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1.  National Trends in Pharmaceutical Opioid Related Overdose Deaths Compared to other Substance Related Overdose Deaths: 1999-2009 
Drug and alcohol dependence  2013;131(3):263-270.
Background:
Pharmaceutical opioid related deaths have increased. This study aimed to place pharmaceutical opioid overdose deaths within the context of heroin, cocaine, psychostimulants, and pharmaceutical sedative hypnotics, examine demographic trends, and describe common combinations of substances involved in opioid related deaths.
Methods:
We reviewed deaths among 15-64 year olds in the US from 1999-2009 using death certificate data available through the CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) Database. We identified International Classification of Disease-10 codes describing accidental overdose deaths, including poisonings related to stimulants, pharmaceutical drugs, and heroin. We used crude and age adjusted death rates (deaths/100,000 person years [p-y] and 95% confidence interval [CI] and multivariable Poisson regression models, yielding incident rate ratios (IRRs), for analysis.
Results:
The age adjusted death rate related to pharmaceutical opioids increased almost 4-fold from 1999 to 2009 (1.54/100,000 p-y [95% CI 1.49-1.60] to 6.05/100,000 p-y [95% CI 5.95-6.16; p<0.001). From 1999 to 2009, pharmaceutical opioids were responsible for the highest relative increase in overdose death rates (IRR 4.22, 95% CI 3.03-5.87) followed by sedative hypnotics (IRR 3.53, 95% CI 2.11-5.90). Heroin related overdose death rates increased from 2007 to 2009 (1.05/100,000 persons [95% CI 1.00-1.09] to 1.43/100,000 persons [95% CI 1.38-1.48; p<0.001). From 2005-2009 the combination of pharmaceutical opioids and benzodiazepines was the most common cause of polysubstance overdose deaths (1.27/100,000 p-y (95% CI 1.25-1.30).
Conclusion:
Strategies, such as wider implementation of naloxone, expanded access to treatment, and development of new interventions are needed to curb the pharmaceutical opioid overdose epidemic.
doi:10.1016/j.drugalcdep.2012.11.018
PMCID: PMC3935414  PMID: 23294765
Overdose; poisoning; pharmaceutical opioids; stimulants; heroin; mortality
2.  Psychostimulant-Related Deaths among Former Inmates 
Journal of addiction medicine  2012;6(2):10.1097/ADM.0b013e318239c30a.
Objectives
Psychostimulants are highly addictive and their use is increasing. Little is known about psychostimulant-related deaths. This study identified characteristics, risk factors, and contributing substances reported upon death among former prison inmates who died from a psychostimulant-related death.
Methods
This retrospective cohort study of released inmates from 1999–2003 (N=30,237) linked data from the Washington State Department of Corrections with the National Death Index. We examined characteristics of individuals who died with psychostimulants listed among their causes-of-death. These were categorized into three groups: 1) non-cocaine psychostimulants, 2) cocaine only, and 3) all psychostimulants. Cox proportional hazards regression determined risk factors for death in each group, and the risk of death in the first two weeks after release from prison
Results
Of the 443 inmates who died, 25(6%) had non-cocaine psychostimulants listed among their causes-of-death. Six of these 25 deaths had both non-cocaine psychostimulants and cocaine listed among their causes-of-death. Most of the former inmates who died with non-cocaine psychostimulants were male (n=21, 84%) and non-Hispanic white (88%, n=22). Cocaine only was listed among the causes-of-death for 49 former inmates; most were male (n=35, 71%) and non-Hispanic white (n=27, 55%). Longer length of incarceration was associated with a reduced risk of death from any psychostimulant use (HR=0.76, CI=0.63–0.920 for each additional year of incarceration) and from use of non-cocaine psychostimulants (Hazard Ratio [HR] =0.42, 95% Confidence interval [CI] =0.22 to 0.80). Risk of death was highest during the first 2 weeks post release for cocaine only-related deaths (Incidence mortality ratio [IMR]=1,224.0, CI=583–1,865).
