ARTICLE IN PRESS

0277-9536/$ - se

doi:10.1016/j.so

�Correspond

E-mail addr

Social Science & Medicine 61 (2005) 649–659

www.elsevier.com/locate/socscimed

Tobacco taxation and public health: ethical problems,policy responses

Nick Wilson�, George Thomson

Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago, PO Box 7343,

Wellington South, New Zealand

Available online 21 January 2005

Abstract

This article aims to describe the major ethical issues surrounding tobacco taxation, and to identify policy responses to

minimise any ethical dilemmas. It uses the standard ethical framework for biomedicine (covering beneficence, non-

maleficence, respect for autonomy and justice), in conjunction with relevant data on tobacco taxation from various

developed countries.

Tobacco taxation contributes substantial benefits at the population level by protecting health (i.e., by deterring the

uptake of smoking by youth, by promoting quitting, and by reducing harm from exposure to second-hand smoke

(SHS)). However, tobacco taxes can contribute to financial hardship among low-socioeconomic status populations

where smoking persists.

Such taxes can contribute to autonomy, by reducing SHS exposure to non-smokers, and by allowing freedom from

nicotine-dependency for those who quit smoking or do not start regular smoking as a result of high tobacco prices.

Furthermore, increases in tobacco taxation may reduce health inequalities and so contribute to justice. Nevertheless, the

additional tax burden imposed on smokers who wish to continue to smoke, or are unable to quit, can be considered

unjust. The autonomy of such smokers may be partly impaired.

Although tobacco tax can be regarded as ethically justifiable because of its substantial overall benefit to society, there

is substantial scope for policy changes to further reduce any harms and injustices for those populations who continue to

smoke.

r 2005 Elsevier Ltd. All rights reserved.

Keywords: Ethics; Tobacco; Smoking; Taxation; Justice; Inequalities

Introduction

The taxing of tobacco has been recently described as

the most cost effective tobacco control option in all

regions of the world (Shibuya et al., 2003). However,

tobacco taxation may contribute to an unjust tax

burden, may increase financial hardship for low-income

populations, and may impair the autonomy of smokers.

e front matter r 2005 Elsevier Ltd. All rights reserve

cscimed.2004.11.070

ing author. Tel./fax: +64 4 4763646.

ess: nwilson@actrix.gen.nz (N. Wilson).

It may involve government dependence on revenue for

general purposes that is raised from the use of a

dangerous, addictive drug. To help ensure that tobacco

tax policy is better designed, this article aims to describe

the major ethical issues involved and to identify the

policy options for reducing the conflicts identified.

Goodin (1989) has previously described the ethics of

smoking and given some consideration to issues of

taxation. Other authors have also considered specific

issues of equity in relation to tobacco tax (McLachlan,

1995, 2002; Smith & Bopp, 1999; Remler, 2004).

d.

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659650

However, a comprehensive analysis specifically on the

ethical issues around tobacco tax does not appear to

have been published in the ethical or scientific literature.

We suggest that consideration of the ethics of public

health interventions is of value in itself, to enable greater

surety of ethical conduct in public health policy. In

addition, there are pragmatic reasons for addressing the

topic, as the justice and hardship issues may discourage

policymakers from using tobacco taxation as a health

policy, due to the potential political response of smokers

(Flynn et al., 1998; Wiltshire, Bancroft, Amos, & Parry,

2001).

This analysis has utilised the standard ethical frame-

work from biomedicine which covers beneficence, non-

maleficence, respect for autonomy and justice (Gillon,

1994). This framework also has general relevance to

public health issues (Calman & Downie, 1997) given that

it captures in a relatively simple way two of the major

streams of ethical thinking: utilitarianism and a rights-

based approach. Other frameworks may potentially

better address the ethical dimensions arising for

populations and public health (Roberts & Reich,

2002). Nevertheless, such other frameworks have not

been used here because of their greater complexity and

lesser familiarity to both the public health community

and also the wider health policy community. The latter

is particularly important since it is those outside the

health sector (and in particular officials in Treasury

Departments) that work with politicians to drive the key

decisions on tobacco taxation policy. Nevertheless, we

acknowledge the limitations of the framework used and

briefly consider the implications of different approaches

to ethics at the end of the article.

