Tobacco Use Among Individuals With Schizophrenia: What Role Has the Tobacco
2Department of Psychiatry, University of California, San
Francisco;3Department of Clinical Pharmacy and Institute for
Health Policy Studies, University of California, San Francisco
Rates of tobacco use among individuals diagnosed with
tobacco use among this vulnerable group. This study exam-
ined the tobacco industry’s efforts to establish and promul-
gate beliefs about schizophrenic individuals’ need to smoke
bacco Documents Library. The search yielded 280 records
dating from 1955 to 2004. Documents indicate the tobacco
industry monitored or directly funded research supporting
self-medication. The tobaccoindustry promoted smokingin
psychiatric settings by providing cigarettes and supporting
engaged in a variety of direct and indirect efforts that likely
contributed to the slowed decline in smoking prevalence in
velopment for this population and slowing the rate of policy
implementation vis-a `-vis smoking bans on psychiatric units.
Key words: nicotine/smoking/cigarettes/psychiatry/
mentally ill/tobacco companies
Individuals with mental illness are one of the largest
remaining groups of smokers, accounting for 44% to
46% of cigarettes sold in the United States.1,2This equa-
tes to 180 billion cigarettes or $37 billion in tobacco
industry sales annually.3,4Tobacco use is particularly
prevalent among individuals diagnosed with schizophre-
of tobacco use among this vulnerable group. Despite a
lack of compelling scientific support, beliefs prevail that
individuals with schizophrenia need to smoke as a form
immunity from tobacco-related diseases.7–10
This study examined the role the tobacco industry has
played in promoting and maintaining cigarette use
amongindividuals diagnosedwith schizophrenia. Theto-
bacco industry documents provide insight into industry
motives, strategies, tactics, and data.11Prior research
has reported on the tobacco industry’s strategies to ma-
nipulate data on the health risks of smoking, including
funding and publishing research that supports their po-
sition, suppressing research that does not support their
position, and disseminating their data and interpreta-
tions to the lay press and policy makers.12The current
study examined evidence of these tactics in relation to
the industry’s efforts to establish and promulgate beliefs
about schizophrenic individuals’ need to smoke and the
hazards of quitting. An awareness of the tobacco indus-
try’s efforts to preserve smoking among individuals with
schizophrenia is needed to better inform treatment and
The 1998 Minnesota Consent Judgment and Master
Settlement Agreement resulted in the public availability
of nearly 40 million pages of the industry’s internal docu-
ments. The initial search was conducted during January–
July 2005 in the Legacy Tobacco Documents Library
(http://legacy.library.ucsf.edu/) using keyword terms
1To whom correspondence should be addressed; University of
California, San Francisco, 401 Parnassus Avenue, TRC 0984, San
Francisco, CA 94143-0984; tel: 415-476-7695, fax: 415-476-7719,
*An earlier version of this manuscript, published online No-
has been edited and the incorrect citation removed. The citation
numbering has been updated to reflect these changes.
Schizophrenia Bulletin vol. 34 no. 3 pp. 555–567, 2008
Advance Access publication on November 5, 2007
? The Author 2007. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: email@example.com.
‘‘psychosis,’’ ‘‘psychotic,’’ or ‘‘schizo*.’’ (Use of an aster-
isk as a ‘‘wild card’’ character allows for a search of var-
iations of word or phrases—in this case, schizophrenia,
schizophrenic, and schizoaffective disorder.) The search
yielded 280 records; the Council for Tobacco Research
(CTR) archive provided the largest number of records
with 130 hits (The CTR, formed by US tobacco compa-
nies in 1954 as the Tobacco Industry Research Commit-
tee (TIRC), was formed with the premise of funding
research. Internal documents have revealed, however, that
the TIRC served largely for public relations purposes,
to convince the public that the hazards of smoking
had not been proven13).
Expanded searches were prompted by clues identified
in reviewed documents, including named individuals,
specific programs, and expansion of dates and reference
(BATES) numbers. Additional follow-up searches were
conducted on tobacco document collection sites search-
able by text words (http://tobaccodocuments.org/ and
http://www.pmdocs.com/), including the Legacy To-
bacco Documents Library, which obtained text word
search capability in March 2006. Identified documents
ranged in date from 1955 through the year 2004.
A postpositivist analytic approach was used,13with
findings organized into 3 main areas concerning tobacco
industry (1) investigations of the health effects of smok-
ing in individuals with schizophrenia, (2) research on the
self-medication hypothesis specific to tobacco use and
schizophrenia, and (c) involvement in policy efforts to
maintain tobacco use in psychiatry settings. As relevant,
we supplemented industry documents with recent re-
search literature on tobacco use and schizophrenia.
Lastly, we conducted systematic searches of PubMed
and PsychInfo to identify publications resulting from to-
bacco industry–funded studies.
Health Effects of Smoking in Individuals With
Earliest evidence of tobacco industry interest in individ-
uals with schizophrenia dates to the mid-1950s with cu-
riosity about apparent low levels of cancer despite high
rates of smoking in this patient group.14The tobacco in-
dustry catalogued reports of low cancer rates in schizo-
phrenics15–18and questioned whether it would be
‘‘practical and sensible to . attempt to quantify these
relationships.’’19The reports of cancer in schizophrenia
were often based on proportionate mortality, calculated
as the number of deaths due to cancer divided by total
deaths from all causes, which was later criticized as
flawed because of the higher total death rate among
patients with schizophrenia due to the increased inci-
dence of syphilis and tuberculosis.20Further, the reports
did not account for the possibility that the institutional-
ized psychiatric settings had failed to detect cancer in
these patients.21–23Nevertheless, the belief that chronic
schizophrenics were somehow biologically resistant to
cancer prevailed at least until the late 1980s.24
Research funded in the 1960s–1970s by CTR, Philip
Morris (PM), and American Brands proposed that per-
sons who denied or repressed grief were more likely to
develop cancer than those who expressed emotion.25–27
This research was used to explain why smokers with
schizophrenia had low rates of lung cancer—‘‘long-
term schizophrenics, outwardly calm . have no capacity
for the repression of significant emotional events and no
need to contain emotional conflict.’’28The tobacco
industry’s research on psychosomatic causes of cancer ul-
timately came under scrutiny for its ‘‘scientific integ-
rity,’’29–31and they grew concerned of criticism that
they were ‘‘financing and giving publicity to an immense
Two proposals were submitted to CTR, in 1964 and
1997, to examine evidence of elevated rates of cancer
and lung disease among patients with schizophrenia
and the potential relationship to smoking.33,34Both pro-
posals were denied funding.35,36One was ‘‘denied in prin-
ciple but referred to the study group on the psycho-
physiological aspects of smoking,’’37
over.’’38CTR questioned ‘‘whether some other kind of
use could profitably be made of his data collection meth-
ods.’’39An internal letter at CTR read, ‘‘What we need to
while results that can be depended on.’’40The investiga-
tor was unknown to CTR, so it was not known whether
he had a track record of producing results that supported
thetobaccoindustry’sinterests. Ultimately,the workwas
Recently, government-funded, well-controlled, epide-
miologic studies have demonstrated an increased risk
to age-matched controls, with the increases attributed to
smoking, and no support for the hypothesis of a genetic
protection against cancer in families with schizophre-
nia.41,42Individuals with schizophrenia also are at
elevated risk for the development of tobacco-related
cardiovascular disease43and respiratory disorders.44
Tobacco Industry–Sponsored Research on the
The tobacco industry monitored the scientific litera-
ture45,46and funded internal and external research on
the ‘‘self-medication hypothesis,’’ which posited that
patients with schizophrenia needed to smoke to manage
their psychiatric symptoms. Twenty-eight proposals
relating to schizophrenia were identified in the tobacco
industry documents, of which 7 were ultimately funded;
all 7 sought to expose the beneficial self-medicating
effects of nicotine and smoking for schizophrenics.
