Paper Calls for Improving Standards of Tobacco Treatment in Prisons and Jails

Prisons and jails are overdue in providing support to incarcerated individuals who use tobacco, wrote colleagues from UW-CTRI, the University of Colorado, and the University of California-San Francisco in a paper published in the American Journal of Preventive Medicine.

Anywhere between 50 to 80 percent of justice-involved people smoke. That’s much higher than the 11 percent prevalence among the general population of adults. Of those who smoke prior to incarceration, around 90 percent will relapse back to smoking after release from prison or jail.

Although the majority of carceral settings have some type of tobacco-free policy, the authors state that more needs to be done to eliminate second-hand smoke exposure while incarcerated. They assert that prisons and jails should provide equal access to tobacco treatment, commensurate with what is offered in the community, and in accordance with the standards for other substance use disorder treatment.

Treatment should include routine assessment of tobacco use, medically supervised withdrawal, access to medication and behavioral support during incarceration, with post-release referral to continued treatment.

According to the Prisons Policy Institute, half of justice-involved individuals have insurance, most on Medicaid. The authors point to expanding Medicaid coverage as one way to increase access to tobacco treatment during incarceration and upon reentry to the community.

Allison Gorrilla
Allison Gorrilla

“Wisconsin suspends Medicaid coverage for individuals while they are incarcerated,” said lead author and UW-CTRI Outreach Specialist Allie Gorrilla. “However, not every incarcerated individual who is eligible for Medicaid has their benefits reinstated before release. Individuals fall through the cracks and this gap in coverage poses a major barrier to accessing much needed health care.

“Health care delayed or not provided in a prison or jail worsens health outcomes for the justice-involved and pushes costs onto the community health care facilities where they access care after release.

“The section 1115 Medicaid demonstration waiver ensures people who are eligible for Medicaid not only enroll before they are released but start to receive treatment services normally covered under Medicaid up to 90 days before release,” Gorrilla said. “The 1115 waivers are an opportunity for states to address the high prevalence of smoking relapse after incarceration and provide tobacco treatment within a substance use treatment benefit package.

“Evaluating how reentry waivers improve health care access during reentry, improve health outcomes, and improve reentry success will be important for the states who have not yet adopted this policy.” While Wisconsin has 1115 waivers, they aren’t available to people released from prison.

In the last five years, the justice-involved population has become more of a focus of the UW-CTRI Outreach Program’s work with health systems, Gorrilla said..

UW-CTRI Outreach Specialists have opened a dialog with colleagues from the Department of Corrections as well as reentry program case managers about nicotine addiction, factors related to tobacco disparities, and motivational interviewing skills to build empathy towards people who smoke.

“Providers who work within correctional facilities have a good understanding of evidence-based treatments for substance use disorders,” she said. “We’re working to fill gaps in understanding tobacco treatments and the importance of co-treating nicotine dependence with other substance use disorders.”

This includes how to invite people into a conversation about their tobacco use, coaching them on how to address it—including accessing medications and support.

“The opioid epidemic in our country has led to increased attention and funding to improve access to substance use disorder treatment during incarceration and reentry to the community, as the period following release is a vulnerable time for relapse,” Gorrilla said.

“For example, the Bureau of Justice Assistance released guidance to improve the standards for substance use withdrawal management and treatment in prisons and jails.

“However, nicotine dependence treatment was left out of this guidance. Between the overlapping behavioral health and criminal justice systems of care, the UW-CTRI Outreach Program is working to change the culture and beliefs around tobacco treatment. It starts with education and helping these health systems navigate the real (and perceived) barriers to providing tobacco treatment within their substance use treatment and preventive health services.”

Gorrilla said one way to do that is by finding partners within the justice system or health system to champion the cause of tobacco dependence treatment. These “champions” are essential to systems change because they provide access to others within the system who can change policies that broadly impact how providers prioritize and treat tobacco dependence.

“That’s our aim working with the criminal justice system,” Gorrilla said, “to create systems change within an organization to align tobacco use screening and treatment standards with other substance use disorder treatment standards. The Center’s decades of experience working with Wisconsin health systems and communities disproportionately impacted by tobacco use can help achieve this aim within correctional facilities. We know the importance of system leadership support, a team approach, incentives to improve provision of treatment, and involving people with lived experience in decisions about tailoring the treatments they receive.”

The authors, including Dr. Jesse Kaye and Karen Conner, call for increased partnerships between public health, behavioral health, and criminal justice facilities to improve the standards of tobacco treatment within correctional facilities and to provide equitable access to these treatments during incarceration and reentry to the community.

Gorrilla AA, Kaye JT, Pavlik J, Bonniot C, Vijayaraghavan M, Conner KL, Morris CD. A Call for Health Equity in Tobacco Control and Treatment for the Justice-Involved Population. American Journal of Preventive Medicine. Online June 3, 2024.