Incarceration and Post-release Health Behavior

Author(s): Lauren C. Porter

Source: Journal of Health and Social Behavior, Vol. 55, No. 2 (JUNE 2014), pp. 234-249
Published by: American Sociological Association
Stable URL: https://www.jstor.org/stable/43186894
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Incarceration and Health
ASA
AMERICAN SOCIOLOGICAL ASSOCIATION

Journal of Health and Social Behavior

2014, Vol. 55(2) 234-249
Incarceration and Post-release © American Sociological Association 20 1 4
DOI: 1 0. 1 1 77/0022 1 465 1 453 1 438

Health Behavior jhsb.sagepub.com

(§)SAGE

Lauren C. Porter1

Abstract
This study investigates the link between incarceration and health behavior among a sample of young adul
from the National Longitudinal Study of Adolescent Health (N = 1 ,670). The association is analyzed using
propensity score methods and a strategic comparison group: respondents who have been convicted
crimes, but not incarcerated. Findings suggest that former inmates consume more fast food and hav
higher likelihood of smoking than do similarly situated peers. These associations operate partly throu
increased financial strife and decreased social standing. Given the role of health behavior in predicti
future health outcomes, poor health behavior may be a salient force driving health and mortality r
among the formerly incarcerated population.

Keywords
Add Health, crime, health behavior, health inequality, incarceration

consequences of poor health behavior and given

Many unfavorable health outcomes, such as obe-
sity and hypertension, result in part from poor
striking disparities in both incarceration and health,
health behavior. In fact, tobacco use and poor diet
any impact of incarceration on health behavior has
potentially far-reaching implications for health
have been identified as the leading causes of death
in the United States (Mokdad et al. 2004, 2005).inequality.
Every year approximately 700,000 inmates areThis study builds on prior research by examin-
ing the association between incarceration and
released from state and federal prisons and millions
more are released from local jails (Carson and health behavior among young adults using the
Sabol 2013; Minton 2013). Research increasingly National Longitudinal Study of Adolescent Health
(Add Health). Young ex-inmates (ages 24-32) con-
suggests that time behind bars exacerbates physical
and mental health problems (Massoglia 2008a; stitute an important group because the majority of
Schnittker and John 2007; Schnittker, Massoglia,
individuals who experience incarceration will first
enter the correctional facility during this stage of
and Uggen 20 1 2; Turney, Wildeman, and Schnittker
their lives, commonly referred to as "emerging
2012), but the role of health behavior in this nexus
has garnered little attention. adulthood." As implied by the term, this age tends
Unhealthy habits are more prevalent among
to be characterized by increasing autonomy, mar-
riage, stable employment, and for many, a time
socioeconomically disadvantaged members of the
population, and it is estimated that differences in
these behaviors account for about 25 percent of
socioeconomic disparities in health (Pampel,
'Department of Criminology and Criminal Justice,
Krueger, and Denney 2010). Incarceration is also
University of Maryland, College Park, MD, USA
rampant in the lives of the "poor, poorly educated,
Corresponding Author:
mentally ill, and socially estranged," and some
Lauren C. Porter, Department of Criminology and
scholars argue that incarceration disparities could
Criminal Justice, University of Maryland, 2220 Samuel J.
be widening health inequalities (Wildeman LeFrak
and Hall, College Park, MD, 20742 USA.
Muller 2012: 12). Considering the potentially lethal
E-mail: lporterl@umd.edu

