Smoking Privileges

Laura D. Hirshbein

• Publisher: Rutgers University Press
• Year: 2015
• ISBN:
  9780813575506
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Current public health literature suggests that the mentally ill may represent as much as  half  of the smokers in America. In  Smoking 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 Privileges  warns 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 Privileges  illuminates the intersection of smoking and mental illness, and offers a new perspective on public policy regarding cigarettes.

Chapter 1

Ecology of Smoking in Mental Hospitals through the 1970s

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—role within such settings.

For decades there was little published psychiatric literature about smoking and its meaning for patients’ mental or physical health. Early psychiatric hospital regulations about smoking focused on fire hazards to the buildings rather than on other issues for patients or staff. During the mid-twentieth-century-high prevalence of smoking in the general population, there were few limitations on smoking within psychiatric institutions. It was a behavior to be managed, a barometer for patient relationships with staff, a method for encouraging socialization, and a potential source of difficulty with certain patient populations.

Until the 1980s and 1990s, smoking was a fact of life in mental hospitals and among psychiatric patients. Recent critics have blamed the culture of mental-health settings for encouraging smoking over the decades. While it is true that the environment—and sometimes the staff—encouraged smoking, the ubiquity of cigarettes and smoking behaviors offer a window into the experiences of mentally ill individuals and their relationships with care providers. Mental-health professionals on the whole accepted that smoking was part of the illness experience, but practitioners within hospital health-care teams approached their patients’ relationship with cigarettes using different management strategies. And individuals with mental illness saw and interpreted smoking and cigarette exchange as important aspects of their relationships with staff and one another. Patients’ (and staff) use of cigarettes within mental hospitals and other locations of psychiatric treatment highlighted the slippery definitions of normal and abnormal behavior and the challenges of proscribed patient and caregiver roles.

Provider Roles and Smoking

The state-mental-hospital system was a key setting for care for seriously mentally ill patients in the first two-thirds of the twentieth century. There were also private psychiatric facilities and hospitals for alcohol or drug-abusing patients, as well as a system of hospital services for military veterans.2 In all of these locations, cigarettes were a near universal part of the culture through most of the twentieth century. Some state hospitals grew and supplied tobacco for patients, and many included a tobacco allotment for patients as part of their basic board.3 Mental hospitals located near tobacco companies often received donations of cigarettes to give to patients, and shortages of cigarettes for psychiatric patients could be reported as a newsworthy problem.4

But smoking was usually not raised as an issue. Hospital-administration guidelines at mid-century did not mention smoking, even though it was widespread.5 Hospitals restricted patients’ smoking patterns (either access to matches or lighters, or identifying specific acceptable indoor locations for smoking) in response to concerns about possible fires.6 But beyond the basic safety issues, psychiatrists, nurses, attendants, and social workers encountered smoking in efforts to connect to patients, to control their behavior (both good and bad), and to effect a cure for their illness. All of these methods shifted over time, but for the most part providers accepted that their patients smoked and did not expect them to quit. Further, mental-health providers as a group tended to smoke and shared the culture of smoking with their patients.

The leader of the mental-health treatment team was the psychiatrist, the physician who was in charge of the mental hospital and who directed patients’ treatment. As both medical professionals and leaders of a team, psychiatrists engaged on the topic of patient smoking on several levels, from understanding the role of tobacco for patients, to using tobacco to connect with patients, to directing smoking policy for the hospital. Physicians’ approaches toward smoking among patients were shaped by their own smoking patterns, as well as their assumptions about who should smoke (or not) and why. Their interpretations of patients’ smoking behaviors depended on their theoretical orientation. Psychoanalytically inspired psychiatrists could, for example, see smoking as displacement of libidinal energy.7 And psychiatrists did not hesitate to use smoking to reinforce power dynamics with patients.