Information on tobacco taxation for developed

countries was gathered from literature searches (i.e.,

Medline from 1966 to April 2004, and ECONbase and

Internet searches in April 2004). As preparation for this

review, we also undertook a specific analysis to quantify

the potential harm from tobacco taxation via financial

hardship (Wilson, Thomson, Tobias, & Blakely, 2004).

Beneficence

The ‘‘principle of beneficence’’ refers to a moral

obligation to act for the benefit of others (Beauchamp &

Childress, 2001). This section considers the ‘‘benefits’’ of

tobacco taxation in terms of protecting health status, as

well as the potential financial and economic benefits.

Benefit to smokers’ health via reduced tobacco

consumption

A recent systematic review of 17 studies of high

methodological quality found that ‘‘strong scientific

evidence demonstrates that increasing the unit price for

tobacco products is effective in increasing tobacco use

cessation and in reducing consumption’’ (Hopkins et al.,

2001). Other reviews have come to similar conclusions

(eg., Jha & Chaloupka, 2000; Shibuya et al., 2003).

Evidence from tobacco industry internal documents also

indicates that tobacco price rises promoted by tax

increases have reduced smoking, particularly for young

people (Chaloupka, Cummings, Morley, & Horan,

2002).

Quitting or reduced daily consumption is likely to

lower the risk of developing a tobacco-related illness.

For example, at a population level, it has been found

that a large tobacco-control programme in the US (that

included tobacco tax increases) was associated with a

reduction in deaths from heart disease in the short term

(Fichtenberg & Glantz, 2000). For hospitalised patients,

quitting tobacco use reduces the number of future

hospitalisations, as well as short-term medical costs

(Lightwood & Glantz, 1997).

One recent global model estimated that current levels

of tobacco tax already save 15 million disability-

adjusted life years (DALYs) each year (Shibuya et al.,

2003). Furthermore, if all countries increased taxation

levels to 75% of the final retail price, an additional 19

million DALYs could be averted (i.e., 56% of the

estimated total burden of lost DALYs attributable to

tobacco in 2000).

Benefit to the health of non-smokers

There is strong evidence from a number of published

reviews and meta-analyses that second-hand smoke

(SHS) is a cause of lung cancer (eg., IARC (Interna-

tional Agency for Research on Cancer), 2002). Two

large cohort studies have also identified increased total

mortality among non-smokers living with smokers (Hill,

Blakely, Kawachi & Woodward, 2004). A number of

major reviews have also reported that exposure to SHS

causes both heart disease and respiratory illness (eg.,

California EPA (Environmental Protection Agency)

Office of Environmental Health Hazard Assessment,

1997; SCTH (Scientific Committee on Tobacco and

Health), 1998). Exposure to SHS can cause middle ear

effusion and sudden infant death syndrome among

children and infants (WHO World Health Organization,

1999).

Children and adults exposed to SHS are likely to

benefit from reduced exposure as a result of smokers

quitting or cutting down (Emmons et al., 2001). A recent

study also indicates that pregnant women are particu-

larly sensitive to cigarette price. It was estimated that in

the US, a cigarette tax increase of $US 0.55 per pack

would reduce maternal smoking by about 22% (Ringel

& Evans, 2001). This is important, given that lower rates

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659 651

of smoking in pregnancy reduce the number of low

birth-weight new-borns and perinatal deaths (Light-

wood, Phibbs, & Glantz, 1999).

Benefit from preventing youth uptake

Ethicists and economists have previously argued in

support of tobacco tax in terms of preventing youth

uptake of smoking (Goodin, 1989; Gruber, 2002). These

arguments are strengthened by a systematic review

which concluded that increasing the price for tobacco

products ‘‘reduces the number of adolescents and young

adults who use tobacco products and the quantity

consumed’’ (Hopkins et al., 2001). Other major reviews

have also reported this finding (eg., Jha & Chaloupka,

1999; Liang, Chaloupka, Nichter, & Clayton, 2003).

However, it has been suggested that a limitation of

tobacco taxation is that it tends to merely delay smoking

uptake and does not generate proportionate reductions

in prevalence rates through adulthood (Glied, 2003).

