Tobacco use in U.S. prisons is akin to air, it’s ubiquitous. And like air, for the vast majority of the incarcerated the need to inhale tobacco smoke approaches desperation. Would providing access to nicotine vaping products fix the craving and maybe save lives? Find out in this interview with health and behaviour researcher Dr. Cheryl K. Olson.
Featuring:
Cheryl K. Olson, MPH, ScD
Health and Behavior Researcher
Behaviour Science Advisor, McKinney RSA
Public Health Columnist, Tobacco Reporter
drcherylolson.com
mckinneyrsa.com
Transcription:
Hi, I'm Brent Stafford and welcome to another edition of Reg Watch on GFN.TV.
For tobacco harm reduction to be successful, there are two factors that must be maximized
– access and choice.
All the contentious issues around safer nicotine products boil down to these two factors.
Let's use vaping as an example.
Choice means a wide variety of devices, satisfying nicotine levels, and of course a plethora
of flavors, while access means not banned, available for legal purchase, easily accessible
via retail or online, and cost-effective for the average consumer.
A disparity in access or choice of safer nicotine products creates inequity that's exacerbated
when a population is disadvantaged and vulnerable.
Joining us today to talk about vaping, public health, and vulnerable populations is Dr.
Cheryl Olson, a health and behavior researcher who holds a Doctor of Science degree in health
and social behavior from the Harvard School of Public Health.
Dr. Olson served as a faculty member of psychiatry at Harvard Medical School for 15 years and
as an assistant clinical professor of psychiatry at Massachusetts General Hospital.
She also has extensive experience with smoking cessation and tobacco harm reduction.
Dr. Olson, thanks for coming on the show.
Oh, it's my pleasure to be with you.
Thank you.
Earlier this year, we spoke with Michael Stoney from the Scottish Prison Service in Scotland's
Smoke-Free Prison Program and how they use vaping to mitigate the impact of banning combustible
tobacco.
I cannot help but think about the United States.
Let me ask you, have many prisons in the U.S. gone smoke-free?
It depends on what you mean by smoke-free.
The federal prison system run by the national government, they're all technically smoke-free
prisons.
And at the state level, it's a mishmash all over the place.
When you look at what do they mean by that, sometimes that's nothing indoors, certain
things allowed outdoors.
And of course, one of the things that I learned in the research that I did and reviewing the
literature is that there really aren't any smoke-free prisons, there are smoke-free policies,
but it's really a choice between what it kind of boils down to is you provide them with
alternative products that they will find acceptable, or do you have a virulent contraband problem?
Yeah, and I guess that is the big issue.
So I mean, just top line, there's nothing that stands out in the U.S. as a successful
smoke-free prison.
I'm sure it would depend on who you ask.
For example, the state of Mississippi in 2021, they'd had a smoke-free policy for decades,
and they started selling tobacco and cigarettes legally in the prisons again, because they
said contraband had gotten so out of control, they were estimating value in the millions.
And these guards, frankly, are paid a pretty paltry sum.
And so if a cigarette is going for, I've heard, five bucks a cigarette, 100 bucks a pack,
this isn't me getting a second hand.
But it's obviously Japan would be very, smoking would be very hard to resist in these sorts
of situations.
Before we dive deeper into this issue, Dr. Olson, please share with our audience a bit
about your background and what brought you to working on smoking cessation and tobacco
harm reduction.
Sure.
As you mentioned, I have a doctorate in public health, health and behavior is my area.
And if you look me up online, a lot of my stuff is about video game violence.
I did a lot of research on the effect of violent video game content on teenagers.
But I got into this, I did some research for the state of California years ago, when they
were transitioning to smoke-free bars, I've got several publications from that era.
And then I was asked around 2005 to work with Philip Morris USA on their quit assist project.
And I thought better I should do this, then, you know, and who's skeptical about working
with a tobacco company, just at least at the time, then somebody who will just say, sure,
no problem.
And we did some very successful work getting these quit assist guidebooks into the hands
of hundreds of thousands of people and quit smoking brochures for teenagers for things
for parents, stapled into major magazines.
I also, in recent years, but I guess about maybe six or seven years ago, I got re-involved.
I see a lot of parallels between the video game violence research I did and tobacco harm
reduction today.
With video game violence, there was this, what you might call a moral panic over, oh
my gosh, video games are turning our kids violent and aggressive.
They're causing school shootings.
That doesn't seem to be the case by the way.
But I saw with youth vaping, hey, you know, certainly we don't want young people to be
using these products.
