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Helen Redmond Helen Redmond

I Want My E-Cigarettes! Here’s Why Mentally Ill People Should Get Them

People with mental illnesses have a unique, intense relationship with smoking, which can ease distress as well as kill. Now that a much safer version of the habit is available, it's no time for the anti-smoking lobby to play Nurse Ratched.

7 Substance

“I want my cigarettes, I want my cigarettes, I want my cigarettes,” Charlie Cheswick, an enraged patient in a mental hospital, screams at the sadistically indifferent Nurse Ratched in the classic film One Flew Over The Cuckoo’s Nest. After several heartbreaking minutes, Jack Nicholson’s character, Randle P. McMurphy, breaks a window at the nursing station, grabs a carton of Marlboros and hands it to his deeply relieved comrade.

The history of psychiatric hospitals is one of abuse, neglect and copious amounts of cigarette smoking. Until the 1970s, hundreds of thousands of mentally ill people were warehoused for decades in state mental asylums. There was typically little to do, and going to the supervised smoking room every 15 minutes became an “activity” to break the tedium. Cigarettes rewarded compliant behavior or were taken away to punish noncompliance. The scene from One Flew Over the Cuckoo’s Nest played out daily in hospitals nationwide.

That almost 90% of people diagnosed with schizophrenia smoke—despite  tobacco’s well-known adverse health consequences—is a testament to the addictiveness of nicotine. But it is also evidence of nicotine’s power to chemically quell anxiety, depression and other upset. (The prevalence of smoking among people with bipolar and panic disorder, depression, anxiety and PTSD is also high.)

Hospital staff have long observed how smoking markedly improves the negative symptoms of mental illness, such as lack of motivation and pleasure, reduced emotional expression and deficits in attention and concentration.

“Whenever he runs out of cigarettes, he becomes highly agitated to the point where he has seriously injured staff and other patients. Providing a cigarette is generally much more effective at decreasing agitation than most medications I can provide,” Elizabeth Roberson, then a psychiatrist at Hawaii State Hospital, wrote to R.J. Reynolds in 2000, asking for free cigarettes for one of her patients.

The mentally ill remain the single-largest demographic of smokers, accounting for 44% to 46% of cigarettes sold in the US. This market earns the tobacco industry $37 billion annually. So it’s no surprise that the industry opposes smoking bans in psychiatric units. What may be surprising is that the National Alliance on Mental Illness (NAMI), a leading advocacy group for the mentally ill, collaborated with Big Tobacco in the 1990s to block smoking bans and to implement designated smoking areas. “It is inhumane to rob these patients of their autonomy and dignity by infringing on one of the few remaining freedoms historically allowed patients,” NAMI advocates said in 1995.

At the same time, the mentally ill also account for half of the estimated 400,000 Americans who die from a smoking-related health condition every year. The National Association of State Mental Health Program Directors reported in 2012 that people receiving public mental health services who have both an addiction and a mental illness die, on average, nearly 32 years earlier than others. Smoking is a major contributor to this premature mortality.

The industry delivered carton-loads of cigarettes to psychiatric institutions. In some states, cigarettes were tax-free, “to be used for patient treatment.” R.J. Reynolds created “value” brands for “street people” and dispensed free samples to soup kitchens and homeless shelters.

Given smoking’s many dangers and few benefits, for the “normal” person, whether or not to abstain is a no-brainer. But for the mentally ill, the risk/benefit analysis is more complicated. Their health-care providers know, on the one hand, that nicotine helps their patients cope with debilitating symptoms of mental illness and, on the other hand,  that smoking causes fatal illness. The debate has polarized the mental health community. But the recent introduction of e-cigarettes—a safe nicotine-delivery device—has the potential to shift the terms of the debate.

Expected Benefits, Exaggerated Risks

Research over the past decade or so supports the view of nicotine as a potential therapeutic tool. It is both a stimulant and a relaxant. A drag on a cigarette sends nicotine from the lungs to the brain in under 10 seconds; once in the brain, it saturates the nicotinic receptors, triggering an instantaneous release of a host of neurotransmitters—acetylcholine, dopamine, endorphins, serotonin and glutamate—that improve mood, memory and concentration. Anxiety and pain are lessened.

Nicotine may even have specific properties that “treat” symptoms of schizophrenia. The drug helps to mitigate “sensory gating,” the ability to make sense of stimuli in the environment. When this function is impaired, as is often the case for schizophrenics, all sensory stimuli seem to be equally important, inducing confusion and fear in otherwise harmless situations. Gunvant Thaker, MD, the director of the schizophrenia-related disorders program at the Maryland Psychiatric Research Center, said, “When schizophrenic patients smoke, or are given nicotine gum, this deficit of sensory gating is reduced or normalized.”

Pharmaceutical companies are investing big bucks in the design and development of potential drugs with affinity for the brain’s nicotinic receptors—they mimic the action of nicotine itself—in order to package and sell these positive neurochemical effects.

Yet nicotine’s deadly connection to smoking tobacco has made it difficult to think rationally about nicotine as a stand-alone chemical. Anti-smoking advocates have also done their part to promote the misconception that nicotine is a dangerous drug with no therapeutic value. Yet the danger lies exclusively in the fact that as a vehicle to transport nicotine, tobacco has to be burned. When a cigarette is lit, the tobacco is transformed into tar and other carcinogens.

Pure nicotine, while addictive, is not dangerous, which is why the FDA has approved nicotine replacement therapies (NRT) like gums, patches, sprays and oral inhalation devices such as Nicotrol. Clinical and observational studies of NRTs have long shown that nicotine is a safe drug.

The Mentally Ill as a Major Market

Big Tobacco identified the mentally ill and the homeless as critical to their bottom line in the early 1970s when health warnings against smoking were first gaining wide acceptance. The industry quickly turned this marginalized group into a lucrative, loyal and captive market, according to the so-called Tobacco Papers, millions of the industry’s internal documents made public as a result of hard-won lawsuits in 1998.

The educated and affluent began to quit in large numbers. The social acceptability of smoking waned and new restrictions on smoking prompted still more quitting. The customer loss cut into profit margins, and tobacco companies sought to reinforce marketing to the mentally ill and the homeless (two thirds of the severely mentally ill are homeless or at risk). The industry delivered carton-loads of cigarettes to psychiatric institutions. In some states, cigarettes were purchased tax-free and were “to be used for patient treatment.” R.J. Reynolds created “value” brands for “street people” and dispensed free samples to soup kitchens, homeless shelters and homeless service organizations.

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