- Smoking Privileges: Psychiatry, the Mentally Ill, and the Tobacco Industry in America by Laura D. Hirshbein
While overall rates of tobacco use have declined in the United States in recent decades, the number of mentally ill consumers of cigarettes has remained remarkably stable—in fact, cigarette smokers with psychiatric disorders are arguably the tobacco industry’s most loyal demographic. In Smoking Privileges, psychiatrist and historian Laura Hirshbein describes how an already-vulnerable population—the mentally ill—became “doubly marginalized” by public health campaigns that sought to stigmatize smoking (p. 127). She argues that the blunt force of smoking bans adopted by many hospitals and mental health settings in the 1990s can be a barrier to effective psychiatric treatment. Sweeping antismoking policies often ignore the multiple ways in which cigarettes function in the lives of psychiatric patients: as social control, self-medication, or a symbol of psychological instability, to name a just few. Covering each of these categories in turn, Hirshbein demonstrates that both the practice and meaning of smoking for psychiatric patients have been jointly shaped by the decline of the asylum and the rise of new corporate research on addiction.
The first two chapters of Smoking Privileges explore the role smoking played in mental hospitals until the 1970s. Cigarettes were ubiquitous in state-run mental [End Page 181] hospitals in the twentieth century and were often used to medicate patients or forge bonds between patients and staff, or as tokens for good behavior. By the 1960s, asylum critics took issue with the ways in which cigarettes were used by staff to police patients’ behavior. In the context of the mental hospital, it became clear that patients smoked for different reasons than the general public. They smoked without regard for brand and were generally impervious to mass-market campaigns that emphasized qualities like sophistication, rebellion, or self-image.
Chapters 3 and 4 describe psychological and psychiatric research on smoking motivation. Tobacco industry research in the 1960s and 1970s explored links between smoking and arousal, stress, and personality. Meanwhile, psychiatric researchers debated whether cigarette use was analogous to drug addiction and ultimately included the category “tobacco dependence” in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. By the 1980s, practicing psychiatrists began to discuss the merits and drawbacks of smoke-free psychiatric units. In this period, most psychiatrists stopped viewing cigarette smoking as a form of behavioral or emotional control; instead, smoking became a sure sign of nicotine addiction.
Chapters 5 and 6 focus on corporate and academic nicotine addiction research in the 1980s and 1990s. Neuroscience investigators, often working in partnership with pharmaceutical companies, began to explore new therapeutic uses for nicotine as a treatment for conditions such as Alzheimer’s and Parkinson’s diseases and schizophrenia. The development of pharmaceutical treatments for nicotine dependence introduced new antismoking interventions for psychiatric patients. Companies began to target the mentally ill with nicotine replacement therapies just as tobacco-control advocates took notice of a “‘hidden epidemic’ of mentally ill smokers” (p. 112).
The final two chapters culminate in Hirshbein’s description of “the unintended consequences of tobacco control,” the most troubling of which is the “double marginalization” of mentally ill smokers (pp. 120–26, 127–41). By exposing tobacco companies’ marketing to psychiatric patients and cracking down on smoking in mental health settings, antismoking activists effectively linked a stigmatized population with a discredited industry. This move, Hirshbein argues, served only to further stigmatize a population that already faces significant issues with health care access and parity. Hirshbein concludes by calling for advocates, clinicians, and policy makers to listen to voices of the mentally ill smokers they seek to help.
Smoking Privileges is a clearly argued and thoroughly researched investigation of an understudied population. Hirshbein’s book is essential reading for scholars interested in the histories of drugs and health, the mental health care system, and vulnerable populations. Her diverse source base includes film and literature as well as scientific research...