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"We mentally ill smoke a lot": identity, smoking, and mental illness in America.

In 1987, a man wrote to the R.J. Reynolds tobacco company from a California mental hospital with a request: "We mentally ill, or allegedly mentally ill, smoke a lot. Most patients here are smokers and we buy a lot of your cigarettes. Many of us like or are addicted to cigarettes - we are often too poor to buy them - then we have to share them - and suffer. Do you think your company could send us free samples ? Any brand would do." (1) This man outlined what for him were three essential reasons why the tobacco company should grant his request: he and his fellow patients were particularly attracted to smoking, they were in an economically disadvantaged position, and they were good customers.

At first glance, this letter is startling - it was written more than two decades after the landmark 1964 Surgeon General's report that elucidated the serious health consequences of smoking. (2) Further, the fact that this man appealed to a tobacco company for help seems incomprehensible in light of historian Allan Brandt's exploration of the tobacco industry's efforts to obscure the health risks of cigarettes and market their products regardless of the long-term consequences to consumers. (3) But instead of accusing the tobacco companies of causing him to become hooked on cigarettes, the California man freely admitted his addiction might be a factor and asked for more product. This man's relationship to both his cigarettes and the tobacco industry, though it goes against the trend of growing public awareness of the physical health hazards of smoking, is representative of letters written by mentally ill consumers to the tobacco industry over the last several decades.

Estimates vary, but most psychiatrists, epidemiologists, and tobacco control experts concur that seriously mentally ill individuals smoke at high rates. Some believe that 60-90% of those with illnesses such as bipolar disorder and schizophrenia smoke, and these populations make up an increasing proportion of the remaining smokers in the United States, a group that policy analyst Kenneth Warner has referred to as "hard cote smokers." (4) While researchers investigate possible biochemical reasons for the attraction that smoking has for the mentally ill, practicing psychiatrists are keenly aware of the strong link between mental illness and smoking. (5)

Populations of the mentally ill have always included large numbers of smokers. Psychiatric hospitals, which were the primary locations of care for the mentally ill until the 1960s and 1970s, included smoking as key features within their culture. (6) Smoking rooms were incorporated into hospital architecture in the late nineteenth and early twentieth centuries (during a time when patients transitioned from other forms of tobacco to cigarettes). (7) Psychiatric hospital directors in the first half of the twentieth century debated issues such as the role of excessive smoking in mental disorders, the problems of smoking in adolescents, and the thorny issue of whether to allow women patients to smoke at the same rate as men. (8) Sociologists who explored the inner workings of psychiatric hospitals in the 1950s and 1960s found that cigarettes provided opportunities for interaction between seriously ill individuals and staff. Further, patients' attachment to cigarettes was sufficiently strong that threats to withhold smoking privileges fueled immediate and dramatic behavior modification. (9)

Just as images of smoking permeated Hollywood through the middle of the twentieth century, film representations of mental illness also included cigarettes. (10) Olivia de Havilland's character in The Snake Pit participated in the active exchange of cigarettes on the wards, while Jack Nicholson's character in One Flew Over the Cuckoo's Nest used access to cigarettes to incite a major patient rebellion." (11) Those who worked with the mentally ill in hospital settings testified that it was quite stressful in that environment - and that cigarettes were essential for both patients and staff. (12)

As a number of historians, journalists, and policy analysts have described, it is easy to see the rise (and decline) of cigarette smoking in the United States over the last century in terms of the actions of the tobacco industry. Many accounts of the history of smoking quite rightly contrast the nefarious, profit-motivated actions of industry executives with the heroic public health work of tobacco control activists. (13) Yet an account of smoking that focuses only on corporate greed or public health concerns misses the more subtle and complicated interactions of mentally ill smokers, their cigarettes, and the tobacco companies. At the same time that tobacco control advocates emphasized the physical risks of smoking, mentally ill smokers proclaimed the mental health benefits of smoking. While growing public health awareness and activism led to increased government regulating of smoking, mentally ill individuals sided with the tobacco companies. And although escalating public outrage led to successful lawsuits against tobacco companies for hiding evidence of tobacco's harms, mentally ill individuals continued to negotiate for the right to smoke and to request support from the industry.

One of the benefits for historians from the lawsuits against the tobacco companies was the release of a wealth of internal tobacco industry documents through the discovery process. While scholars have used these sources to uncover secret company activities, the tobacco archives also include letters written to the tobacco companies by consumers, including individuals who identified themselves as mentally ill. (14) The letters by mentally ill consumers are uniformly positive about cigarettes, and they reveal a different perspective on the conflicts between the tobacco industry and tobacco control efforts.

