Tobacco Use Among Individuals With Schizophrenia: What Role Has the Tobacco Industry Played?

Department of Psychiatry, University of California, San Francisco, CA 94143-0984, USA.
Schizophrenia Bulletin (Impact Factor: 8.45). 06/2008; 34(3):555-67. DOI: 10.1093/schbul/sbm117
Source: PubMed
ABSTRACT
Rates of tobacco use among individuals diagnosed with schizophrenia have been estimated as high as 80%. A variety of hypotheses
have been proposed to explain the high rate of tobacco use among this vulnerable group. This study examined the tobacco industry's
efforts to establish and promulgate beliefs about schizophrenic individuals’ need to smoke and the hazards of quitting. The
current study analyzed previously secret tobacco industry documents. The initial search was conducted during January–July
2005 in the Legacy Tobacco Documents Library. The search yielded 280 records dating from 1955 to 2004. Documents indicate
the tobacco industry monitored or directly funded research supporting the idea that individuals with schizophrenia were less
susceptible to the harms of tobacco and that they needed tobacco as self-medication. The tobacco industry promoted smoking
in psychiatric settings by providing cigarettes and supporting efforts to block hospital smoking bans. The tobacco industry
engaged in a variety of direct and indirect efforts that likely contributed to the slowed decline in smoking prevalence in
schizophrenia via slowing nicotine dependence treatment development for this population and slowing the rate of policy implementation
vis-à-vis smoking bans on psychiatric units.

Full-text

Available from: Judith J Prochaska, Jan 02, 2014
Tobacco Use Among Individuals With Schizophrenia: What Role Has the Tobacco
Industry Played?*
Judith J. Prochaska
1,2
, Sharon M. Hall
2
, and Lisa A. Bero
3
2
Department of Psychiatry, University of California, San
Francisco;
3
Department of Clinical Pharmacy and Institute for
Health Policy Studies, University of California, San Francisco
Rates of tobacco use among individuals diagnosed with
schizophrenia have been estimated as high as 80%. A variety
of hypotheses have been proposed to explain the high rate of
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
and the hazards of quitting. The current study analyzed pre-
viously secret tobacco industrydocuments.Theinitialsearch
was conducted during January–July 2005 in the Legacy To-
bacco Documents Library. The search yielded 280 records
dating from 1955 to 2004. Documents indicate the tobacco
industry monitored or directly funded research supporting
the idea that individuals with schizophrenia were less suscep-
tible to the harms of tobacco and that they needed tobacco as
self-medication. The tobacco industry promoted smoking in
psychiatric settings by providing cigarettes and supporting
efforts to block hospital smoking bans. The tobacco industry
engaged in a variety of direct and indirect efforts that likely
contributed to the slowed decline in smoking prevalence in
schizophrenia via slowing nicotine dependence treatment de-
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
Introduction
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.
1,2
This equa-
tes to 180 billion cigarettes or $37 billion in tobacco
industry sales annually.
3,4
Tobacco use is particularly
prevalent among individuals diagnosed with schizophre-
nia, with estimates ranging from 49% to 80%.
2,5,6
A variety
of hypotheses have been proposed to explain the high rate
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
of self-medication; that quitting smoking will worsen their
psychiatric symptoms; that they cannot and do not want to
quit their tobacco use; and that they may hold some special
immunity from tobacco-related diseases.
7–10
This study examined the role the tobacco industry has
played in promoting and maintaining cigarette use
among individuals diagnosed with schizophrenia. The to-
bacco industry documents provide insight into industry
motives, strategies, tactics, and data.
11
Prior 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.
12
The 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
policy strategies.
Methods
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
1
To 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,
e-mail: JProchaska@ucsf.edu.
*An earlier version of this manuscript, published online No-
vember 5, 2007, contained an incorrect citation (#77) in the Results
section devoted to funded external research. The pertinent sentence
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
doi:10.1093/schbul/sbm117
Advance Access publication on November 5, 2007
Ó The Author 2007. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: journals.permissions@oxfordjournals.org.
555
Page 1
‘‘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 proven
13
).
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,
13
with
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.
Results
Health Effects of Smoking in Individuals With
Schizophrenia
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.
14
The tobacco in-
dustry catalogued reports of low cancer rates in schizo-
phrenics
15–18
and questioned whether it would be
‘‘practical and sensible to . attempt to quantify these
relationships.’’