But also if you look at the data, it's the adults who need these sorts of products.
There's a stagnant level of smoking as we'll get into more, I think, among low income people
and disadvantaged people.
If you look at the latest data, people on Medicaid, it's just not budging.
It's around 28% and has been for years.
And we need to get these folks off this very dangerous product and save their lives.
And so the grayness, I think, and the controversy of the era, just like the video game violence
that attracted me, and people having very narrow, rigid views that aren't always in
touch with the reality of the data, that interested me.
And I wanted to see if I could try to get people to talk to each other and come together
to save lives.
Is there some form of predilection that social scientists have for moral panics?
I do see it happen a fair amount.
I think there's something about America in particular that seems to lend itself to panics
over if you look historically.
I mean, one of the things my husband and I wrote a book about our video game research
called Grand Theft Childhood.
And we covered the research on things like moral panics in the 1920s over gangster films
and how they thought that showing how to do crimes in a movie would literally teach young
people and all those ignorant masses of immigrants how to commit crimes.
And that's what led to some of the first what became movie ratings today.
And then in the 50s, comic books, they thought that Batman and Robin were a gay couple and
that juvenile delinquents would be created by all of these crime and horror comic books.
Yeah.
And we see this sort of thing happening over and over.
Panics over, in this case, I'm talking about media, but it can also be there was a panic
over a chemical called ALR and apples.
There's panics over so many things.
And I do think that we often look for easy answers and our politicians, frankly, are
looking for something easy they can point to to say, aha, I'll protect your children
from this menace.
And I think vaping, to some extent, came under that as well.
And people weren't looking closely at what is the actual danger.
I mean, I'm much more worried about just briefly about youth drinking, because that can kill
a kid today, whether they get drunk drive or they fall out a window or they have alcohol
poisoning.
Vaping is, you know, the risk of that is going to be a long, you know, it's going to take
years to show up.
And I if I had a teenager today, my son is in his 30s, but if he were I caught him with
a vape device today, I'd be talking to him about it.
But I'd be much more relieved than if he were drinking or smoking cigarettes or doing almost
any of the other substances.
Dr. Olson, you also have experience working with regulators and you briefly mentioned
industry.
I know that you're an advisor at McKinney Regulatory Science Advisors quickly.
You know, what do you do there?
Julie McKinney used to work at some of the big companies like Altria and Juul as a toxicologist
and a VP of regulatory affairs and so on.
Interesting guy.
He spent his whole career in industry on tobacco harm reduction from the time he came out of
grad school.
He had an advisor who said you can do more good from the inside.
And I like working with McKinney Regulatory Science Advisors because it's sort of an umbrella
group of consultants who choose to come together to work on projects that we couldn't easily
do by ourselves.
And I've done some really interesting work with them.
I'm currently working on a qualitative study that I'm writing up this week on a product
that's mostly used by people in their 60s and 70s, which is a disadvantaged group that
has a lot of, I mean, they're at risk of imminent health problems and deaths from continuing
to smoke.
And often folks have been doing it for decades.
I'll be presenting, I hope, results of that study, you know, late in the year.
But I like, I've had a chance to study a lot of what you might consider vulnerable populations
and people who are really at risk if they don't transition off cigarettes.
And that's where I find it very rewarding and exciting to work.
Dr. Olson, you recently delivered a presentation at the 75th Tobacco Science Research Conference
titled Where Cigarettes Serve as Currency, Can Vaping Be Better?
And it addresses reducing harm for people in custody.
Let me ask you, are there more smokers in the incarcerated population in the U.S. than
say out?
Absolutely.
Smoking is, I mean, it's hard to find a good estimate, but it varies from, I've seen two
to four times more.
And in the surveys that we did, it looked like it was, you know, somewhere around 70,
80% or more of people who are incarcerated are smoking.
And most, actually the majority seem to use some form, often multiple forms of tobacco.
I just saw an article on vaping and smoking in English prisons.
And they mentioned up to five times higher rate of cigarette use in that population.
So internationally, you're seeing much higher rates of smoking among people in custody.
So are the incarcerated considered a vulnerable population?
And if so, why?
People in public health usually look at this in several ways.
And one is these are folks who have disproportionately, they're less educated, lower income, often
have a lot of history of trauma and difficulty in their lives.
They also are people under current tremendous stress in the environment that they're in.
And then also historically speaking, if you're ever going to do research on prisoners, the
studies that we did for McKinney, which were for an FDA pre-market tobacco application
process for someone, we worked with people who were, had been released from prison within
the last couple of years.