The perspective from mentally ill smokers complicates the narrative about smoking as told by historians, journalists, and policy analysts. The view of the mentally ill smokers suggests that the tobacco story can be seen as a rise in government control with the result of worsening price-based economic conditions for mentally ill consumers. Further, while we might expect that a vulnerable population such as the mentally ill would be at significant risk from the multibillion dollar tobacco industry, individuals who acknowledged their mental illness instead felt supported by the cigarette companies. In addition, most accounts of smoking and the tobacco industry assume that the largest battle has already been won - the recognition that smoking is harmful. The further decrease of smoking behaviors may he safely assumed to he just a matter of time and education. Yet the arguments amassed by mentally ill smokers in the last three decades of the twentieth century, after the battle about the risks of tobacco had been settled, suggests that public health and tobacco control face unprecedented challenges to address smoking in the mentally ill.

The letters from mentally ill consumers from the 1970s through the 1990s illustrate that health is a complicated concept that is interpreted differently in different populations and settings. Further, it is clear that public health advances - often seen as epic battles between parties with enormous resources - affect those on the margins of society in ways not anticipated by the battles' protagonists. Mentally ill smokers have not been a pun of the lawsuits, public health advocacy work, or government regulation that have resulted from the conflict between the tobacco industry and tobacco control advocates. Yet as letters written by these smokers to the tobacco industry illustrate, they did not passively accept health decisions made by others. Indeed, the ways in which mentally ill smokers and their advocates framed their arguments about smoking shed light not only on their relationship to cigarettes, but also their priorities in life.

Mental Health Benefits of Smoking

Cigarette smoking became widely prevalent across most segments of American society in the first half of the twentieth century, but decreased by the 1960s and 1970s in the wake of emerging information about the connection between smoking and lung cancer (and other respiratory diseases). But in the 1980s and 1990s, though education campaigns had helped to spread the word that there were major physical health consequences to smoking, letters from mentally ill individuals and their advocates minimized the physical risks of smoking in favor of what they described as the mental health benefits. Mentally ill smokers and their advocates did not necessarily follow tobacco company policy and deny that smoking could cause health problems. Instead, they insisted that the mentally ill had good reasons to smoke.

Without denying that smoking could cause lung cancer, some advocates for mentally ill smokers speculated that the particular biology of the mentally ill affected their likelihood of getting cancer. One former nurse wrote in 1984 that mental patients - who smoked in great numbers - had a low incidence of lung cancer, and attributed this to the fact that they were protected from "our hostile negative society" inside hospitals. (15) During congressional hearings on tobacco in 1994, a former hospital chaplain wrote an angry letter to California Representative Henry Waxman, who was chairing the hearings, explaining that quality of life was more important than quantity. He asserted that patients on the back wards of psychiatric institutions appeared not to suffer from lung cancer and needed the improved quality of life from cigarettes. (16) Whether or not these assertions were true, those who worked with the mentally ill rated the risk of lung cancer lower than the need for smoking for those suffering from serious mental illness.

Even when mentally ill individuals developed serious physical illnesses that could easily be attributable to smoking, they generally refused to blame cigarettes. One New Hampshire woman, who identified herself as a "depressive manic," wrote to R.J. Reynolds in 1985 to explain that she tried to quit smoking after she developed lung cancer. She found that her mental illness got worse, so she went back to smoking - and claimed to have developed a "natural cure" for cancer. In the end, her priorities were clear: "I don't even know if this is a cure for cancer but just as long as I feel good about smoking my cigarettes that's all that matters." (17) Further, mentally ill smokers asserted that mental benefits were more important than physical risks, and that the climate of blame for cigarettes had led to too much focus on smoking cessation instead of other medical interventions. (18) One woman at a Texas state mental hospital explained that she had experimented with methods to make cigarette smoking healthful for all. Whether or not there was a realistic basis to her suggestions, this woman wanted cigarettes to be part of the solution to health problems identified with smoking. (19)

Individuals with mental illness argued that smoking helped their thinking, even when they were aware of the physical health hazards. A Minnesota man wrote to R.J. Reynolds in 1989 to emphasize that smoking helped him control his moods and emotions, despite what he acknowledged were "unpleasant side effects." (20) A Seattle man wrote in 1987 that he found that smoking helped mitigate the effects of the Trilafon (a medication for psychosis) he was taking. He speculated that the Surgeon General was "ignorant of the beneficial effects of the drug nicotine and the convenient form in which it is administered in cigarettes." (21) While mentally ill smokers were aware that nicotine was the active substance in smoking, they asserted that the cigarette as a vehicle for nicotine delivery was superior to other methods because it allowed them to precisely calibrate the effects of the drug through inhalation patterns. A Massachusetts woman criticized the nicotine patch for being artificial and praised the control smokers could gain with cigarettes. (22)