J. J. Prochaska et al.
The tobacco industry also conducted internal re-
search on the use of nicotine and its analogues for
Funded External Research.
long histories of tobacco industry support. Five of the 7
ers for studies considered too sensitive to conduct in the
formation through litigation.47The studies are described
below. Notably, the results of many of the funded studies
schung or Institute for Biological Research] was set up to
hide PM funding for research and protect it. Research
showing greater toxicity of sidestream rather than main-
stream smoke was not published.48)
In 1982, a Canadian researcher submitted a proposal
to the Canadian Tobacco Manufacturer’s Council
(CTMC) to study ‘‘Tobacco Smoking as a Coping Mech-
anism in Psychiatric Patients’’ with particular attention
to ‘‘possible tobacco-induced normalization of arousal
deficits in . schizophrenics.’’49The investigator empha-
sized that his proposed studies ‘‘promise to bear fruitful
findings. It is particularly interesting that the psychia-
trists, who are medical professionals, are very aware of
the role of tobacco use in patients and are very interested
in thesestudies. Iftobacco canbe shown tobeanefficient
form of ‘self-medication’ for these patients then this
would be [a] significant bonus for the tobacco indus-
try.’’50The $84 281 budget request indicated the psychi-
atric patient subjects were to be paid with money or
(RJR) Research and Development noted that the inves-
tigator ‘‘has been sponsored by CTMC for some years .
his own salary was paid by us—so he was totally depen-
dent on CTMC funding . once again, he seems to be
looking at this from our point of view. Apart from his
project with children, all previous requests have been ap-
proved by the CTMC in general and by RJR in particu-
lar.’’51It was a common practice for the tobacco
andinsteadbefundedonthe basisofthepotential topro-
tect and promote the interests of the companies.52,53The
investigator was funded, though our search of the liter-
ature was unable to identify publications arising from
this particular study.
In 1987, a US investigator was funded for 3 years by
CTR for a study of nicotinic receptors in normal and dis-
ease states including schizophrenia.54The study raised
concern among the reviewers who suggested that animal
studies be initiated first, warning, ‘‘Studies in man, these
studies included, can be risky; and risks to human sub-
jects should be avoided whenever possible.’’55Despite
the reviewers’ concerns that the study be conducted in
The funded researchers had
animals before humans due to the potential risks to hu-
man subjects, the study was approved as initially pro-
posed with a budget of $416 551. The second year
report listed 8 publications with 3 acknowledging CTR
funding.56Our literature search, however, did not iden-
tify publications from this group concerning nicotinic
receptors in schizophrenia.
The tobacco industry funded research to examine la-
tent inhibition and prepulse inhibition (PPI), a measure
of attention and sensory gating, in patients with schizo-
phrenia. Funded by CTR for 2 proposals in 1994 and
1997, UK investigators reported that nicotine enhanced
PPI in both healthy and schizophrenia groups.57–59
some,59but not all, articles appearing to result from these
studies.60Funded by PM in 1994, an investigator in New
Zealand examined whether nicotine improves neural
inhibition in smoking and nonsmoking schizotypes
(definedbytheinvestigator asthe traitunderlyingschizo-
was budgeted for study completion. Study findings were
discussed with colleagues and reanalyzed but apparently
In 1994, investigators in Sweden submitted a proposal
to CTR with the goals ‘‘to facilitate and guide the devel-
ing nonaddictive drugs, to assist in smoking cessation
programs . to develop more rational pharmacothera-
pies for mentally ill patients in order to facilitate
a smoke-free environment for physicians and other staff
members in psychiatric hospitals.’’63The budget request
was $336 123. The investigator had been supported by
CTR since the 1980s with prior reviews noting, ‘‘ . it
is clear that there is a strong dependence on our sup-
port.’’64The 1994 proposal was funded. The 1997 prog-
ress report, however, suggested a primary focus on the
self-medication hypothesis with no mention of efforts
to develop tobacco treatments for this patient popula-
tion. Reported findings were ‘‘The data strongly support
our initial hypothesis that nicotine, indeed, provides
a form of self-medication in schizophrenia, especially
against so-called negative symptoms.’’65The progress re-
port listed 17 resulting publications, 5 of which did not
acknowledge CTR funding66–70; none of the 17 publica-
tions concerned tobacco treatment in schizophrenia.
In 1998, US investigators were funded by PM to char-
acterize the pharmacological properties of nicotine using
functional magnetic resonance imaging.71The project
in schizophrenia .. For these individuals, nicotine may
substantially reverse certain cognitive deficits, and we
aim to determine the brain mechanisms underlying this
potential therapeutic benefit.’’ One of the reviewers, a re-
search scientist at PM, discouraged funding, stating ‘‘I
simply do not see this as one of our key business interests.
Again, since we extensively fund such research I defer to
Tobacco Industry and Smoking in Schizophrenia
those who successfully justify such expenditures.’’72The
research was viewed by PM to be of ‘‘great interest to
the public health community,’’73and the proposal was
funded at $178 930 per year for 3 years.74,75The research-
ers presented their funded work at a scientific meeting.76
Further search in PubMed failed to identify any other
publications specific to the project.
proposals were submitted between 1966 and 1999,
to TIRC/CTR, RJR, PM, and Brown and Williamson.
Proposal objectives included study of tobacco-related
cancers among patients with schizophrenia (detailed
above)33,34; smoking prevalence among schizophrenics77;
social uses of tobacco among psychiatric patients78,79;
nicotine’s effects on neuroleptic blood levels80; nicotine
withdrawal effects in schizophrenia81; vitamin depletion
in schizophrenia due to tobacco use82; animal models of
nicotine’s effects in schizophrenia83; genes related to ag-
gression inschizophrenia84; nicotinic
tiation85–89; the dopamine D4 receptor’s role in the path-
ophysiology and treatment of schizophrenia90,91; and use
of nicotine and nicotine metabolites for treating schizo-
phrenia.92–95One of the review letters emphasized that
the decision to deny funding ‘‘does not reflect in any
way upon scientific merit96;’’ 6 other researchers were en-
unfunded proposals were submitted by foreign investiga-
tors; both aimed to examine the role of nicotine and
nicotinic receptors in the treatment of schizophrenia.
The twenty-one unfunded
on schizophrenia focused on the use of nicotine and nic-
otine analogs as pharmaceutical agents. By 1989, RJR
owned the rights to over 130 nicotine analogs with the
goal ‘‘to understand how nicotine interacts with the cen-
tral nervous system’’ and to apply this knowledge to
‘‘evaluation of various aspects of new products.’’102
RJR’s initial interests included a specific question into
‘‘nicotinic effects in schizophrenia.’’103Goals were to
‘‘positively impact [the] research community’s attitude
about nicotine,’’ ‘‘improve [the] public perception of nic-
otine through marketing of products,’’ and ‘‘change [the]
perception of nicotine in [the] medical community.’’103
Additional benefits included ‘‘evaluation of various
aspects of new products,’’ having ‘‘a vehicle for RJRT
scientists to contribute to the literature in this area,’’
and to ‘‘gain credibility for RJR and gain access to lead-
ing scientists, active in nicotine research, throughout the
In 1997, RJR ‘‘formed a wholly-owned subsidiary
known as Targacept, Inc.,’’ named for ‘‘targeted recep-
tors.’’104Targacept was developed ‘‘to rapidly commer-
cialize RJRT’s nicotine pharmaceutical technologies,’’105
and, it has been suggested, to circumvent nicotine regu-
Tobacco industry internal research
helpwith concentrationandattentionaldeficits inschizo-
phrenia, with an estimated target market of $1.5–$6 bil-
emphasized the knowledge of their scientific advisory
board including leading schizophrenia researchers.105,108
In industry documents and the popular press, RJR ex-
plicitly stated that the developed drugs were not to be
used for smoking cessation,109,110rationalizing that the
tobacco treatment pharmaceutical market was already
saturated. Yet at the time (January 1999), there were
only 4 drugs for treating tobacco dependence compared
with 15 medications for treating schizophrenia.111
Promoting Smoking in Psychiatric Patients
The tobacco industry promoted smoking in psychiatric
patients using both direct (ie, distribution, advertising,
scientific publications, and meetings) and indirect (ie,
policy effort) strategies. Figure 1 shows an advertisement
for Merit cigarettes with the headline reading, ‘‘Schizo-
phrenic.’’112It is not clear whether the marketing cam-
paign targeted individuals with schizophrenia or was
aimed at the general public, seeking to capitalize on
Fig. 1. A 1986 Advertisement for Philip Morris’ Merit Cigarettes
Suggests Evidence of Direct Marketing of Tobacco Products to
a pack of Merit cigarettes and reads, ‘‘Schizophrenic . For New
Merit, having two sides is just normal behavior.’’
