A "why and how" guide to aid penal system administrators in helping prison inmates, correctional officers and staff break free from nicotine, smoking and tobacco.
Imagine being a prisoner inside your own mind, inside prison walls
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 substantial factor in helping fill the world's prisons?
This article briefly reviews some disturbing study findings, followed by insights into how correctional facilities adopting smoke-free, tobacco-free or nicotine-free policies can use the ban as a highly teachable period to diminish prison demand for tobacco products, and reduce nicotine relapse rates upon release.
Are Smoke-free Prisons Inevitable?
Although diminished impulse control lies at the root of most criminal convictions, meaningful opportunities to educate prison inmates on the ABCs of basic impulse control are rare. But such a period arises when prison policymakers decide to transform correctional facilities having tobacco use rates in excess of 50% into smoke-free, tobacco-free or nicotine-free environments. This highly teachable quitting period is fertile ground for planting broad insights into what may be the most relentless impulse of all, satisfying the brain's endless need to feed upon a new supply of smoked, chewed or dipped nicotine.
According to the U.S. government, secondhand smoke is an entirely preventable health risk, yet lung cancer caused by the 50 known cancer causing chemicals within tobacco smoke is estimated to annually claim approximately 3,000 American nonsmokers.(1) In addition to lung cancer deaths, passive smoking is blamed for elevating the risk of heart disease by 25-30% and annually responsible for an estimated 22,700-69,600 heart disease deaths.(2)
The two leading causes of death in U.S. state prisons from 2001 to 2004 were heart disease (3,314) and cancer (2,820), accounting for 50.6% of all deaths. One in three cancer deaths was attributable to lung cancer, more than the next six leading cancer sites combined.(3) How many of those 6,000 deaths, if any, were attributable to involuntary breathing of secondhand smoke? Frankly, I do not know.
What I do know is the U.S. Supreme Court opened the door to secondhand smoke inmate lawsuits with its 1993 holding in Helling v. McKinney that, "McKinney states a cause of action under the Eighth Amendment [cruel and unusual punishment clause] by alleging that petitioners have, with deliberate indifference, exposed him to levels of ETS [environmental tobacco smoke] that pose an unreasonable risk of serious damage to his future health."(4)
Will continuing inmate success in secondhand smoke lawsuits eventually compel all prisons to both adopt and enforce smoke-free policies? Here in the United States, as of January 1, 2008, 24 states will have 100% smoke-free indoor areas, including three mandating that the entire prison be smoke-free (Arkansas, Nebraska and South Carolina).(5)
But public health officials in Australia are attempting to throw a wrench into the smoke-free prison movement. An article in the October 2007 edition of Tobacco Control is entitled "Should smoking be banned in prisons?" It suggests that taking cigarettes from inmates violates their human rights, that U.S. prisons with smoking bans are doing a horrible job at keeping cigarettes out, and that all cigarettes should be allowed into prisons with administrators somehow better controlling where they are smoked.
In my response I question the smoking rationalizations offered in support of the authors' assertion of a human rights violation (liberty, freedom, socialization and custom). As to the issue of "better" control, I suggest that the most important control element is the sharing of knowledge and coping skills that empower inmates to break nicotine's grip upon their minds.
But the smoke-free indoor air movement appears to be sweeping the globe.(6) As an increasing percentage of society develops expectations of smoke-free indoor air, should we expect increasingly sympathetic juries to render more and possibly larger judgments against systems perceived as demonstrating "deliberate indifference," systems that either fail to adopt smoke-free policies, or fail to enforce existing ones?
Forced Cessation Not the Same as Quitting
Penal systems having already made the conversion are developing increasing awareness that forced cigarette, tobacco or nicotine cessation is not the same as "quitting." A 2002 study found that 97% of inmates released following forced tobacco cessation had relapsed to tobacco within six months.(7)
A basic tenant of chemical dependency recovery is 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.(8) But in that penal systems have plenary power to force cessation, why should administrators care how an inmate internalizes their own cessation motivations?