Mentally ill individuals and their advocates who emphasized the mental health benefits of smoking had some backing within the scientific literature. In the 1990s, several psychiatrists investigated the possible positive mental effects of smoking for individuals with schizophrenia. A number of individuals included copies of articles about this research in their correspondence with the tobacco companies. (23) One Indianapolis woman shared with R.J. Reynolds an article about smoking and schizophrenia from her home town newspaper. She explained that she had been diagnosed with schizophrenia and that smoking helped calm her down - and she stated emphatically that she had no interest in quitting. (24) Advocates for the mentally ill echoed this sentiment. A caseworker at a Texas clubhouse for the mentally ill explained to R.J. Reynolds that, "Some schizophrenics report that smoking improves specific brain functions that are known to be impaired in this disease." (25) Although the scientific community never fully reached consensus about the mental effects of smoking in serious diseases such as schizophrenia, mentally ill smokers and their advocates seized upon available research as a logical explanation for their strong attraction to tobacco and ongoing consumption. (26)

The tobacco companies were clearly aware that some segments of their consumer population viewed smoking as a beneficial habit from an emotional point of view, yet they generally did not make the argument that it was worth the physical risks in order to gain some mental benefit. Instead, the tobacco industry continued to engage in debate with the public health community over the extent of proof about the physical risks of smoking. Though tobacco company executives insisted (beyond what many have seen as remotely credible) that the evidence for the harms of smoking were not proven, mentally ill individuals had no doubt on that score. The difference for them was that they viewed the emotional benefit to be more important than the risk of physical harm.

Patients' Rights

Mentally ill individuals understood that their argument that smoking helped them - even when backed by research - was not a popular one in the climate of increased attention toward the harmful effects of smoking. One Texas man wrote to the Doral Smokers' service in 1996, "Thank you for producing cigarettes because I like them and I believe the U.S. government is prejudiced against tobacco and the U.S. government told scientists not to admit or study anything good that tobacco does to a person." (27) Mentally ill individuals' concerns about the government were not entirely paranoid. During the 1990s, government and private regulation increasingly affected how, when, and to what extent individuals could smoke. Many mentally ill individuals were keenly aware of the effect of rules and regulations on their personal freedoms, and were vocal about their right to smoke.

Mentally ill individuals' complaints about government efforts to control tobacco took place against a backdrop of increasing empowerment within the mental health consumers movement. Beginning in the late 1970s, groups of the mentally ill began to use the language of rights as expressed by other groups, including civil rights activists, feminists, and gay rights proponents. A number of individuals who were being treated for mental illness articulated their identity as consumers (or survivors) rather than patients. (28) While some were hostile to authority and adopted the more extreme rhetoric of critic Thomas Szasz (who claimed that mental illness was a myth), others emphasized that mentally ill individuals had been too long stigmatized in society and controlled by psychiatry and needed a voice in their own care. (29)

Not only did mentally ill individuals increasingly insist on being part of treatment decisions, a series of court cases in the 1960s and 1970s led to the creation of mental health codes to ensure due process for individuals accused of being mentally ill. (30) In this environment, people with mental illness were increasingly likely to speak up for their rights, including the right to purchase and consume cigarettes. Mentally ill individuals protested psychiatrists' power to commit them to hospitals and force them to take medications, and they viewed government regulation of the tobacco industry as a similar erosion of rights. Further, mentally ill smokers saw parallels in their fight for personal freedoms with the companies' efforts to fight government intrusion into their business. One South Carolina man wrote to Forsyth Tobacco in 1998 and offered to help the company in its fight against excessive government regulation. As he explained, "I am on disability with a chemical imbalance and have the time to devote to such a hobby. It keeps me from dwelling on my mental problems and helps me focus on what is more important FREEDOM!" (31) A Mississippi woman the same year wrote to R.J. Reynolds to contrast her ideas about smoking and freedom with her experiences of being locked up against her will and being forced to take medications. (32)

Advocates for the mentally ill strongly supported their right to smoke in circumstances in which their other rights were limited. In 1994, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) announced that hospitals could no longer retain their accreditation without going smoke free. (33) Though they granted an exemption for psychiatric hospitals, many New York facilities chose to ban smoking entirely. In response, the Alliance for the Mentally Ill issued a policy statement asserting that it was inhumane to prevent individuals with mental illness from having the opportunity to smoke, especially when they had been put in the hospital against their will. One leader within the Friends and Advocates of the Mentally Ill (FAMI), whose schizophrenic sister was a diehard smoker, organized a campaign to protest the hospital smoke free policy and distributed literature, including preprinted postcards for individuals to send to the chief administrator of Bellevue Hospital in New York. (34)

A flyer was also circulated that endeavored to help non-mentally ill non-smokers understand the problem: "Imagine, the Police have just taken you in handcuffs to the Psychiatric Emergency Room of the local City Hospital. The doctor is trying to explain something to you but everything is confusing. She tells you that you will be held against your will until you are stabilized. You are given medication for your psychosis. You are nervous and scared. You ask for a cigarette. The nurse sarcastically tells you that you won't be able to smoke, the hospital is smoke free and there are no discrete smoking areas." (35) Although the tobacco companies were highly interested in this campaign, the individuals involved denied support from the tobacco industry and internal industry documents do not suggest that they were in any way connected to it.