Conclusions
Former prisoners have a significant risk of death from psychostimulants, especially within the first two weeks post release.
doi:10.1097/ADM.0b013e318239c30a
PMCID: PMC3883279  PMID: 22134174
methamphetamine; prison; overdose
3.  Psychostimulant-Related Deaths as Reported by a Large National Database 
Introduction
Increased methamphetamine use occurred during the last decade and little is known about factors associated with death.
Objective
This study assesses trends in psychostimulant deaths in the United States.
Methods
Using the CDC Wonder Database we reviewed all deaths among 15-64 year olds from 1999 to 2009. We identified decedents who died with “psychostimulants with abuse potential, excluding cocaine” using the ICD code T43.6 to identify methamphetamine-related deaths. We determined trends in death rates and the most common underlying causes of death. We calculated age-stratified and age-adjusted death rates/100,000 person-years (p-y) and (95% confidence interval [CI]) among those who died with psychostimulants from 2005 to 2009.
Results
The rate of psychostimulant-related deaths increased three fold from 1999 (0.37/100,000 (p-y) (95% CI 0.354-0.39) to 2005 (1.05/100,000 p-y (95% CI 1.01-1.10). Deaths steadily declined from 2006 to 2008, but rose again in 2009 to 0.97/100,000 p-y (95% CI 0.92-1.01). Across all age groups, men had a 2-3 times higher rate of death than women. American Indians/Alaska Natives were twice as likely to die a psychostimulant-related death as compared to non-Hispanic whites. The Northwestern/Western region of the US had the highest rates of psychostimulant-related deaths, while the Northeastern region had the lowest death rates. “Accidental poisonings” (ICD-10: X40-49) was the most frequently listed cause of death among those who died with psychostimulants.
Conclusions
Psychostimulant related deaths declined from 2006 to 2008 but are rebounding. Interventions targeting those at highest risk of death must be implemented and studied to prevent increasing deaths.
doi:10.1080/08897077.2012.726959
PMCID: PMC3876881  PMID: 23577906
methamphetamine; amphetamine; psychostimulant; overdose
4.  Primary Care Physician Perceptions on Caring for Complex Patients with Medical and Mental Illness 
ABSTRACT
BACKGROUND
Mental illness is common and associated with poor outcomes for co-occurring medical illness. Since primary care physicians manage the treatment of complex patients with both mental and medical illnesses, their perspectives on the care of these patients is vital to improving clinical outcomes.
OBJECTIVE
To examine physician perceptions of patient, physician and system factors that affect the care of complex patients with mental and medical illness.
DESIGN
Inductive, participatory, team-based qualitative analysis of transcripts of in-depth semi-structured interviews.
PARTICIPANTS
Fifteen internal medicine physicians from two university primary care clinics and three community health clinics.
RESULTS
Participant characteristics were balanced in terms of years in practice, practice site, and gender. Physicians identified contributing factors to the complexity of patient care within the domains of patient, physician and system factors. Physicians identified 1) type of mental illness, 2) acuity of mental illness, and 3) communication styles of individual patients as the principal patient characteristics that affected care. Physicians expressed concern regarding their own lack of medical knowledge, clinical experience, and communication skills in treating mental illness. Further, they discussed tensions between professionalism and emotional responses to patients. Participants expressed great frustration with the healthcare system centered on: 1) lack of mental health resources, 2) fragmentation of care, 3) clinic procedures, and 4) the national healthcare system.
CONCLUSIONS
Physicians in this study made a compelling case for increased training in the treatment of mental illness and improvements in the delivery of mental health care. Participants expressed a strong desire for increased integration of care through collaboration between primary care providers and mental health specialists. This approach could improve both comfort in treating mental illness and the delivery of care for complex patients.
doi:10.1007/s11606-012-2005-9
PMCID: PMC3403152  PMID: 22370766
mental health services; comorbidity; ambulatory care; qualitative research
5.  HIV risk after release from prison: a qualitative study of former inmates 
Background
Former prison inmates are at risk for HIV and Hepatitis C (HCV). This study was designed to understand how former inmates perceived their risk of HIV and HCV after release from prison, the behaviors and environmental factors that put patients at risk for new infection and the barriers to accessing health care.
