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 …