Using positive deviance techniques to improve smoking cessation outcomes in New South Wales prison settings.

Average smoking prevalence among New South Wales (NSW) prisoners exceeds 72%. Most inmates have no intention to stop smoking in the short term, making management of prisonbased smoking cessation (Quit) programs difficult.1-3 The NSW Tobacco Action Plan identifies prisoners as a priority group for smoking cessation initiatives.4 The cost to Justice Health of structured smoking cessation programs is substantial – typically $400 per inmate, including cost of nicotine replacement therapy and weekly peer-support and counselling sessions. It is therefore important to explore less expensive ways to help smoker prisoners quit. Since 2006, the authors introduced positive deviance techniques5 to complement structured Quit programs in a NSW prison, highlighting positive exceptions (i.e. non-smokers and quitters) to smoking stereotypes in prison settings, and encouraging mainstream adoption of the success strategies of these ‘positive deviants’. Positive deviance is an ‘assets-based’, four-stage approach that focuses on using the resources already available among communities to promote health (see Table 1).6 Over a 15-month review period, smoking prevalence fell by 20 percentage points in this prison, 70% of Quit participants were not smoking three months after the program started (compared with an average 52% success rate for other comparable Justice Health structured Quit programs between 2001-05). Eleven of 14 long-sentence prisoners who participated in the program remained abstinent for at least 12 months, compared with 16 out of 41 patients similarly followed-up at other sites. Furthermore, the documented number of smokers making efforts to quit smoking on their own in this centre by contacting clinic nurses during the review period was significantly higher than in the other sites where similar Quit programs were being undertaken. The recognition accorded positive deviants by Justice Health staff and their ‘no-smoking’ advocacy (e.g. during World No Tobacco Day activities) apparently also served to promote a smoking abstinence norm in this prison.