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 Porter 235

when "many
health behavior by constricting financial resources,
2000:469). Th
time behind bars and subsequent reintegration hurdles
behavior, wh
also present more impalpable or nuanced threats to
(Harris 2010)
health behavior. For example, ex-inmates may feel
may be
that their identitiesexplo
are beyond their control, leading to
are increased stress and fatalism, both of which are asso-
confrontin
prison rathe
ciated with a higher risk of smoking and with poor
Western 200
eating habits. In this study, incarceration is theorized
to worsen these behaviors through a myriadar
individuals of pro-
As scholars
cesses, including financial hardship, social isolation,
makesand diminished
it psychological
diffi well-being.
conditions. To
compares the
Incarceration and Financial
strategic comHardship
been convicted of crimes but who have not been Former inmates confront numerous barriers to
incarcerated. In addition, respondents are matched on financial stability, including difficulties obtaining
observable characteristics using propensity scoreloans, housing, and employment (see Tonry and
methods. While the use of propensity score matching Petersilia 2000 for an overview). With respect to
leverages observable characteristics of respondents to employment in particular, employers are reluctant
address selection, comparing ex-inmates to those who to hire ex-felons due to the stigma of a criminal
have been "convicted only" helps account for poten-record (Pager 2003) and ex-inmates may confront
tially unobservable traits that may bias the association challenges due to their hiatus from the labor market
as well. Second, this study investigates why incarcer- (Western, Kling, and Weiman 2001). Financial
ation may lead to poor health behavior. Availablewell-being can worsen health behavior by affecting
mediators are tested, including subjective socialthe "means and motives" associated with maintain-
standing, perceived stress, and financial difficulties.ing a healthy lifestyle (Pampel et al. 2010:14). For
In short, this study advances prior research by (1) example, nutritious foods are typically more costly
investigating the link between incarceration andthan less healthy options (Pampel et al. 2010), are
health behavior among young adults and (2) explicat-less available in relatively poor neighborhoods,
ing the mechanisms potentially linking incarceration and fruits and vegetables that are available in poor
to such behaviors. neighborhoods are on average 15 to 20 percent
more expensive than in wealthier neighborhoods
(Emmons 2000; Powell et al. 2007).
BACKGROUND
With respect to motives, financial strife acts as a
An expansive body of literature considers thestressor
collat-in its own right, but living in economically
eral consequences of incarceration, including precarious
effects situations is accompanied by chronic
stressors as well (Pampel et al. 2010). Residents of
on employment, family life, and civic engagement.
More recently, research suggests that incarceration
disadvantaged neighborhoods are exposed to neigh-
increases the risk of several physical and borhood
mental decay, noise pollution, and violence. Van
health ailments, such as hypertension (Massoglia
Lenthe and Mackenbach (2006) find that individuals
2008a), sexually transmitted diseases (Hammett,
living in relatively disadvantaged areas are more
Harmon, and Rhodes 2002; Massoglia 2008a), dis-
likely to smoke in part because of increased exposure
to such
abling conditions (Greifinger 2007; Schnittker and neighborhood stressors. Individuals of low
John 2007), major depression (Schnittker et al. 2012;
socioeconomic status are also more likely to be fatal-
Turney, Wildeman, and Schnittker 2012), and anxiety
istic and to deprioritize long-term consequences, both
of which
(Massoglia 2008a). In addition to increasing the risk are associated with poor health behavior
(Adams and White 2009; Niederdeppe and Levy
of poor health, incarceration may also negatively
affect health behavior. Poor diet and cigarette2007;
smok-Pampel et al. 2010).
ing are associated with many of the commonly cited
consequences of incarceration, such as increased
Incarceration and Social Ties
financial strain, social isolation, and heightened stress
(Krueger and Chang 2008; Pampel et al.While
2010;behind bars, inmates are displaced from
Umberson, Crosnoe, and Reczek 2010). While some
family and friends. Maintaining contact with out-
side ties
of these outcomes present more tangible threats to can be difficult, as can maintaining the

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 236 Journal of Health and Social Behavior 55(2)

rise to a series
quality of such relationships (Christian 2005; of related
Clearobstacles. A stressful
2007; Comfort 2008). Once released, however,
event sequence is for-
also distinguished by having a
mer inmates continue to be isolated due to others'
foreseeable endpoint for individuals. Inmates may
fearing the "contagion of stigma" or due to theperceive their release as an endpoint, given ethno-
strain of being separated from loved ones
(Massoglia, Remster, and King 201 1). Studies sug-
gest that incarceration is especially damaging with
respect to marital bonds, increasing the risk of
divorce and decreasing the likelihood of marriage
(Western, Lopoo, and McLanahan 2004).
Social ties are integral components to a healthy
lifestyle. People offer instrumental support for health
needs, such as helping to buy groceries (Berkman
et al. 2000). They can also be helpful in terms of find-
ing employment (Granovetter 1973; Yakubovich
2005). In addition, family and friends offer emotional
support by providing "love and caring, sympathy and
understanding and/or esteem or value" (Thoits 1995,
cited in Berkman et al. 2000:848). Research suggests
that this type of support acts as a stress buffer, pre-
venting or reducing stress-driven unhealthy behaviors
(Kamarck, Manuck, and Jennings 1990; Steptoe et al.
1990). As well as providing a source of support, social
ties can influence health behavior via control pro-
cesses (Thoits 201 1). For example, a romantic partner
can monitor smoking habits and marriage restructures
a person's life in ways that foster healthy habits
(Umberson et al. 2010).
Incarceration and Psychological Well-
being
Stress. In accordance with the tenets of stress pro-
cess theory (Pearlin 1989), the experience of incar-
ceration is likely to expose individuals to a number
of stressors. More specifically, the effects of incar-
ceration can be likened to Pearlin' s concept of
stress proliferation, which distinguishes between
primary and secondary stressors (Pearlin, Anesh-
ensel, and LeBlanc 1997). The primary stressors of
incarceration include the loss of liberty and control,
isolation, the need to make behavioral adjustments,
and fear of other inmates (Sykes 1958; Massoglia
2008a). The stressors of prison life may also be
magnified by the social isolation of inmates, since
family and friends who otherwise provide emo-
tional support during times of strain are absent (see
Braman 2004; Comfort 2008; Zambie and Por-
porino 1988). To draw on Elliot and Eisdorfer's
(1982) taxonomy of stressors, it is useful to con-
ceptualize such primary stressors as a stressful
event sequence. According to Elliot and Eisdorfer
(1982), a stressful event sequence entails a focal
event, such as being incarcerated, which then gives
graphic work showing that inmates tend to be opti-
mistic about their release and changes they want to
make in their lives (Phillips and Lindsay 2011;
Zambie and Porporino 1988).
Once people are released from prison, second-
ary stressors of incarceration may compound pri-
mary stressors, especially given that such obstacles
are not fully anticipated (Phillips and Lindsay
2011). Secondary stressors include difficulties
securing identification, finding a place to live, and
finding a source of income. Former inmates can
find themselves prohibited from political participa-
tion, without parental rights, and still struggling for
social acceptance. Also, and unlike primary stress-
ors, the secondary stressors of imprisonment may
resist adaptation and have no foreseeable endpoint
(Bronsteen, Buccafusco, and Masur 2009). To that
end, the secondary stressors of incarceration can
also be conceptualized as chronic stressors. Elliot
and Eisdorfer (1982) argue that in contrast to a
stressful event sequence, chronic stressors have no
foreseeable endpoint and "pervade a person's life,
forcing him or her to restructure his or her identity
or social roles" (cited in Segerstrom and Miller
2004:2).
Two recent studies suggest that incarceration
has profound effects on major depression, a well-
established correlate of perceived stress (Schnittker
et al. 2012; Turney et al. 2012). For instance,
Schnittker and colleagues (2012) find that incar-
ceration more than doubles the likelihood of dys-
thymia and increases the odds of major depression
by 50 percent. In Turney and colleagues' (20 1 2:477)
study, the authors surmise that incarceration is a
source of stress proliferation. They find that both
current and recent incarceration increases the like-
lihood of depression among fathers and that this
effect is explained by a combination of economic
and relational difficulties experienced both during
and after incarceration.
Stigma and Social Standing. For many scholars, the
tribulations of former inmates can be traced to
stigma. From this perspective, spending time in a
correctional facility stains an individual's identity,
ostracizing him or her from others. Indeed, inter-
view-based studies find that ex-felons believe their
criminal past serves as a "scarlet letter, leaving
them permanently marked or 'branded'" (Uggen,
Manza, and Behrens 2004:280; see also Maruna

