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Original Investigation | Health Care Reform

Forced Smoking Abstinence:  Not Enough for Smoking Cessation

Jennifer G. Clarke, MD, MPH; L. A. R. Stein, PhD; Rosemarie A. Martin, PhD; Stephen A. Martin, MD; Donna Parker, ScD; Cheryl E. Lopes, PhD; Arthur R. McGovern, PhD; Rachel Simon, BS; Mary Roberts, MS; Peter Friedman, MD, MPH; Beth Bock, PhD
JAMA Intern Med. 2013;173(9):789-794. doi:10.1001/jamainternmed.2013.197.
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Importance Millions of Americans are forced to quit smoking as they enter tobacco-free prisons and jails, but most return to smoking within days of release. Interventions are needed to sustain tobacco abstinence after release from incarceration.

Objective To evaluate the extent to which the WISE intervention (Working Inside for Smoking Elimination), based on motivational interviewing (MI) and cognitive behavioral therapy (CBT), decreases relapse to smoking after release from a smoke-free prison.

Design Participants were recruited approximately 8 weeks prior to their release from a smoke-free prison and randomized to 6 weekly sessions of either education videos (control) or the WISE intervention.

Setting A tobacco-free prison in the United States.

Participants A total of 262 inmates (35% female).

Main Outcome Measure Continued smoking abstinence was defined as 7-day point-prevalence abstinence validated by urine cotinine measurement.

Results At the 3-week follow-up, 25% of participants in the WISE intervention (31 of 122) and 7% of the control participants (9 of 125) continued to be tobacco abstinent (odds ratio [OR], 4.4; 95% CI, 2.0-9.7). In addition to the intervention, Hispanic ethnicity, a plan to remain abstinent, and being incarcerated for more than 6 months were all associated with increased likelihood of remaining abstinent. In the logistic regression analysis, participants randomized to the WISE intervention were 6.6 times more likely to remain tobacco abstinent at the 3-week follow up than those randomized to the control condition (95% CI, 2.5-17.0). Nonsmokers at the 3-week follow-up had an additional follow-up 3 months after release, and overall 12% of the participants in the WISE intervention (14 of 122) and 2% of the control participants (3 of 125) were tobacco free at 3 months, as confirmed by urine cotinine measurement (OR, 5.3; 95% CI, 1.4-23.8).

Conclusions and Relevance Forced tobacco abstinence alone during incarceration has little impact on postrelease smoking status. A behavioral intervention provided prior to release greatly improves cotinine-confirmed smoking cessation in the community.

Trial Registration clinicaltrials.gov Identifier: NCT01122589

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Figure 1. Participant flowchart. CBT indicates cognitive behavioral therapy; MI, motivational interviewing; WISE, Working Inside for Smoking Elimination.11

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Figure 2. Tobacco abstinence at the 3-week follow-up by the study condition group (adjusted survival curves). *Effect seen in treatment group is significant (P =.001) (β [SE], 0.56 [0.16]; hazard ratio, 1.75), indicating that the risk of smoking after release was over 1.75 times greater for those in the control condition compared with those in the WISE (Working Inside for Smoking Elimination11) intervention.

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