Living Life Without Brakes
Studies suggest that fetal,(9) and adolescent nicotine exposure diminish impulse control thus increasing the risk of behavioral problems as evidenced by increased stealing, drug use, gambling, predatory and relational violence, and ultimately impacting academic performance and school dropout rates. What studies do not agree upon is the magnitude of the problem: whether chronic tobacco use makes diminished impulse control two times,(10) three times(11) or five times(12) more likely.
Impulsivity is measured using go/no-go tasks to assess inhibition and preference tasks to assess delay aversion. Although smokers are more impulsive on these measures than nonsmokers,(13) such observations alone do not prove causation. But new research following nicotine's impact upon the animal model through fetal development, adolescence and adulthood is raising eyebrows.
A College of Charleston student shares truth about where he now finds himself
Almost 90% of adult smokers became addicted to tobacco at or before the age of 18.(14) We've long known that adolescent nicotine exposure desensitizes brain dopamine pathways, causing them to grow or activate (up-regulate) millions of extra nicotinic type acetylcholine receptors. But new animal research is proving that nicotine actually causes cell damage and alters synaptic activity of cholinergic, noradrenergic, dopaminergic and serotonergic systems that persist for extended periods after exposure ends, and that animal behavioral changes are commensurate with neurochemical changes.(15)
A 2005 study found that 87% of students smoking nicotine at least once daily were chemically dependent under nicotine dependency standards contained in The Diagnostic and Statistical Manual for Mental Disorders, 4th Edition (DSM-IV).(16) As harsh as it sounds, nicotine dependency is not just some social problem but a mental disorder that enslaves the mind,(17) 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.(18) But the vehicle analogy doesn't stop there, as nicotine's impact upon serotonin levels may be akin to trying to drive through life without brakes, while nicotine induced adrenaline flow keeps the gas pedal floored.
In animal studies, prenatal, youth and adult nicotine exposure produces permanent sex selective alterations in male brain serotonin systems and synaptic signaling. Even with first nicotine exposure as late as adulthood, serotonin changes can persist long after exposure ends. Although females appear somehow protected against serotonergic system vulnerability, prenatal nicotine exposure followed by adult nicotine exposure somehow overcomes those protections.(19)
Although it is hard to ignore the correlations between female delinquency and smoking,(20) does nicotine's impact upon serotonergic systems and impulse control somehow contribute to the 13 to 1 disparity in rates of male versus female prison incarceration?(21) We simply don't know.
What we do know is that nicotine is a super toxin whose lethal dose is 60mg (LD50) and that drop for drop it is deadlier than strychnine (75mg), diamond back rattlesnake venom (100mg), arsenic (200mg) or cyanide (500mg). What we know is that 1mg of nicotine, the amount entering the bloodstream after smoking a single cigarette, is sufficient to kill the largest rat you've ever seen. What we know is that smoking or chewing it is highly addictive, fostering one of the most overwhelming compulsions known to man, and that it negatively impacts upon human behavior.
What we know is that a penal system's failure to make any attempt to help inmates intellectually shift prison cessation from an issue of system control to one of personal desire and self control, or prepare them to meet, greet and defeat real-world crave triggers, will contribute to almost all of them relapsing within six months of release.
While the alcoholic's dopamine high is drunk and the heroin addict's numb, the nicotine addict's dopamine high is alert. But if this amazing chemical truly is a gateway to diminished impulse control, anger, depression and destruction of brain gray matter, the full societal cost of not treating alert dopamine intoxication on a drug treatment par with other flavors of dopamine intoxication boggles the imagination.
SCDC's Bold Tobacco-Free Initiative
A former thirty-year, three pack-a-day smoker, in 1999 I founded WhyQuit.com, what was then primarily a cessation motivation site, and the same year co-founded Freedom, a free online peer cessation support group. Having studied under Joel Spitzer of Chicago since early 2000 (one of the world's leading cessation educators), I started presenting live programs in 2001.
Three years of presenting bimonthly two-hour seminars at the College of Charleston had burned into my brain the reality that penetrating the young nicotine addict's thick protective wall of dependency denial and somehow motivating them to attend a cessation program was one of the greatest challenges on earth. The dependent and rationalizing mind is capable of inventing hundreds of excuses to protect its nicotine de-sensitized homeostasis. Short of offering significant bribes (money, food or free nicotine) or somehow making attendance mandatory (underage youthful offender or employer programs), most planning live cessation programs for new quitters live in a world of shattered expectations.