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 Porter 237

causes and correlates

2001). As of health behavior differSc
(Pampel et al. 2010).
former Although the salience of each
inmat
of a diminish
mechanism may vary, it is predicted that a combi-
their nation of social, economic, and psychological vari- i
social
ables will be consequential. Based on this
incarceratio
afterprediction,
consid
two hypotheses are proposed:
quences of i
2013).Hypothesis Subjec
1: Former inmates will be more
consistent
likely to smoke cigarettes than respondents who p
measures have been convicted, but not incarcerated. of
2000; Demak
According
Hypothesis 2 : Former inmates will consumeto
tus ismore fast
such
food than respondents who have been a
convicted but not incarcerated.
mortality be
tions are able to exercise more control and auton-
omy over life circumstances. To Marmot, these are
basic human needs that are met more adequately at
DATA AND METHODS
each progressive rung up the ladder. Sample
Being stigmatized is a potential stressor for
This research draws on a sample of young adults
former inmates, but they may also react to any per-
from the National Longitudinal Study of Adolescent
ceived discrimination by adopting fatalistic mentali-
Health (Add Health). Add Health is a nationally
ties and feelings of low self-worth. Consistent with
representative survey of adolescents who were
symbolic interactionist theory, individuals develop a
enrolled in grades 7 through 12 during the 1993-
sense of self in reference to others (Goffman 1963;
1994 academic year. Following an initial in-school
Link and Phelan 2001; Mead 1934). If ex-inmates
survey of 90,000 students, approximately 20,000
experience "felt stigma," they may develop negative
attitudes about themselves that are consistent with
participants were randomly selected for in-home
interviews at wave I. Three subsequent follow-up
how they believe others see them (see also Green et
interviews have been conducted since wave I, the
al. 2005). Diminished feelings of self-worth and
most recent of which was administered in 2007 and
self-efficacy can lead to poor health behavior by
2008 when the respondents were 24 to 32 years old.
leading to depression and, relatedly, by leading indi-
viduals to give less priority to their futures (Kearney
and O' Sullivan 2003; McGee and Williams 2000; Measures
Strecher et al. 1986). Health Behavior. Two measures of health behavior at
wave IV are used in this study: fast food consumption
and cigarette smoking (see Table 1 for a complete list
Incarceration and Health Behavior
of items). Fast food consumption is measured as the
Taken together, research suggests that incarcera-number of times in the past seven days a respondent
tion has profound effects on social, economic, and consumed fast food. Fast food is defined as food from
psychological well-being. Although a combination restaurants such as "McDonalds, Burger King, Wen-
of socioeconomic and psychosocial factors may dy's, Arby's, Pizza Hut, Taco Bell, or Kentucky Fried
link incarceration and health behavior, certain Chicken or a local fast food restaurant." Despite some
mechanisms may be more consequential than oth-improvements in the nutritional quality of fast food
ers depending on the outcome. For example, mar-options, fast food consumption is still associated with
riage and socioeconomic status are strong and an increased risk of obesity (Fowles et al. 201 1) and a
consistent predictors of smoking, but married peo- recent study finds that from 1997-1998 to 2009-
ple tend to be overweight compared with unmar- 2010, the average Healthy Eating Index score across
ried individuals (Grzywacz and Marks 2001). eight popular fast food restaurants increased only
Socioeconomic disparities in smoking also tend to slightly from 45 to 48 (out of 100). In addition, none
be more pronounced than disparities in diet of the restaurants "achieved or approximated opti-
(Pampel et al. 2010). Thus, the salience of each mum scores" for fruit, dark green and orange vegeta-
mechanism may differ according to outcome.1 bles, legumes, whole grains, or sodium (Hearst et al.
More research is warranted in this area alone, since2013:592). Among Add Health respondents at wave
there is still much to be learned about how the IV, fast food consumption is associated with a higher

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238 Journal of Health and Social Behavior 55(2)

Table I. Description of Add Health Variables.