Because to do studies of people who are currently incarcerated, you need to go through a lot
of hoops, a lot of institutional review boards.
And rightly so, because these are folks who, you know, they can't say no.
I mean, their lives are tightly controlled.
And even if it's a volunteer thing, are they really volunteering?
And there's a lot of history of abuse of these sorts of things.
Dr. Olson, isn't another reason why smoking is still have a lot of prevalence, at least
with the incarcerated, is that they've got substance use disorder.
There's a lot of related alcohol and psychoactive drug use.
Absolutely.
I know in the U.S. the government estimates were that maybe almost half of people newly
entering prison or jail have, could be diagnosed with a substance use disorder, rampant substance
use, you know, often to address, you know, the trauma and stress, you know, the things
we discussed.
And there was just a new article in, that came out in the Journal of Health Affairs,
which I will hold up here for those nerds.
And it's called a widening divide, cigarette smoking trends among people with substance
use disorder and criminal legal involvement.
And it's talking about how you're looking at U.S. national surveys that smoking rates
have gone down, you know, between nine and 10 percentage points for people with substance
use disorders, you know, over the last decade or so.
But for people with criminal legal involvement, stagnant smoking rates absolutely stuck in
these national surveys.
And so we see that, you know, this is a, this population of people in custody is, you know,
they're stubbornly high tobacco use, and it's just, it's just not getting any better.
The things that people have been trying, you know, they've been, back in the 80s, you know,
they had very few smoke-free policies.
More and more places are rolling them out, but they're not getting rid of the smoking.
They're getting, they're basically creating contraband problems.
Dr. Olson, tell us more about the challenges of smoke-free policies in prison.
You already mentioned contraband, which of course generally means that tobacco products
are used as currency in prison.
But you also mentioned in some of your presentation materials, something called a vulture.
What are vultures?
I've read research reports and investigator reports, at least for the U.S.
In some prisons, the term vulture applies to a person who will follow around a guard
who had legal access to chewing tobacco, which the prisoners did not have.
And they would, when the guard spit out the used chewing tobacco outside on the ground,
this vulture would rush up with maybe a playing card and a little, you know, sweeper or something,
sweep up that used chewing tobacco, dry it out, wrap it in, you know, a page from a Bible
or toilet paper wrapper, and then they sell that.
And supposedly, you know, one report from a few years back said that they could get,
you know, basically 10 bucks for a wad of used chew, and that there'd be competition.
The people would compete, they would fight to get a hold of this wad of disgusting used
chewing tobacco.
That's a vulture.
And that just shows you how desperate people are in prison to acquire something like this.
And we did, I know we'll get more into this in a minute, but I did a survey and a qualitative
study and in our phone interviews for the qualitative study, one of the, we had people
verifying this saying, yeah, I'm just actually reading off my screen here to get this right,
saying that, yeah, the officers still walk around chewing tobacco, so the yard workers
go out and pick it up and roll cigarettes.
The cops would spit out regular chew, and they'd turn that into cigarettes.
I've seen guys pick it up off the ground and re-chew it.
That's how desperate some of these guys are.
Tobacco in jail is basically air, he said.
Wow, that's amazing.
Well, on the outside, it's pretty big too, I can imagine that.
Look, there's also problems in prison, and this I'd never heard of until I read your
materials with nicotine patches.
Can you elaborate on that for us?
Yeah, there are studies from a number of countries, including Australia, where people very properly,
when they would institute smoke-free policies, they would give people alternatives.
They would give them nicotine patches or lozenges or other things.
They found, this is in multiple published reports, that people were taking these nicotine
patches, and either they would soak the nicotine out and soak it up into tea leaves, or they
would shred the nicotine patches, and they would smoke them.
There are reports of guards saying, I don't want to go into that cell block because the
chemical smell is so bad, it makes my eyes water.
There's one report that they were getting the nicotine out of nicotine lozenges.
People have been studying the chemistry of this.
What harm does it do to you, and finding out that, as you'd expect, smoking this sort of
stuff is probably worse for you than smoking cigarettes.
This lovely, well-intended thing of giving people nicotine replacement was backfiring.
I've seen quotes from incarcerated people saying they just crave smoking, they want
to inhale something.
I've never been a nicotine user myself, but I understand it hits the brain differently
when you inhale, and that's what they're looking for.
What were the goals of the study around prisons that you did?
