol: pharmacological influences on smoking and drinking motivation. J Abnorm Psychol. 2013; 122(4):1154-1165..

Similar to previous alcohol use, in our study, previous marijuana use was also associated with smoking, as found in another study²²22 Richmond RL, Indig D, Butler TG, Wilhelm KA, Archer VA, Wodak AD. Smoking and other drug characteristics of aboriginal and non-aboriginal prisoners in australia. J Addict 2013; 2013:516342.. The pre-incarceration biopsychosocial conditions and the health situation of the prison population show that disorders related to other drugs commonly precede imprisonment among people deprived of their liberty. Another study shows that using tobacco and marijuana, two of the most used substances worldwide, are strongly linked in several aspects²⁴24 Lemyre A, Poliakova N, Bélanger RE. The Relationship Between Tobacco and Cannabis Use: A Review. Subst Use Misuse 2019; 54(1):130-145..

Possibly, the use of other drugs may influence tobacco use, both in initiating and maintaining dependence, qualifying these users as polyaddicts²⁵25 Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, Okuda M, Wang S, Grant BF, Blanco C. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend 2011; 115(1-2):120-130.^,2626 Liu Y, Williamson V, Setlow B, Cottler LB, Knackstedt LA. A importância de considerar o uso de polissubstâncias: lições da pesquisa sobre cocaína. Drug Alcohol Depend 2018; 192:16-28.. A study shows that most (64%) individuals sentenced to prison reported drug use in the month preceding their arrest. Furthermore, nearly half of the subjects met the criteria for the disorder related to substance use before incarceration, with 40% having a drug use-related disorder and 21% alcohol use-related disorder²⁷27 Maruschak LM, Bronson J, Alper M. Survey of prison inmates, 2016: Alcohol and drug use and treatment reported by prisoners. Washington: Bureau of Justice Statistics; 2016.. In another study with 102 adults incarcerated in an urban prison in the U.S., more than 70% of the participants were smokers, despite solid knowledge (95%) of the link between smoking and severe diseases²⁸28 Ahalt C, Buisker T, Myers J, Williams B. Smoking and Smoking Cessation Among Criminal Justice-Involved Older Adults. Tob Use Insights 2019; 12:1179173x19833357..

Epidemiological studies have shown that nicotine use is a gateway to marijuana and cocaine use in human populations. The licit drug problem usually starts in adolescence and continues with illicit drugs²⁹29 Kandel DB, Kandel ER. A molecular basis for nicotine as a gateway drug. N Engl J Med 2014; 371(21):2038-2039.. Aligned with this, our research found that the mean age of tobacco use initiation was lower than alcohol, marijuana, and cocaine.

A study conducted with a sample of 287 women in a female penitentiary in Porto Alegre-RS, Brazil, found that 54.4% had used psychoactive substances (throughout their lives), 15.7% had alcohol dependence, and 38.3 % were addicted to other substances, such as marijuana, cocaine, and crack³⁰30 Mello DC. Quem são as mulheres encarceradas? [dissertação]. Porto Alegre: Pontifícia Universidade Católica do Rio Grande do Sul; 2008.. Another study with a sample of 134 women in a penitentiary in Rio de Janeiro-RJ, Brazil, identified that 45.5% of the women used illicit drugs when released, and marijuana was the most commonly used, followed by cocaine and crack³¹31 Quitete B, Paulino B, Hauck F, Aguiar-Nemer AS, Silva-Fonseca VA. Transtorno de estresse pós-traumático e uso de drogas ilícitas em mulheres encarceradas no Rio de Janeiro. Rev Psiquiatr Clin 2012; 39(2):43-47..

In this study, the model of interaction between prison time and cocaine consumption ended up remaining in the multivariate model, indicating an association between cocaine and tobacco use among those deprived of liberty with extended imprisonment. Possibly, the prevalence of cocaine use was higher among the latter, consistent with another study that shows the use of illicit substances associated with an adjusted 2.47 higher likelihood of tobacco use (95%CI 1.29-5.39). The bivariate analysis showed that each additional five years of incarceration history was associated with a 1.32-fold more significant likelihood of tobacco use (95%CI 1.02-1.71)¹⁵15 Howell BA, Guydish J, Kral AH, Comfort M. Prevalence and factors associated with smoking tobacco among men recently released from prison in California: A cross- sectional study. Addict Behav 2015; 50:157-160..

Some limitations of the study must be considered. Cross-sectional studies do not necessarily establish a relationship between cause and effect and the use of subjective or self-report information, which can lead to memory bias. Another limitation is that the information collected was self-reported, which could have contributed to underestimating the proportions of the explanatory variables. However, using the prevalence ratio as a measure of effect in the bivariate and the multivariate Poisson model analyses allowed a good adjustment of the measures of effect and prevented the overestimation of the measures of association.

Knowledge about the factors associated with tobacco use in the population studied becomes relevant when planning to implement a cessation program. This work is one of the first studies to evaluate the factors associated with tobacco use in the entire female population deprived of liberty in a Brazilian penitentiary. The diversity of factors involved should be considered, such as obstacles to cessation, highlighting aspects related to this woman’s social space condition and that she is polyaddicted. The public authorities should allow these smokers to become tobacco-free, which will reduce harm to this population’s health.

Conclusion

The prevalence of tobacco use among women deprived of liberty in this study was high. The main variables associated with tobacco use were age group 18-39 years, alcohol and marijuana use, and interaction between 36 months and over prison time and cocaine use. Women’s incarceration offers an excellent opportunity to address smoking cessation treatment. Among so many adverse circumstances related to prison life, we should highlight that it is possible to develop actions such as approaching smoking cessation, improving health education, and establishing health support networks for this vulnerable and neglected population if it is in the interest of the prison public service and the SUS.

References

Publication Dates

History