Variable Description
Dependent variables
Fast food consumption Number of
Cigarette smoking Respondent s
days (yes = I )
Independent variables
Incarcerated, convicted Responden
wave IV (yes = I )
Convicted only Respondent ha
Control variables

Age Respondent's age in years at wave IV

Black Respondent is black (yes = I )
Hispanic Respondent is Hispanic (yes = I)
Other Respondent is other race (yes = I )
Male Respondent is male (yes = I )
High school education Respondent graduated from high school or
equivalent by wave IV (yes = I )
Parent education Highest educational attainment of either parent
5 = postgraduate education )
Neighborhood disadvantage - Scale combining the proportion of respond
wave I wave I on welfare, living at or below poverty, unemployed, and
proportion of female headed households (a = .95)
Future orientation - wave I The degree to which respondent agreed with the following
statement: When making a decision , I go with my gut feeling and
don't think much about the consequences of each alternative
Fatalism - wave I Scale reflecting the respondent's perceived likelihood that she or
he will live to be 35 (reverse coded)
Depression - wave I Scale combining responses on 1 1 items, where respondents were
asked on a scale of 0 to 3 how often they experienced each of
the following during the past week (a = .80):
• Being bothered by things that don't usually bother them
• Not feeling like eating, appetite was poor
• Could not shake off the blues , even with the help of family and
friends
• Feeling like they were just as good as other people (reverse
coded)
• Felt depressed
• Felt too tired to do things
• Felt hopeful (reverse coded)
• Felt like a failure
• Enjoyed life (reverse coded)
• Felt sad
• Felt life was not worth living
Diet - wave I Number of times respondent ate fruits or vegetables in past
24 hours

Cigarette smoking - wave I Respondent smoked cigarettes within the past 30 days (yes = I )
Delinquency - wave I A weighted scale ranging from 0 to 1 9.2 indicated the level of
delinquency at wave I based on involvement in vandalism,
shoplifting, other theft, burglary, fighting, selling drugs, and
robbery (a = .79)
Violent arrestee Respondent has been arrested for a violent offense after the age
of 1 8 (yes = I )

(continued)

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 Porter 239

Table I. (co

Variable Description

Repeat arrestee Respondent has been arrested more than once (yes = I )
Mediators
Mental health and attitudes
Fatalism The degree to which a respondent agreed with the following
statement (reverse coded): I'm always optimistic about my future
Perceived stress Scale constructed from responses to four items, indicating how
often in the past 30 days respondents (a = .79)
• Felt unable to control the important things in life
• Felt confident in the ability to handle personal problems (reverse
coded)
• Felt that things were going their way (reverse coded)
• Felt that difficulties were piling too high to overcome
Perceived discrimination How often a respondent feels he or she is treated with less
respect or courtesy than other people (0 = never, 3 = often)
Social integration
Perceived isolation How often a respondent feels isolated from others (0 = never,
3 = often)
Number of friends The number of "close friends" a respondent reported
Married Respondent is married (yes = I )
Social standing Scale indicating where respondents perceive their social s
relative to others in the United States, where 1 0 = high and I =
Socioeconomic status

Employed Respondent is employed (yes = I )

Financial difficulties Respondent indicated he or she, or the household, experie
one of the following in the prior year (yes = I ):
• Not having enough money to pay the full mortgage or rent
payment
• Not having enough money to pay the phone bill
• Not having enough money to pay the energy bill
• The gas or electric being turned off due to outstanding bills
• Being worried about food running out

risk of diabetes and high blood pressure. Cigarette Controls. Analyses control for demographic and
smoking is measured as a dichotomous variable indi- socioeconomic characteristics of respondents,
cating whether or not an individual smoked at least including age, race, sex, parental education,
one cigarette per day in the past 30 days.2 respondent education, and prior neighborhood dis-
advantage. Each variable is measured at wave I,
Incarceration. Respondents were asked the follow- except for respondent education, which is mea-
ing two survey items at wave IV: Have you ever sured as whether the respondent had graduated
been convicted of or pled guilty to any charges high school by wave IV. Measures also include
other than a minor traffic violation? Have you ever prior depression, future orientation, and fatalism.
spent time in a jail, prison, juvenile detention cen- Analyses control on prior delinquency, which is
ter, or other correctional facility?3 Respondents measured by summing weighted responses to ques-
who have been convicted and incarcerated are tions about participation in fighting, theft, robbery,
compared with those who have been convictedand destruction of property. Respondents were
only as indicated by responses to these items.asked how many times they had engaged in each
Respondents were also asked how old they were offense during the prior 12 months, and indicated
the first time or only time these events occurred.the frequency as one or two (1), three or four (2), or
five or more times (3). Each response was multi-
Those who indicated only being convicted or incar-
cerated prior to the age of 1 8 were excluded. plied by a corresponding severity score culled from

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 240 Journal of Health and Social Behavior 55(2)

recent work by Ramchand and and colleagues (2009).