Mentally ill smokers in New York and across the country understood their right to be treated with respect and to have input into their treatment plans - and also articulated their right to smoke. One activist in California, a woman who was diagnosed with schizophrenia but who was also a nationally recognized poet, wrote to R.J. Reynolds in 2000 and included a poem about smoking. The first stanza of the poem complains about excessive taxes and the loss of privileges. The second part expresses the deep attachment of mentally ill individuals to their cigarettes: "The only joy some know/Just to find a butt/To sooth a troubled soul/A potent antidepressant/Nicotine fills a void/To make it through the day." (36) For this woman, smoking and rights were inextricably tied to her identity as an individual and as a poet. Mentally ill individuals, caught up in the conflict between big tobacco and government regulation, articulated their rights to consume.

Mentally Ill Consumers

The mental health consumer movement that arose in the last few decades used terminology to reflect choice and empowerment in medical care decisions. But advocates for the movement emphasized that mentally ill individuals were not only defined by their relationship to psychiatric treatment. Indeed, the letters from mentally ill smokers to the tobacco industry suggest that these individuals viewed their role as consumers of tobacco products to be central to their identity. As they explained their right to purchase and use cigarettes, mentally ill individuals strongly identified themselves as purchasers of commodities, and they expressed their support and allegiance with the increasingly beleaguered tobacco companies. For many, identification as consumers allowed them to feel a part of a community with others who also purchased and used tobacco products. (37)

A major barrier to consumption of cigarettes, though, was the economically vulnerable position of most mentally ill individuals. Many people who suffered from mental illness experienced significant financial difficulties that interfered with their ability to buy cigarettes. Advocates for mentally ill individuals appealed to the tobacco companies for help in this area. As one administrator wrote, "Smoking is the single most enjoyable pleasure they seek; and the most expensive. Can you help us?" The administrator commented that individuals who met the financial criteria to be eligible for Medicaid did not have sufficient funds to purchase cigarettes. (38) A caseworker for a clubhouse for the mentally ill pointed out that the scramble for money to obtain cigarettes got in the way of other kinds of activities for the clients. Instead, she asked for donations from a tobacco company to help those who experienced the benefits of smoking. (39)

Mentally ill smokers clearly attributed their economic problems with purchasing cigarettes to government regulation. Letters from mentally ill smokers consistently sided with the tobacco industry against the government, even as the writers acknowledged the health risks of cigarettes. One of the reasons that these consumers were so upset with the government is that one of the main tobacco control efforts - to increase the taxes on cigarettes - affected those who had little money but did have strong attachments to tobacco. As a guardian for a 72 year old mentally ill man explained, "One of the few pleasures left for Joe is smoking his beloved cigarettes and drinking his cup of coffee," - but as she pointed out, Joe smoked a carton a week (at $19 a carton) and only received $40 a month for personal expenses. (40) An Oklahoma man explicitly connected the importance of smoking to mental illness with an enclosure outlining research conducted by the National Alliance for Research on Schizophrenia and Depression (NARSAD), and put this in consumer terms: "Please help us all cut unnecessary taxation, restore civil liberties, and lower the price of cigarettes." (41) A Massachusetts woman wrote in 2000 to explain that she needed to smoke to retain her sanity (the voices she heard told her to smoke), but she couldn't afford the seven cartons of cigarettes she smoked in a month. (42) Mentally ill smokers identified their role as consumers and expressed their serious opposition to government policy.

Many individuals, not just those who identified themselves as mentally ill, emphasized to the tobacco companies that they were good consumers of their products. Among the papers of the tobacco industry made available to researchers, there are a large number of letters written by general consumers of tobacco products. While some supported the industry in their struggles against the government, others were more angry with the companies. And some made the argument that they deserved something from the companies when they suffered illness as a result of smoking. Although there has not yet been a systematic review of the thousands of consumer letters in the archives, many of these letters are fairly angry and accusatory - they assert that they were deceived or misled and they want compensation. Some say that they are trying to avoid having to file a lawsuit, with the implication that the company should pay them to avert the hassle of litigation - a tragic argument given the decades of tobacco company success in defeating lawsuits. (43)

But the letters from the mentally ill consumers appear different, even as they are asking for things from the industry. Few of the letters from the mentally ill smokers assert damage from the product, and even when they do talk about their physical illness they emphasize their loyalty to the company. For example, a mentally ill Oregon man wrote to R.J. Reynolds in 1997 explaining that he had a lung removed due to cancer and had many medical bills. He asked for a modest payment per month ($522) with the argument that, "I have been a consumer of your products for some 30 years. I hope you will do the right thing by us, and I would be willing to go on TV and tell people how you help others." (44) In a similar vein, staff from a mental health rehabilitation center in Pittsburgh requested money from Philip Morris to help with a trip for mentally ill individuals to go to the beach. The staff argued that their clients spent so much money on cigarettes that they had little left for anything else, and requested a donation equivalent to what clients spent on cigarettes in a week. (45) Mentally ill individuals and their advocates did not ask the companies for compensation, they asked for support based on their status as consumers.

