Studies document the tobacco industry’s marketing of cigarettes to marginalised groups. To increase sales and defuse potential political opposition, tobacco firms have directed marketing, philanthropy, and outreach campaigns to African Americans,¹ Asian Americans,² Latinos,³ and gay men,⁴ and made appeals to different segments of society based on factors such as age and sex.^5,6 However, searches revealed no previous research on tobacco industry marketing to the homeless and seriously mentally ill, populations marked by extremely high smoking rates and unique in their simultaneous economic, psychological, social, and physiological vulnerability.^7–11

Despite their low incomes, the homeless have characteristics that make them desirable “downscale” customers, a population segment that the tobacco industry identified as critical to its sales at least as early as the 1970s.^12,13 While there is no consistent definition in the literature of what constitutes the population of mentally ill individuals, most studies find that smoking rates are high in this population as well as among the homeless. Research identifies between a quarter and a third of the homeless as mentally ill,^14,15 and rates of mental illness and disability are even higher among the chronically homeless.¹⁶

Approximately two thirds of the severely mentally ill experience or risk homelessness,¹⁶ and the mentally ill are estimated to buy nearly half the cigarettes sold in the USA.¹⁷ Mental illness and chemical dependency, both of which impair critical judgment, may make the homeless more susceptible to marketing efforts that suggest cigarettes help people “cope with stress”.¹⁷ Overall, less than one quarter of the US population smokes and smoking rates have declined since the 1960s.¹⁸ By comparison, although it is difficult to determine the level of smoking in the homeless population, studies suggest that between 70–99% of homeless adults smoke.^7–10 Also, smoking rates for individuals with severe mental illness, who are over-represented among the homeless population, have not been declining as have rates in the general population.¹⁹

Unlike some other disadvantaged groups, the homeless and seriously mentally ill do not share a common culture or pride in their identity that might lead them to organise on their own behalf. In addition, these groups are marginalised^20–22 both socially and economically and their needs are rarely a focus of tobacco control efforts.²³ Organisations providing services may have different goals than homeless individuals.¹⁶ For all these reasons, it is important to better understand the nature and extent of tobacco industry influence on tobacco use among the homeless and seriously mentally ill. This paper examines internal tobacco industry documents to analyse tobacco industry involvement with the homeless and seriously mentally ill population.

DATA AND METHODS

In conjunction with legal settlements between 46 state attorneys general and the major tobacco companies in the USA, over 40 million pages of internal tobacco industry documents have been made publicly available. These documents are web accessible at the Legacy Tobacco Documents Library²⁴ and Tobacco Documents Online,²⁵ as well as major US tobacco companies. Documents used for this paper were retrieved between December 2003 and December 2004.

Using previously established techniques for systematically searching tobacco documents archives,²⁶ we began with initial search terms such as “homeless”, and “mental illness”. Searches were expanded with a “snowball” strategy, using contextual information from initial searches to identify additional search terms and relevant documents, including names of individuals/organisations, date ranges, places, and reference (Bates) numbers. Approximately 2500 internal tobacco industry documents pertaining to the homeless, mentally ill, homeless organisations, and psychiatric institutions were identified and screened for relevance. After eliminating irrelevant material and duplicates, we drew on approximately 400 documents to prepare this paper, dated from 1977 to 2001. We also reviewed relevant secondary data sources including newspaper and journal articles, accessed via PubMed, Jstor, and internet searches using Google. Data were managed using EndNote software, and analysed to determine the tobacco industry’s practices and goals in dealing with the homeless and seriously mentally ill, and with organisations providing services to these populations.

Tobacco industry marketing to the homeless

In 1977, an international tobacco industry trade group, including representatives of all major cigarette companies, noted in a document on the social acceptability of smoking that “cigarette smoking is becoming a downscale social activity”.²⁷ As the disease effects of smoking became better understood, more affluent and educated people were the most likely to quit.^28,29 Cigarette companies thus increasingly marketed toward lower income, less educated, and minority segments of the US population.^1,12 A marketing study done for RJ Reynolds (RJR) noted in a downscale market profile that this demographic was “more impressionable to marketing/advertising… they’re more susceptible. They’re less formed intellectually… more malleable” [Ellipses in original].¹²