has gained considerable momentum in the social
The weighted items were then sciences.
summed for
Rather than each
adjusting for the influence of
respondent. Since this item waspossible
asked of respon-
confounders in a regression framework,
dents during their adolescent and teenage
PSM draws years, to generate a
on such characteristics
models also adjust for more recent indicators
"synthetic ofwhich to compare
control group" with
criminal involvement. Variables are included to treated respondents. First, the likelihood of treat-
indicate whether a respondent had ever been
ment (in this case, incarceration) is estimated using
arrested for a violent crime as an adult and whetheravailable background characteristics. Each case is
a respondent had been arrested as an adult more then assigned a propensity score corresponding to
than once, information that is available at wave IV.
the conditional probability of assignment to treat-
Finally, models control for prior smoking and diet
ment given the vector of covariates (Rosenbaum and
at wave I.4 Rubin 1983). Finally, treated and untreated respon-
dents are matched based on the proximity of their
Mediators. The second aim of this study is to eluci- scores. After matching, the two groups should be
date any mechanisms linking incarceration to risky similar with respect to relevant background covari-
health behavior. All measures are constructed from ates. Any differences in outcome variables can thus
wave IV survey items. Economic well-being is be more confidently attributed to the treatment.
captured using employment status and whether a While it is possible to match on available
respondent experienced financial difficulties in the covariates that may bias the association between
last year, including not being able to pay bills on incarceration and health behavior, some variables
time, not having enough money to pay them, and of interest may be missing or measured impre-
having services shut off in the household due to cisely. For example, prior research indicates that
payment delinquency. Social integration is mea- self-control is an important determinant of health
sured using three variables: married, perceived iso- and criminal behavior, but the proper measurement
lation, and number of friends. Importantly, these of this characteristic is the subject of much debate
variables capture friendship ties as well as marital (Piquero 2008). Where unobserved heterogeneity
ties and are both objective and subjective. A series is an issue, Massoglia and Warner (201 1) note that
of variables also capture variation in psychological identifying a strategic group with which to com-
well-being, including fatalism , perceived stress, pare former inmates is a promising approach. For
perceived discrimination , and social standing. example, Apel and Sweeten (2010) compare the
Social standing is measured using a survey item in employment outcomes of first-time offenders sen-
which respondents were asked to look at a picture tenced to incarceration to those who were con-
of a 10-step ladder. They were instructed to think of victed but not incarcerated. The investigators find
people at step 10 as having the "most money and that incarceration leads to employment difficulties
education and the most respected jobs." At step 1, that outstretch that of being convicted but not
in contrast, are people who have the "least money, incarcerated.5 Using an appropriate comparison
education, and least respected jobs or no jobs at group can thus help account for (although not com-
all." Respondents indicated where they stand rela- pletely eliminate) unobserved heterogeneity.
tive to other people in the United States by choos- Using a strategic comparison group is also use-
ing a step on the ladder. This measure is especially ful for identifying possible mechanisms. For exam-
advantageous since many scholars discuss the ple, Massoglia and colleagues (2011) compare
potentially stigmatizing effects of incarceration, individuals who have been incarcerated to deployed
but few have been able to gauge it using available military personnel and find that incarceration has a
data (Schnittker and Bacak 2013). similar effect on divorce as deployment, leading
them to conclude that separation, rather than
stigma, may be the key mechanism. In addition, it
Analytic Strategy can be difficult to disentangle the effects of incar-
Isolating the consequences of incarceration is diffi- ceration from conviction, which makes those who
cult considering that many "outcomes," such as have been convicted a particularly useful compari-
unemployment, also typically precede incarceration son group. For example, Apel and Sweeten (2010)
(Wakefield and Uggen 2010). An attractive option find that incarceration leads to a detachment from
for addressing selection bias is the use of propensity the labor market that is less likely among respon-
score methods. Propensity score modeling (PSM) dents who were convicted but not incarcerated.
was introduced by Rosenbaum and Rubin in 1983 Similarly, this study compares the health behavior

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 Porter 24 1

of convicted 84 percent have graduated from high school, com-

been convicted of crimes but not incarcerated. This pared with 92 percent of the full sample. Roughly
strategy is then combined with propensity score 40 percent smoked cigarettes as teenagers, com-
methods to account for both observable and unob- pared with only 25 percent of the full sample (full
servable characteristics that may bias the associa- sample statistics are available upon request).
tion. The Add Health survey includes a number of
useful items to account for selection, such as for-
mer health behavior, delinquency, and prior mental
Nearest Neighbor Matching
health. However, since there is still likely to be a In the first phase of the analysis, the propensity to
degree of unobserved heterogeneity after account- be incarcerated among convicted respondents was
ing for observable differences across groups, the predicted using a probit model. Convicted respon-
propensity of incarceration is estimated using only dents who were missing on background covariates
those who have been convicted of crimes. As Apel were dropped from the analysis, yielding a total
and Sweeten (2010) note, convicts who have not sample size of 1 ,670. Propensity scores were then
been incarcerated are especially meaningful as assigned to respondents that correspond to their
comparison cases because they are "closest to the conditional probability of being incarcerated given
incarceration decision" and should thus be similar the vector of covariates. Nearest neighbor match-
on a number of dimensions (p. 454).6 If the associa- ing was then used, which effectively matches each
tions between being a convicted former inmate and ex-inmate with a convicted-only respondent who
health behaviors are significant when comparing has a similar propensity score. Matched pairs could
this group to individuals who have been convicted differ by no more than .01 in their scores, and com-
only, it would suggest that the behavioral conse- parison cases could be used more than once.
quences of incarceration outstretch those of The purpose of matching is to generate a com-
conviction. parison group that is similar with respect to back-
In sum, using a strategic comparison group ground characteristics. Balance diagnostics
helps address unobserved heterogeneity, while pro- confirms this to be the case, showing that the stan-
pensity score analysis helps address observed het- dardized bias across variables was reduced from