J. J. Prochaska et al.
the common misunderstanding of schizophrenia as
reflecting a split personality: here, lower tar and big taste.
throughthe scientificliterature, popularpress, andpolicy
settings. A book published by a former RJR researcher
included discussion of smoking to self-medicate psycho-
pathology.113A review article in Chemistry and Industry
titled ‘‘Nicotine: Helping those who help themselves?’’114
suggested that ‘‘nicotine may have beneficial effects that
are ‘therapeutic’ rather than addictive.’’ The author con-
cluded that ‘‘many people who use tobacco . do so be-
cause of some potential therapeutic benefit they receive,
such as to relieve depression, schizophrenia or pain,’’ and
emphasized that ‘‘we first need to pull away from this
conceptofdemonismand treat nicotineand itsanalogues
like any other drug.’’ The author encouraged the use of
nicotine even among nonsmokers with schizophrenia.
funding from CTR and PM from at least 1977–1994 and
contributed to papers conceived by PM.115–119Another
CTR, PM, and RJR-funded researcher120–123published
ing the merits of nicotine and nicotine analogues in the
treatment of schizophrenia.124–127The same researcher
held scientific conferences sponsored by RJR128and
PM129,130from 1995 to 2006 with presentations on the
therapeutic indications and targeting of nicotinic treat-
ments for schizophrenia.131–133Though not mentioned
in meeting announcements,134tobacco industry sponsor-
ship was acknowledged in the programming materi-
nicotine researchers and tobacco industry scientists.
The meeting proceedings were published127,137without
recognition of tobacco industry funding.127Previous re-
search has revealed that publications resulting from to-
bacco industry–sponsored conference proceedings are
more likely to present unbalanced data and be authored
by tobacco industry–affiliated individuals than nonto-
bacco industry–sponsored publications.138On behalf of
the American Tobacco Company, a psychiatrist with
research expertise in the genetics of schizophrenia pro-
vided expert commentary to the Food and Drug Admin-
istration Drug Abuse Advisory Committee arguing that
nicotine is nonaddictive.139
The most direct approach to promoting tobacco con-
sumption was through provision of cigarettes to psychi-
atric institutions. In 1975, a letter from the Associate
General Counsel for PM to the President of the Tobacco
Institute indicated that mental health facilities were or-
dering cigarettes on a tax-free basis specifying the ciga-
rettes were ‘‘to be used for patient treatment.’’140
Other letters came from medical staff at psychiatric insti-
tutions requesting cigarette donations for their patients.
In 1980, a letter from the medical director at the National
Institute of Mental Health’s St Elizabeth’s Hospital
requested a donation from RJR of 5000 cigarettes per
week for their psychiatric inpatients, stating the hospital
was no longer able to purchase cigarettes for patients
because of the change in the Department of Health
and Human Services’ (DHHS) regulations.141RJR staff
determined who was responsible for the policies and en-
couraged the medical director to contact the DHHS
Secretary to cancel the regulations.142In 1992, a case
manager in Oregon wrote to RJR requesting ‘‘outdated
or damaged cigarettes’’ in donation to the county mental
for patients’ work activities.143In 1996, a social worker
from a mental health center in Texas wrote to RJR for
cigarette donations stating ‘‘with all the publicity of
smoking harming so many people, this would be a posi-
tive aspect of smoking. [The] lung cancer rate in
schizophrenics appears to be ‘lower’ than the general
population rate of cancer.’’144A tax-exempt letter was
enclosed. In 2000, a staff psychiatrist at the Hawaii State
Hospital wrote to RJR requesting cigarettes for a patient
stating, ‘‘providing a cigarette is generally much more ef-
fective at decreasing agitation than most medications I
can provide.’’145It is unclear whether these requests
The tobacco industry worked indirectly to promote
smoking in psychiatric patients via financial contribu-
tions and ties to patient advocacy groups. At a cost of
$1000 per table, Brown and Williamson accepted an in-
vitation to attend a black tie affair for the Schizophrenia
Foundation, Kentucky with the promise that they would
be provided ‘‘any guest you may wish among our public
officials or Legislators.’’146A 1987 fax from the public
relations firm Hill & Knowlton to RJR included contact
information for the president of the American Schizo-
phrenia Association. A handwritten note indicated,
‘‘good list for press conference invites.’’147The tobacco
industry also hired legal counsel to monitor research
on hospital smoking restrictions and to fight policy
efforts aimed at restricting smoking among psychiatric
to offer assistance with grievance procedures against
smoking bans at a state mental hospital150; and coordi-
In 1990, the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) mandated that all
ronments by December 31, 1993. The JCAHO decision
made hospitals the first worksites to attempt an industry-
wide smoking ban. The proposal included all hospital-
bying. However, a 1991 memo from the RJR Public
Issues Department to the RJR Vice President for Federal
Government Affairs concluded ‘‘there is little connection
between JCAHO and Congress by which we can request
assistance and expect JCAHO to pay closer attention
Tobacco Industry and Smoking in Schizophrenia
than it would to its members.’’153Instead, the memo sug-
gested that ‘‘of the hospitals that have contacted us,
we should consider having them write JCAHO . to
challenge the reasonableness prior to the standard being
implemented. In essence, the first shot to JCAHO should
come from some of its members.’’153
A strong response to the JCAHO mandate came from
the National Alliance for the Mentally Ill (AMI, now
NAMI) and Friends and Advocates of the Mentally Ill
(FAMI). These patient advocacy groups emphasized
the need for mentally ill patients to smoke, based on
the self-medication hypothesis discussed above. In
a 1994 article in Psychiatric News, a publication of the
American Psychiatric Association, the executive director
of FAMI stated, ‘‘The issue is important to us because it
is important in the lives of people with mental illness.’’154
A 1995 AMI/FAMI policy paper, approved by the Board
of Directors, asserted ‘‘Psychiatric patients should have
access to discrete smoking areas,’’ stating ‘‘nicotine
may work to reduce their psychotic symptoms’’ and
‘‘it is inhumane to rob these patients of their autonomy
and dignity by infringing on one of the few remaining
freedoms historically allowed patients.’’155AMI/FAMI
launched a ‘‘Campaign to bring discrete smoking areas
to city hospital.’’ Figure 2 is an example of campaign
materials found in the tobacco industry documents.156
PM monitored the popular press reporting on AMI/
FAMI’s opposition to the hospital smoking bans. A vo-
cal leader in the effort was a member of the AMI/FAMI
board of directors who, according to a 1994 Wall Street
Journal article, ‘‘organized a tidal wave of letters and
petitions to the Joint Commission.’’157The article
reported that her ‘‘crusade is backed by the National Al-
liance for the Mentally Ill. The group says it hasn’t had
any contact with the tobacco industry.’’ The board mem-
ber’s business card, however, was found among the PM
documents with this handwritten note and her signature
on the back: ‘‘Philip Morris: FAMI is fighting the city,
HHC and Bellevue Hospital bureaucracy. The patients
in the psychiatric inpatient units, emergency unit and
admissions units need a discrete smoking area and not
be forced to go cold turkey.’’158,159A 1995 PM ‘‘Hearing
Report/Bill Signing Report’’ summarized a public event
environmental tobacco smoke restriction bill. The report
noted that the board member ‘‘of the Friends of the Men-
tally Ill spoke in opposition to the bill.’’160Another PM
JCAHO ultimately ‘‘yielded to massive pressure from
mental patients and their families, relaxing a policy that
called on hospitals to ban smoking.’’162The acting direc-
tor of the commission’s Department of Interpretation
explained that ‘‘The mental health advocacy groups
came out in opposition to our original policy and we
sat down with them and, as a result of those discussions,
use facilities for long-term patients.
