Rose on Hirshbein, 'Smoking Privileges: Psychiatry, the Mentally Ill, and the Tobacco Industry in America'

Laura D. Hirshbein
M. Lynn Rose

Laura D. Hirshbein. Smoking Privileges: Psychiatry, the Mentally Ill, and the Tobacco Industry in America. New Brunswick: Rutgers University Press, 2015. 228 pp. $90.00 (cloth), ISBN 978-0-8135-6397-8.

Reviewed by M. Lynn Rose (American University of Iraq, Sulaimani) Published on H-Disability (July, 2017) Commissioned by Iain C. Hutchison

Smoking Privileges interweaves the history of psychiatric institutions in the United States with the history of the medical community’s perception of tobacco. Both histories are complex and dynamic, and Hirshbein succeeds at creating a worthwhile narrative that is more than either of the histories alone.

The introduction, "Smoking Privileges," is a reflection on the author's relationship with E. K., an inpatient in the psychiatric ward in which the author worked as a psychiatrist, and to whom the book is dedicated. Much of the dynamic of the relationship involved E. K.'s wish to smoke in the context of Hirshbein’s decisions about when and where he could. Hirshbein goes on to position smoking as a historical factor with interactions between and among people with psychiatric diagnoses, psychiatric institutions and their employees, the tobacco industry, and public health policymakers. As she puts it, "part of what makes this story so complicated is that it sits at the relationship between medicine and business, one that has become increasingly complex in the last several decades" (p. 9).

Eight chapters trace this complex relationship, from the mid-twentieth century through the 2010s. A conclusion considers trends in public health and the pharmaceutical industry up to 2013, with the publication of the DSM-5.[1] Over fifty pages of notes are followed by an index.

In chapter 1, “Ecology of  Smoking in the Mental Hospitals through the 1970s,” the reader is reminded that tobacco's role in mental hospitals was taken for granted before the mid-twentieth century. Smoking privileges were a control, a reward, and a bonding activity, and before the 1980s, the effects of tobacco on physical health were unlinked in this setting. Under the subheading “The Other Side,” Hirshbein draws on narratives of patients of the mental health system as well as novels and professional medical records to illustrate the ubiquitousness of smoking.

Chapter 2, “Conflict and Smoking in Mental Hospitals in the 1960s and 1970s,” traces the persistence of the acceptance of smoking in mental health settings despite a growing awareness of the physical dangers of cigarettes. Psychiatry was under attack by social scientists such as Erving Goffman (1922-82); the coercion of mental health workers was critiqued in popular culture in the 1975 movie One Flew Over the Cuckoo's Nest. Beyond the perception of smoking as normal behavior on mental wards, mentally ill people came to be seen as having a special social and economic relationship with cigarettes. Hirshbein points out, in “Gender and Smoking,” the complexities of choice and control in terms of the growing popularity of smoking among women in the mid-twentieth century: “Women's demands for smoking opportunities were interpreted as part of their mental illness, while women providers’ efforts to control male patients appeared as emblematic of psychiatry’s inauthentic use of power” (p. 48).

Chapter 3, “Smoker Psychology and the Tobacco Industry through the Early 1980s,” focuses on the tobacco industry in the wake of the 1964 surgeon general’s report linking smoking and health issues. The tobacco industry became involved in researching this link: Philip Morris’s Project 1600 studied the relationship between smoking and stress. R. J. Reynolds’s investigation into consumer psychology also focused on the relationship between cigarettes and mental and emotional stress.

Chapter 4, “Psychiatry Engages Smoking,” begins with the observation that, in the 1960s and 1970s, the tobacco industry was far ahead of psychiatry in perceiving smoking as a psychological issue. Tobacco dependence was included in the DSM-III (1980) against hearty professional objection. In the late 1970s and 1980s, the issue of smoking among psychiatric patients was about the behavior of smoking, not about its risks to physical health. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced in 1991 that hospitals would need to prohibit smoking in order to be accredited. As Hirshbein relates, “although the logical argument for tobacco-control enthusiasts regarding smoking in hospitals was based on long-term health risks, this issue was somewhat more contentious in the case of the mentally ill” (p. 75). The smoking ban came to be perceived as a civil rights violation.

“The Many Faces of Nicotine” (chapter 5) considers nicotine as a substance of addiction, nicotine as a therapeutic agent, and R. J. Reynolds’s involvement in the pharmaceutical industry. By the 1990s, people who smoked were people who were on the margins of society, and “tobacco-control activists and psychiatrists began to notice that the largest numbers of remaining smokers in the United States were among the mentally ill” (p. 96).

Chapter 6, “From Tolerance to Treatment,” covers the shift, in the 1990s, in the perception of smoking to the medical model. Among psychiatrists, smoking had become a mental disorder. Until the late 1990s, though, seriously mentally ill patients were exempt from smoking cessation efforts. Nicotine, in fact, was found to help in treating schizophrenia.

In “Tobacco Control and the Mentally Ill” (chapter 7), Hirshbein continues to trace conflicting attitudes. While smoking bans in the early 1990s in psychiatric hospitals were met with arguments about individual choice and freedom, intolerance and disgust for smoking increased throughout the decade. Advocates of smoking cessation called into question the idea that smoking among the mentally ill was a tradition and that people with mental illness would not want to quit. The profound shift in American attitudes toward smoking since the initial surgeon general warning has had consequences for the mentally ill population: “In the span of a few decades, mentally ill smokers moved from displaying behaviors common to most of the general population to being labeled, judged, and controlled for those same behaviors” (p. 125).

Chapter 8, “Double Marginalization,” situates smoking within the mental health consumer movement where it has not been as major a concern as it has been among tobacco-control advocates. Smoking is not, in general, the biggest problem for people with mental illness, though the idea of smoking as a symptom of insanity has made its way into popular culture, where smoking cessation is equated with recovery from psychiatric illness. “Both inside and outside Hollywood,” Hirshbein writes, “smoking marked people as mentally ill” (p. 136).

The conclusion, entitled “Corporate Squeeze,” takes up the implications of the inclusion of “tobacco use disorder” in the DSM-5. The pharmaceutical industry has been eager to reduce nicotine dependence with pills and patches. But smoking among mentally ill people is more than an issue of health: it is a power dynamic. Hirshbeim poses problems, not solutions, but ends the book with a clear call to a rational approach: “Whatever we as a society choose to do, we need to respect that smokers who also have mental illness need to be empowered to live better lives—and that we cannot assume that we know what is best for them. We need to start a conversation, and really listen” (p. 154).

Smoking Privileges synthesizes many contradictory and disparate strands into a coherent and meaningful narrative about health, choice, and the powers of public perceptions. The focus remains on the population of people with mental illness who are prone to institutionalization. In these ways, this research very much deserves to be counted among disability studies. The book is clearly written and lively, accessible to a general audience, and achieves a good balance between narration and evidence. It should be in every library, and would be an interesting supplemental text in a US history or cultural studies course, as well as courses on epidemiology and public policy.


[1]. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the American Psychiatric Association's classification and diagnostic tool.

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