19
The 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.
20
Further, the reports
did not account for the possibility that the institutional-
ized psychiatric settings had failed to detect cancer in
these patients.
21–23
Nevertheless, 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.’’
28
The tobacco
industry’s research on psychosomatic causes of cancer ul-
timately came under scrutiny for its ‘‘scientific integ-
rity,’’
29–31
and they grew concerned of criticism that
they were ‘‘financing and giving publicity to an immense
smoke-screen.’’
32
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.
33,34
Both pro-
posals were denied funding.
35,36
One was ‘‘denied in prin-
ciple but referred to the study group on the psycho-
physiological aspects of smoking,’’
37
‘‘for working
over.’’
38
CTR questioned ‘‘whether some other kind of
use could profitably be made of his data collection meth-
ods.’’
39
An internal letter at CTR read, ‘‘What we need to
know is whether he has been in the habit of getting worth-
while results that can be depended on.’’
40
The investiga-
tor was unknown to CTR, so it was not known whether
he had a track record of producing results that supported
the tobacco industry’s interests. Ultimately, the work was
not funded.
35
Recently, government-funded, well-controlled, epide-
miologic studies have demonstrated an increased risk
of lung cancer among patients with schizophrenia relative
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.
41,42
Individuals with schizophrenia also are at
elevated risk for the development of tobacco-related
cardiovascular disease
43
and respiratory disorders.
44
Tobacco Industry–Sponsored Research on the
‘‘Self-Medication’’ Hypothesis
The tobacco industry monitored the scientific litera-
ture
45,46
and 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.
556
Page 2
The tobacco industry also conducted internal re-
search on the use of nicotine and its analogues for
schizophrenia.
Funded External Research. The funded researchers had
long histories of tobacco industry support. Five of the 7
funded proposals were submitted by foreign investigators.
The tobacco industry was known to fund foreign research-
ers for studies considered too sensitive to conduct in the
United States in an effort to prevent discovery of study in-
formation through litigation.
47
The studies are described
below. Notably, the results of many of the funded studies
were not published in the scientific literature. (An example
is how INBIFO in Germany [Institut Fur Biologische For-
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.’’
49
The 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 these studies. If tobacco can be shown to be an efficient
form of ‘self-medication’ for these patients then this
would be [a] significant bonus for the tobacco indus-
try.’’
50
The $84 281 budget request indicated the psychi-
atric patient subjects were to be paid with money or
cigarettes.
50
Correspondence within RJ Reynolds
(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.’’
51
It was a common practice for the tobacco
industry’s funded research to bypass scientific peer review
and instead be funded on the basis of the potential to pro-
tect and promote the interests of the companies.
52,53
The
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.
54
The 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.’’
55
Despite
the reviewers’ concerns that the study be conducted in
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.
56
Our 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
Tobacco industry funding was acknowledged in
some,
59
but not all, articles appearing to result from these
studies.
60
Funded by PM in 1994, an investigator in New
Zealand examined whether nicotine improves neural
inhibition in smoking and nonsmoking schizotypes
(defined by the investigator as the trait underlying schizo-
phrenia).
61
He received $250 000 plus an additional $3000
was budgeted for study completion. Study findings were
discussed with colleagues and reanalyzed but apparently
never published.
62
In 1994, investigators in Sweden submitted a proposal
to CTR with the goals ‘‘to facilitate and guide the devel-
opment of improved pharmacological treatments, includ-
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.’’
63
The 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.’’
64
The 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.’’
65
The progress re-
port listed 17 resulting publications, 5 of which did not
acknowledge CTR funding
66–70
; 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.
71
The project
was positioned with ‘‘direct relevance to ongoing research
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
557
Tobacco Industry and Smoking in Schizophrenia
Page 3
those who successfully justify such expenditures.’’
72
The
research was viewed by PM to be of ‘‘great interest to
the public health community,’’
73
and the proposal was
funded at $178 930 per year for 3 years.
74,75
The 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.
