Tobacco use among prison staff in Germany: a crosssectional study

C. Ritter, A. Gayet-Ageron, S. Buth, H. Stver

DOI: http://dx.doi.org/10.1093/eurpub/ckv195 ckv195 First published online: 24
October 2015

Abstract
Background: Studies on tobacco in the prison environment report high
prevalence of use among detainees, but little data regarding staff are available. An
observational study addressing tobacco control in German prisons was conducted
in 2011. It involved multiple strands (quantitative and qualitative components)
both among detainees and staff. This article presents quantitative results regarding
staff.Methods: Cross-sectional study among prison employees in 16 different
institutions in nine regions (Lnder) in Germany. Tobacco use and second-hand
smoke (SHS) exposure (primary outcomes) were assessed by a questionnaire
designed specifically. Logistic regression models were used to assess the risk
factors associated with each outcome. Results: Among 704 participants (60.6%
male, mean age 43.9 years 9.33), 27.7% are smokers and 68% declared to be
exposed to SHS. Independent factors associated with smoking were female gender
[odds ratio (OR) 1.49, P = 0.026], an age below 45 years (OR 1.35, P = 0.08) and
working in areas other than administration (OR P = 0.08). An age below 45 was
associated with a higher degree of self-reported SHS exposure. The association
between SHS and gender was different depending on occupational area with
significantly more men exposed to SHS in administrative area and more women in
health/social area (interaction between gender and occupational area, P =
0.02). Conclusion: Importance of SHS exposure among prison employees and
confirm the need for a comprehensive tobacco control policy including support to
smoking cessation and better enforcement of the smoke-free regulation, especially
where staff contributes to SHS. Particular attention has to be given to female
employees.

Introduction
Research on tobacco in prison settings has mainly concentrated on tobacco use by
detainees. International literature describes high prevalence of smoking in this

group with prevalence of smoking between 64% and 90%, whereas the prevalence
of smokers among staff is largely unknown.1 Between 2005 and 2009, the German
smoking regulation changed in the prison environment and a partial ban was
introduced (smoking is allowed in cells, including in prison hospitals). Leisure
areas, office or administrative areas, break rooms and eating areas are usually
smoke-free, even though this can vary locally. Indoor smoking areas do exist for
staff. There are numerous differences in the smoke-free regulation, its application
and enforcement.2,3
Studies describing tobacco use (or active smoking) and second-hand smoke (SHS)
exposure4 in German prisons have not been carried out so far. Therefore, in 2010,
the Federal Ministry of Health mandated the University of Applied Sciences in
Frankfurt am Main (Germany) to conduct an extensive observational study based
on multiple methods (quantitative and qualitative assessments) in German prisons.
The research aimed at (i) determining the prevalence of smokers among detainees
and staff in German prisons, (ii) exploring its relationship with certain
characteristics of participants and the prison environment, (iii) assessing the
current policies which aim at reducing SHS in prisons, and (iv) catalysing the
debate on tobacco issues in prisons. This article presents the results of the two first
aims of the survey among prison staff during 2011.

Methods
Study design and setting
In 1 January31 December 2011, a cross-sectional study was conducted among
staff working in 16 different penitentiary institutions across 9 of 16 states (Lnder)
in Germany (Baden-Wrttemberg, Bavaria, Berlin, Hesse, MecklenburgVorpommern, Lower Saxony, North Rhine-Westphalia, Saxony and Thuringia).
Prisons employ 38 000 people. The federal prison committee in Germany
approved the study and recommended to the regional ministries of justice to
participate. Participation in a given institution was only possible when both the
regional ministry of justice and prison administrators agreed to do so. At the same
time, the research team invited the prisons to participate in the survey in writing.
Sixteen different institutions across 9 states (Lnder) showed interest. Either
written or electronic questionnaires were then distributed to staff by one local
correspondent in each institution and completed anonymously and on a voluntary
basis before being sent back to the researchers (by post or electronically). The

research fellow (C.R.) prepared a written summary of the main results, and
presented them orally to the participants within each prison in 2012. This was
done to reward the participants and to provide them with local results, in order to
promote changes in their institutions with regard to tobacco control policies. As
there was no risk to the health of participants, consent form was not required.