Methods
Qualitative study utilizing individual, face-to-face, semi-structured interviews exploring participants’ perceptions and behaviors putting them at risk for HIV and HCV and barriers to engaging in regular medical care after release. Interview transcripts were coded and analyzed utilizing a team-based general inductive approach.
Results
Participants were racially and ethnically diverse and consisted of 20 men and 9 women with an age range of 22–57 years who were interviewed within the first two months after their release from prison to the Denver, Colorado community. Four major themes emerged: 1) risk factors including unprotected sex, transactional sex, and drug use were prevalent in the post-release period; 2) engagement in risky behavior occurred disproportionately in the first few days after release; 3) former inmates had educational needs about HIV and HCV; and 4) former inmates faced major challenges in accessing health care and medications.
Conclusions
Risk factors for HIV and HCV were prevalent among former inmates immediately after release. Prevention efforts should focus on education, promotion of safe sex and needle practices, substance abuse treatment, and drug- free transitional housing. Improved coordination between correctional staff, parole officers and community health care providers may improve continuity of care.
doi:10.1097/QAI.0b013e31821e9f41
PMCID: PMC3685495  PMID: 21522015
6.  Confined to Ignorance: The Absence of Prisoner Information from Nationally Representative Health Data Sets 
Abtract
BACKGROUND
Incarceration is associated with poor health and high costs. Given the dramatic growth in the criminal justice system’s population and associated expenses, inclusion of questions related to incarceration in national health data sets could provide essential data to researchers, clinicians and policy-makers.
OBJECTIVE
To evaluate a representative sample of publically available national health data sets for their ability to be used to study the health of currently or formerly incarcerated persons and to identify opportunities to improve criminal justice questions in health data sets.
DESIGN & APPROACH
We reviewed the 36 data sets from the Society of General Internal Medicine Dataset Compendium related to individual health. Through content analysis using incarceration-related keywords, we identified data sets that could be used to study currently or formerly incarcerated persons, and we identified opportunities to improve the availability of relevant data.
KEY RESULTS
While 12 (33%) data sets returned keyword matches, none could be used to study incarcerated persons. Three (8%) could be used to study the health of formerly incarcerated individuals, but only one data set included multiple questions such as length of incarceration and age at incarceration. Missed opportunities included: (1) data sets that included current prisoners but did not record their status (10, 28%); (2) data sets that asked questions related to incarceration but did not specifically record a subject’s status as formerly incarcerated (8, 22%); and (3) longitudinal studies that dropped and/or failed to record persons who became incarcerated during the study (8, 22%).
CONCLUSIONS
Few health data sets can be used to evaluate the association between incarceration and health. Three types of changes to existing national health data sets could substantially expand the available data, including: recording incarceration status for study participants who are incarcerated; recording subjects’ history of incarceration when this data is already being collected; and expanding incarceration-related questions in studies that already record incarceration history.
doi:10.1007/s11606-011-1858-7
PMCID: PMC3270223  PMID: 21922160
incarceration; prisoner; data; health; disparities
7.  Health Disparities and the Criminal Justice System: An Agenda for Further Research and Action 
Although racial and ethnic minorities are more likely to be involved with the criminal justice system than whites in the USA, critical scientific gaps exist in our understanding of the relationship between the criminal justice system and the persistence of racial/ethnic health disparities. Individuals engaged with the criminal justice system are at risk for poor health outcomes. Furthermore, criminal justice involvement may have direct or indirect effects on health and health care. Racial/ethnic health disparities may be exacerbated or mitigated at several stages of the criminal justice system. Understanding and addressing the health of individuals involved in the criminal justice system is one component of a comprehensive strategy to reduce population health disparities and improve the health of our urban communities.
doi:10.1007/s11524-011-9614-1
PMCID: PMC3284594  PMID: 21915745
Prisons; Health disparities; Health care delivery
8.  Risk Factors for Cervical Cancer in Criminal Justice Settings 
Journal of Women's Health  2011;20(12):1839-1845.