And then it happened. A July 1, 2007 editorial in my local paper attacked the South Carolina Department of Corrections (SCDC) for its bold decision to not simply go smoke-free at five institutions on August 1, 2007, but tobacco-free, and if successful, its remaining 24 insitutions doing the same on January 1, 2008.
A bit of quick research explained why South Carolina was assuming a national leadership role in banning 100% of tobacco and all nicotine products except the lozenge (with at least one SC warden wanting to dump the lozenges too). According to Internet news stories, some institutions attempting to limit smoking to outdoor areas were failing miserably. If smoking is banned but oral tobacco allowed, the oral tobacco will get smoked as Bible roll-ups. Bible paper is apparently thin and suitable for smoking. In at least one Canadian prison they have removed Bibles.
Inmates discovered that nicotine patches were not only great for hiding and transporting small contraband items but could be cut-up, soaked with old tea bags, dried then smoked (but see 2015 study finding that boiling patches in water containing tea does not transfer nicotine, but that cutting and smoking patches does).
They learned that not only can nicotine gum be used to disable prison locks or as molds to reproduce keys, inmates report boiling the gum, harvesting the nicotine residue, sprinkling it on redried tea, rolling and smoking it. If true, the same could probably be done with nicotine lozenges too.
I immediately sent an email commending SCDC Director Jon Ozmint on his boldness and offering to assist in any way possible. Four days later I was invited to Columbia to meet with SCDC Health Services Director Campbell and Clinical Services Director Dunlap. We reviewed my last college PowerPoint presentation, a rough draft of a proposed inmate quitting tips sheet and Joel Spitzer's free book, "Never Take Another Puff." They seemed genuinely concerned about providing inmates access to high quality quitting programs and after eight years of preparation I was confident about delivering.
Lieber Correctional Institution, Ridgeville, SC, site of my first two cessation programs before approximately 600 inmates.
I'd always dreamed of a large captive audience but never in the context of prisons. But here it was, Monday, July 30, 2007, 10a.m. and I'm standing in one corner of a quickly warming gymnasium at Lieber Correctional Institution, in Ridgeville, SC, a level three, maximum security prison. Beside me is a laptop tied to a PowerPoint projector. My first slide is visible just below the rafter's on the gym wall to my left. It reads, "Freedom from Nicotine - The Journey Home." Before me are about 300 inmates, many defiant looking with arms folded and facial expressions that seem to somehow want to blame me for having banned the sale of all prison tobacco six weeks earlier.
It seemed that Warden Stan Burtt was one of the advocates of the policy change and had gotten off to an early start. It made one inmate's preprogram mumblings -- "You're a bit late there, aren't you buddy?" -- somehow seem fair. Fairness aside, there are benefits in being tardy, as this group was now living though much of what they were about to hear, making some degree of connection between the lessons and their current situation inevitible.
It didn't take clicking too deeply into the presentation's 250 slides before most began to sense that what they were hearing and seeing was somehow new and different, that this guy was not the enemy but here to try and help. Watching their interest slowly grow was one of those strange moments in life where all the tumblers seem to click and you suddenly realize that you've spent your entire life preparing for this moment. The applause and "thanks" that struck these ears two hours later was all I needed to motivate me to want to do it again and again and again.
By the end of August I had presented ten seminars before inmates at five South Carolina prisons: Lieber, Tyger River, Evans, Kirkland and Broad River. The five institutions had an average inmate tobacco use rate of 58.2%. Three solid decades of battling to break smoked nicotine's grip upon my own mind, and there I stood, reaching out to inmates inside a prison in Marlboro County, South Carolina, a prison seemingly surrounded by three foot high tobacco plants [Note: after this article was written, by March 2008 I had presented 63 seminars in all 28 S.C. state prisons].
Program Objectives and Lessons Shared
Terminal program learning objectives included: (1) shifting core motivations from a sense of compelled cessation to a personal desire to quit; (2) reducing chronic withdrawal anxieties and institutional demand for contraband tobacco by motivating those relying upon greatly reduced levels of daily nicotine intake to end their cycle of perpetual withdrawal; (3) driving home The Law of Addiction - the most important recovery lesson of all; and (4) preparing inmates to meet, greet and extinguish post-release tobacco use triggers and cues.