Despite JCAHO’s decision and state legislation to per-
mit smoking in inpatient psychiatric facilities, some hos-
pitals voluntarily implemented smoking bans, and
reports in the literature suggest little difficulty in convert-
ing to a smoke-free environment.163Even among psychi-
atric inpatient units with smoke-free policies, however,
tobacco cessation treatment is rarely provided,164and
most patients return to smoking immediately upon
This analysis of internal tobacco industry documents
shows that the industry has attempted to promote and
maintain tobacco use among individuals with schizo-
phrenia. The industry has monitored or directly funded
research supporting the idea that individuals with schizo-
phrenia are less susceptible to the harms of tobacco and
that they need tobacco as self-medication. Through its
funding mechanisms, the tobacco industryhas influenced
the types of questions asked about tobacco use among
grants based on whether they could trust the scientists or
knew the scientists had previously produced research fa-
vorable to the industry. The industry did not fund studies
that the results of some industry-funded studies were not
published in the scientific literature raises the question of
whether findings unfavorable to the industry were sup-
pressed.47,166Investigations into tobacco industry docu-
ments have demonstrated similar tactics of driving the
research agenda through funding and publication to
Fig. 2. An Example of Campaign Materials from the Alliance for
the Mentally Ill (AMI) and Friends and Advocates of the Mentally
Ill (FAMI) in Opposition to the Mandate to Make all Hospitals,
Including Psychiatric Units, Smoke Free.154
J. J. Prochaska et al.
More than 40 years after publication of the 1964
it is now recognized that tobacco use places patients with
schizophrenia at increased risk for lung cancer, cardio-
vascular disease, and respiratory disorders.42–44The to-
bacco industry’s efforts to promote research showing
that schizophrenic patients were less susceptible to
lung cancer may have contributed to this 4-decade delay.
of smokers and yet astoundingly little research has been
published on treatment of their tobacco dependence. A
search of PubMed on February 12, 2005 using the key-
words ‘‘schizophrenia’’ and ‘‘nicotine, tobacco or smok-
ing’’ yielded 534 publications. Only 12, however,
evaluated cessation treatment for this patient group. Ev-
idence in the documents suggests the tobacco industry
restructured proposal objectives away from smoking ces-
sation and toward the self-medication hypothesis.
The tobacco industry has promoted smoking among
patients with schizophrenia through research funding
and dissemination; has used the self-medication hypoth-
esis to garner exceptions to permit continued smoking
among hospitalized psychiatric patients; and has sought
credibility through development of nicotine analog med-
ications for the mentally ill. Though the current article
does not attempt to systematically review the literature
on the cognitive effects of nicotine and nicotine analogs
in schizophrenia, it is worth mentioning findings from
a few studies. In summarizing the literature, investigators
recently have concluded that nicotine’s neurocognitive
effects in schizophrenia are comparable to effects seen
in healthy adults, are greatly limited by tachyphylaxis,
and are not clinically significant.169A recent study of nic-
otine’s neurocognitive effects in schizophrenia reported
small increases in attention among nonsmokers, de-
creased attention among nicotine-abstinent smokers,
and no effects on learning and memory, language, or
visuospatial/constructional abilities.170Among studies
that have reported cognitive enhancements of nicotine
in smokers with schizophrenia, many have used nicotine-
deprived heavy smokers; have reported effects in some
outcomes, but not others; and, again, have shown effects
comparable to nonpsychiatric samples. For example, an
investigation of the nicotine nasal spray with chronic
smokers with schizophrenia who were deprived of nico-
tine overnight (for 10–12 hours) reported small effects on
enhanced attention and spatial working memory.171The
study did not assess nicotine withdrawal effects, a weak-
ness they acknowledged in their design. A study compar-
ing smokers with and without schizophrenia who were
deprived of nicotine and then given active or placebo nic-
otine patch, reported 1 of 8 diagnosis-by-nicotine inter-
multiple comparisons, the finding would have been non-
significant.172Additionally, the analyses did not control
for differences in baseline plasma cotinine levels between
the 2 groups, and the authors acknowledged that the ef-
fect of antipsychotic medication, rather than diagnosis,
nia, all 13 were taking antipsychotics with metabolism
known to be induced by smoking (ie, olazapine, cloza-
pine, and haloperidol). In a third study comparing the
effects of transdermal nicotine on cognition in non-
smokers with schizophrenia and nonpsychiatric controls,
nicotine modestly improved attentional performance in
both groups, with a greater improvement among schizo-
phrenia patients on errors of commission and perfor-
mance on a Card Stroop task.173The study did not
tory of smoking (60% among patients and 25% among
controls). Studies have not examined the implications
of giving nicotine to never or former smokers on future
Moving beyond nicotine, the National Institute of
Mental Health Measurement and Treatment Research
to Improve Cognition in Schizophrenia initiative has iden-
potential therapeutic targets, and research in this area is
likely to expand.174A recent proof-of-concept trial of an
a7 nicotinic agonist in schizophrenia reported nonsignif-
icant effects on performance when the effect of repeated
testing was controlled.169Strongest effects were seen at
the lowest dose suggesting possible tachyphylaxis. In
August 2007, Targacept announced its Phase IIb clinical
trial of an a7 nicotinic agonist for addressing cognitive
deficits in schizophrenia.175The President and Chief Ex-
ecutive Officer of Targacept explained, ‘‘Research has
shown that almost 90% of schizophrenics smoke. One ex-
planation for this high rate of smoking is that schizo-
phrenic patients may be self-medicating with nicotine
in order to address the cognitive impairment associated
with the disease and thus function better.’’ Smoking ces-
sationis nowlisted on the company’sWeb site as ayetto-
be-determined target for product development.
Effective tobacco cessation treatments are needed, and
if the tobacco industry, and now Targacept, truly wanted
to help mentally ill smokers, they would be leveraging
their knowledge of nicotine drugs to reduce tobacco
use in this vulnerable group. The National Institutes of
Health and the California Tobacco-Related Disease Re-
search Program are funding investigations in this area,
and initial findings suggest good reason for optimism
for helping individuals with schizophrenia quit smok-
ing.176–178Importantly, a 3-day investigation of placebo
versus baseline or active patch did not find acute ex-
acerbation of clinical symptoms, challenging the self-
The tobacco industry documents were obtained
of the tobacco industry’s activities in this area. The
Tobacco Industry and Smoking in Schizophrenia
mentally ill are a disenfranchised group and are less likely
to pursue litigation, so documents specific to the schizo-
phrenic population may be missing. Furthermore, advo-
cacy groups for the mentally ill have focused on
maintaining their tobacco use rather than treating this
deadly addiction. While opponentsof secondhand smoke
exposure have vigorously fought for antismoking legisla-
tion, psychiatric and substance abuse treatment centers
have been exempted. The documents we found were
largely limited to the year 2000, and thus current activity
is unknown. Given these limitations, published research
literature and news material were incorporated to pro-
vide a relevant historical, research, and clinical context
for the obtained documents. We conducted extensive
searches in PubMed and PsychInfo to identify publica-
tions resulting from the tobacco industry–funded studies,
but it is possible that the work was published in journals
not indexed by these databases including nonpeer
reviewed journals and texts.
Beliefs that individuals with schizophrenia need to
smoke as a form of self-medication, that quitting smok-
ing will worsen their psychiatric symptoms, and that they
cannot and do not want to quit their tobacco use have
been some of the biggest barriers to tobacco treatment
for schizophrenic patients.7–10The tobacco industry
has contributed to the promulgation of these beliefs.
The problem of tobacco use among schizophrenic indi-
viduals will not go away unless effective treatments for
smoking cessation are developed and delivered to smok-
the largest remaining group of smokers, not because they
need to smoke but rather because they are among the last
to be treated? Given the tobacco industry’s track record
likely that the industry will make a valid effort to develop
cessation treatments for this population.
State of California Tobacco-Related Disease Research
Program (#13KT-0152); the National Institute on
Drug Abuse (#K23 DA018691, #K05 DA016752, and
The authors acknowledge Desiree Leek for her editorial
assistance. Disclosures: Drs Prochaska, Hall, and Bero
report no competing interests. Paper presented at the
2007 Annual Meeting of the American Psychological
Association in San Francisco, CA.
1. Grant BF, Hasin DS, Chou SP, Stinson FS, Dawson DA.
Nicotine dependence and psychiatric disorders in the United
States: results from the national epidemiologic survey on al-
coholand related conditions.
2. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU,
McCormick D, Bor DH. Smoking and mental illness: a
population-based prevalence study. JAMA. 2000;284:2606–
3. FederalTrade Commission.Federal
Cigarette Report for 2003. Washington, DC: Federal Trade
4. Womach J. U.S. Tobacco Production, Consumption, and
Export Trends (Report for Congress Received Through the
of Congress. Available at: http://www.nationalaglawcenter.
5. Hughes JR. Possible effects of smoke-free inpatient units on
psychiatric diagnosis and treatment. J Clin Psychiatry.