Even if this finding is true outside the US setting, a delay

in itself is still beneficial, as it increases the likelihood of

a person being less dependent on nicotine, being able to

quit successfully, and being a lighter smoker (Lando

et al., 1999; Jefferis, Power, Graham, & Manor, 2004).

Financial and economic benefits to society, smokers, and

their households

The households of smokers who succeed in quitting

after a tax increase will save on tobacco-related

spending, through lower out-of-pocket medical ex-

penses, lower health and life insurance premiums, and

lower cleaning costs for clothes and furnishings.

For a society, there is a direct financial benefit from

tobacco tax when some of the tax revenue is tied to

tobacco control spending, as it can assist in funding

programmes that reduce smoking prevalence (eg., CDC

(Centers for Disease Control and Prevention), 1996).

Less directly, any reduction of smoking attributable to

taxation levels should reduce health sector costs overall.

Tobacco smoking ‘‘imposes costs on an annual basis, y

it leads to increased medical costs over the life span, and

y many of these costs are borne by employers’’ (Max,

2001). A recent study has also found that the direct and

indirect lifetime health costs were higher in ever-smokers

than in never smokers (Rasmussen, Prescott, Sørensen,

& Søgaard, 2004). Such potential health sector savings

from reduced tobacco use are of particular relevance in

those societies with publicly funded health systems.

There are also societal benefits from reduced smoking

in terms of increased work productivity, reductions in

premature deaths among workers, reduced accidents,

lower absenteeism from tobacco-related illness, and

reduced employment instability. Reduced smoking low-

ers insurance costs, decreases tobacco-related fire

damage, and reduces ventilation and cleaning costs

(Osinubi & Slade, 2002; Parrott, Godfrey, & Raw,

2000).

At a societal level, there is disagreement about the net

tangible financial and economic benefits or loss from

smoking (i.e., the effect on the gross domestic product of

a country). This is partly because of differences in

assumptions and methodologies (Bates, 2001). While the

lifetime healthcare costs of smokers may be higher than

for non-smokers, the relative net tax and pension

contributions and receipts of smokers and non-smokers

vary by country, and generalisations are debated (Jha &

Chaloupka, 1999; Warner, 2000). Nevertheless, in what

appears to be the most sophisticated analysis to date

using a traditional economic framework (Peck, Cha-

loupka, Jha, & Lightwood, 2000), it was estimated that

there is a net decline in economic welfare if individual

smokers underestimate the cost of smoking to their

health by more than 23% (which the authors considered

likely given the low levels of consumer understanding of

the risks). Furthermore, this study found that net

economic welfare benefited from a 10% tobacco tax

increase even if only a very small percentage of smokers

were uninformed of the risks (i.e., 2.2%).

Non-maleficence

It has been suggested that ‘‘the traditional Hippo-

cratic moral obligation of medicine is to provide net

medical benefit to patients with minimal harm—that is,

beneficence with non-maleficence’’ (Gillon, 1994). Simi-

larly, it is generally accepted that public health inter-

ventions should also seek to avoid or minimise harm.

Harm from financial hardship

In Australia, expenditure on tobacco has a significant

negative association with expenditure on nearly all

household items (including necessities such as clothing,

footwear, and food) (Siahpush, Borland, & Scollo,

2003). In New Zealand it has been estimated that

tobacco spending involved up to 14% of the non-

housing budgets of households with smokers (i.e., for

those in the second lowest income decile) (Thomson,

Wilson, O’Dea, Reid, & Howden-Chapman, 2002).

These findings indicate that tobacco tax is contributing

to financial hardship among low-income households in

some settings.

Quantification of this harm has been attempted in a

New Zealand analysis—of the adverse impact of the

deprivation associated with financial hardship that could

be attributed to tobacco taxation (Wilson et al., 2004).

It was estimated that the loss of life expectancy

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659652

attributable to tobacco tax ranged from 0.005 years to

0.027 years for the total population (smokers and non-

smokers) and from 0.009 to 0.044 years for all people

living in the most deprived 30% of neighbourhoods (i.e.,

from around 3 to 16 days of lost life expectancy for the

latter estimate). Furthermore, the harm in households

with smokers would be higher.