It is impossible to tell how many of these letters received responses from the tobacco companies. From the internal documents, it is clear that the tobacco industry was quite aware of the connection between smoking and mental illness (and probably knew more about it than most psychiatrists). But mentally ill individuals did emphasize that they were not just asking for handouts, they were customers, too. One New York woman wrote to R.J. Reynolds in 1995 to ask for cigarettes to be donated to a psychiatric hospital where she had formerly been a patient. She pointed out the benefits of smoking for patients, and also observed that they did not stay in the hospital forever - "People like myself do get out of these hospitals and purchase cigarettes." The company representative who received this letter evidently understood the message and wrote a note on the top directing the letter to the attention of the vice president of community affairs with the question, "Who turns these down?" (46)

Cigarette purchases helped structure identity for mentally ill individuals who were dealing with multiple social and occupational deficits. One "grateful consumer," who admitted that he was otherwise a "basket case" explained his attraction to cigarettes in terms of the empowerment of purchasing: "What I like most about R.J. Reynolds or anybody else is that you give me a freedom of choice." (47) Mentally ill individuals extended their relationships with tobacco products beyond the point of sales to the manufacturers of their favorite products. One woman wrote to R.J. Reynolds in 1970 and addressed her letter, "To my dear friends." She went on to explain that she felt that the company employees were friends because of her sense of attachment to her cigarettes. (48) Several individuals wrote a series of letters to the company, and provided chatty accounts of their activities and their thoughts about smoking. (49) One man was so enamored of R.J. Reynolds that he wrote a very personal letter addressed to Zachary Reynolds, implying a relationship with the deceased grandson of the company's founder. (50)

Mentally ill individuals identified so much with cigarette transactions that they were highly interested in the process. In fact, one North Carolina man wrote to R.J. Reynolds in 1999 explaining that his goal was to become "a purchaser of cigarettes from your powerful industry." He enclosed a note from his psychiatrist explaining his diagnosis of paranoid schizophrenia, and claimed that his doctor (whom he said was a smoker) suggested to him that he take up the business of selling cigarettes. The man asked for help in setting up this business, as well as some administrative support, though he made it clear that this would not be an act of charity as he could afford to buy the cigarettes. (51) Whether or not the man's doctor really suggested that he work to sell cigarettes, it made sense that this individual would make the connection between his strong attachment to cigarettes, his purchasing power, and a business opportunity.

It would be surprising if the tobacco industry did not take advantage of their most loyal and eager customers. Indeed, much of the information about the alleged mental benefits of smoking mentioned by mentally ill consumers was carefully tracked by the tobacco industry. Companies were certainly willing to exploit advocates for mentally ill smokers. For example, St. Elizabeth's Hospital Medical Director E. Fuller Torrey - a psychiatrist and outspoken activist for the seriously mentally ill - wrote to R.J. Reynolds in 1980 to request cigarettes for patients after the Department of Health and Human Services (HHS) changed its regulations to forbid the use of public funds to purchase cigarettes. Company representatives denied Torrey's request by explaining that they had too many cigarette donation requests to fulfill them all. Instead, they suggested that Torrey use his influence with the HHS Secretary to change to the regulations. (52)

But though the tobacco companies were looking out for their own interests, they did donate money and cigarettes to mental health centers over the decades, and were perceived by both mentally ill consumers and their advocates as supporters. Although some scholars have interpreted the tobacco industry's support of the mentally ill as manipulation of a vulnerable population, the individual letters do not just echo tobacco company propaganda. (53) Mentally ill individuals saw their relationship to smoking in a unique light, and they received support from the industry both on an individual level and through community mental health programs. The letters from mentally ill consumers of cigarettes to the tobacco industry reveal that these individuals perceived themselves to have a different relationship to the fierce battles between tobacco control advocates and the tobacco industry. While many of these mentally ill individuals were willing to acknowledge that they were addicted to cigarettes, it was also clear that they understood their smoking behaviors to be affecting them in a positive way. Further, these individuals had their own interpretations of both their smoking habits and the industry, and were interested in what the industry had to offer.

In the past decade, the conflict between the tobacco industry and tobacco control advocates has begun to tip in favor of tobacco control. Regulation of both cigarettes and smoking behaviors have continued to increase. And while the mentally ill continue to smoke at very high rates, in the last few years their advocacy groups have begun to back away from their support of the right to smoke. In 2008, the National Alliance for the Mentally Ill reversed its policy demanding smoking privileges for the mentally ill and instead emphasized the importance of offering support for smoking cessation. (54) Psychiatric hospitals have generally gone smoke free, and despite some dire predictions about adverse events (from increase in individual psychopathology to the risk of riots), the transition appears to have proceeded smoothly. (55)

But while decreasing rates of smoking - and tobacco-related diseases - appear to be clear indications of improved public health, the letters from mentally ill smokers raise the question of the best way to define health. Are there some groups of individuals who prioritize health concerns in different ways than policy analysts? And if there is disagreement between major policy measures and portions of the population, is there a way to listen to those who may feel that they are adversely affected by public health regulations? Those who design public health policy and write government regulations generally take a point of view to maximize health for the greatest number of people. But what happens to a population of individuals who traditionally have not had much of a voice in society - and certainly not in public health policy?