Abstract
Background
Women in criminal justice settings have an increased prevalence of cervical cancer compared with the general population. However, little is known about abnormal cervical cancer screening results among women in jail and community-based criminal justice settings. Thus, the aims of this study were to compare the prevalence of self-reported abnormal Papanicolou (Pap) test results in women in jail and under community criminal justice supervision and to examine factors associated with abnormal Pap tests in these criminal justice settings.
Methods
We analyzed data from two cross-sectional surveys of women in jails and community corrections in two Southern cities (n=380) about their history of abnormal Pap tests and risk factors for cervical cancer. Univariate analyses (analysis of variance [ANOVA] and chi-square) and a binary logistic regression analysis were conducted to test associations between a history of abnormal Pap testing and factors known to be associated with cervical cancer.
Results
Nearly half of the women surveyed (n=163, 43%) reported ever having an abnormal Pap test. There was a high prevalence of risk factors for cervical cancer among women with and without an abnormal Pap test. After controlling for age and race, there were significant associations between an abnormal Pap test and inconsistent use of barrier protection (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.18-3.43), having a history of gynecologic infections (OR 1.68, 95% CI 1.05-2.67), and having a history of sexually transmitted diseases (OR 1.92, 95% CI 1.17-3.15).
Conclusions
Women in jail and under community justice supervision reported a high prevalence of risk factors for cervical cancer. Because of their high prevalence of abnormal Pap testing, women in criminal justice settings may be appropriate targets for improved cervical cancer screening, prevention with human papillomavirus (HPV) vaccination, risk reduction education, and treatment.
doi:10.1089/jwh.2011.2864
PMCID: PMC3236985  PMID: 22004180
9.  Patient, Resident Physician, and Visit Factors Associated with Documentation of Sexual History in the Outpatient Setting 
ABSTRACT
BACKGROUND
Providers need an accurate sexual history for appropriate screening and counseling, but data on the patient, visit, and physician factors associated with sexual history-taking are limited.
OBJECTIVES
To assess patient, resident physician, and visit factors associated with documentation of a sexual history at health care maintenance (HCM) visits.
DESIGN
Retrospective cross-sectional chart review.
PARTICIPANTS
Review of all HCM clinic notes (n = 360) by 26 internal medicine residents from February to August of 2007 at two university-based outpatient clinics.
MEASUREMENTS
Documentation of sexual history and patient, resident, and visit factors were abstracted using structured tools. We employed a generalized estimating equations method to control for correlation between patients within residents. We performed multivariate analysis of the factors significantly associated with the outcome of documentation of at least one component of a sexual history.
KEY RESULTS
Among 360 charts reviewed, 25% documented at least one component of a sexual history with a mean percent by resident of 23% (SD = 18%). Factors positively associated with documentation were: concern about sexually transmitted infection (referent: no concern; OR = 4.2 [95% CI = 1.3–13.2]); genitourinary or abdominal complaint (referent: no complaint; OR = 4.3 [2.2–8.5]); performance of other HCM (referent: no HCM performed; OR = 3.2 [1.5–7.0]), and birth control use (referent: no birth control; OR = 3.0 [1.1, 7.8]). Factors negatively associated with documentation were: age groups 46–55, 56–65, and >65 (referent: 18–25; ORs = 0.1, 0.1, and 0.2 [0.0–0.6, 0.0–0.4, and 0.1–0.6]), and no specified marital status (referent: married; OR = 0.5 [0.3–0.8]).