Questionnaires
As there was no validated tool to assess prison staffs tobacco use prevalence, a
study questionnaire was prepared based on a previous example used in prisons in
Switzerland.5 The content was adapted by using available tools interrogating
health behaviour and smoking among the general population in Germany in order
to facilitate the comparison of the results. 6 Finally questionnaires were pre-tested
among a sample of eight prison staff and three tobacco experts and re-adapted
after feedback was obtained (see supplementary Appendix, available in German).
According to the local correspondent in charge of handing out and collecting the
questionnaires, two recalls were usually necessary.

Primary outcomes
Primary outcomes assessed in the questionnaire were the prevalence of tobacco
use in the last 30 days, and self-reported SHS exposure (being exposed or not to
SHS, and in which area of exposure), according to the following definition of
SHS: Second-hand tobacco smoke is the combination of smoke emitted from the
burning end of a cigarette or other tobacco products and smoke exhaled by the
smoker.4

Variables
In the questionnaires, the following variables were also requested: personal data
(age, sex, area of occupation within the prison environment, i.e. general wards,
administration, health and social area, and others), smoking behaviour (mean
number of cigarettes smoked per day and the duration of the smoking), existence
of a relationship between the areas of occupation and the smoking behaviour or
SHS exposure. They were all considered as potential independent variables.

Sample size estimation

We anticipated 40% prevalence of tobacco use among prison staff. 1 A number of
370 participants would be needed to estimate a 95% confidence interval (95% CI)
for tobacco use of 0.4 0 0.10.

Statistical analysis
Continuous variables are described by their mean (SD); categorical variables are
described by frequency of subjects per strata (proportion, %). Employees
characteristics are presented by smoking status (smoker and non-smoker), then by
SHS exposure (SHS exposed and SHS non-exposed). Categorical variables are
compared using Chi-square or Fischers exact tests, depending on application
criteria; Student t or nonparametric MannWhitney tests are used to compare
continuous variables.
Finally, logistic regression models were used to assess independent risk factors
[odds ratio (OR) > 1.00] associated first with individual smoking, and then with
SHS exposure. The risk factors assessed are related to staffs sociodemographic
characteristics (smoking status, age and gender) and factors related to the area of
occupation. We choose to present parsimonious models with all independent
variables associated with the outcome with P < 0.10. Two multivariate models are
presented using a backward stepwise procedure. The interaction between gender
and occupational area was considered as interesting to assess the risk for SHS
exposure and an interaction term was introduced in the model addressing
independent variables associated with SHS exposure.
All analyses were performed using Stata intercooled 13.0 (STATA Corp., College
Station, TX, USA). Statistical significance is defined as P < 0.05 (two sided).
Results
Among a total of approximately 38 000 prison employees working in
approximately 180 closed settings, 704 persons of the 16 institutions answered the
questionnaire, including 54 persons who completed the electronic questionnaire
(7.6%).

Description of participants
Among the 704 participants, 451 were employed in male prisons (64.1%), 153 in
female prisons (21.7%), 66 in minors of age prisons (9.4%) and 34 in other types
of prisons (4.8%). The mean age was 43.9 years (9.33).

In total, 424 participants were men (60.6%), with different distribution in the
various occupational areas (P < 0.001); 402 participants worked in the general
wards (57.4%, 67.2% men and 42.4% women P < 0.001); 138 in the health and
social services (19.7%, 28.7% women and 13.9% men P < 0.001); 105 in the
administration (15%, 10.1% men and 22.5% women P < 0.001); and 55 in other
areas (7.9%).

Active smoking
Among respondents, 194 (27.7%) reported to be active smokers in the last 30
days; there was no gender difference (25.5% men vs. 31.2% women, P = 0.10). In
total, 278 (41%) of participants were former smokers, 174 (25.7%) daily smokers
and 20 (2.9%) occasional smokers.
The mean duration of regular smoking was 22.6 years (10.8), with a longer
duration among men compared with women (24.0 years 11.5 vs. 20.8 10.1, P =
0.04). The mean number of cigarettes smoked per day was 15.1 ( 8.3) with a
higher mean number of cigarettes smoked among men compared with women
(16.2 8.13 vs. 13.7 8.32, P = 0.04).
Comparing smokers and non-smokers, the risk factor for active smoking was
female gender; an age below 45 years tended to increase the odds for active
smoking. Regarding occupational area, there was a trend for an association with
active smoking: the risk of smoking is higher for those who work in general
wards, in health and social areas (even if non-significant) and for those who work
in other areas (such as occupational areas for detainees) compared with those who
work within administration (see tables 1 and2).
Table 1
Comparison among smokers and non-smokers
Smokers (N = 194)