6. Poirier MF, Canceil O, Bayle F, et al. Prevalence of smoking
in psychiatric patients. Prog Neuropsychopharmacol Biol
7. Levin ED, Wilson W, Rose JE, McEvoy J. Nicotine-
haloperidol interactions and cognitive performance in
8. Barak Y, Achiron A, Mandel M, Mirecki I, Aizenberg D.
Reduced cancer incidence among patients with schizophre-
nia. Cancer. 2005;104:2817–2821.
9. Dalack GW, Meador-Woodruff JH. Smoking, smoking
withdrawal and schizophrenia: case reports and a review
of the literature. Schizophr Res. 1996;22:133–141.
10. Sandyk R, Kay SR. Tobacco addiction as a marker of
age at onset of schizophrenia. Int J Neurosci. 1991;57:
11. Bero L. Implications of the tobacco industry documents for
12. Bero LA. Tobacco industry manipulation of research. Public
Health Rep. 2005;120:200–208.
13. Carter SM. Tobacco document research reporting. Tob
14. Lewis NDC. Research in Dementia Praecox.Bates No.
HK2333032/3032. Available at: http://legacy.library.ucsf.
15. Modrzewska K, Book JA. Schizophrenia and malignant
1979;1:275–276 Bates No. 10412696B/2697. Available at:
16. Gopalaswamy AK, Morgan R. Smoking in chronic schizo-
phrenia correspondence. Br J Psychiatry. 1986;149:523
Bates No. 508153978. Available at: http://legacy.library.ucsf.
17. Jancar J. Cancer in the long-stay hospitals. Br J Psychiatry.
1979;134:550–551Bates No. 2025876464/6465. Available at:
18. Rice D. No lung cancer in schizophrenics? Br J Psychiatry.
1979;134:128Bates No. 501729733. Available at: http://lega-
19. Lincoln JE. Schizophrenics.Bates No. 1005062041/2042.
20. Perrin GM, Pierce IR. Psychosomatic aspects of cancer: a re-
view. Psychosom Med. 1959;21:397–421.
AnnuRev Public Health.
J. J. Prochaska et al.
21. Breen MJ. The incidence of lung cancer among schizo-
phrenic males versus nonschizophrenic males. A dissertation
presented to the graduate faculty of the School of Education
United States International University. 1981. Bates No.
504848496/8514. Available at: http://legacy.library.ucsf.edu/
22. Fox BH, Howell MA. Cancer risk among psychiatric
patients: a hypothesis. Int J Epidemiol. 1974;3:207–208.
23. Tsuang MT, Perkins K, Simpson JC. Physical diseases in
schizophrenia and affective disorder. J Clin Psychiatry.
24. Harris AE. Physical disease and schizophrenia. Schizophr
25. Bahnson CB. Letter to Dr. Hockett Requesting Continued
Research Funding on Dr. Kissen’s Unit in Glasgow.August
8, 1967. Bates No. CTRSP/FILES003163/3164. Available
26. Hetsko C. Memo to William W. Shinn Confirming American
Brands’ $8,000 Contribution to Dr. Claus Bahnson’s Project.
September 15, 1972. Bates No. 945369841/9842. Available
27. Holtzman A. Special Project—Dr. Claus Bahnson. August
23, 1972. Bates No. 1005135608. Available at: http://legacy.
28. Parfitt DN. Lung cancer and schizophrenia. Br J Psychiatry.
1981;138:179–180. Bates No. 1003050027/0028. Available at:
29. Colby FG. Report on trip to Germany.June 12, 1980. Bates
No. 500926090–500926097. Available at: http://legacy.library.
30. Marcus MG. The shaky link between cancer and character.
Psychol Today. 1976;10:52,54,59,85. Bates No. 2023065144/
5147.Available at: http://legacy.library.ucsf.edu/tid/
31. Wakeham H. Letter about Doubts of Dr. Bahnson’s Research
Involvement.April 16, 1971. Bates No. 1003728541. Avail-
able at: http://legacy.library.ucsf.edu/tid/dlq08e00.
32. Todd GF. Private Letter No. 12 to Mr. Addison Yeaman.
April 14, 1967. Bates No. 2015063868/3870. Available at:
33. Gaudet FJ, Owen HE. Application for Research Grant Ex-
ploring Cancer Rates and Cigarette Use among Different
Types of Schizophrenia. January 24, 1964. Bates No.
01128311/8314. Available at: http://legacy.library.ucsf.edu/
34. Lavietes MH. Cigarette Smoking in Schizophrenic Patients.
February 12, 1997. Bates No. 50533019/3021. Available at:
35. Hockett RC. Research Application from Frederick J. Gaudet.
August 5, 1965. Bates No. HK0352042/2042. Available at:
36. McAllister HC. Decline of Research Support for Dr. Marc
Lavietes. April 14, 1997. Bates No. 50532999/2999. Avail-
able at: http://legacy.library.ucsf.edu/tid/nwv06d00.
37. CTR Collection.Confidential Report Scientific Advisory
Board Meeting New York, NY. March 8, 1964. Bates No.
38. CTR Collection. New proposals. 1964. Bates No. HK2039136/
9136. Available at: http://legacy.library.ucsf.edu/tid/gvo2aa00.
39. Hockett RC. Letter to Dr. Taguiri Concerning Research Pro-
posals, Including Smoking and High Academic Achievement.
March 11, 1964. Bates No. HK1507074/7074. Available at:
40. Wilson EB. Letter to Dr. Hockett.March 15, 1964. Bates No.
HK1507061/7062. Available at: http://legacy.library.ucsf.
41. Dalton SO, Laursen TM, Mellemkjaer L, Johansen C,
Mortensen PB. Risk for cancer in parents of patients with
schizophrenia. Am J Psychiatry. 2004;161:903–908.
42. Lichtermann D, Ekelund J, Pukkala E, Tanskanen A,
Lonnqvist J. Incidence of cancer among persons with schizo-
phrenia and theirrelatives.
43. Goff DC, Sullivan LM, McEvoy JP, et al. A comparison of
ten-year cardiac risk estimates in schizophrenia patients
from the CATIE study and matched controls. Schizophr
44. Himelhoch S, Lehman A, Kreyenbuhl J, Daumit G, Brown
C, Dixon L. Prevalence of chronic obstructive pulmonary
disease among those with serious mental illness. Am J Psy-
45. Gullotta. WSA Categorization form Smoking Behavior: Clin-
ical Depression and Schizophrenia.October 20, 1999. Bates
No. 2074168169/8170. Available at: http://legacy.library.ucsf.
46. Southwick MA. Literature Search: Schizophrenia and Nicotine.
March 6, 1997. Bates No. 2075745247. Available at: http://
47. Glantz SA, Slade J, Bero LA, Hanauer P, Barnes DE. The
Cigarette Papers. Berkeley, Calif: University of California
48. Deithelm PA, Rielle J-C, McKee M. The whole truth and
nothing but the truth? The research that Philip Morris did
not want you to see. Lancet. 2005;366:86–92.
49. Knott V. Tobacco Smoking as a Coping Mechanism in
Psychiatric Patients: Psychological, Behavioral and Physio-
logical Investigations Phase I. April 18, 1983. Bates No.
1002647660/7696. Available at: http://legacy.library.ucsf.
50. Knott V. Research Proposal. Tobacco Smoking as a Coping
Mechanism in Psychiatric Patients: Psychological, Behavioral
and Physiological Investigations.April 11, 1983. Bates No.
504332664/2666. Available at: http://legacy.library.ucsf.edu/
51. Crawford DA. Letter to Dr. R. Suber in the Consideration
Dr. Knott’s Research Proposal.May 1, 1985. Bates No.
504195870/5871. Available at: http://legacy.library.ucsf.edu/
52. Barnes DE, Bero LA. Industry-Funded Research and
Conflict of Interest: An Analysis of Research Spon-
sored by the Tobacco Industry through the Center for In-
door Air Research. J Health Polit Policy Law. 1996;21:
53. Bero L, Barnes DE, Hanauer P, Slade J, Glantz SA. Lawyer
control of the tobacco industry’s external research program.