CONCLUSIONS
Our findings highlight the need for an emphasis on documentation of a sexual history by internal medicine residents during routine HCM visits, especially in older and asymptomatic patients, to ensure adequate screening and counseling.
doi:10.1007/s11606-011-1711-z
PMCID: PMC3138976  PMID: 21523496
communication skills; medical education; aging; sexually transmitted disease; ambulatory care
10.  Return to drug use and overdose after release from prison: a qualitative study of risk and protective factors 
Background
Former inmates are at high risk for death from drug overdose, especially in the immediate post-release period. The purpose of the study is to understand the drug use experiences, perceptions of overdose risk, and experiences with overdose among former prisoners.
Methods
This qualitative study included former prison inmates (N = 29) who were recruited within two months after their release. Interviewers conducted in-person, semi-structured interviews which explored participants' experiences and perceptions. Transcripts were analyzed utilizing a team-based method of inductive analysis.
Results
The following themes emerged: 1) Relapse to drugs and alcohol occurred in a context of poor social support, medical co-morbidity and inadequate economic resources; 2) former inmates experienced ubiquitous exposure to drugs in their living environments; 3) intentional overdose was considered "a way out" given situational stressors, and accidental overdose was perceived as related to decreased tolerance; and 4) protective factors included structured drug treatment programs, spirituality/religion, community-based resources (including self-help groups), and family.
Conclusions
Former inmates return to environments that strongly trigger relapse to drug use and put them at risk for overdose. Interventions to prevent overdose after release from prison may benefit from including structured treatment with gradual transition to the community, enhanced protective factors, and reductions of environmental triggers to use drugs.
doi:10.1186/1940-0640-7-3
PMCID: PMC3414824  PMID: 22966409
Drug use; Overdose; Prisoners; Relapse; Prison re-entry
11.  Gender Differences in Chronic Medical, Psychiatric, and Substance-Dependence Disorders Among Jail Inmates 
American journal of public health  2009;100(3):476-482.
Objectives
We investigated whether there were gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates and whether substance dependence mediated any gender differences found.
Methods
We analyzed data from a nationally representative survey of 6982 US jail inmates. Weighted estimates of disease prevalence were calculated by gender for chronic medical disorders (cancer, hypertension, diabetes, arthritis, asthma, hepatitis, and cirrhosis), psychiatric disorders (depressive, bipolar, psychotic, posttraumatic stress, anxiety, and personality), and substance-dependence disorders. We conducted logistic regression to examine the relationship between gender and these disorders.
Results
Compared with men, women had a significantly higher prevalence of all medical and psychiatric conditions (P≤.01 for each) and drug dependence (P<.001), but women had a lower prevalence of alcohol dependence (P<.001). Gender differences persisted after adjustment for sociodemographic factors and substance dependence.
Conclusions
Women in jail had a higher burden of chronic medical disorders, psychiatric disorders, and drug dependence than men, including conditions found more commonly in men in the general population. Thus, there is a need for targeted attention to the chronic medical, psychiatric, and drug-treatment needs of women at risk for incarceration, both in jail and after release.
doi:10.2105/AJPH.2008.149591
PMCID: PMC2820077  PMID: 19696388
12.  Release from Prison — A High Risk of Death for Former Inmates 
The New England journal of medicine  2007;356(2):157-165.
BACKGROUND
The U.S. population of former prison inmates is large and growing. The period immediately after release may be challenging for former inmates and may involve substantial health risks. We studied the risk of death among former inmates soon after their release from Washington State prisons.
METHODS
We conducted a retrospective cohort study of all inmates released from the Washington State Department of Corrections from July 1999 through December 2003. Prison records were linked to the National Death Index. Data for comparison with Washington State residents were obtained from the Wide-ranging OnLine Data for Epidemiologic Research system of the Centers for Disease Control and Prevention. Mortality rates among former inmates were compared with those among other state residents with the use of indirect standardization and adjustment for age, sex, and race.