The tobacco control movement has done important work in fighting the actions of the tobacco companies, and former FDA commissioner David Kessler is probably right in his assessment that the only solution to the tobacco problem is the dismantling of the tobacco industry. (56) Yet amidst the clear demonstrations of the physical health hazards of smoking, mentally ill smokers continue to assert their strong attachment to their cigarettes. It is too simplistic to frame this attachment in terms of addiction, though mentally ill smokers are clearly addicted. Instead, an inquiry into the thoughts and feelings of mentally ill individuals who smoke suggests that cigarettes fill social, cultural, and perhaps biochemical holes left by their illness.

From the perspective of academics and socially progressive individuals, there is consensus that corporations that harm citizens should be regulated or even stopped. In addition, advocates for mentally ill individuals emphasize that these vulnerable people require treatment, as well as economic and social support. Yet as the letters from mentally ill consumers to the tobacco industry indicate, these two positions - that the tobacco industry needs to be constrained while the mentally ill need to be helped - are potentially in conflict. The only way to address this issue is by attending to the views of the mentally ill smokers themselves. By listening to the stories of the mentally ill and understanding their arguments, we can begin to appreciate that those individuals might make health decisions in a different way than most policy analysts. Health and policy issues - like history itself - need to incorporate not only major players, but also those whose voices are hard to hear.


(1.) Letter from consumer to R.J. Reynolds, postmarked 29 August 1987, Legacy Tobacco Documents (Bates 505915047/5048). Emphasis in the original.

(2.) Surgeon General's Advisory Committee on Smoking and Health, Smoking and Health; Report of the Advisory Committee to the Surgeon General of the Public Health Service (Washington, D.C., 1964). See also, Michael Housman, "Smoking and Health: The 1964 U.S. Surgeon General's Report as a Turning Point in the Anti-Smoking Movement," Harvard Health Policy Review 2 (2001): 118-26.

(3.) Allan M. Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America (New York, 2007).

(4.) Kenneth E. Warner and David M. Burns, "Hardening and the Hard-Core Smoker: Concepts, Evidence, and Implications," Nicotine & Tobacco Research 5 (2003): 37-48.

(5.) Gregory W. Dalack, Daniel J. Healy, and James H. Meador-Woodruff, "Nicotine Dependence in Schizophrenia: Clinical Phenomena and Laboratory Findings," American Journal of Psychiatry 155 (1998): 1490-501. For a much older article that indicates a special attraction for smoking among schizophrenics, see Harry Stack Sullivan, "Peculiarity of Thought in Schizophrenia," American Journal of Psychiatry 82 (1925): 21-86.

(6.) For the history of the treatment of the mentally ill in America, see Gerald N. Grob, Mental Institutions in America: Social Policy to 1875 (New York, 1973), Gerald N. Grob, Mental Illness and American Society, 1875-1940 (Princeton, 1983), Gerald N. Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton, 1991), Gerald N. Grob, The Mad Among Us: A History of the Care of America's Mentally Ill (Cambridge, 1994). See also, Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York, 1997).

(7.) For an example of a plan for an influential hospital that included a smoking room, see Henry M. Hurd, "The New McLean Hospital," American Journal of Insanity 52 (1896): 477-502. On debates about the forms of tobacco, see for example, J.C. Mulhall, "The Cigarette Habit," Quarterly Journal of Inebriety 20 (1895), abstracted in the American Journal of Insanity 52 (1896): 430.

(8.) For excessive smoking as a warning sign prior to psychiatric difficulties in servicemen, see Wilbur E. Kellum, "Recent Developments in Selection of Candidates for Aviation Training," American Journal of Psychiatry 100 (1943): 80-84. For the issue of smoking in adolescents, see for example, Frank J. Curran, "Organization of a Ward for Adolescents in Bellevue Psychiatric Hospital," American Journal of Psychiatry 95 (1939): 1365-88. For the issues of smoking in women and men, see for example, Karl M. Bowman, "A Constructive Criticism of Certain Hospital Procedures," American Journal of Psychiatry 94 (1938): 1141-52.

(9.) Alfred H. Stanton and Morris S. Schwartz, The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment (New York, 1954), Thomas Joel Scheff, "Staff Resistance to Change in a Mental Hospital" (PhD dissertation, 1960). See also, Frederick J. Fuoco et al., Behavioral Procedures for a Psychiatric Unit and Halfway House (New York, 1985).