The Brown and Williamson documents. JAMA. 1995;
54. Amey MB, Wong DF. Application for Research Grant:
In Vivo Studies of Nicotinic Cholinergic Receptors in the
Human Brain. November 26, 1986. Bates No. 40047640/
7657. Availableat: http://legacy.library.ucsf.edu/tid/
55. Smith C. Comments on Dr. Wang’s Grant Proposal: In Vivo
Studies of Nicotinic Cholinergic Receptors in the Human
Tobacco Industry and Smoking in Schizophrenia
Brain. September 18, 1987. Bates No. 40047615/7619. Avail-
able at: http://legacy.library.ucsf.edu/tid/cks99c00.
56. Stone D. Second Renewal Application: In Vivo Studies of
Nicotinic Cholinergic Receptors in the Human Brain.July
11, 1989. Bates No. 40047549/7549. Available at: http://legacy.
57. Gray JA. CTR Progress Report Mediation by Catecholamine
Systems of Effects of Nicotine on Behaviours. Bates No.
50716862/6864. Available at: http://legacy.library.ucsf.edu/
58. Gray JA. Project Details: Nicotine Neuroprotection and
Animal Models of Neurodegenerative Cognitive Dysfunction.
Bates No. 566948811. Available at: http://legacy.library.ucsf.
59. Gray JA, Joseph MH, Hemsley DR, et al. The role of mes-
olimbic dopaminergic and retrohippocampal afferents to the
nucleus accumbens in latent inhibition: implications for
schizophrenia. Behav Brain Res. 1995;71:19–31. Bates No.
50379603/9615. Available at: http://legacy.library.ucsf.edu/
60. Postma P, Gray JA, Sharma T, et al. A behavioural and
functional neuroimaging investigation into the effects of
nicotine on sensorimotor gating in healthy subjects and per-
61. Mangan GL. Application to Philip Morris USA for Research
Funding. October, 1994. Bates No. 2050754698/4704. Avail-
able at: http://legacy.library.ucsf.edu/tid/dcm79e00.
of Philip Morris Research Programme at the University of
Auckland.September 25, 1995. Bates No. 2051517565/7568.
Available at: http://legacy.library.ucsf.edu/tid/umw14c00.
63. Hedqvist P, Svensson TH. Research Grant Application. Nic-
otine Dependence in Psychiatric Illness: an Experimental
Study. May 24, 1994. Bates No. 50708221/8247. Available
64. Glenn JF. Brief Site Visit Report.July 18, 1989. Bates No.
60037022/7022. Available at: http://legacy.library.ucsf.edu/
65. Svensson TH. CTR Progress Report (for Competing Renewal
Application) Nicotinic Dependence in Psychiatric Illness: an
50733862/3868. Available at: http://legacy.library.ucsf.edu/
66. Svensson TH, Mathe JM, Andersson JL, Nomikos GG,
Hildebrand BE, Marcus M. Mode of action of atypical neu-
roleptics in relation to the phencyclidine model of schizo-
phrenia: role of 5-HT2 receptor and alpha1-adrenoreceptor
J Clin Psychopharmacol.
1):11S–18S. Bates No. 50733819/3826. Available at: http://
67. Nisell M, Nomikos GG, Svensson TH. Systemic nicotine-
induced dopamine release in the rat nucleus accumbens is
regulated by nicotinic receptors in the ventral tegmental
area. Synapse. 1994;16:36–44. Bates No. 50708314/8314.
Available at: http://legacy.library.ucsf.edu/tid/luf46d00.
68. Nisell M, Nomikos GG, Svensson TH. Infusion of nicotine
in the ventral tegmental area or the nucleus accumbens of
the rat differentially affects accumbal dopamine release.
Pharmacol Toxicol. 1994;75:348–352.
69. Nisell M, Nomikos GG, Svensson TH. Nicotine depen-
dence, midbrain dopamine systems and psychiatric disor-
ders. Pharmacol Toxicol. 1995;76:157–162.
70. Grillner P, Bonci A, Svensson TH, Bernardi G, Mercuri NB.
Presynaptic muscarinic (M3) receptors reduce excitatory
transmission in dopamine neurons of the rat mesencephalon.
71. Furlong P, Tanabe J. Project Proposal Effects of Nicotine
on Brain Activation.
2072044334/4360. Available at: http://legacy.library.ucsf.
72. Kassman A. SRRC Proposals: Tanabe, Bilder & Lajtha/
Friedman.November 27, 1998. Bates No. 2076627440.
Available at: http://ltdlimages.library.ucsf.edu/imagesm/m/
73. Gullotta FP. Bilder/Lajtha Grant. March 13, 2000. Bates No.
2078527898/7899. Available at: http://legacy.library.ucsf.
74. Philip Morris Collection.Approval of Grant Proposal Enti-
tled: ‘‘Effects of Nicotine on Brain Activation’’.February 8,
2001. Bates No. 2081497294. Available at: http://legacy.
75. McAlpin L. Philip Morris Voucher. January 11, 1999. Bates
No. 2064324795. Available at: http://legacy.library.ucsf.edu/
76. Bidler RM, Lajtha A, Thomas T. Nicotine Effects on Cogni-
tion: Meta-analysis and Implications for Neuroimaging. Ab-
stract presented at the annual meeting of the American
College of Neuropsychopharmacology. December, 1999.
Bates No. 2074597992. Available at: http://legacy.library.
77. de Leon J. Epidemiology of Tobacco Use in Psychiatric Dis-
orders.Bates No. 682349577/9582. Available at: http://legacy.
78. Esser AH, Lee MG. Application for Research Grant: The
Social Use of Tobacco. August 8, 1966. Bates No. 50080837/
0845. Available at: http://legacy.library.ucsf.edu/tid/qtf9aa00.
79. Hoyt WT. Research Funding Decline for Dr. Aristide
H. Esser. September 20, 1966. Bates No. 50080835/0835.
Available at: http://legacy.library.ucsf.edu/tid/otf9aa00.
80. Smith RC. Effects of Smoking on Blood Levels of Neuroleptic
and Antidepressant Drugs. November 22, 1977. Bates No.
50264775/4790. Available at:http://legacy.library.ucsf.edu/
81. Goff DC. Nicotine in Schizophrenia. July 2, 1991. Bates No.
50596565/6567. Available at: http://legacy.library.ucsf.edu/
82. Barclay GL, Devlin RJ, Grant FW, McDonald RD, Ozerengin
MF, Voorhees W. Application for Research Grant: Vitamin
‘‘C’’ Depletion in Tobacco Smokers. Influence on Psycho-
pathology and Therapeutic Drug Requirements in a Mental
Hospital Setting. November 14, 1972. Bates No. 50197194/
83. Deutsch SI. Effect of Nicotine in an Animal Model of Schizo-
phrenia. February 15, 1996. Bates No. 50521602/1604. Avail-
able at: http://legacy.library.ucsf.edu/tid/etr06d00.
84. Lachman H. Molecular Genetic Analysis of Aggression in
Rats.August 13, 1996. Bates No. 50532660/2662. Available
85. Javaid JI, Longone P, Pesold C. Functional Characterization
of Neuronal Nicotinic Acetylcholine Receptor (NACHR)
Subtypes. February 14, 1997. Bates No. 50529673/9675.
Available at: http://legacy.library.ucsf.edu/tid/trv06d00.
86. Liu Y, Nisbett N. Research Grant Application: Physiological
Role(s) of SNAP-25. November 29, 1995. Bates No.
J. J. Prochaska et al.
50387789/7800. Available at: http://legacy.library.ucsf.edu/
Precursors in the Brain. January 30, 1993. Bates No.
50617622/7624. Available at: http://legacy.library.ucsf.edu/
88. Paskevich PA, Tarazi FI. Research Grant Application Local-
ization and Regulation of Neurotensin Receptor and Gene
Expression. May 28, 1997. Bates No. 40045371/5385. Avail-
able at: http://legacy.library.ucsf.edu/tid/icr99c00.
89. Regehr WG. The Control of Synaptic Transmission in the
Mammalian Brain by Presynaptic Waveform. August 13,
1996. Bates No. 50543076/3078. Available at: http://legacy.
90. Arnason B. Drug abuse and the Dopamine Transporters.
March 29, 1994. Bates No. 50494964/4965. Available at:
91. Tarazi FI. Pharmacological and Functional Characterization
of Dopamine D4 Receptor. 1996. Bates No. 50549783/9786.
Available at: http://legacy.library.ucsf.edu/tid/cok36d00.
92. RJ Reynolds Collection. Review of a Proposal Submitted
by Sheila Carter, M.D. 1985. Bates No. 504808412/8413.