The study that we did at McKinney Regulatory Science Advisors was for a company called
E-Cig for Inmate.
There were a number of these products on the market.
I think there might just be a couple left that went through the regulatory process in
the U.S. to stay on the market.
These products are really interesting for several reasons.
They were designed with the input of sheriffs and so on, people who work in prisons, to
deal with the specific problems that they have.
For one thing, if you saw that picture, they look a little weird.
They are clear silicone so that you can't try to smuggle something in there.
They have a very low-voltage battery so you can't explode something.
They have tracking barcodes so that prisons can track who they're issued to and who returns
the empty device.
They also don't have any metal, so you frankly can't stab somebody with it.
One of the things we're looking at is could this product be repurposed for other populations
that are at risk of problems such as an inpatient mental health facility or a memory care unit
for elderly people who might start fires or otherwise injure themselves but might have
high smoking rates.
Who knows?
There's a lot of vulnerable groups out there that could benefit from a specialty product
of some kind.
Dr. Olson, I know that you will be on a panel titled, Inequality of Access, How Do We Achieve
a Level Playing Field?
At the Global Forum on Nicotine, the annual conference on safer nicotine products and
tobacco harm reduction, GFN is coming up again this June from June 21st to the 24th.
Let me ask you, why is an event like GFN important?
I know for me, I think it's very exciting to have a chance to look at what colleagues
are doing internationally to address problems like this.
I'm very excited to talk with my fellow panelists about this and see how they've approached
it philosophically, how their ideas have changed over time and what is going on that I can
learn from.
I know being an American, it's very frequently Americans get blinders on and only look at
research that applies to this country because it's so big and they get a little provincial.
I think it's very important for us to look at what is working internationally, what can
we learn from, just as the Scottish researchers did when they implemented their smoke-free
prison policies, looked around at what could go wrong, what could go right, and we need
to learn more from each other.
I unfortunately won't be able to attend in person because I'm taking care of a family
member who was recently out of the hospital, but I still want to participate as fully as
I can and learn.
Dr. Olson, you mentioned that you had done a phone survey and I know that there was other
surveying too as well.
When the study is all said and done, what were the results?
It was very interesting.
First of all, we found that of the sample of people who had access to buying this sort
of a product while they were incarcerated, this product e-cig for inmate in particular
they had access to, we found that of the people who had been smoking before they entered prison,
over 95% of them tried it.
Of those who tried one, 99% kept on using it, which is just unbelievable.
They were clearly desperate to find something to meet the need.
And when we asked them about it, some of them really liked it and waxed about, oh, we like
this flavor or this or that.
And other ones were just like, I was just going to use whatever.
I didn't care what it was.
I just needed my nicotine fix.
We did find that of the people who had been daily smokers before going into prison, one
in 10 of them were no longer daily smokers after using this vaping product in custody.
So given the odds here, that's a win.
How could a program like this using a product like this be applied across the U.S.?
Is that possible?
This particular product was being used in the Pennsylvania state prison system and in
city and county jails in a number of different states.
I think one of the things that we need to do is just raise more awareness.
I know that the example of Scotland, I think is a great one to look to because they really
looked at, from what I had read, the mistakes that were made internationally, and they tried
to implement this roll out the smoke-free prisons and rolling in vaping concurrently.
And they seem to be the only group that I know of that has documented a reduction in
secondhand smoke of about 90 percent.
And they've also documented that they really have a minimal contraband problem.
So I think publicizing results like that is one thing.
I think also fighting the myths, I mean, when we asked some of the people in the phone interviews
and also on the survey, do you think vaping is more hazardous, less hazardous, the same
as smoking?
A lot of them are talking about saying, well, we figured that if it was something they're
giving to us, it was probably crappy and dangerous, but we didn't care because we needed it.
Or they might have said, I had heard, someone even came and lectured to us.
A couple said that vaping was dangerous, but they didn't care because they want it.
And we need to, I think, research in the rest of the world shows that beliefs that vaping
is as dangerous or more dangerous than smoking, those beliefs are increasing, very erroneous
beliefs.
And those are associated with people being reluctant to switch.
And since the estimates that we've seen, we won't know for decades exactly how dangerous
obviously vaping is, but estimates are it's at least 95 percent less dangerous than smoking.
And you know, these are folks who are, you know, remember, as we discussed, people in
custody are often they're coming down off other drugs as well.
They're going to use whatever is there.
And I think it's unethical for us to not provide them with an alternative that they can use.
They've got nothing else to go to.