One of the issues for psychiatric patients was that they could not always communicate their thought processes or use words to express their distress, and psychiatrists used smoking as a barometer to gauge patients’ internal states. In the 1920s, psychiatric pioneer Henry Stack Sullivan attended to the utterances of his patients and noted the frequency with which patients discussed their preoccupation with smoking.8 During World War II, observers noted that smoking could be a marker of emotional distress due to combat-related anxiety: “Excessive smoking results in large areas of cigarette stain on the fingers. It seems that the patient is reluctant to toss his cigarette away, smoking it until it almost burns his fingers. One cigarette follows another.”9 Even without a conversation, psychiatrists could understand patients’ mental condition by observing their relationship with cigarettes.

Physicians incorporated smoking behaviors as part of their assessment and evaluation of patients.10 Sometimes patients did bizarre things with their cigarettes, and this became a management issue.11 One patient at a Veterans Administration (VA) hospital in Virginia had been placed on a work assignment outside the hospital in the late 1940s. He did well, except that his supervisor was upset by his pattern of picking up cigarette butts and smoking them, especially since he had enough money to buy cigarettes. The patient’s psychiatric team worked with the patient and noted as a mark of his progress that the patient eventually stopped picking up butts and began purchasing his cigarettes.12 Patients also harmed themselves with cigarettes, either by extreme smoking behaviors or by burning themselves with cigarettes, accidentally or as part of their delusional systems.13 Treatment-team leaders engaged with staff and patients to contain or stop these behaviors but often focused on changing circumstances to allow patients to smoke in a safer manner.

For some psychiatrists, the recognition of their patients’ needs and desires to smoke reflected their benevolent intent. In 1933, Richard Dewey returned to the theme of tobacco helping patients adjust to hospital life in an address to the American Psychiatric Association (APA). He suggested that patients responded better when their staff displayed kindness: “A good humored attitude is hard to resist, a little refreshment, liquid or solid; even a cigarette; a little compliment would be well received and easy to give.”14 The offer of cigarettes seemed to be a benign and easy intervention. In 1938, New York psychiatrist Karl Bowman explained, “I would state unhesitatingly that it is better to give a patient one or two cigarettes at bed time than to dose him with barbiturates or other hypnotics. I believe that intelligent observation will indicate that the amount of hypnotics can be diminished by the judicious use of cigarettes at bedtime.”15 Psychiatrists understood cigarettes to be part of their armamentarium in dealing with potentially problematic patient behaviors and saw them to be more humane and less potentially harmful than medications.

Further, smoking allowed psychiatrists to connect with patients. One psychiatrist reported on his efforts to make contact with a psychotic Canadian Indian girl. The psychiatrist commented that he had been smoking, and so offered the girl a cigarette—which she accepted. This became the basis of a working relationship that, according to the psychiatrist, helped the girl recover.16 Psychiatrists also used smoking to help patients relate to one another. One of the most frequently discussed deficits in schizophrenia, according to mental-health professionals, was difficulty with social interactions. Smoking was a ritualized behavior that allowed patients to engage with one another in a highly structured way. A Canadian psychiatrist experimented with using a variety of drugs in order to try to promote good social interactions with patients. In addition, “to make the atmosphere congenial, peanuts and cigarettes were provided freely.”17 Cigarette use smoothed the way to assess for other kinds of interventions.

Of course, one of the reasons for psychiatrists’ awareness of patient smoking was probably their own smoking rates. Several University of Pennsylvania psychiatrists explored the behaviors of students at their medical school during times of stress and found that more than 60 percent smoked more while feeling nervous.18 Popular cartoons in this time period illustrated psychiatrists smoking cigarettes as part of their patient interactions.19 Even after other physicians began to focus on the health consequences of smoking, psychiatrists seemed to respond to a different set of priorities regarding their own smoking behaviors. Two psychiatrists in the 1970s speculated that since a psychiatrist had to sit and listen to patients instead of moving around during patient care, “he may thus experience an intense need to continue smoking as one of the few vehicles available to him for drive release and tension reduction.” Further, since psychiatrists did not take care of patients with serious physical health problems, it might have been easier for them to ignore the health effects of smoking.20

While psychiatrists accepted patients’ smoking behaviors (perhaps for their own reasons), other members of the mental-hospital team had different perspectives on the role of smoking in the hospital. Psychologists and social workers described the dynamics of smoking among staff members. Nurses recognized the power of smoking restrictions and privileges in the hospital. And aides regularly interacted with patients around their smoking needs and were left to interpret and enforce any hospital rules or limitations on smoking. Because smoking was part of everyday life within hospitals, providers within the team interacted with—or attempted to manage—smoking behaviors at different levels.