Available at: http://legacy.library.ucsf.edu/tid/stm55d00.
93. Callery PS. Metabolites of Tobacco Constituents Related to
GABAas Potential Therapeutic
1625002–1625003. Available at: http://legacy.library.ucsf.
94. Ellis C. WWSA Project Justification Role of Neuronal Nico-
tinic Receptors in Brain Function. January 5, 1998. Bates No.
20725972780. Available at: http://legacy.library.ucsf.edu/tid/
95. Hayes AW. Letter to Dr. D.A. Crawford Concerning Review
of Research Grants. August 19, 1985. Bates No. 504198469.
Available at: http://legacy.library.ucsf.edu/tid/kor58d00.
96. Hockett RC. Research Proposal Decline for Robert C. Smith.
October 24, 1978. Bates No. 50264764/4764. Available at:
97. Glenn JF. Rejection for Dr. Neve’s Research Proposal: Drug
Abuse and the Dopamine Transporter.April 25, 1994. Bates
No. 50494962/4962. Available at: http://legacy.library.ucsf.
98. Glenn JF. Decline of Dr. Yuechueng Liu’s Research Proposal:
Physiological Role(s) of SNAP-25.April 24, 1996. Bates No.
50387782/7782. Available at: http://legacy.library.ucsf.edu/
99. Glenn JF. Rejection of Dr. F. Tarazi’s Research Proposal:
Localization and Regulation
and Gene Expression.April 24, 1997. Bates No. 50404261/
4261.Available at: http://legacy.library.ucsf.edu/tid/
100. McAllister HC. Decline of Research Funds for Donald C.
Goff. July 25, 1991. Bates No. 50596550/6550. Available
101. McAllister HC. Decline of Support for Dr. Wade Regehr’s
Research Proposal. October 1, 1996. Bates No. 50543046/
102. Lippiello PM, Fluhler EN. Nicotine Receptor Pharmacology.
June, 1989. Bates No. 507973662/3665. Available at: http://
103. Lillpiello PM, Caldwell WS, DeBethizy JD, Smith CJ,
Pritchard WS. Progress Report on the RJRT-Hoechst-Roussel
Collaborative Scientific Program. January 16, 1991. Bates
of Neurotensin Receptor
No. 508209460/9503. Available at: http://legacy.library.ucsf.
104. Wellesley MA. Corporate Overview of Pharmaceutical Re-
lated Technologies of the R.J. Reynolds Tobacco Company.
March, 1997. Bates No. 516889375/9378. Available at:
105. Targacept.Targacept Key Messages.March 18, 1999. Bates
No. 530420558/0616. Available at: http://legacy.library.ucsf.
106. Vagg R, Chapman S. Nicotine analogues: a review of
tobacco industry research interests. Addiction. 2005;100:
107. Targacept. Targacept Pharmaceutical Technologies of the
R.J. Reynolds Tobacco Company. August 31, 1999. Bates
No. 529222194/2321. Available at: http://legacy.library.ucsf.
108. Targacept.Targacept Leader in Neuronal Nicotinic Receptor-
Based pharmaceutical R&D. August, 2000. Bates No.
2085792578/2589. Available at: http://legacy.library.ucsf.
109. Hwang S. ‘‘R.J. Reynolds Hopes to Spin Nicotine Into
Drugs’’. Wall St J. 1999. Jun 28:Sect. B1. Bates No.
535070496/0497. Available at: http://legacy.library.ucsf.edu/
110. RJ Reynolds Collection. Nicotinic Compound Q&A. January
15, 1999. Bates No. 521107424/7431. Available at: http://
111. US Department of Health & Human Services FDA/Center
for Drug Evaluation and Research.A Catalog of FDA Ap-
proved Drug Products. 2006 [cited 1/17/2006]. Available
112. Philip Morris Collection.Advertisement: schizophrenic. The
new merit. We’ve got flavor down to a science. 1986. Bates
No. 2040270976. Available at: http://legacy.library.ucsf.
113. Gilbert DG. Smoking: Individual Differences, Psychopathol-
ogy, and Emotion. Washington, DC: Taylor & Francis; 1995.
114. Rosecrans JA. Nicotine: helping those who help themselves?
Chem Ind. 1998;525–529. Bates No. 2063591851/1855. Avail-
able at: http://legacy.library.ucsf.edu/tid/ryp67e00.
115. Tobacco Institute Collection.Active Projects. Bates No.
CORTI0007337/7346. Available at: http://legacy.library.ucsf.
116. American Tobacco Collection. Projects Supported 1977.
Bates No. 966003844/3850. Available at: http://legacy.library.
117. Council for Tobacco Research. Report of the Council for
Tobacco Research USA Inc. 1992. Bates No. TIMN0397062/
7351. Available at: http://legacy.library.ucsf.edu/tid/csi62f00.
118. Nixon G. Fax. May 2, 1994. Bates No. 2029238971. Avail-
able at: http://legacy.library.ucsf.edu/tid/hee69e00.
119. Philip Morris Collection. Pharmacology of Nicotine. May,
1994. Bates No. 2029238974. Available at: http://legacy.
120. Levin ED. Thank You to Robert F. Gertenbach for $75,000/
year Grant Concerning the Behavioral and Neural Mecha-
nisms Underlying Nicotine-Induced Cognitive Facilitation.
November 8, 1991. Bates No. 50689418/9418. Available at:
121. Levin ED. Thank You to Dr. Robert F. Gertenbach for
$85,000 Grant to Investigate Beneficial Effect Nicotine Has
on Memory Function. October 21, 1992. Bates No.
Tobacco Industry and Smoking in Schizophrenia
50689408/9408. Available at: http://legacy.library.ucsf.edu/
122. Levin ED. Thank You for $43,777 Gift to Support Work on
Nicotinic Psychopharmacology at Duke. December 15,
1995. Bates No. 515718437. Available at: http://legacy.
123. Levin ED. Thank You to Dr. McAllister for $92,000 Grant to
Investigate Beneficial Effect Nicotine Has on Memory Func-
tion. January 3, 1994. Bates No. 60038721/8721. Available
124. Levin ED, Karan L, Rosecrans J. Nicotine: an addictive
drug with therapeutic potential. Med Chem Res. 1993;509–
125. Levin ED, Rezvani AH. Development of nicotinic drug
therapy for cognitive disorders. Eur J Pharmacol. 2000;393:
126. Levin ED, Rezvani AH. Nicotinic treatment for cognitive
dysfunction. Curr Drug Targets. 2002;1:423–431.
127. Levin ED. Nicotinic receptors in the nervous system. New
York, NY: CRC Press. Chapter 11 by Joseph McEvoy Nic-
otine and Schizophrenia, 2001; 227–234.
128. Levin ED. Letter to RJR’s Dr. J. Donald DeBethizy Request-
ing $15,000 for Duke’s Nicotine Research Symposium.May 2,
1995. Bates No. 515718445. Available at: http://legacy.
129. Levin ED. Thank You to Dr. Frank Gullotta of Phillip Morris-
USA for $10,000 Donation to Duke Nicotine Conference.
August 4, 1998. Bates No. 2063120664. Available at:
130. Levin ED. Request for Monetary Contribution for Duke Nic-
otine Conference from Dr. Frank Gullotta of Phillip Morris-
USA. July 22, 1999. Bates No. 2084272438. Available at:
131. Levin ED. First Annual Duke Nicotine Research Symposium.
Neurobehavioral Effects of Nicotine. November 8, 1995.
Bates No. 516546711/6713. Available at: http://legacy.library.
132. Philip Morris Collection. Synopsis of the 5th Annual Duke
Nicotine Research Conference.October 22, 1999. Bates No.
2074407740/7741. Available at: http://legacy.library.ucsf.
133. Rose JE, Levin ED. Duke Nicotine Research Conference.
Available at: http://psychiatry.mc.duke.edu/nicotineresear/
Conf.html. Accessed October 8, 2007.
134. Brandt L, Brearley E. Future Events: 5th Annual Duke Nic-
otine Research Conference, Targeting Nicotinic Treatments.
SRNT Newsletter Vol. 5 (3), October 1999. Bates No.
521955007/5025. Available at: http://legacy.library.ucsf.edu/
135. Duke University.Third Annual Duke Nicotine Research Con-
ference, Nicotinic Systems: Molecular Heterogenecity And
Individual Differences Program. Bates No.2063126391/6401.