(10.) For more on representations of smoking, see Sander L. Gilman and Xhou Zun, eds., Smoke: A Global History of Smoking (New York, 2004).

(11.) For an overview of Hollywood representations of psychiatry, see Glen O. Gabbard and Krin Gabbard, Psychiatry and the Cinema, Second edition ed. (Washington, D.C., 1999).

(12.) Letter from hospital attendant to R.J. Reynolds, 1 May 1937, Legacy Tobacco Documents (Bates 500717909).

(13.) See Brandt, The Cigarette Century, Richard Kluger, Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris (New York, 1996), Philip J. Hilts, Smoke Screen: The Truth Behind the Tobacco Industry Cover-Up (New York, 1996), Michael Orey, Assuming the Risk: The Mavericks, the Lawyers, and the Whistle-Blowers Who Beat Big Tobacco (Boston, 1999), Dan Zegart, Civil Warriors: The Legal Siege on the Tobacco Industry (New York, 2000).

(14.) For a discussion of the papers that became available in the 1990s, see Stanton A. Glantz et al., The Cigarette Papers (Berkeley, 1996). Tobacco industry documents are now located on two major fully text-searchable websites. See (National Cancer Institute) and (American Legacy Foundation).

(15.) Letter from nurse to R.J. Reynolds, 4 February 1984, Legacy Tobacco Documents (Bates 503110059).

(16.) Letter addressed to The Honorable Henry Waxman, 14 April 1994, Legacy Tobacco Documents (Bates 513207723/7725).

(17.) Letter from consumer to R.J. Reynolds, 12 November 1985, Legacy Tobacco Documents (Bates 505438082/8084).

(18.) Letter from consumer to R.J. Reynolds, 20 September 1996, Legacy Tobacco Documents (Bates 524115114/5121).

(19.) Letter from consumer to R.J. Reynolds, 8 March 2000, Legacy Tobacco Documents (Bates 522753007/3009).

(20.) Letter from consumer to R.J. Reynolds, 22 July 1989, Legacy Tobacco Documents (Bates 507704718/4720).

(21.) Letter from consumer to R.J. Reynolds, 15 November 1987, Legacy Tobacco Documents (Bares 507707054/7055).

(22.) Letters from the same Massachusetts consumer to RJ. Reynolds, dated 23 August 1995 and 25 September 1995, Legacy Tobacco Documents, (Bates 524103784/3786 and 524103864/3867).

(23.) For an example of this research, see Lawrence E. Adler et al., "Normalization of Auditory Physiology by Cigarette Smoking in Schizophrenic Patients," American Journal of Psychiatry 150 (1993): 1856-61.

(24.) Letter from consumer to R.J. Reynolds, 18 August 1997, Legacy Tobacco Documents (Bates 515626340/5342).

(25.) Letter from a caseworker at the Heart of Texas Region Mental Health and Mental Retardation Center, 22 January 1996, Legacy Tobacco Documents (Bates 524108319/8322).

(26.) Some researchers argued that smoking helped to correct a biochemical deficit in schizophrenia, while others argued that mentally ill individuals' attraction to cigarettes was connected to the deficits in their disease. Others have even put forth the more radical idea that smoking itself helps to produce mental illness.

(27.) Letter from consumer to National Smokers' Service, 10 January 1996, Legacy Tobacco Documents (Bates 524217276/7288).

(28.) For an overview of this movement, see Nancy Tomes, "The Patient as a Policy Factor: A Historical Case Study of the Consumer/Survivor Movement in Mental Health," Health Affairs 25 (2006): 720-29, Philip R. Beard, "The Consumer Movement," in American Psychiatry After World War II (1944-1994), ed. Roy W. Menninger and John C. Nemiah (Washington, DC:, 2000), 299-320. For an important explanation of the movement from one of its key members, see Judi Chamberlain, On Our Own: Patient-Controlled Alternatives to the Mental Health System (New York, 1978). See also, U.S. Department of Health and Human Services, "Overview of Consumer and Family Movements," in Mental Health: A Report of the Surgeon General (Washington, D.C., 1999), 92-97. For the historical context for consumer movements around issues of health care, see Nancy Tomes, "Merchants of Health: Medicine and Consumer Culture in the United States, 1900-1940," Journal of American History 88 (2001): 519-47.

(29.) For Szasz's formulation about mental illness, see Thomas S. Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York, 1961). For Szasz in historical perspective, see Norman Dain, "Critics and Dissenters: Reflections on 'Anti-Psychiatry' in the United States," Journal of the History of the Behavioral Sciences 25 (1989): 3-25.

(30.) Paul S. Appelbaum, Almost a Revolution: Mental Health Law and the Limits of Change (New York, 1994).

(31.) Letter from consumer to Forsyth Tobacco Products, 7 May 1998, Legacy Tobacco Documents (Bates 517728668/8670). Emphasis in the original.

(32.) Letter from consumer to R.J. Reynolds, 9 May 1998, Legacy Tobacco Documents (Bates 515957213).