By the early 1990s the homeless had become one of the subpopulations specifically targeted by major cigarette companies, in addition to general marketing efforts directed toward downscale consumers.³⁰ For example, RJR included direct targeting to the homeless as part of an urban marketing plan in the 1990s, focused on the advertising of “value” brands to “street people”.³⁰ In 1990, American Tobacco supplied cigarettes for the movie “Robocop 3”, which showed homeless activists smoking Pall Malls and Lucky Strikes.³¹ In addition to advertising, tobacco companies gave away cigarette brand logo products to the homeless—for example, in 1994 Philip Morris (PM) apparently distributed 7000 “Merit” cigarette brand labelled blankets to New York homeless shelters and homeless individuals.³² By the late 1990s, the ties between homelessness and smoking had grown so overt that a major marketing periodical characterised the target market of Brown and Williamson’s GPC brand as “Homeless Man”.³³

Offering free samples is a well established strategy by which tobacco companies recruit new smokers,^34–36 and cigarette samples were distributed to homeless shelters, mental hospitals, and homeless service organisations. In 1988 alone, Lorillard Tobacco Company spent over $570 000 on cigarette donations,³⁷ though not all of these were distributed to marginalised populations. Internal company documents show that in a single month in 1990, however, Lorillard distributed over 100 sample packs apiece to a homeless shelter, a soup kitchen, and a mental health association.³⁸ Similar donations were logged regularly from 1983 to at least 1993.^39–46

Cultivation of organisations serving the homeless and mentally ill

At the same time that tobacco companies targeted consumers, they cultivated relationships with service organisations, apparently as a means to gain positive media coverage and fight smoking restrictions. Homeless service organisations received charitable contributions from tobacco companies over several years,^47–49 at times as part of larger brand promotions.^50–52 A single contribution sometimes served both to develop sales for the product and to develop a relationship with the recipient organisation, such as when cigarettes were donated to homeless shelters at Christmas.⁵³ Some psychiatric hospitals were also targeted by the “value” brands of major cigarette companies for sales promotions and giveaways throughout the 1980s and 1990s.^54,55

Although the public health community is widely aware that cigarette use kills one in two long time smokers,¹⁸ homeless services workers may express only limited concern about smoking.⁵⁶ When service providers consider smoking, they sometimes focus on the type of cigarettes smoked rather than on the hazards of smoking itself. A 1993 article in Cancer Nursing, for example, discussed the higher health risks faced by homeless smokers because they often smoke butts, or re-roll used cigarettes, risking the spread of infectious diseases. However, the proposed solution to this problem was itself problematic: suggesting that public health workers find ways for homeless smokers to acquire “clean” cigarettes while encouraging them to quit. Although the authors were aware of this tension, they believed that promoting cessation alone would be ineffective. They suggested that

“…telling a homeless person to quit smoking may not be as effective an intervention as providing a way to more easily obtain fresh, unadulterated, “clean” cigarettes while simultaneously offering smoking cessation classes… one must consider that smoking is a major coping mechanism used by the homeless to deal with the stress of their day-to-day existence.”⁵⁷

Homeless people do face multiple stressors, but smoking and the associated tobacco addiction have themselves been shown to increase anxiety^58,59 and to exacerbate existing mental health problems.²³ In addition, research suggests that the majority of homeless and seriously mentally ill smokers are interested in quitting,^7,60,61 and some homeless individuals prefer non-smoking facilities.⁶² Moreover, recent evidence shows that smoking cessation interventions in these populations can be successful.^{23,60,63–71}

Many organisations providing services to the homeless and seriously mentally ill appear to have been relatively sanguine about their relationship to the tobacco industry. Several organisations, including teen shelters,⁷² received or requested grants from the tobacco industry, particularly PM.^48,73–76 In part, this may reflect the fact that tobacco companies have specifically targeted workers at homeless shelters in marketing efforts. A marketing study commissioned by PM in 1995, for example, stated that volunteers in homeless shelters were the kind of urban consumer it was trying to reach with a new menthol cigarette.⁷⁷

In some cases, organisations that provide services to the homeless and seriously mentally ill have purchased cigarettes for clients.^78,79 Other organisations have sought cigarette donations.^80,81 Although Lorillard was the only company for which we could locate detailed records of cigarette donations, we found documents dated as late as 1999 showing that a range of organisations solicited cigarettes or coupons. These included psychiatric institutions, homeless shelters, nursing homes, drug treatment facilities, thrift stores, and convalescent care centres.^{53,76,78,80–97,130} For example, the executive director of a shelter serving women and children wrote to RJR in 1992:

“… I am specifically asking if you might consider giving us cigarettes, factory rejects or irregulars would be fine for our clients. When clients come to our door they are usually depleted of all funds and resources. We do not believe this is the most appropriate time to give up smoking, it simply add [sic] to their stress.”⁹⁶

Similarly, a residential treatment services organisation requested cigarettes from Lorillard for a client population made up largely of homeless substance abusers and the seriously mentally ill, and received two cases, containing 800 sample cigarettes, in response.⁹² The attitude of many service providers seeking tobacco industry assistance is illustrated by a 1995 letter from a mental hospital representative seeking donations of cigarettes, in which she characterised the provision of cigarettes as “caring” for patients:

“If you could, by some miracle, donate cigarettes or tobacco to the hospital to the patients [sic] it would be very much appreciated. As you know, it is very hard to stop smoking and for some here it is all they have. A majority of the patients here do not have family who are involved or care enough about them to bring cigarettes to them.”⁷⁸

In addition, local homeless organisations have accepted the presence of tobacco industry employees as volunteers on work projects—for example, in 1998, PM arranged for employees to paint two women’s dormitories as a work project at a homeless shelter.⁵⁰ Such activities position the tobacco industry as sympathetic and benevolent, drawing attention away from its primary aims of promoting smoking and selling cigarettes.

Two specific cases offer further detail regarding this relationship between service providers and the tobacco industry.

Benson & Hedges music festivals

Beginning in 1988, PM made charitable contributions to homeless services organisations using a portion of ticket revenues from Benson & Hedges arts and music festivals.^98,99 In addition, PM made a two year grant of $100 000 to the National Coalition for the Homeless.^99–101 Shortly after making these contributions, in 1992, PM requested that another recipient, the Coalition for the Homeless in New York, ask local legislators to stop trying to pass clean indoor air laws and instead focus on problems of homelessness. The Coalition for the Homeless refused and claimed that they would not accept future tobacco industry funding.¹⁰² After hearing about the incident, New York Times columnist Anna Quindlen wrote an opinion piece supporting the Coalition for the Homeless and suggesting that other charitable organisations follow their lead.¹⁰² This was the sole incident uncovered in our research where the tobacco industry received negative publicity for its relationship with homeless organisations.

The Benson & Hedges music festivals, which featured jazz, R&B, and blues, continued to seek out local homeless service organisations as recipients of charitable contributions in cities where music festivals were held at least through 1999.^103,104 Although we found no discussions of negative publicity from the Coalition for the Homeless incident in PM’s internal memos, all organisations chosen to receive contributions were pre-screened by public relations firms, and proposed to the company for funding if they met two criteria.^104,105 First, the organisations stated that they had no problem accepting tobacco industry money. Second, shelters agreed to hold a press conference with industry representatives to advertise the contribution. While the majority of shelters proposed as recipients of contributions served adult men, PM also considered family shelters.¹⁰⁵

The Benson & Hedges promotions served two purposes: they were a means to reach a target market for the brand,⁵ and they were a way for PM to position itself as a “socially responsible” company through philanthropy.^6,98 In at least one case, PM held a Benson & Hedges blues concert in a homeless shelter, and most concert attendees were reportedly homeless.¹⁰⁶ Contemporaneous media coverage of the Benson & Hedges blues concerts, as well as the PM country music and jazz festivals sponsored by other brands, noted that proceeds from the concert would benefit local or national homeless organisations.¹⁰⁷ PM’s effort to gain direct political support from the Coalition for the Homeless was ultimately unsuccessful, but the company did succeed in gaining considerable positive media coverage of its contributions.^106,107

Homeless veterans groups

Cigarettes were included as part of military rations to soldiers from the first world war until 1972,¹⁰⁸ resulting in tobacco addiction among thousands of soldiers. Once returned from active duty, veterans constituted a substantial market for tobacco companies, which have maintained close relationships with veterans’ groups for decades. For example, the industry has sought out veterans’ organisations to rally in support of industry policy positions, in recent years specifically to fight clean indoor air laws.¹⁰⁹

Veterans themselves often experience long term health consequences after their service, suffering high rates of homelessness and mental illness compared to the population as a whole.¹¹⁰ Veterans’ organisations estimate that over 250 000 veterans are homeless, constituting a third of the homeless population.¹¹¹ The tobacco industry has made financial contributions to several organisations that provide services to homeless veterans or claim to advocate on their behalf, and then used these relationships to advance its political agenda. Tobacco industry documents suggest that of these organisations, the National Coalition for Homeless Veterans (NCHV) has been most active in advocating for tobacco industry political goals.