Non-smokers (N = 506)

P values

Male

108 (55.7)

316 (62.5)

0.100

Age mean year (SD)

42.3 (9.39)

44.64 (9.24)

0.004

Gender, n (%)

Area of occupation, n (%)

General (wards)

0.068
115 (58.4)

287 (56.6)

Smokers (N = 194)

Non-smokers (N = 506)

40 (20.3)

99 (19.5)

Administration

20 (10.2)

85 (16.8)

Others

22 (11.2)

36 (7.1)

Health
and
areas

P values

social

Table 2
Independent risk factors associated with active smoking
Univariate analysis
OR

Multivariate analysis

95% CI

P values

OR

95% CI

P values

0.991.95

0.052

1.35

0.961.90

0.083

0.951.85

0.101

1.50

1.052.14

0.026

Age
45 years

1.00

<45 years

1.39

Gender
Male

1.00

Female

1.32

Occupational area

0.063

0.078

Administration

1.00

1.00

General
wards

1.70

0.992.90

0.05

1.86

1.073.22

0.028

Health/social

1.72

0.933.16

0.082

1.74

0.943.21

0.080

Other

2.60

1.265.34

0.0009

2.58

1.215.50

0.014

SHS exposure
Among the 704 participants, 476 (67.9%) reported SHS exposure and there was a
gender difference with a higher proportion of men reporting SHS exposure than
women (72.2% vs. 61.6%, respectively, P = 0.003) (see table 3).
Table 3
Comparisons among staff exposed and non-exposed to SHS

Exposed to SHS (N =
467)

Not exposed to SHS (N =

223)

P value

Male gender, n (%)

306 (64.3)

118 (52.7)

0.003

Age mean year (SD)

42.9 ( 9.25)

46.42 (9.06)

<0.001

Occupational area, n (%)

<0.001

Administration

28 (5.9)

77 (34.1)

General wards

311 (65.1)

91 (40.3)

Health/social

96 (20.1)

43 (19.0)

Other

43 (9.0)

15 (6.6)

At univariate analysis, the other risk factors for SHS exposure were the
occupational areas with higher proportion of SHS exposure for those who work in
the general wards (in particular within the cell area) compared with administrative
areas, and also a younger age below 45 years. We tested for an interaction
between gender and occupational area, which was significant (P = 0.016). The
association between SHS exposure and gender was different depending on
occupational area with a greater likelihood of SHS exposure for women who are
working in health/social compared with men and for men who are working in
administration compared with women (see table 4).
Table 4
Independent risk factors associated with SHS exposure
OR

95% CI

P values

1.512.92

<0.001

1.172.23

0.003

Multivariate analysis
Univariate analysis
Age (years)
45

1.00

<45

2.10

Gender
Female

1.00

Male

1.62

OR

95% CI

P values

Multivariate analysis
Occupational area

<0.001

Administration

1.00

General wards

9.40

5.7515.37

<0.001

Health/social

6.14

3.5010.78

<0.001

Other

7.88

3.8016.35

<0.001

Occupational area and gender

0.017

Administration

0.045

Female

1.00

Male

2.47

1.025.97

General wards

0.089

Female

1.00

Male

1.54

0.942.52

Health/social

0.039

Male

1.00

Female

2.17

1.044.50

Other

0.86

Male

1.00

Female

1.13

0.294.30

Age (years)

<0.001

45

1.00

<45

1.91

1.342.74

Occupational area and gender

0.016

Administration

0.037

Female

1.00

Male

2.58

1.066.30

General wards

0.07

OR

95% CI

Female

1.00

Male

1.59

0.962.63

P values

Multivariate analysis

Health/social

0.049

Male

1.00

Female

2.12

1.004.47

Other

0.736

Male

1.00

Female

1.29

0.295.70

At multivariate analysis, risk factors for SHS exposure were being younger than
45 years, being a male employee in administrative area and female employee in
health/social area. There was an interaction between gender and occupational area
(P = 0.016) (see table 4).