RESULTS
Of 30,237 released inmates, 443 died during a mean follow-up period of 1.9 years. The overall mortality rate was 777 deaths per 100,000 person-years. The adjusted risk of death among former inmates was 3.5 times that among other state residents (95% confidence interval [CI], 3.2 to 3.8). During the first 2 weeks after release, the risk of death among former inmates was 12.7 (95% CI, 9.2 to 17.4) times that among other state residents, with a markedly elevated relative risk of death from drug overdose (129; 95% CI, 89 to 186). The leading causes of death among former inmates were drug overdose, cardiovascular disease, homicide, and suicide.
CONCLUSIONS
Former prison inmates were at high risk for death after release from prison, particularly during the first 2 weeks. Interventions are necessary to reduce the risk of death after release from prison.
doi:10.1056/NEJMsa064115
PMCID: PMC2836121  PMID: 17215533
13.  Predictors of Hospitalization for Injection Drug Users Seeking Care for Soft Tissue Infections 
BACKGROUND
Soft tissue infections (STIs) from injection drug use are a common cause of Emergency Department visits, hospitalizations, and operating room procedures, yet little is known about factors that may predict the need for these costly medical services.
OBJECTIVE
To describe a cohort of injection drug users seeking Emergency Department care for STIs and to identify risk factors associated with hospitalization. We hypothesized that participants who delayed seeking care would be hospitalized more often than those who did not.
DESIGN
Cohort study using in-person structured interviews and medical record review. Logistic regression assessed the association between hospital admission and delay in seeking care as well as other demographic, clinical, and psychosocial factors.
PARTICIPANTS
Injection drug users who sought Emergency Department care for STIs from May 2001 to March 2002.
RESULTS
Of the 136 participants, 55 (40%) were admitted to the hospital. Delay in seeking care was not associated with hospital admission. Participants admitted for their infection were significantly more likely to be living in a shelter (P = .01) and to report being hospitalized 2 or more times in the past year (P < .01).
CONCLUSIONS
We identified a subpopulation of injection drug users, mostly living in shelters, who were hospitalized frequently in the past year and who were more likely to be hospitalized for their current infections compared to others. As members of this subpopulation can be easily identified and located, they may benefit from interventions to reduce the health care utilization resulting from these infections.
doi:10.1007/s11606-006-0079-y
PMCID: PMC1824763  PMID: 17356973
injection drug use; soft tissue infection; cellulitis; abscess; substance abuse
14.  Predictors of Hospitalization for Injection Drug Users Seeking Care for Soft Tissue Infections 
BACKGROUND
Soft tissue infections (STIs) from injection drug use are a common cause of Emergency Department visits, hospitalizations, and operating room procedures, yet little is known about factors that may predict the need for these costly medical services.
OBJECTIVE
To describe a cohort of injection drug users seeking Emergency Department care for STIs and to identify risk factors associated with hospitalization. We hypothesized that participants who delayed seeking care would be hospitalized more often than those who did not.
DESIGN
Cohort study using in-person structured interviews and medical record review. Logistic regression assessed the association between hospital admission and delay in seeking care as well as other demographic, clinical, and psychosocial factors.
PARTICIPANTS
Injection drug users who sought Emergency Department care for STIs from May 2001 to March 2002.
RESULTS
Of the 136 participants, 55 (40%) were admitted to the hospital. Delay in seeking care was not associated with hospital admission. Participants admitted for their infection were significantly more likely to be living in a shelter (P = .01) and to report being hospitalized 2 or more times in the past year (P < .01).
CONCLUSIONS
We identified a subpopulation of injection drug users, mostly living in shelters, who were hospitalized frequently in the past year and who were more likely to be hospitalized for their current infections compared to others. As members of this subpopulation can be easily identified and located, they may benefit from interventions to reduce the health care utilization resulting from these infections.
doi:10.1007/s11606-006-0079-y
PMCID: PMC1824763  PMID: 17356973
injection drug use; soft tissue infection; cellulitis; abscess; substance abuse
15.  Meta-analysis of drug-related deaths soon after release from prison 
Addiction (Abingdon, England)  2010;105(9):1545-1554.