(33.) For background on JCAHO, see Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York, 1989).

(34.) "Mental Illness Advocacy Group Battling Hospital Smoking Ban in New York," Psychiatric News 29 (1994): 1, 9, Lisa W. Foderaro, "Battling Demons, and Nicotine: Hospitals' Smoking Bans Are New Anxiety for Mentally Ill," New York Times, 19 February 1995.

(35.) Undated flyer from AMI/FAMI, Legacy Tobacco Documents (Bates 2071540436).

(36.) Letter from consumer to R.J. Reynolds, 25 April 2000, Legacy Tobacco Documents (Bates 522752999/3004).

(37.) For historical context on the importance of consumer identity to American society and culture in the twentieth century, see Lizbeth Cohen, A Consumers' Republic: The Politics of Mass Consumption in Postwar America (New York, 2003), Susan Strasser, ed., Commodifying Everything: Relationships of the Market (New York, 2003).

(38.) Letter from a community health services agency in South Carolina to Camel, 2 May 1996, Legacy Tobacco Documents (Bates 517304212/4213).

(39.) Letter from a caseworker at the Heart of Texas Region Mental Health and Mental Retardation Center, 22 January 1996, Legacy Tobacco Documents (Bates 524108319/8322).

(40.) Letter from a public guardian in Vermont to Philip Morris, 9 December 1997, Legacy Tobacco Documents (Bates 2070397644/7645).

(41.) Letter from consumer to R.J. Reynolds, 11 March 1998, Legacy Tobacco Documents, (Bates 515558405/8408).

(42.) Letter from consumer to Salem, 10 July 2000, Legacy Tobacco Documents (Bates 522751918/1919).

(43.) See for example, letter from a retired New York attorney who developed lung cancer and wrote to R.J. Reynolds to threaten action, 26 February 1973, Legacy Tobacco Documents (Bates 505744395). A woman (who identified herself as a loyal customer) asked for $175,000 from R.J. Reynolds to cover her medical bills and to "ease my mental suffering." Letter dated 3 February 1997, Legacy Tobacco Documents (Bates 520721325/1332).

(44.) Letter from consumer to R.J. Reynolds, 16 July 1997, Legacy Tobacco Documents (Bates 520721145/1146).

(45.) Letter from members and staff of a social rehabilitation center to Philip Morris, 26 August 1997, Legacy Tobacco Documents, (Bates 2073480716).

(46.) Letter from consumer to R.J. Reynolds, 3 July 1995. Legacy Tobacco Documents (Bates 517224635/4636).

(47.) Letter from consumer to R.J. Reynolds, 20 February 1992, Legacy Tobacco Documents (Bates 508468442/8443).

(48.) Letter from consumer, 8 September 1970, Legacy Tobacco Documents (Bates 500336632/0634).

(49.) See for example, letters from the same Minnesota man to R.J. Reynolds, 22 July 1989, 26 November 1990, 29 November 1990, Legacy Tobacco Documents (Bates 507704718/4720, 507704732/4733, 507704734/4736). The notes from the files indicate that this man's letters were filed under the heading, "Pen Pal."

(50.) Letter form consumer addressed to Zachary Reynolds, 1 August 1997, Legacy Tobacco Documents (Bates 517727611/7613). Zachary Reynolds died in 1979. A Zachary Smith Reynolds, son of company founder R.J. Reynolds, died in 1932.

(51.) Letter from consumer to R.J. Reynolds, 6 July 1999, Legacy Tobacco Documents (Bates 522762510/2513).

(52.) Letter from Max Crohn, General Counsel, to H.R. Kornegay (enclosing the letter from Dr. Torrey), 28 August 1980, Legacy Tobacco Documents (Bates TI7931387/TI17031388). Reply to Dr. Torrey dated 8 October 1980, (Bates 502358664). For an example of Torrey's activist writing, see E. Fuller Torrey. Out of the Shadows: Confronting America's Mental Illness Crisis (New York, 1997).

(53.) For concerns about industry manipulation of the mentally ill, see Dorie Apollonio and Ruth E. Malone, "Marketing to the Marginalised: Tobacco Industry Targeting of the Homeless and Mentally Ill," Tobacco Control 14 (2005): 409-15.

(54.) Public Policy Committee of the Board of Directors and the NAMI Department of Public Policy and Legal Affairs, "Public Policy Platform of the National Alliance for the Mentally Ill," (Arlington, Virginia: 2008).

(55.) See for example, Dikla Shmueli et al., "Changes in Psychiatric Patients' Thoughts About Quitting Smoking During a Smoke-Free Hospitalization," Nicotine & Tobacco Research 10 (2008): 875-81.

(56.) David Kessler, A Question of Intent: A Great American Battle with a Deadly Industry (New York, 2001).

By Laura Hirshbein

University of Michigan

Department of Psychiatry

Ann Arbor, MI 48109-5020
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Date:Sep 22, 2010
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