Available at: http://legacy.library.ucsf.edu/tid/ltf33e00.
136. Lipowicz PJ. 6th Duke Nicotine Research Conference Trip
Report. Bates No. 2715200604. Available at: http://legacy.
137. Lukas RJ, Bencherif M, Eisenhour CM. Regulation by Nic-
otine of its Own Receptors. March 11, 1996. Bates No.
520924868/4870. Available at: http://legacy.library.ucsf.edu/
138. Bero LA, Galbraith A, Rennie D. Sponsored symposia
139. Cloninger CR. The State of Texas vs. the American Tobacco
Company, et al. Videotaped Oral Deposition of C. Robert
Cloninger. July 30, 1997. Bates No. 524800001/0218. Avail-
able at: http://legacy.library.ucsf.edu/tid/nvq20d00.
140. Holtzman A. Memo to Horace Kornegay about Tax-Free
Cigarettes for Patient Treatment. February 5, 1975. Bates
No. TCAL0004383. Available
141. Torrey EF. Cigarette Donation Request for Long-Term Psy-
chiatric Patients. August 4, 1980. Bates No. 502358650.
Available at: http://legacy.library.ucsf.edu/tid/xjg19d00.
142. RJ Reynolds Collection. Letter Declining Request for Ciga-
rette Supply at Saint Elizabeth’s Hospital. October 3, 1980.
Bates No. 502358644. Available at: http://legacy.library.ucs-
143. Buckingham J. Cigarette Request for Day Treatment Pro-
gram for Mentally Ill Adults. September 11, 1992. Bates
No. 508467552. Available at: http://legacy.library.ucsf.edu/
144. Hayworth P. Cigarette donation request for chronically
mentally ill clients. January 22, 1996. Bates No. 524108319/
145. Robertson ES. Hawaii State Hospital Request to RJ
Reynolds for Cigarettes. October 4, 2000. Bates No.
522700931/0932. Available at: http://legacy.library.ucsf.edu/
146. Ardery PP. Kentucky’s Legislators Thank You Letter. April
19, 1985. Bates No. 516001701. Available at: http://legacy.
147. Reynolds RJ. West Palm Beach/Ft. Lauderdale Fax for Con-
ference Invites. December 15, 1987. Bates No. 506131373/1381.
Available at: http://legacy.library.ucsf.edu/tid/myo84d00.
148. Shook, Hardy, Bacon. Report on Recent ETS and IAQ
Developments. February 24, 1992. Bates No. 2050751036/
149. Shook, Hardy, Bacon. Report on Recent ETS and IAQ Devel-
opments. September 22, 1995. Bates No. 2046363816/3823.
Available at: http://legacy.library.ucsf.edu/tid/iqt45d00.
150. Lyons J. Support of Region III Public Smoking Issues.
May 9, 1989. Bates No. TIDN0003235/3236. Available at:
151. Doyle JR. Memo to Kent Wold Including the Maine Public
Health Association Bulletin. March 29, 1991. Bates No.
507601201/1203. Available at: http://legacy.library.ucsf.edu/
152. Doyle JR. Letter to Lawrence Tilton about Smoking in Restau-
3, 1991. March 21, 1991. Bates No. 507601208. Available at:
153. Payne T. Hospital Accreditation.April 8, 1991. Bates No.
507687499/7500. Available at: http://legacy.library.ucsf.edu/
154. Mental Illness Advocacy Group Battling Hospital Smoking
Ban in New York from Psychiatric News. September 16,
1994. Bates No. 2071540448. Available at: http://legacy.li-
155. Alliance for the Mentally Ill, Friends & Advocates of the
Mentally Ill. AMI/ FAMI Policy Paper on Nicotine Addiction
and Psychiatric Patients. March 28, 1995. Bates No.
2071540442. Available at: http://legacy.library.ucsf.edu/tid/
J. J. Prochaska et al.
156. Alliance for the Mentally Ill, Friends & Advocates of Download full-text
the Mentally Ill. Plea for Freedom to Smoke for Bellevue
Hospital Psychiatric Patients. March, 1995. Bates No.
2071540428. Available at: http://legacy.library.ucsf.edu/tid/
157. Miller MW. Mental Patients Fight to Smoke in the Hospital.
Wall St J. October 11 1994. Bates No. 2071540445. Avail-
able at: http://legacy.library.ucsf.edu/tid/eic60c00.
158. Konopka H. Note to Philip Morris. January 1995. Bates No.
2071540439. Available at: http://legacy.library.ucsf.edu/tid/
159. Konopka H. Hellen Konopka AMI and FAMI Business Card.
January, 1995. Bates No. 2071540426. Available at: http://
160. Philip Morris Collection. Hearing Report/Bill Signing
Report.January 10, 1995. Bates No. 2044332448/2451. Avail-
able at: http://legacy.library.ucsf.edu/tid/uim38d00.
161. Connelly, McLaughlin. Witnesses for Smoke-Free Air Act
Hearing. Bates No. 2045959527. Available at: http://legacy.
162. Foderaro LW. Battling demons, and nicotine hospitals’
smoking bans are new anxiety for mentally ill. NY Times.
February 19, 1995. Bates No. 2071540443/0444. Available
163. El-Guebaly N, Cathcart J, Currie S, Brown D, Gloster S.
Smoking cessation approaches for persons with mental illness
or addictive disorders. Psychiatr Serv. 2002;53:1166–1170.
164. Prochaska JJ, Gill P, Hall SM. Treatment of tobacco use in an
165. Prochaska JJ, Fletcher L, Hall SE, Hall SM. Return to
smoking following a smoke-free psychiatric hospitalization.
Am J Addict. 2006;15:15–22.
166. Yano E. Japanese spousal smoking study revisited: how a to-
bacco industry funded paper reached erroneous conclusions.
Tob Control. 2005;14:227–233; discussion 233–235.
167. Barnes DE, Bero LA. Why review articles on the health
effects of passive smoking reach different conclusions.
168. US Department of Health Education and Welfare. Smoking
and Health: Report of the Advisory Committee of the Surgeon
General of the Public Health Service. Washington, DC: US
Government Printing Office; 1964.
169. Olincy A, Harris JG, Johnson LL, et al. Proof-of-concept
trial of an alpha7 nicotinic agonist in schizophrenia. Arch
Gen Psychiatry. 2006;63:630–638.
170. Harris JG, Kongs S, Allensworth D, et al. Effects of nicotine
on cognitive deficits in schizophrenia. Neuropsychopharma-
171. Smith RC, Warner-Cohen J, Matute M, et al. Effects of nic-
otine nasal spray on cognitive function in schizophrenia.
172. Jacobsen LK, D’Souza DC, Mencl WE, Pugh KR,
Skudlarksi P, Krystal JH. Nicotine effects on brain function
and functional connectivity in schizophrenia. Biol Psychia-
173. Barr RS, Culhane MA, Jubelt LE, et al. The effects of
transdermal nicotine on cognition in nonsmokers with
schizophrenia and nonpsychiatric controls. Neuropsycho-
pharmacology. 2007; Available at: http://www.ncbi.nlm.nih.
174. Scriabine A. CNS FORUM Advancements in clinical trials
and drug development Philadelphia, PA, USA, July 29–30,
2003. CNS Drug Rev. 2003;9:389–395.
175. Targacept. Press Release: Targacept announces initiation
of phase IIb development of AZD3480 (TC-1734) for
cognitive deficits in schizophrenia. August 23, 2007.
176. Evins AE, Cather C, Deckersbach T, et al. A double-blind
placebo-controlled trial of bupropion sustained-release for
smoking cessation in schizophrenia. J Clin Psychopharma-
177. Spiegel EP, Schrock DA, Smith MW. Effectiveness of
a Transdermal Nicotine Replacement Intervention in Schizo-
phrenic Smokers. New Orleans, La: American Psychological
178. Williams JM, Ziedonis DM, Foulds J. A case series of nico-
tine nasal spray in the treatment of tobacco dependence
among patients with schizophrenia. Psychiatr Serv. 2004;55:
179. Dalack GW, Becks L, Hill E, Pomerleau OF, Meador-
symptoms in cigarette smokers with schizophrenia. Neuro-
Tobacco Industry and Smoking in Schizophrenia