1. Free self-help behavioral resources to help inmates quit

    During July and August I presented ten nicotine cessation seminars in five South Carolina prisons, prisons that were not just banning smoking from the entire prison but all tobacco. Although in total agreement that prison administrators should be offering inmates high quality cessation programs, it is our job to teach them why doing so is in everyone's best interests and, frankly, until now we have not done a very good job.

    What I cannot accept is the authors' contention that so much tobacco contraband is coming into prisons with bans, or that tobacco's value to inmates is so wonderful, that we'd be better off allowing all tobacco into prisons and then somehow "better" controlling where we allow it to be smoked. The authors cite California's $125 per-pack prison price as a negative. What higher prices actually demonstrate is effective contraband interdiction with vastly less availability than the authors suggest. Yes, surveys may show that inmates have smoked but if cigarettes are $8 each, how often and how much?

    Regarding interdiction burdens, a number of wardens have told me that they'd much rather that inmates be occupied with, and spending limited disposable income on, attempting to get tobacco into prison, than chemicals whose dopamine high is not alert but numb, dangerously intoxicated or moving at the speed of light.

    It's a bit strange to see public health advocates paint what is likely the most significant prison health event ever, as a violation of human rights, while suggesting that some imposing bans may be motivated by attempts to further punish inmates instead of desires to diminish tobacco related health care costs, fires, dependency, morbidity and mortality. I certainly hope not. It is almost as if the authors seek to chill the smoke-free and tobacco-free prison movement before its pros and cons can be fairly weighed, firsthand, within their own nation.

    If incapable of protecting air quality inside government buildings then where? If government is not going to treat nicotine dependency as true chemical addiction then who will? As drug addiction counselors, if we accept liberty, freedom, socialization, and custom as valid and legitimate drug dependency rationalizations, and justification for allowing a penitentiary's single greatest cause of premature demise to continue, what does that say about our own chemical dependency recovery understanding, or at least our biases regarding nicotine? Both legal products, couldn't similar rationalizations be used to justify giving alcohol to prison alcoholics?

    Yes, a combination of insufficient advance policy change notice, little or no nicotine dependency recovery education for inmates (and just as important, correctional officers), poor interdiction efforts, and pretending that inmates do not possess the intelligence to transform oral tobacco into smoked tobacco or nicotine replacement products (NRT) into Bible rolled and smoked tea-bacco, could make the most glorious prison health event ever far more challenging than need be. Ending use of this powerful central nervous system stimulant should be one of the most calming events any penal institution has ever known.

    As I stood before 300 inmates at my first seminar it wasn't hard to see and feel their collective anger. But it didn't take moving too deeply into my 250 slide PowerPoint presentation before they started to sense that maybe they didn't know as much about this most amazing chemical as they thought. Having repeatedly witnessed their anger melt into curiosity, attention, focus and then applause have been my most rewarding teaching experiences ever.

    But as the authors correctly note, 97% of inmates released following forced cessation can be expected to relapse to tobacco within six months. It is a basic tenant of chemical dependency recovery that the drug addict must quit for themselves, that quitting for others or feeling compelled to quit fosters a natural sense of self-deprivation that erodes cessation motivations, fuels smoking expectations and is a recipe for relapse.

    It is our job to: (1) help inmates shift core motivations from a sense of compelled cessation to a personal desire to quit; (2) reduce chronic withdrawal anxieties and institutional demand for contraband tobacco by motivating those relying upon greatly diminished levels of daily nicotine intake to end their cycle of perpetual withdrawal; (3) drive home the law of addiction, the most important recovery lesson of all, that just one powerful brain bolus of nicotine will trigger relapse; and (4) prepare inmates to meet, greet and extinguish post-release tobacco use triggers and cues that cannot be encountered while institutionalized.

    Inmates are thirsty for dependency recovery understanding. It is a major mistake for any penal system to neglect educating them. A growing body of evidence ties chronic nicotine use to diminished impulse control. The question is, is the synergy between nicotine controlled serotonin levels (negatively impacting depression and impulse control), adrenaline releases (endlessly stimulating the body's fight or flight response), and dopamine flow (from desensitized and captive reward pathways) a significant factor in helping fill the world's prisons?

    The disagreement in the studies is the degree to which nicotine exposure increases the risk of behavioral problems associated with increased stealing, illegal drug use, gambling, or predatory and relational violence (see Ellickson PL 2001, Vittetoe K 2002, Caris, L 2003, and Mitchell, SH 2004). New research following nicotine's impact upon the animal model through fetal development, adolescence and adulthood gives weight to behavioral observations by allowing us to watch as nicotine causes cell damage and alters synaptic activity of cholinergic, noradrenergic, dopaminergic and serotonergic systems that persist for extended periods after exposure ends, that in animals produce behavioral changes commensurate with neurochemical changes, and in regard to serotonin pathway alterations, appear selective in males (Slotkin TA 2002 and 2007).