Aims
The transition from prison back into the community is particularly hazardous for drug-using offenders whose tolerance for heroin has been reduced by imprisonment. Studies have indicated an increased risk of drug-related death soon after release from prison, particularly in the first 2 weeks. For precise, up-to-date understanding of these risks, a meta-analysis was conducted on the risk of drug-related death in weeks 1 + 2 and 3 + 4 compared with later 2-week periods in the first 12 weeks after release from prison.
Methods
English-language studies were identified that followed up adult prisoners for mortality from time of index release for at least 12 weeks. Six studies from six prison systems met the inclusion criteria and relevant data were extracted independently.
Results
These studies contributed a total of 69 093 person-years and 1033 deaths in the first 12 weeks after release, of which 612 were drug-related. A three- to eightfold increased risk of drug-related death was found when comparing weeks 1 + 2 with weeks 3–12, with notable heterogeneity between countries: United Kingdom, 7.5 (95% CI: 5.7–9.9); Australia, 4.0 (95% CI: 3.4–4.8); Washington State, USA, 8.4 (95% CI: 5.0–14.2) and New Mexico State, USA, 3.1 (95% CI: 1.3–7.1). Comparing weeks 3 + 4 with weeks 5–12, the pooled relative risk was: 1.7 (95% CI: 1.3–2.2).
Conclusions
These findings confirm that there is an increased risk of drug-related death during the first 2 weeks after release from prison and that the risk remains elevated up to at least the fourth week.
doi:10.1111/j.1360-0443.2010.02990.x
PMCID: PMC2955973  PMID: 20579009
street drugs; substance-related disorders; mortality; overdose; prisons; prisoners; meta-analysis
16.  Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis 
Objective To determine the mortality attributable to smoking and years of potential life lost from smoking among people in prison and whether bans on smoking in prison are associated with reductions in smoking related deaths.
Design Analysis of cross sectional survey data with the smoking attributable mortality, morbidity, and economic costs system; population based time series analysis.
Setting All state prisons in the United States.
Main outcome measures Prevalence of smoking from cross sectional survey of inmates in state correctional facilities. Data on state prison tobacco policies from web based searches of state policies and legislation. Deaths and causes of death in US state prisons from the deaths in custody reporting program of the Bureau of Justice Statistics for 2001-11. Smoking attributable mortality and years of potential life lost was assessed from the smoking attributable mortality, morbidity, and economic costs system of the Centers for Disease Control and Prevention. Multivariate Poisson models quantified the association between bans and smoking related cancer, cardiovascular and pulmonary deaths.
Results The most common causes of deaths related to smoking among people in prison were lung cancer, ischemic heart disease, other heart disease, cerebrovascular disease, and chronic airways obstruction. The age adjusted smoking attributable mortality and years of potential life lost rates were 360 and 5149 per 100 000, respectively; these figures are higher than rates in the general US population (248 and 3501, respectively). The number of states with any smoking ban increased from 25 in 2001 to 48 by 2011. In prisons the mortality rate from smoking related causes was lower during years with a ban than during years without a ban (110.4/100 000 v 128.9/100 000). Prisons that implemented smoking bans had a 9% reduction (adjusted incidence rate ratio 0.91, 95% confidence interval 0.88 to 0.95) in smoking related deaths. Bans in place for longer than nine years were associated with reductions in cancer mortality (adjusted incidence rate ratio 0.81, 95% confidence interval 0.74 to 0.90).
Conclusions Smoking contributes to substantial mortality in prison, and prison tobacco control policies are associated with reduced mortality. These findings suggest that smoking bans have health benefits for people in prison, despite the limits they impose on individual autonomy and the risks of relapse after release.
doi:10.1136/bmj.g4542
PMCID: PMC4122735  PMID: 25097186

Results 1-16 (16)