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Smoking Privileges

Smoking Privileges: Psychiatry, the Mentally Ill, and the Tobacco Industry in America

Laura D. Hirshbein
Copyright Date: 2015
Published by: Rutgers University Press
Pages: 228
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  • Book Info
    Smoking Privileges
    Book Description:

    Current public health literature suggests that the mentally ill may represent as much ashalfof the smokers in America. InSmoking Privileges, Laura D. Hirshbein highlights the complex problem of mentally ill smokers, placing it in the context of changes in psychiatry, in the tobacco and pharmaceutical industries, and in the experience of mental illness over the last century.

    Hirshbein, a medical historian and clinical psychiatrist, first shows how cigarettes functioned in the old system of psychiatric care, revealing that mental health providers long ago noted the important role of cigarettes within treatment settings and the strong attachment of many mentally ill individuals to their cigarettes. Hirshbein also relates how, as the sale of cigarettes dwindled, the tobacco industry quietly researched alternative markets, including those who smoked for psychological reasons, ultimately discovering connections between mental states and smoking, and the addictive properties of nicotine. However,Smoking Privilegeswarns that to see smoking among the mentally ill only in terms of addiction misses how this behavior fits into the broader context of their lives. Cigarettes not only helped structure their relationships with other people, but also have been important objects of attachment. Indeed, even after psychiatric hospitals belatedly instituted smoking bans in the late twentieth century, smoking remained an integral part of life for many seriously ill patients, with implications not only for public health but for the ongoing treatment of psychiatric disorders. Making matters worse, well-meaning tobacco-control policies have had the unintended consequence of further stigmatizing the mentally ill.

    A groundbreaking look at a little-known public health problem,Smoking Privilegesilluminates the intersection of smoking and mental illness, and offers a new perspective on public policy regarding cigarettes.

    eISBN: 978-0-8135-6398-5
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Acknowledgments
    (pp. ix-xii)
  4. Introduction: Smoking Privileges
    (pp. 1-9)

    When I first encountered E.K. in 2003, he was an inpatient on our psychiatric ward at the University of Michigan Hospital. He was thirty-five, but looked about sixty. E.K. had not had an easy life. He was diagnosed with schizophrenia in his teens, but no one knew if he really had the disease or if years of hard use of every illicit substance he could get his hands on had fried his brain. He had no social support—he had a chaotic relationship with his mother, his father was in and out of the picture (and in and out of...

  5. Chapter 1 Ecology of Smoking in Mental Hospitals through the 1970s
    (pp. 10-29)

    In 1892, Illinois Eastern Hospital for the Insane superintendent Richard Dewey commented that tobacco had a powerful influence over patients in mental institutions. To get patients to cooperate with treatment, he suggested an inducement: “The privilege of a smoke or a bit of plug tobacco will bring a great many patients to the shop [occupational therapy] who would otherwise feel disinclined to go.”¹ Like Dewey, psychiatrists and other mental-health care providers over the last century noticed that their patients had a strong relationship to tobacco and cigarette smoking. And for nearly a century, cigarettes played an important—and mostly unquestioned...

  6. Chapter 2 Conflict and Smoking in Mental Hospitals in the 1960s and 1970s
    (pp. 30-49)

    In the 1960s and 1970s, psychiatrists faced growing public criticism for their treatment settings, their approaches to patients, and even their definitions of mental illness. Social-science theorists and researchers such as R.D. Laing and Erving Goffman, along with psychiatrist Thomas Szasz, publically castigated the profession for confining patients for no reason, treating them badly while confined, and making up categories of illness. Some of these critiques aligned with shifts within psychiatry itself, but others dovetailed with growing distrust for authority in these turbulent decades, and psychiatrists found themselves on the defensive about their care of patients, especially in hospitals.¹


  7. Chapter 3 Smoker Psychology and the Tobacco Industry through the Early 1980s
    (pp. 50-62)

    In 1964, the United States surgeon general released a report confirming what many had suspected for a decade—that smoking caused cancer and significantly contributed to other major health problems.¹ The report galvanized action in the public-health community, and advocacy groups such as the American Cancer Society worked to educate the public about the health hazards of smoking.² The surgeon general’s report acknowledged in a small section, though, that some individuals might have psychological reasons to smoke, despite the health risks. The authors commented that humans had a long history of using pharmaceutical substances for psychological purposes, and it was...

