You thought Big Pharma marketing was unethical? Then read the shocking research paper Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill, Apollonio and Malone, Tobacco Control 2005;14:409-415; doi:10.1136/tc.2005.011890 [free full text online]. Zoloft ads seem downright friendly in comparison.

After I wrote about stigma and high smoking rates with mental illness, a reader passed along this link. The article provides analysis of 400 relevant documents culled from 40 million pages of tobacco industry internal documents made public in a legal settlement (accessible here and here). Researchers uncovered marketing techniques (such as giving out 7,000 blankets with a brand logo, and holding concerts in shelters) aimed at homeless and severely mentally ill people, and recruitment of homeless advocacy groups, veteran’s organizations and even psychiatric hospitals (which have often used tobacco as a reward) to promote tobacco along with political support against clean indoor air legislation.

Despite making relatively small financial contributions, tobacco companies appear to have been successful in recruiting homeless veterans groups as allies and in attracting associated positive media coverage. For example, a 2000 media event created by RJR benefited the Louisiana Coalition for Homeless Veterans (LCHV). In exchange for Doral cigarette pack seals collected at its “Red, White and Blue Salute” at a local bar, RJR contributed $1000 to help build a drop-in centre for disadvantaged and homeless veterans. At another location in North Carolina, the company donated $1000 to Disabled American Veterans.121 According to a company public relations document, the events gained RJR extensive positive media coverage. In several cases, the RJR press release lauding its contribution was printed verbatim in local newspapers. RJR internal documents, however, revealed that the event was arranged to sell cigarettes to veterans, an important market because 42% of Doral customers have ties to the military. According to the firm hired by RJR, the Quixote Group, each event generated approximately 20 media stories, all positive, reaching over a million readers and listeners, and increased cigarette sales at event locations.

Service organizations tended to embrace the tobacco funding and samples, with shelters and hospitals requesting samples along with grant money. One hospital pleaded, “As you know, it is very hard to quit smoking and for some here that is all they have.” A common perception seems to have been that it’s too stressful to quit and they wouldn’t even suggest it. The researchers respond:

Homeless people do face multiple stressors, but smoking and the associated tobacco addiction have themselves been shown to increase anxiety and to exacerbate existing mental health problems. In addition, research suggests that the majority of homeless and seriously mentally ill smokers are interested in quitting, and some homeless individuals prefer non-smoking facilities. Moreover, recent evidence shows that smoking cessation interventions in these populations can be successful.

Keep in mind that smoking kills half of all long-term smokers – not a great treatment for stress. Smoking and its relationship to mental illness is complicated and can’t be addressed in a single article (or blog post) but by using cessation programs designed with special considerations, surely headway can be made. Consider that high smoking rates may be boosted by marketing, not just caused by factors unique to mental illness, and think about consequences:

The ethical implications of marketing an addictive and deadly product to a population characterised by high rates of mental illness, substance abuse, and economic disadvantage are even more troubling than those that are normally raised about cigarette marketing. The tobacco industry claims that it does not market to children because they are not capable of making adult judgments about smoking, yet it markets to adults with mental illness whose judgment may be impaired. Targeting an addictive product to the economically disadvantaged means that individuals may buy cigarettes at the expense of food and shelter.

The authors recommend recruiting and educating service providers to help people quit smoking, instead of reinforcing the addiction.

First, tobacco control advocates need to challenge the apparently common assumptions among service providers that tobacco is a resource and that their clients are too “stressed” to consider quitting smoking. Some service providers presume that cigarettes calm the homeless and seriously mentally ill, making the provision of services less difficult. In some cases, service providers have argued that smoking bans in environments populated by the mentally ill (including many homeless shelters) threaten clients’ mental and physical health. Similarly, family groups that speak on behalf of severely mentally ill patients have also advocated against smoke-free environments. Thus, despite the high incidence of tobacco related diseases among the homeless and seriously mentally ill, organisations created to serve these individuals’ needs may be furthering their addiction through misplaced compassion.

On the other hand, it is true that smoking may be a sole “comfort” in hospital and on the street. What to do instead, ideally or realistically? It’s a complex matter – what are your thoughts?