erogeneity. In the first stage of the analysis, the 18.2 to 2.6 after matching. The standardized bias is
propensity to be incarcerated is predicted among computed by dividing the difference of means for
all respondents who have ever been convicted of a each covariate by the standard deviation (see bal-
crime. Nearest neighbor matching is then used to ance diagnostics in Appendix A, available at http://
compare the average fast food consumption and hsb.sagepub.com/supplemental). Notably, an ade-
predicted probability of smoking across groups. To quate standardized bias statistic is considered to be
test mediating variables, the propensity score is any value less than 20, suggesting that the two
included as a control variable in a regression frame- groups were already fairly balanced prior to match-
work (Coffman 2011). Negative binomial and ing (Rosenbaum and Rubin 1983). This balance
logistic regressions are used, and the significance also provides further evidence that convicted-only
and total mediation of mechanisms are tested. respondents constitute a more suitable comparison
Causal mediation is employed, which is moregroup for ex-inmates.
Results of 1:1 nearest neighbor matching are
robust to violations of functional form and distribu-
tional assumptions than conventional methodsshown in Table 3. Before and after matching,
(Imai, Keele, and Tingley 2010). respondents who have been incarcerated exhibit
higher probabilities of smoking and higher levels
of fast food consumption than their matched coun-
RESULTS terparts. On average, respondents who have been
Table 2 presents descriptive statistics for Add incarcerated eat fast food about .5 more times per
Health respondents who have been convicted ofweek than those who have been convicted only.6
crimes (13 percent of the total sample). Among Ex-inmates are also about 1 1 percent more likely to
convicted respondents, 70 percent have been con- smoke cigarettes. Notably, the predicted probabil-
victed and incarcerated, while a remaining 30 per- ity of smoking is fairly high in both groups, with
cent have been convicted only. Seventy-five 45 percent of ex-inmates reporting that they smoke
percent of respondents are male and 24 percent are daily, compared with 34 percent of their never-
black. They are also more socioeconomically dis- incarcerated counterparts. Only 22 percent of the
advantaged than the full Add Health sample. Onlyfull sample indicates being daily smokers.

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 242 Journal of Health and Social Behavior 55(2)

Table 2. Descriptive Statistics.

Variable Mean Standard Deviation Minimum Maximum

Dependent variables
Cigarette smoking .4 1 9 .493 0 I
Fast food consumption 3.112 3.576 0 55
Independent variable
Incarceration .70 .46 0 I
Matching covariates
Respondent age 28.965 1 .7 1 1 24.279 34.05 1
Male .753 .431 0 I
Black .238 .426 0 I
Hispanic .136 .343 0 I
Other .083 .275 0 I
High school graduate .840 .367 0 I
Parent education 2.243 1.624 0 5
Neighborhood disadvantage - .004 .908 -1.148 4.703
wave I
Future orientation - wave I 2.764 1 . 1 68 I 5
Fatalism - wave I 1 .707 .892 I 5
Cigarette smoking - wave I .395 .489 0 I
Depression - wave I 6.882 4.873 0 33
Diet - wave I 2. 1 1 7 1 . 1 92 0 4
Delinquency - wave I 1 .657 2.69 1 0 1 9.2
Repeat arrestee .655 .476 0 I
Violent arrestee .154 .361 0 I
Mediators

Employed .786 .410 0 I

Financial difficulties .380 .485 0 I
Married .274 .446 0 I
Number of friends 3.059 1 .047 I 5
Perceived isolation 1 .070 .965 0 3
Perceived disrespect 1 .057 .828 0 3
Social standing 4.570 1.778 I 10
Perceived stress 5.328 3.052 0 1 6
Fatalism .093 .290 0 I

Propensitythan score
that of being male and prior
methoddelinquency.
tion that Results of this test suggest that selection to
assignment into incar- tre
able after ceration is sufficiently addressed in these
matching. In models,
oth
models relies
although these
on models arguably
selection
reduce selection
for by bias by addressing both observable and unobserv-
observables. Rosen
sensitivity analysis
able to
heterogeneity by using convicted-only det
respon-
the effect an omitted variable would need to exert dents as a reference.
on the probability of treatment to alter the observed
effect. This sensitivity analysis was performed
Mediation
using the rbounds program in Stata (see Diprete
and Gangl 2004). Results suggest that all else being Results of propensity score matching suggest that
equal, an unobserved covariate would need to ex-inmates are more likely to smoke and eat more
increase the odds of imprisonment by 35 to 40 per- fast food than are convicted-only respondents. The
cent to alter results. This effect would be stronger next step in the analysis is to examine why