Psychologists and social workers were active participants in psychiatric inpatient settings, though their roles were variable. Psychologists in the early twentieth century primarily focused on formal testing of patients, but by mid-century they became more established experts on social dynamics and interpretations of behavior.21 Social workers in mental hospitals initially worked with families, though they also expanded their role to include more individual encounters with patients.22 And they visited patients in their homes and were able to observe potential discrepancies between family reports and home environment. Members of both of these professions made efforts to understand and analyze patient behaviors, including smoking.23

For these practitioners, smoking was a behavioral manifestation of an emotional state rather than a determinant of health. In the 1920s, a psychologist interpreted patients’ oral needs with regard to nutrition and psychological factors. While eschewing psychoanalytic connections between oral needs and sex, the psychologist argued that the mouth was an important site for learning and that the existence of smoking behavior at meals was a remnant of “infantile sucking projected into the medium of adult social intercourse.”24 Psychologists also observed behavior and interpreted the effects of interventions with patients. Two psychologists from a Pittsburgh VA hospital tried techniques to reduce anxiety in a chronic schizophrenic and could tell he was better because his cigarette smoking decreased.25

Other psychologists and social-work observers analyzed the social environment of psychiatric hospitals, including the role of smoking in interactions. Psychologist David Kantor, who did his dissertation on social relationships in a mental hospital, found that students who volunteered in the hospital often had difficulty relating to the patients. Smoking, though, helped the students to see the patients as people, such as when the male patients lit up cigarettes for the female volunteers.26 Another social scientist observed a problematic dynamic on an inpatient unit in which a patient made excessive demands (especially for cigarettes) on hospital staff and divided them over the ideal approach to the problem. The investigator was able to present his observations about the patient and the group in a meeting, which resulted in an intervention to proactively provide the patient with a cigarette before she asked. The intervention helped the patient and the group.27

Social workers were particularly attentive to the group dynamics of hospital settings, and took on roles as facilitators and problem solvers. A 1955 social worker explained a situation in which there had been a conflict on a unit between a rigid, controlling nurse and a more permissive woman head psychiatrist. The psychiatrist instituted group work to be run by a social worker. Before they had the opportunity to engage in group interactions, the patients were apathetic and did not interact. With the introduction of group activity, the patients were much better groomed and more involved: “In the recreation room, some patients sat together smoking, talking, and playing games with the workers and each other while others danced to records.”28 In this case, smoking was a sign that patients were developing positive social connections. And the easing of restrictions, particularly around smoking, helped alleviate the conflict.

As the previous example illustrates, there were often clashes between the roles of different mental-health providers. Nurses were key members of the treatment group and functioned to direct the day-to-day activities of mental hospitals. And the fact that nursing was dominated by women shaped power dynamics. As a number of historians have pointed out, nurses had ongoing challenges in their relationships with their physician supervisors and in their efforts to become more autonomous profes...

Table of contents

• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Introduction: Smoking Privileges
• Chapter 1. Ecology of Smoking in Mental Hospitals through the 1970s
• Chapter 2. Conflict and Smoking in Mental Hospitals in the 1960s and 1970s
• Chapter 3. Smoker Psychology and the Tobacco Industry through the Early 1980s
• Chapter 4. Psychiatry Engages Smoking
• Chapter 5. The Many Faces of Nicotine
• Chapter 6. From Tolerance to Treatment
• Chapter 7. Tobacco Control and the Mentally Ill
• Chapter 8. Double Marginalization
• Conclusion: Corporate Squeeze
• Notes
• Index
• About the Author
• Read More in the Series