    As harsh as it sounds, nicotine dependency is not a "freedom" or "social lubricant" but a mental disorder that enslaves the mind, establishes false priorities, and to some degree permanently alters cerebral cortex and brain stem function. As with all drugs of abuse, the brain's dopamine pathways are clearly the over-revving engine driving nicotine addiction. But the vehicle analogy doesn't stop there, as nicotine's impact upon serotonin levels may be akin to trying to drive through life with bad brakes, while nicotine induced adrenaline flow keeps the gas pedal floored.

    I encourage all penal system administrators to consider sharing the following free cessation resources with inmates:

    1. Inmate Nicotine Cessation Tips, a six page quitting tips handout - )
    2. Never Take Another Puff - a free PDF quit smoking book that you are encouraged to print, bind and put into the prison library or given to dependent correctional officers -
    3. 64 video quitting lessons - these can be formatted to play in any manner you desire -

    Drug addiction is about an external chemical so resembling one of our own natural neuro-chemicals that once inside the brain it fits locks allowing it to take the brain's priorities teacher -- our dopamine pathways -- hostage. It is about how an enslaved mind elevates the next encounter with its captor to its new #1 priority in life. Home to core survival instincts, dopamine pathways are designed to record the most salient and high definition memories the mind may be capable of generating. But now a growing collection of such memories quickly convince the drug user to falsely believe that this chemical gives them their edge, helps them cope, relieve stress, defines who they are, and that life without it may not be worth living.

    Inmates need to be reminded of their own long-held dream of someday quitting on their own terms and invited to consider substituting that dream for their current sense of feeling controlled and compelled by department of corrections policy to stop. We need to teach them about internal endless tug-o-war between the impulsive limbic brain and the rational thinking mind, that if they can master craves, urges and impulses associated with what many dependency experts contend is the most challenging compulsion of all, imagine the possibilities in regard to control over the impulse that ultimately resulted in their conviction and incarceration.

    We need to destroy a long list of rationalizations, minimizations and blame transference invented by the rational thinking mind to try and explain its endless surrender to the impulsive limbic mind. Is their best friend really a chemical, like table salt? Do they smoke or chew because they like smoking or because they don't enjoy what happens when they don't smoke? If they "like" smoking yet have no remaining memory of what it was like to live without it (which is the case for nearly all), then what basis exists for honest comparison? Does nicotine really relieve stress or is stress an acid producing event that quickly neutralizes the body's reserves of the alkaloid nicotine? Doesn't alcohol turn the body's fluids more acidic too? Flavor, taste? How many taste buds are inside human lungs? Relaxation? Isn't nicotine a central nervous system stimulant that makes the heart pound 20 beats per minute faster?

    What about rationalizations associated with socialization, boredom, coffee, pleasure, an adult choice activity, coming cures, freedom or the right to smoke, weight gain, it being too late to quit, withdrawal never ending, relapse being inevitable, or quitting being too painful? Getting them to laugh at or seriously question their core smoking rationalizations is a giant step toward helping them see that drug addiction is about living a lie. In fact, if the inmates have been off of all nicotine for some period of time, they already have awareness that most rationalizations were false but probably never gave it much thought.

    Although nearly all inmates have been bombarded by an endless stream of smoking health warnings throughout life, amazingly few understand how each and every puff inflicts additional damage upon the body. I challenge you to find any inmate who can explain why circulatory disease is smoking's #1 cause of death. They need to see, feel and touch the combined damage done by nicotine, a vasoconstrictor and nervous system stimulant that endlessly pumps stored fats into their bloodstream, and carbon monoxide, which poisons the blood's oxygen carrying capacity while allowing gathering fats to stick to vessel walls whose delicate Teflon like lining (endothelium) has been damaged by long-term exposure to both nicotine and carbon monoxide.

    What might we expect to find inside the arteries of a 32-year-old smoker? Let's show them. What are the different types of lung cancer, what do they look like, and which one is most frightening? What does it feel like to try and breathe with emphysema? Let's teach them. What is a stoma, what is Buerger's disease, what does lung cancer look like on an x-ray, or a stroke on a brain MRI? With smoking claiming half of adult smokers 13-14 years early, let's prepare them.

    I leave you with the most important nicotine dependency recovery lesson of all, what we term " The Law of Addiction." It states that "administration of a drug to an addict will cause reestablishment of dependence upon the addictive substance." Mastering it requires acceptance of three principles: (1) dependency upon smoking nicotine is a true chemical addiction; (2) once established, you cannot cure or kill an addiction but only arrest it; and (3) once arrested, regardless of how long you have remained nicotine free, just one powerful puff, dip or chew of nicotine all but guarantees full and complete relapse.

    A valuable lesson Joel Spitzer has pounded into my brain, the true measure of nicotine's power isn't in how hard it is to quit but in how easy it is to relapse. Sincere thanks to the authors for addressing this critical issue.

    John R. Polito
    Nicotine Cessation Educator

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