The two-hour program, with a five minute break at approximately 1:15 minutes, was broken down into ten segments: (1) introduction and program objectives; (2) understanding nicotine addiction; (3) shattering tobacco use rationalizations; (4) assessing the full cost of tobacco use, including health consequences; (5) harmful vs. beneficial cessation motivations; (6) physical nicotine withdrawal; (7) subconscious trigger extinguishment via distraction, relaxation, oral and psychological crave episode coping techniques; (8) confronting conscious thought fixation with honesty; (9) relapse prevention upon release; and (10) a question/answer period lasting up to one additional hour for those wanting to stay.
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 are 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. They are taught about the 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 examine 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 via urine acidification? Doesn't alcohol turn the body's fluids more acidic too (see 2014 finding that nearly all inmates who use tobacco are convince it relieves stress).
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 botth 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.
But costs are not just related to health. How much could be saved during the time remaining on an inmate's sentence if they were to develop a healthy new compulsion to set aside and save the amount spent daily to purchase their particular nicotine delivery device? But question and answer periods quickly taught me that not all had actually quit.
Tobacco was still finding its way into these five prisons but the price for a rather slim hand-rolled Topps cigarette ranged from $3-8 depending upon the institution's demand and supply. It became apparent from the questions being asked at the five correctional institutions that many in attendance were living in a chronic state of perpetual withdrawal, punishing themselves by attempting to survive on vastly diminished quantities of tobacco, used far less frequently than normal.
It compelled me to drive home the timing and sequencing of withdrawal, and the fact that the worst possible withdrawal syndrome anxiety scenario would be to use tobacco once every three days, the amount of time needed to purge the body of all nicotine and achieve peak withdrawal. Why would anyone inflict such anguish upon themselves (see Quitting By Gradual Withdrawal)?
The most important nicotine dependency recovery lesson of all is 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 lesson Spitzer pounds home, the true measure of nicotine's power isn't in how hard it is to quit but in how easy it is to relapse.
The second most important concept is getting inmates (and correctional officers) to adopt a manageable "one day at a time" recovery philosophy while abandoning the big bite concept that insists on measuring victory in terms of "quitting forever." They are reminded that if they insist on using "forever" as their yardstick for success then on which day will they be allowed to celebrate? What good is a party once you are dead? They are encouraged to see each day of freedom and healing as the full and complete victory it reflects.
Another key lesson is how to minimize blood sugar swing type symptoms such as an inability to concentrate by again learning to properly fuel the body and mind. Nicotine allowed those dependent upon it to skip meals yet still get fed stored fats and sugars via the body's fight or flight pathways with each nicotine replenishment.
Inmates are briefed on understanding the timing and sequencing of withdrawal, time distortion, the smoking dream, how ending nicotine use can double blood serum caffeine levels, the importance of crutch avoidance including limitations and risks of using buddy systems, and the phases of emotional loss.
Although inmates can address most aspects of recovery while incarcerated, what they cannot confront are conditioned nicotine feeding cues awaiting them once released. What will happen the first time they encounter that old smoking buddy, drink alcohol, or after intimate romance? They have conditioned their subconscious mind to expect nicotine upon encountering specific times, places, people, emotions or events and some of those triggers cannot be extinguished until release. They should anticipate and fully expect each to generate a brief anxiety episode lasting less than three minutes. But the beauty of each such encounter is that at its conclusion they are rewarded with the return of yet another aspect of life.
Cessation programs should challenge inmates to want to see what it is like to come home again, to want to experience the amazing sense of calm that eventually arrives after years of living on a powerful central nervous system stimulant. What is it like to have your mind's motivational engine fueled by life not nicotine, to at last take your foot of the accelerator and have better brakes when it comes to making a split second decision that can mean the difference between recidivism or continued freedom? Recovery and coming home should be fully embraced and welcomed, not feared, or delayed a second longer.
1. Mandatory Attendance - If planning upcoming cessation programs, make attendance by all inmates with a recent history of tobacco use mandatory, as they will not attend if attendance is made voluntary. Some may be angry but your program presenter should be able to quickly disarm most, and turn their anger to curiosity. Prison tobacco sales records may be an excellent source of identifying tobacco users.