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 Porter 243

Table 3. Eff

Variable Sa
Fast food Unmatched 3.326 2.571 .755 .186 4.050**
Matched 3.322 2.802 .520 .260 2.000*
Smoking Unmatched .453 .311 .142 .026 5.480**
Matched .454 .344 .110 .039 2.840*

*p<.05, **p<.0l.

incarceration may lead assess to

the significance
poorand total mediation
health of an
behavior
Potential mediators are intervening
tested variable. using
These analysesawere carried
regressio
framework, where propensity out using the medeffscores
command available
arein include
Stata
as a control variable to minimize selection bias (Hicks and Tingley 201 la).
(Coffman 2011; see also Wiley, Slocum, and Table 4 displays results from regression analy-
Esbensen 2013). There are two common ways ofses. After the analysis controls for the propensity of
testing mediators in social science research. The subjects to be incarcerated, ex-inmates are pre-
first is to assess changes in slope coefficients afterdicted to eat fast food at 1 .25 the rate of convicted-
mediators are included in the model. The second is only respondents and are 1.5 times more likely to
the product of coefficients method. Two coeffi- smoke cigarettes. After mediators are included, the
cients are multiplied (the coefficient for the inde- association between incarceration and fast food
pendent variable when the mediating variable is consumption decreases slightly and the coefficient
regressed on the independent variable as well as for smoking is reduced by 22 percent. Mediation
controls, and the coefficient for the mediating vari- analyses suggest that social standing and financial
able when the dependent variable is regressed ondifficulties are both significant mediators of the
the mediating variable, independent variable, andincarceration-smoking link, each of which medi-
controls), and standard errors are estimated toates the association by about 10 percent. For fast
ascertain the mediation effect (Preacher and Hayes food consumption, financial difficulties emerge as
2008). However, each of these methods is inappro-a salient mediator as well, accounting for roughly 6
priate when estimating nonlinear models (Hickspercent of the total effect. In sum, the effects of
and Tingley 2011b). As such, causal mediationincarceration on these health behaviors are driven
analysis is used, which can be applied to other in part by reductions in social standing and
functional forms and basic model assumptions can increases in financial difficulties.
also be relaxed (Imai et al. 2010).
The logic of causal mediation analysis is based
CONCLUSION
on the following counterfactual question: How
much would an outcome change for the treatedThis study finds that incarceration is associated with a
group if the value of a mediator was changed to that higher rate of fast food consumption and a higher
under the control condition (see Imai et al. 2010)?likelihood of smoking. Ex-inmates are predicted to
In other words, how would predicted fast food con-eat fast food an average of 3.3 times per week, which
sumption and smoking among ex-inmates change is .5 more times than similarly situated peers.
if the value of a mediator (e.g., social standing) was Although recent work finds that fast food consump-
that of convicted-only respondents? The averagetion is associated with a higher risk of obesity, it is not
causal mediation effect is then calculated by draw- associated with obesity in this sample. This could be
ing on a quasi-Bayesian Monte Carlo distribution due to the young age of respondents (24-32 years),
of potential outcomes (King, Tomz, and Wittenberg but even among Add Health respondents at this age,
2000). More specifically, the model is fit and thenfast food consumption is associated with higher blood
model parameters are simulated from their sam- pressure and a higher risk of diabetes. If ex-inmates
pling distribution. Then potential values are esti- follow this health behavior trajectory, obesity effects
mated for the mediator and for the potential may be observed in future waves of data collection.
outcomes (given the potential values of mediators). Nearly half of ex-inmates report smoking every day,
The average total effect and standard errors are compared with about one out of every three matched
then estimated. From these results, it is possible to counterparts. This finding is particularly alarming

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 244 Journal of Health and Social Behavior 55(2)

Table 4. Regressions of Health Behaviors on Incarceration and Other C

Fast Food Smoking

Incarceration .201** .193** .413** .323**
(.058) (.058) (.121) (.124)
Propensity score .694** .627** 1 .459** 1 .04 1 **
(.170) (.172) (.351) (.364)
Employed .243** .030
(.065) (.134)
Financial difficulties . 1 39* .409**
(.054) (.114)
Marriage -.033 -.188
(.057) (.122)
Number of friends -.05 1 * -.077
(.025) (.053)
Perceived isolation -.027 .004
(.029) (.062)
Perceived discrimination -.013 -.002
(.032) (.068)
Social standing -.002 -. 1 55**
(.016) (.033)
Perceived stress .020* .024
(.010) (.021)
Fatalism -.090 . 1 45
(.088) (.183)
Constant .501** .419* -1.669** -.648
(.116) (.195) (.239) (.404)
N 1,602 1,602 1,597 1,597
Log likelihood -3,6 1 1 .2 1 -3,595.88 - 1 ,058.96 - 1 ,023.8 1

*p < .05, **p <.01.