Discussion
Carrying out research on tobacco use in prisons is a way to raise awareness about
this important public health issue, and at the same time produce valid data on
which a comprehensive tobacco control policy can be based.4,7,8 Therefore, the
number of participants within the quantitative strand of the study conducted in
German prisons in 2011 was not limited to the number of subjects necessary to
ensure statistical power. However, there is a striking difference between the
number of participants who completed the questionnaire (704) and the possible
number of total participants among staff (38 000). Three factors may explain this:
(i) prison administrators declared to be solicited to participate in numerous
researches and cannot accept all of them, due to their burden of work; (ii) tobacco
issue is a delicate matter in prison and one reason for not participating might be
the fear of total ban when initiating at all a debate; and (iii) it is not a priority for
prison administrators who consider this matter as unproblematic and resolved.
The prevalence of smokers of 27.7% among staff in prisons is similar to
comparative data available for the general population in Germany, i.e. 29.7% of

adults aged between 18 and 79 years are smokers (23.7% regular, 6% occasional).
However, the proportion of men smokers is higher in the general population with
32.6% of men and 27% of women smoking, whereas an opposite tendency was
observed in prison, although statistically non-significant. In Germany, the
proportion of women among smokers has increased constantly over the last 20
years with differences in prevalence decreasing among men and women since
2003.9
Results found in this study in German prisons are lower than comparable data
available (although scarce). Values as high as 40% (2.5 times higher than in the
general population) were reported in Canada. 10 In the USA, 24% of staff were
smokers (38% former smokers).11, 12 In Australia, the rate of smokers had
decreased from 44.3% in 1982 to lower than among the general population
(comparative value of 18.6%).13 In Europe, values between 10% and 55% of daily
and occasional smokers were reported in three different prisons in Switzerland.5
Therefore, the relatively low prevalence of smokers (28%) among prison staff in
this study raises questions. A bias in the selection of participants cannot be
excluded, and in particular, smokers may have declined to answer the
questionnaire, being afraid of possible consequences such as complete prohibition
of smoking at work. Also the study was based on self-report. This might have
underestimated the prevalence of smokers.
Being a woman is an independent risk factor for smoking when working in the
prison environment. Working in occupational areas that allow closer contact with
detainees is also associated with a greater risk of being a smoker. Further research
is needed to understand the reasons that might explain this trend. One can
hypothesize that as a great majority of detainees are smokers, staff working in
contact with them is not working in a smoke-free environment, and therefore less
inclined to reconsider his or her own behaviour. In other words, the predominance
of smoking among detainees could have an impact on staffs behaviour too.
Indeed, the prevention of smoking initiation is more realistic in a smoke-free
environment.14 A smoke-free work place legislation decreases tobacco
consumption while at work, and increases the likelihood of workers implementing
smoke-free policies at home, whereas the existence of indoors designed smoking
areas decreases the impact of smoke-free regulation.4
Almost three quarters of participants report SHS exposure. Exposition is higher
than in prisons with comparable regulation, as for example in Switzerland, except

in the cell areas where they are similar,5and lower when compared with other selfreported values in Canada where up to 92% of employees had declared to be
exposed to SHS (before the legislation change and the introduction of total ban in
the Canadian prison system).10 Again, the results are based on self-report, and they
were not confirmed with measurements of air quality. Smoking bans result in
significant reduction of nicotine concentration and suspended particulates in the
air.1517 An association with significantly reduced smoking-related mortality
among detainees has also been shown.18 A similar impact on health and mortality
of employees still needs to be described.
In our study, men report more frequently exposition to SHS and the places where
exposition is more important are general wards and health and social services.
Again, those are the places where contact with detainee smokers is predominant,
and also, where staff and detainees might smoke together (even if the regulation
does not actually allow it). Younger male employees are most at risk of SHS
exposure. Even if administrative area is more protective, the multivariate analysis
showed that the risks of SHS are greater for men working in administrative area
and women working in health/social area. In the administrative area, the source of
SHS is largely staffs smoking, whereas in the health and social area, SHS might
also result from detainees smoking. However, as female participants of the study
were more represented in health and social area, and given the fact that a risk
factor for active smoking was the female gender, staffs smoking is most probably
an important contributor to SHS exposure.
Regarding WHO FCTC regulation for staff protection while at work, prisons
clearly represent one working area where staff is still not fully protected. 19 and a
comprehensive package of measures considering both prisoners and staffs
smoking is necessary to resolve this situation. 20 Indeed, one risk of presenting
such results would be to immediately implement a repressive solution that is to
prohibit smoking for detainees, which in certain areas (cell areas) most probably
represents the main source of SHS given the high numbers of detainees smoking
that were reported previously in European prisons under partial bans regulation
and in Germany.21 A complete smoke free ban is not an option in Germany. This
was experimented in 2007 in a forensic unit, before being reversed again due to
legal complaints brought up by the patients.22
Tobacco control should include support for tobacco reduction or cessation
specifically designed to take into consideration womens smoking and