2. High Quality Staff Programs - Consider separate mandatory programs for tobacco dependent correctional officers and staff, from those of inmates, as they truly are two different quitting populations and they'll be vastly more comfortable not having inmates present when discussing their own chemical dependency. Again, it is not that the vast majority don't want to quit but that they live behind a thick wall of denial and no one has ever taught them how to quit. The temptation of just one $25-50 dollar carton of cigarettes generating nearly $1,000 if smuggled into the prison is tremendous. You should fully expect to lose correctional officers to tobacco contraband violations, but if even one, at what cost? Your best weapon against it may be in helping them break nicotine's grip upon their mind and life, while at the same time teaching them to appreciate the striking similarities between methamphetamine, heroin and nicotine addiction.
3. Stay Alert for Hesitant Implementation - Tobacco use statistics suggest that you will have senior prison administrators, wardens or even medical staff who are nicotine dependent. They may have some difficulty taking tobacco interdiction efforts as seriously. You may not see a prison tobacco shakedown after the ban is implemented. They may also have a problem with the prospect of mandatory cessation programs for inmates or staff. To some degree, such resistance is normal, natural and expected as they live in a world of nicotine normal. Remember, the hallmark of any chemical dependency is a core belief that the chemical is central to your very being or your means of coping. Remain firm yet understanding and don't forget that they probably need help too but due to their stature or position may feel a greater sense of embarrassment in seeking it. Work with them. Get them to real Joel Spitzer's book. They'll do just fine.
4. Give Plenty of Policy Change Notice - It seems the more notice to inmates and staff the smoother the transition. More than once I was told that South Carolina expected problems in going totally tobacco-free but that there was so much advance notice that everyone had plenty of time to mentally prepare. I've read the same thing in a couple of policy change news stories.
5. Put Our Materials to Work Today - Why wait on some future policy change date when department annual health spending can be reduced today by assisting inmates and employees in learning to live nicotine-free lives? We invite you to review our free program materials linked below and consider putting them to work.
Free Program Materials
Although my passport is in order and I can think of no more rewarding way to spend my time than assisting inmates and correctional officers in breaking nicotine's grip upon their mind and life, as I've shared with the SCDC, all of our materials are freely available online and can be immediately put to work for the benefit of inmates, officers and staff.
Our only requirements are that our materials never be used to endorse any product or service, that they be made freely available to the end user without charge, cost or requests for donations, that all existing copyrights remain in place, and that they not be used for any commercial purpose.Here are a few key links to materials we hope your institution will consider making available. Let us know if you have any additional questions about their use. I (John R. Polito) can be reached at firstname.lastname@example.org or +1 (843) 797-3234 (U.S. EST) or you can contact Joel Spitzer at email@example.com or +1 (847) 328-7229 (U.S. CST).
1. Inmate Nicotine Cessation Tips - a six-page PDF handout of basic quitting tips that when printed front and back requires just three sheets of paper.I would recommend printing a copy for each inmate, correctional officer and staff member with a history of tobacco use.
2. Never Take Another Puff - this popular free PDF quit smoking book by Joel Spitzer celebrated its one millionth Internet download on 08/16/07. It is an outstanding resource containing more than 90 short quitting articles on almost every cessation topic imaginable, and provides a solid foundation for building a lasting recovery. I'd recommend that a healthy supply of copies be printed and kept in the prison library, that one copy be maintained in each pod, wing, module or cell block, and that a supply be printed and made available for correctional officers and staff.
Freedom from Nicotine: The Journey Home - Taking direct aim at all forms of nicotine delivery, my free ebook is available in a number of formats and is a broader than just cigarettes. Although free to reprint and share as little or as much as desired, paperback copies for your prison's library are also available via Amazon.
3. Video Quitting Lessons - Joel Spitzer has recorded more than 200 short video quitting lessons that allow you to bring the Internet's most popular nicotine cessation educator into your prison library or educational center. You are free to download and use as few or as many as you deem best. Your media expert can reformat them to play in any format you desire, either individually or continuously. They'd be a great addition to your intake facility waiting area, in helping new arrivals adjust to freedom from cigarettes, tobacco and/or nicotine.