Unfunded External Research. The twenty-one unfunded
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 schizophrenics
77
;
social uses of tobacco among psychiatric patients
78,79
;
nicotine’s effects on neuroleptic blood levels
80
; nicotine
withdrawal effects in schizophrenia
81
; vitamin depletion
in schizophrenia due to tobacco use
82
; animal models of
nicotine’s effects in schizophrenia
83
; genes related to ag-
gression in schizophrenia
84
; nicotinic acetylcholine
receptors in schizophrenia and neurotransmitter differen-
tiation
85–89
; the dopamine D4 receptor’s role in the path-
ophysiology and treatment of schizophrenia
90,91
; and use
of nicotine and nicotine metabolites for treating schizo-
phrenia.
92–95
One of the review letters emphasized that
the decision to deny funding ‘‘does not reflect in any
way upon scientific merit
96
;’’ 6 other researchers were en-
couraged to seek funds elsewhere.
36,97–101
Only 2 of the 21
unfunded proposals were submitted by foreign investiga-
tors; both aimed to examine the role of nicotine and
nicotinic receptors in the treatment of schizophrenia.
Internal Research. Tobacco industry internal research
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.’’
103
Goals 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
world.’’
102
In 1997, RJR ‘‘formed a wholly-owned subsidiary
known as Targacept, Inc.,’’ named for ‘‘targeted recep-
tors.’’
104
Targacept was developed ‘‘to rapidly commer-
cialize RJRT’s nicotine pharmaceutical technologies,’’
105
and, it has been suggested, to circumvent nicotine regu-
lation.
106
One goal was development of an add-on drug to
help with concentration and attentional deficits in schizo-
phrenia, with an estimated target market of $1.5–$6 bil-
lion.
105,107
In presentations for venture capital, Targacept
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,
109,110
rationalizing 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.’’
112
It 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
Individuals with Schizophrenia.
113
The ad shows a double image of
a pack of Merit cigarettes and reads, ‘‘Schizophrenic . For New
Merit, having two sides is just normal behavior.’’
558
J. J. Prochaska et al.
Page 4
the common misunderstanding of schizophrenia as
reflecting a split personality: here, lower tar and big taste.
The tobacco industry disseminated its position
through the scientific literature, popular press, and policy
settings. A book published by a former RJR researcher
included discussion of smoking to self-medicate psycho-
pathology.
113
A 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
concept of demonism and treat nicotine and its analogues
like any other drug.’’ The author encouraged the use of
nicotine even among nonsmokers with schizophrenia.
Tobacco industry documents indicate the author received
funding from CTR and PM from at least 1977–1994 and
contributed to papers conceived by PM.
115–119
Another
CTR, PM, and RJR-funded researcher
120–123
published
at least 11 review articles and an edited textbook concern-
ing the merits of nicotine and nicotine analogues in the
treatment of schizophrenia.
124–127
The same researcher
held scientific conferences sponsored by RJR
128
and
PM
129,130
from 1995 to 2006 with presentations on the
therapeutic indications and targeting of nicotinic treat-
ments for schizophrenia.
131–133
Though not mentioned
in meeting announcements,
134
tobacco industry sponsor-
ship was acknowledged in the programming materi-
als.
135,136
Participants included leading academic
nicotine researchers and tobacco industry scientists.
The meeting proceedings were published
127,137
without
recognition of tobacco industry funding.
127
Previous 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.
138
On 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.
141
RJR staff
determined who was responsible for the policies and en-
couraged the medical director to contact the DHHS
Secretary to cancel the regulations.
142
In 1992, a case
manager in Oregon wrote to RJR requesting ‘‘outdated
or damaged cigarettes’’ in donation to the county mental
health center’s prevocational program for use as payment
for patients’ work activities.
143
In 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.’’
144
A 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.’’
145
It is unclear whether these requests
were granted.
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.’’
146
A 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.’’
147
The tobacco
industry also hired legal counsel to monitor research
on hospital smoking restrictions and to fight policy
efforts aimed at restricting smoking among psychiatric
staff and patients
148,149
; they contacted a teamster official
to offer assistance with grievance procedures against
smoking bans at a state mental hospital
150
; and coordi-
nated testimony to allow smoking in psychiatric hospitals
in Maine.
151,152
In 1990, the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) mandated that all
hospitals in the United States implement smoke-free envi-
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-
based care. The tobacco industry evaluated the legislation
and considered one of its usual tactics—congressional lob-
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
559
Tobacco Industry and Smoking in Schizophrenia
Page 5
than it would to its members.’’