characteristics,23, 24 as well as better enforcement of smoke-free regulation.

Regarding SHS, some areas show an increased risk of exposure, which again has
to be given particular attention when designing the policy. In particular,
enforcement of the regulation has to be improved within administrative areas and
prison hospitals should be declared smoke free. In the cell area, staff protection
can also be improved when they must enter cells. This had been included in the
Policy designed in Ireland for example, where simple measures such as asking the
prisoner to stop smoking and ventilate his/her cell prior to searching or to meet
with the prisoner in a different room have been mentioned. 25 Health promotion in
prisons can provide an overhead frame to tobacco use, alongside with other major
issues that involve prison staff.26, 27
With relation to the general society prisons represent a world apart characterized
by specific structure and rules. This particular posture often creates isolation from
predominant changes occurring in the civil society, as tobacco use very well
illustrates: prisons have been left behind with high smoking prevalence and SHS
exposure, whereas the general community shows an opposite move. Other
contributing factors to this situation are related to the particular status given to
tobacco itself within closed environment. It is belonging to prison culture, and a
mark of freedom in an environment highly characterized by rules and prohibition
regarding prisoners use of psycho-active substances.1, 20 Staffs resistance to
changes in tobacco control policy and the lower importance given by health staff
to tobacco dependence compared with other addictions28 are more reasons, along
with the absence or little support to reduce or stop smoking programmes. 25, 26,
29
Furthermore, prison health care and administrative authorities are often tied to
two different authorities. This creates confusion over the ownership of the tobacco
issue that involves both the health department and custodial authorities.30 Health
professionals provide treatment for smokers in this specific environment, and
conversely smoke-free regulation needs to be enhanced by tobacco reduction or
cessation support.
Creating the conditions that make the positive impact of a smoke-free working
place possible in prisons too, as described in other occupational environments, is a
major challenge. Tobacco control policy should aim to protect both staff and
detainees from SHS, to provide an environment that encourages staff to reduce or
stop smoking, and at the same time remain in line with the regulation and tobacco
control activities that prevail in Germany. Considering prisons alongside within
other national public health strategies or drug policies is necessary to bring

coherency and consistency in prison drug policies and avoid their isolation from
public health interventions.

Funding
This work was supported by The Federal Ministry of Health in Germany (grant
number 15 02 Title 684 69 awarded to H.S in 2011).
Conflicts of interest: None declared.
Key points

Prisons are left behind with regards to tobacco control activities in the
general society; this study illustrates the consequences of such an unbalance.

Previous studies focus mainly on detainees tobacco use. They underline

their high prevalence of smoking, the negative consequences that are associated,
and present cessation programmes. Data regarding at those aspects among the
prison employees are almost inexistent.

In German prisons where partial smoking ban regulations prevail, the

prevalence of tobacco use and SHS exposure among staff were unknown before
this study.

Employees are exposed to SHS, but also contribute to it. Considering

detainees smoking habits and regulating them in a unilateral restrictive way
without taking into account staffs smoking will ensure partial protection only for
employees working in this environment.

Tobacco control policy in prisons has to address both detainees and staff.
Particular attention has to be given to female employees who smoke. Interventions
both at local (within the prisons) and at national (strategic) levels are necessary in
order to consider prisons along way with mainstream tobacco control activities in
the general society.

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