  8. Chapter 4 Psychiatry Engages Smoking
    (pp. 63-81)

    From the pages of the flagship journal of the American Psychiatric Association in the 1960s and 1970s it would be impossible to tell that the surgeon general had published an important report in 1964 or that smoking caused illness. TheAmerican Journal of Psychiatryhad only five articles that even mentioned smoking between 1960 and 1970, and none of them addressed health issues.¹ A few psychiatrists mentioned smoking in the context of other concerns in the 1970s, but in general there was a deafening silence about smoking in mental-health circles, despite robust public attention to smoking and active tobacco-industry response...

  9. Chapter 5 The Many Faces of Nicotine
    (pp. 82-96)

    In May of 1988, a new surgeon general’s report,Nicotine Addiction,synthesized research from a variety of fields to support the conclusion that people continued to smoke despite the health consequences because nicotine was addictive.¹ Many perceived this report as a direct assault on the tobacco industry’s claims that smoking represented personal choice. But the publication ofNicotine Addictionalso signaled the beginning of tobacco research, policy, and practices directed toward the brain rather than the rest of the body and highlighted the potential significance of nicotine itself.

    The stance that nicotine was addicting was a step up from that...

  10. Chapter 6 From Tolerance to Treatment
    (pp. 97-112)

    In 1992, the same year that the Joint Commission published its rule that all hospitals should go smoke free, New York State Psychiatric Institute psychiatrists Gregory Dalack and Alexander Glassman reviewed the challenges faced by mentally ill smokers, especially those on psychiatric units. Dalack and Glassman noted that many providers were unwilling to address the issue of smoking cessation among the mentally ill, sometimes out of an idea that patients needed to smoke for stress relief. The authors encouraged mental-health practitioners to take up the smoking issue with their patients. Dalack and Glassman pointed out, though, that enforced abstinence from...

  11. Chapter 7 Tobacco Control and the Mentally Ill
    (pp. 113-126)

    In a widely citedJAMAarticle in 2000, Harvard researcher Karen Lasser and her colleagues analyzed data from the National Comorbidity Survey (a series of questionnaires given to a sample of the population in the early 1990s) that had determined that almost 50 percent of the United States population had a mental illness, including nicotine dependence, at some point in their lives. Lasser’s team found that those who had both a psychiatric disorder (such as schizophrenia, depression, or bipolar disorder) and nicotine dependence composed a majority of the cigarette consumers in the country. And, in an interesting twist on the...

  12. Chapter 8 Double Marginalization
    (pp. 127-141)

    In 2004, health analysts Ronald Bayer and James Colgrove pointed out that tobacco-control policies in the United States over the previous decades had succeeded by focusing on children and innocent bystanders. Even though Americans typically disliked paternalistic public-health measures, those that seemed to be protecting vulnerable populations were acceptable. Bayer and Colgrove suggested, though, that because of the major shift in how cigarettes were perceived in society, Americans were able to tolerate broader regulation and restriction on tobacco.¹ But one reason that many are more willing to accept limitations on smoking is not just that smoking is less tolerated in...

  13. Conclusion: Corporate Squeeze
    (pp. 142-154)

    In 1999, a North Carolina man wrote to R.J. Reynolds to request that the company assist him in becoming “a purchaser of cigarettes from your powerful industry.” The man, who enclosed a letter from his community mental-health clinic verifying that he was diagnosed with schizophrenia, explained that he was not asking for a handout. Instead, he was asking for administrative help as he thought it made sense for him to earn a living by selling cigarettes. He claimed that his doctor, who was also a smoker, recommended this to him as an appropriate course of action.¹ This letter, written more...

  14. Notes
    (pp. 155-208)
  15. Index
    (pp. 209-212)
  16. Back Matter
    (pp. 213-216)