The NCHV, a group based in Washington DC made up of community based homeless veteran service providers, claims 250 members¹¹² and has appeared repeatedly on behalf of the industry’s efforts to prevent new smoking restrictions. The organisation testified during US Occupational Safety and Health Administration (OSHA) hearings on the regulation of tobacco in the workplace,¹¹³ was recruited again to advocate against smoke-free bars in New York, and worked to maintain unrestricted smoking in other states after the passage of smoke-free bars legislation in California.^114,115 NCHV’s executive director argued in 1994 before OSHA that,

“[Prohibiting] on the job smoking… would force homeless veterans – and others like them – back on the streets. We simply cannot place a recovering, unemployed veteran in such a restrictive environment and expect success.”¹¹⁶

RJR recruited the NCHV (and other veterans groups such as the American Legion, AMVETS and local Veterans of Foreign Wars (VFW) groups) in 1994 and 1995 to appear in lieu of cigarette companies themselves in the industry’s advocacy against clean indoor air laws.¹¹⁷ NCHV was also listed in an internal company document as a “very active” ally on behalf of PM’s policy goals in 1997.¹¹⁴ Other organisations such as Colorado’s Veterans for the Homeless, though apparently less politically active, received rent and food contributions from Kraft,¹¹⁸ another subsidiary of PM’s parent company, now called Altria.¹¹⁹ PM, however, made press releases regarding the same contributions under its own name.¹²⁰

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.¹²¹ 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.¹²¹ 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.¹²¹ 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.¹²¹

DISCUSSION

Our study has limitations. Because the company documents available to us for review are limited to those requested during legal discovery processes, and because of the sheer volume and limited indexing of the document collections, we have no way to determine whether we have reviewed all documents relevant to tobacco industry interest in the homeless and seriously mentally ill populations. This limitation means that we are unable to determine, for example, how trends in industry interest in the homeless and seriously mentally ill populations may have changed over time. The evidence also does not allow us to determine industry motivation for some activities, such as the donation of “value” brands to shelters, which could have been done to enhance marketing to this downscale segment of the market, but could also represent cost or excess inventory considerations, concerns about preserving the “upscale” reputation of “premium” brands, or other factors.

However, despite these limitations, this research reveals several ways that the tobacco industry has marketed cigarettes to the homeless and seriously mentally ill, and shows how it has used service providers to try to further its political goals. No previous studies we could locate have documented this phenomenon, which is congruent with the industry’s targeting of other marginalised groups. These findings have several important implications for public health.

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.^96,116 Some service providers presume that cigarettes calm the homeless and seriously mentally ill,^122,123 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.¹²⁴ Similarly, family groups that speak on behalf of severely mentally ill patients have also advocated against smoke-free environments.⁷⁹ Thus, despite the high incidence of tobacco related diseases among the homeless and seriously mentally ill,^{8,9,125–128} organisations created to serve these individuals’ needs may be furthering their addiction through misplaced compassion.

In general, homeless service organisations have viewed the proximate problems of lack of employment, income, counselling, and long term housing as more relevant to their clients than harms caused by smoking.^84,116 Service organisations rarely consider smoking related disease effects in the homeless and seriously mentally ill population.¹⁰ Casual attitudes about smoking by service providers can lead non-smokers to initiate smoking, creating long term consequences more serious than the issues for which these individuals sought help.⁵⁶ This triage by providers regarding the problems of homeless and seriously mentally ill individuals has led some service organisations to request goods and services from the tobacco industry and to accommodate its media and policy demands^75,129 without necessarily recognising that they may be further compromising their clients’ health and helping sustain tobacco addiction.

Second, because homeless shelter employees who smoke may not view client smoking as a problem,^78,85 tobacco control advocates need to consider ways to educate and partner with service providers. For example, Hamilton Family Center, an emergency family shelter in San Francisco, is working with Tobacco Free Kids to develop an education programme about the dangers of secondhand smoke (Schick S, January 2005, personal communication). Education should also focus on the costs to homeless clients when organisations accept tobacco industry support and thereby enhance marketing opportunities.

Organisations that fund tobacco control programmes should consider making these populations a primary focus, encouraging service providers to develop cessation programmes and policies against tobacco distribution and tobacco industry funding. Programmes attempting to help these populations should also strive to find ways for service providers to benefit by choosing not to accept tobacco industry support.

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,^123,131 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.^132,133

The industry’s efforts to develop connections with other marginalised groups have drawn criticism from public health advocates within the relevant communities.^1–4 In some cases, marketing plans have been forestalled by vigorous advocacy, such as the aborted “Uptown” brand that RJR attempted to introduce for African Americans, which became a public relations disaster for the company.^134,135 Targeting of homeless people, however, has drawn very little defensive response.

This research suggests the complexity of intervening in smoking behaviour in marginalised populations suffering from multiple forms of disadvantage. Tobacco control advocates, public health workers, and funding organisations should consider whether and how their efforts affect homeless and seriously mentally ill individuals and those who provide services for them. Education of service providers about the tobacco industry’s efforts to exploit the homeless and seriously mentally ill, and their organisations, could help address the harms from smoking suffered by these populations.