153
Instead, 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.’’
155
AMI/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.’’
157
The 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.’’
158,159
A 1995 PM ‘‘Hearing
Report/Bill Signing Report’’ summarized a public event
held by the New York City mayor to discuss the proposed
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.’’
160
Another PM
document lists FAMI as a witness for the Smoke-Free Air
Act hearing.
161
JCAHO ultimately ‘‘yielded to massive pressure from
mental patients and their families, relaxing a policy that
called on hospitals to ban smoking.’’
162
The 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,
revised the standard.’’
162
An exception was made to allow
continued smoking in psychiatric inpatient and substance
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.
163
Even among psychi-
atric inpatient units with smoke-free policies, however,
tobacco cessation treatment is rarely provided,
164
and
most patients return to smoking immediately upon
discharge.
165
Discussion
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 industry has influenced
the types of questions asked about tobacco use among
patients with schizophrenia. Industry executives reviewed
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 might expose tobacco as harmful. Lastly, our finding
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.
47,166
Investigations 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
560
J. J. Prochaska et al.
Page 6
influence research and policy on the harms of secondhand
smoke.
52,167
More than 40 years after publication of the 1964
Surgeon General’s Report on lung cancer and tobacco,
168
it is now recognized that tobacco use places patients with
schizophrenia at increased risk for lung cancer, cardio-
vascular disease, and respiratory disorders.
42–44
The 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.
The mentally ill are one of the largest remaining groups
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.
169
A 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.
170
Among 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.
171
The
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-
actions as significant, though had the study controlled for
multiple comparisons, the finding would have been non-
significant.
172
Additionally, 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,
could not be excluded. Of the 13 patients with schizophre-
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.
173
The study did not
control for group differences in IQ, age, education, or his-
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
smoking behavior.
Moving beyond nicotine, the National Institute of
Mental Health Measurement and Treatment Research
to Improve Cognition in Schizophrenia initiative has iden-
tified the alpha 7 nicotinic receptor as one of the top rated
potential therapeutic targets, and research in this area is
likely to expand.
174
A 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.
169
Strongest 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.
175
The 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-
sation is now listed on the company’s Web site as a yet to-
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.
176–178
Importantly, a 3-day investigation of placebo
versus baseline or active patch did not find acute ex-
acerbation of clinical symptoms, challenging the self-
medication hypothesis.
179
The tobacco industry documents were obtained
through litigation and thus provide an incomplete picture
of the tobacco industry’s activities in this area. The
561
Tobacco Industry and Smoking in Schizophrenia
Page 7
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 opponents of 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.
7–10
The 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-
ers with mental illness. Might it be that the mentally ill are
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
on research related to tobacco and schizophrenia, it is un-
likely that the industry will make a valid effort to develop
cessation treatments for this population.
Funding
State of California Tobacco-Related Disease Research
Program (#13KT-0152); the National Institute on
Drug Abuse (#K23 DA018691, #K05 DA016752, and
#P50 DA09253).
Acknowledgments
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.
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Tobacco Industry and Smoking in Schizophrenia
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  • Source
    • "Tobacco smoking has attracted the attention of mental health professionals worldwide in recent years. Experts attribute the link between smoking and mental illness to a number of factors, which include the biochemistry of tobacco and nicotine, the nature of mental illnesses and the culture of mental health system [9]. However, most of the research that explored the association between tobacco smoking and mental illness was based on cigarette smoking and not WTS [20]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Smoking has been associated with several types of mental illness namely schizophrenia, depression, bipolar disorders with a prevalence of smoking twice that of the general population. The study objective was to ascertain whether waterpipe tobacco smoking (WTS), cigarette smoking and all types of tobacco smoking are more common among Bahraini patients with severe and persistent mental illness (SPMI) than the general population. Methods: A cross-sectional study was conducted on 222 adult SPMI both in- and out- patients who attended the Psychiatric Hospital in Bahrain. A 29-item questionnaire, which included sociodemographic variables, pattern and history of psychiatric illness and a comprehensive smoking history, was used. Comparative smoking data were obtained from the Bahraini National Non-communicable Diseases Risk Factors Survey. Results: The prevalence of smoking of tobacco among SPMI patients was 30.2 % compared to 19.9 % in the general population. The corresponding values for cigarette smoking were 25.2, 13.8 %, respectively and for WTS, 11.3, 8.4 %, respectively. SPMI patients were 1.7 (95 % CI 1.3, 2.4 %) times more likely to be smokers, 2.1 (95 % CI 1.5, 2.9 %) times, cigarette smokers and 1.4 (95 % CI 0.9, 1.9 %) times WTS than the general population. SPMI patients smoked at a younger age and consumed more cigarettes than the general population. The mean age started smoking was lower among men than women, similar for cigarettes, and higher for WTS. Conclusions: The prevalence of smoking among patients with SPMI in Bahrain is twice that of the general population. The findings of the study have implications on the provision of healthcare to mentally ill patients in the country.