4. WhyQuit.com, Freedom and AskJoel - Although inmates do not normally have Internet access, these three resources are available to correctional officers, staff and their loved ones, and can also be used to download, print and share additional materials with inmates.
According to Google, since late 2000 WhyQuit has been the Internet's leading cold turkey quitting destination, the cessation method responsible for generating nearly 90% of all successful long-term ex-smokers. It is loaded with empowering motivational stories that help put the challenges of cessation into perspective.
1. U.S. Environmental Protection Agency, Setting the Record Straight: Secondhand Smoke is a Preventable Health Risk, http://www.epa.gov/smokefree/pubs/strsfs.html, last updated August 23, 2007
2. Centers for Disease Control and Prevention, Fact Sheet, Secondhand Smoke, http://www.cdc.gov/tobacco/data_statistics/Factsheets/SecondhandSmoke.htm, updated September 2006.
3. U.S. Dept. of Justice, Bureau of Justice Statistics, Medical Causes of Death in State Prisons, 2001-2004, January 2007
4. Helling v. McKinney, 113 S.Ct. 2475, 509 U.S. 25, 125 L. Ed.2d 22, 61 LW 4648, 8.2 TPLR 2.201 (United States Supreme Court 1993)
5. American Nonsmokers' Rights Foundation, 100% SmokeFree Correctional Facilities, http://www.no-smoke.org/pdf/100smokefreeprisons.pdf, July 3, 2007
6. American Nonsmokers' Rights Foundation, SmokeFree Restaurants and Bars Around the World, http://www.no-smoke.org/pdf/internationalbarsandrestaurants.pdf, July 3, 2007
7. Tuthill RW et al, "Does involuntary cigarette smoking abstinence among inmates during correctional incarceration result in continued abstinence post release?" (poster). 26th National Conference on Correctional Health Care, Nashville, Tennessee, October 21, 2002
8. Spitzer, J, Quitting for Others, Joel's Library, www.WhyQuit.com/joel, 1984
9. Cornelius MD et al, Smoking during teenage pregnancies: effects on behavioral problems in offspring, Nicotine Tob Res. 2007 July;9(7):739-50
10. Caris, L et al, Behavioral problems and tobacco use among adolescents in Chile, Rev Panam Salud Publica. 2003 Aug;14(2):84-00
11. Ellickson PL et al, High-risk behaviors associated with early smoking: results from a 5-year follow-up, J Adolesc Health, 2001 June;28(6):465-73
12. Vittetoe K, et al, Behavioral problems and tobacco use among adolescents in Central America and the Dominican Republic, Rev Panam Salud Publica. 2002 Feb;11(2):76-82
13. Mitchell, SH, Measuring Impulsivity and Modeling Its Association With Cigarette Smoking, Behavioral and Cognitive Neuroscience Reviews, Vol. 3, No. 4, 261-275 (2004)
14. American Cancer Society, Child and Teen Tobacco Use, ACS, 2013
15. Slotkin TA, Nicotine and the adolescent brain: insights from an animal model, Neurotoxicol Teratol, 2002 May-Jun;24(3):369-84
16. Kandel, D, On the measurement of nicotine dependence in adolescence: comparisons of the mFTQ and a DSM-IV-based scale [link to free full text copy], Journal of Pediatric Psychology, 2005 June;30(4):319-32
17. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Nicotine Dependence, online, 09/24/07
18. National Institute on Drug Abuse, Like Other Drugs of Abuse, Nicotine Disrupts the Brain's Pleasure Circuit, NIDA Notes, Vol. 3, Number 13, July 1998
19. Slotkin TA, Lasting effects of nicotine treatment and withdrawal on serotonergic systems and cell signaling in rat brain regions: Separate oor sequential exposure during fetal development and adulthood; Brain Research Bulletin 73 (April 2007) 259-272
20. Olivn Gonzalvo G, Health and nutritional status of delinquent female adolescents, An Esp Pediatr. 2002 Feb;56(2):116-20
21. U.S. Dept. of Justice, Bureau of Justice Statistics, Prison Statistics, June 30, 2006, http://www.ojp.usdoj.gov/bjs/prisons.htm