considering that many states have banned smoking

attributed solelyin
to conviction. Importantly, many
prisons. By 2010, 25 states had bannedformal
tobacco use such as voting restrictions, loan
barriers,
(see Seaman 2010). It is not possible to discern the
disqualification, and the "box" on job applications,
geographic location of incarcerations using
apply these One possibility is that indi-
to conviction.
viduals
data, but it also seems likely that any with both
benefits ofincarceration and conviction his-
smoking bans would begin to emerge in this
tories sample
boast relatively stigmatizing records. For
of ex-inmates, who were interviewed example,
between 2007
a sex offense may be more stigmatizing
and 2008. than a drug possession. Stigma may also be cumu-
Results of the mediation analysis suggest that lative, such that greater contact with the criminal
financial strife and decreased social standing con- justice system is accompanied by progressively
tribute to higher rates of fast food consumption and unfavorable stains on one's identity (see also
smoking among ex-inmates. Ex-inmates exhibit Schnittker and Bacak 2013).
relatively poor health behavior in part because of To be sure, there is still likely unobservable varia-
tangible difficulties related to financial stability, tion across these groups with respect to offense char-
but they may also feel as though their status rela- acteristics that can sway sentencing decisions, such as
tive to others is low. Using convicted-only respon- relationships with any victims (e.g., stranger, roman-
dents as comparison cases offers some leverage tic partner, etc). In addition, though, there is likely
with respect to theoretical interpretation here as substantial variation within these types of contact (see
well, since lower social standing cannot be also Schnittker and Bacak 2013). Restrictions are

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 Porter 245

oftenthis article:
convictThis research uses data from Add Health, a
respectprogram project directed
to by Kathleen Mullansoc
Harris and

sex designed by J. Richard Udry, Peter S. Bearman, and

offenders
ers in Kathleen
terms Mullan Harris at the University of North of
Carolina at Chapel Hill, and funded by grant
barriers to rei
PO 1 -HD3 1 92 1 from the Eunice Kennedy Shri ver National
variation in te
Institute of Child Health and Human Development, with
tics, duration
cooperative funding from 23 other federal agencies and
to capture the
foundations. No direct support was received from grant
tation
P01-HD31921 for thisin
analysis. th
Schnittker a
2013; Turney
NOTES
tially meaning
The 1. Diet and smoking differ in important ways. As
relativel
Pampel and colleagues (2010) note, preparing nutri-
the Add Healt
tious meals involves a time investment, whereas
rates of chron
smoking does not. Eating unhealthy food is argu-
future. While
ably more socially accepted, while smoking is less
consequences
accepted. Although it is not an explicit aim of this
threats to
study, Pampel and colleagues (2010)ex-
note the need
leading to
for more research comparing health poo
behaviors and
ification and
their determinants (p. 14). Thus, the results of this e
for interven
study also contribute to the understanding of the
(2009:613)determinants of health behaviors more generally.
no
such 2. Cigarette smoking was also assessed as the level of
program
smoking in a multinomial framework. Respondents
taged groups,
were asked how many of the last 30 days they smoked
these investig
a cigarette and how many cigarettes they usually
can be effecti
smoked each day. The product of these items was first
ing informati
calculated. These respondents were then categorized
ing barrier id
as light, moderate, and heavy smokers based on per-
low-income
centile cut points. Results suggest that incarceration g
Finally, the
is associated with higher odds of moderate and heavy
that smoking, although effects
are hard- were not significantly dif-

health ferent across groups (results available upon request).

epidem
3. One hundred and twentyexpo
ferential respondents indicated
exposure to the criminal justice system prior to
health dispa
age 18 only. These respondents were considered
Massoglia 200
"arrested only." First, juvenile facilities may be a
tially lethal c
qualitatively different experience than adult facili-
and given str
ties. Second, many juvenile offenders may not bear
and health,
the stain of a criminal record if such records have ad
and poor heal
been expunged. To ensure that the classification
reducing
of these cases does not alterhealt
the results, sensitivity
analyses were conducted in which these observa-
tions were considered "missing." Results did not
ACKNOWLEDGMENTS
differ substantively (results available upon request).
4. Rather than prior fast food consumption at wave I,
The author thanks Ryan D. King, Christopher Wildeman,
Michael Massoglia, and Kristin Turney for feedbackprior
on consumption of fruit and vegetables is used as
earlier versions of this work. Special acknowledgmenta control.
is Fast food consumption is not available at
due Ronald R. Rindfuss and Barbara Entwisle for assis- this wave; however, fruit and vegetable consumption
tance in the original design. Information on how to obtain does predict lower levels of fast food consumption by
the Add Health data files is available on the Add Health wave IV and studies find that people who eat higher
website (http://www.cpc.unc.edu/addhealth). quantities of fast food tend to eat lower quantities of
healthier foods (Fowles et al. 201 1; Moore et al. 2009;
Sebastian, Wilkinson, and Goldman 2009).
FUNDING 5. A vast body of research investigates the collateral
The author disclosed receipt of the following financial consequences of incarceration, but many studies
support for the research, authorship, and/or publication of do not or cannot isolate the "incarceration effect"

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All use subject to https://about.jstor.org/terms
 246 Journal of Health and Social Behavior 55(2)

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 Porter 249

AUTHOR BIOGRAPHY research largely focuses on the consequences of incarcera-

tion for individuals and families. Other interests include the
demographic patterning of imprisonment and the role of
Lauren C. Porter is an Assistant Professor of Criminology
place
and Criminal Justice at the University of Maryland. Herand space in shaping crime.

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