    Preview · Article · Dec 2016 · BMC Research Notes
  • Source
    • "e l s e v i e r . c o m / l o c a t e / s c h r e s criticized for its implied justification of tobacco smoking in schizophrenia (Prochaska et al., 2008). Alternatively, the addiction vulnerability hypothesis proposes that neurobiological dysfunctions common to schizophrenia and tobacco use disorder, make persons with schizophrenia more vulnerable to the rewarding effects of tobacco (Krystal et al., 2006). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Highly prevalent in schizophrenia, tobacco smoking substantially increases the risk of cardiac-related death. Compared to the general population, tobacco smoking cessation rates are lower in schizophrenia. Unfortunately, the reasons for these low cessation rates remain poorly understood. Recently, it has been shown that tobacco cravings are increased in schizophrenia smokers compared to smokers with no comorbid psychiatric disorder. In view of these results, we sought to examine - for the first time - the neurophysiologic responses elicited by cigarette cues in schizophrenia smokers. We hypothesized that cigarettes cues would elicit increased activations in brain regions involved in drug cravings in schizophrenia smokers relative to control smokers. Methods: Smokers with (n=18) and without (n=24) schizophrenia (DSM-IV criteria) were scanned using functional magnetic resonance imaging (fMRI) while viewing appetitive cigarette images. Results: Schizophrenia smokers and smokers with no psychiatric comorbidity did not differ in subjective cravings in response to appetitive smoking cues. However, in schizophrenia smokers relative to control smokers, we found that appetitive cigarette cues triggered increased activations of the bilateral ventro-medial prefrontal cortex, a core region of the brain reward system. Moreover, a negative correlation was observed between cigarette cravings and activations of the right ventro-medial prefrontal cortex in schizophrenia smokers. Discussion: The current results highlight a key role of the brain reward system in cigarette craving in schizophrenia, and suggest that the neurophysiologic mechanisms involved in the regulation of cue-induced cigarette craving are impaired in this population.
    Full-text · Article · Mar 2016 · Schizophrenia Research
  • Source
    • "These findings, however, were not missed by the tobacco industry. In another study Prochaska, Hall and Bero [15] found that the tobacco industry had acted upon this knowledge by slowing down efforts to treat smokers with schizophrenia through promoting selfmedication as one of the strategies used to market cigarettes to patients with schizophrenia. "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: Global tobacco control efforts in both prevention and treatment have advanced to levels never imagined 20 years ago. This review examines the relationship between mental illness and tobacco use, with particular focus on the role of psychiatrists in the treatment of tobacco dependence. Methods: The literature search utilised MEDLINE, Embase and PsychINFO databases using the terms psychiatry, psychiatrist, smoking cessation, tobacco use disorder and tobacco dependence treatment. A manual search of all references from relevant scientific articles obtained was also conducted. Finally, further material sourced included all major guidelines for smoking cessation or tobacco dependence treatment from the United States, United Kingdom, Canada, Australia and New Zealand. Results: Psychiatry has ignored tobacco dependence and its treatment resulting in multiple missed opportunities in improving the health and well-being of smokers with mental illness. Improvement in the training and knowledge of psychiatrists and those in the mental health sector will be the most effective activity to rectify this situation. Conclusion: Psychiatry must recognise tobacco dependence as equally important as the primary mental illness and to treat accordingly. A significant change in the training of future psychiatrists, introducing or implementing smoke free mental health services, changes in the management of caring for the mentally ill, and the introduction of tobacco treatment specialists within the mental health system is needed if psychiatry is serious about confronting this problem.
    Full-text · Article · Jan 2015
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