A limitation with this type of analysis is that it ignores

other potential harms, such as the impact of increased

financial hardship on morbidity, and on non-health

outcomes such as deprivation-associated crime. It also

remains unclear the extent to which all such harmful

outcomes can appropriately be attributed to tobacco

taxation. This is because if there were no tobacco taxes,

then smoking rates and consumption would be higher

and would therefore increase financial stress in other

ways (eg., medical costs and sick leave from work

associated with tobacco-related illness).

Harm from industry job losses

A reduction in tobacco sales from tobacco taxation

might be expected to reduce employment in tobacco

production, cigarette manufacture, and tobacco sales. In

the long term however, new jobs should be created

elsewhere in national economies as a result of re-diverted

consumer spending (Jha & Chaloupka, 2000; Warner,

2000). The majority of workers would probably benefit

in the longterm, since economies should grow more as

tobacco sales decline (since tobacco use impairs work-

force productivity and reduces the size of the population

of consumers).

Harm from tobacco smuggling

A potential negative effect of tobacco tax is its impact

on illegal cross-border transport and sale of untaxed

tobacco products. Any increased levels of surveillance

and law enforcement to counter smuggling is an

additional cost burden to the state and its tax paying

citizens. But at the margin, these additional costs to

control tobacco smuggling may be relatively small for

most countries, since intensive border control is usually

required anyway to prevent other types of smuggling

(eg., arms, banned drugs, and endangered species), and

to reduce terrorist incursions. The World Bank con-

siders that ‘‘rather than foregoing [tobacco] tax in-

creases, the appropriate response to smuggling is to

crack down on criminal activity’’ (Jha & Chaloupka,

1999).

Harm from loss of ‘‘benefits’’ to smokers

Smokers who quit or lower consumption due to high

tobacco prices can be considered to be losing perceived

‘‘benefits’’ from smoking (eg., perceived enjoyment of

smoking, socialising, and perceived weight-control

benefits). But if most smokers would prefer not to be

smoking (as per US data (CDC (Centers for Disease

Control and Prevention), 1997)), and largely consume

tobacco because of nicotine addiction, then such loss of

‘‘benefits’’ are generally limited to the proportion of

smokers who never regret starting or continuing

smoking (Orphaides & Zervos, 1998; Laux, 2000). Even

within this group, the value of reported ‘‘benefits’’ from

smoking are greatly limited by the lack of adequate

information to smokers—eg., the relatively weak effect

of tobacco consumption on weight control. The degree

to which smoking fails to achieve the aims which

smokers use it for (such as ‘‘stress relief’’) also needs

to be considered. There appears to be a net increase in

anxiety as a result of smoking, compared to not smoking

or to long-term successful cessation (Parrott, 1995, 1998;

West & Hajek, 1997).

When considering overall well-being, there is some

evidence that tobacco tax is actually beneficial for

smokers. Survey data from both the US and Canada

indicate that tobacco excise tax at a state or provincial

level is associated with higher subjective well-being or

‘‘happiness’’ among those with a propensity to smoke

(Gruber & Mullainathan, 2002). These results indicate

that smokers may be benefiting from the effects of

taxation as a self-commitment device (Gruber &

Koszegi, 2002). Such a view is consistent with survey

data that some smokers actually favour cigarette taxes.

For example, 19% of African American smokers favour

tobacco taxes being increased and another 25% say they

should stay at the same level (King, Mallett, Kozlowski

& Bendel, 2003). In Taiwan, 27% of current smokers

and 58% of ex-smokers support tobacco tax (Tsai, Yen,

Yang, & Chen, 2003).

Respect for autonomy

At a minimum, personal autonomy can be regarded as

‘‘self-rule that is free from both controlling interference

by others and from limitations, such as inadequate

understanding, that prevent meaningful choice’’ (Beau-

champ & Childress, 2001).

Enhanced autonomy for those quitting, those not starting,

and those exposed to SHS

Siegel and Donor (1998) describe how public health

interventions can confer freedom to control one’s life—a

form of ‘‘positive liberty’’. That is, for the majority of

smokers who want to quit smoking (CDC (Centers for

Disease Control and Prevention), 1997) or do not start

as a result of tobacco taxation levels, their personal

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659 653

autonomy and freedom can be considered to be

enhanced or at least protected. This is because

dependence on nicotine reduces autonomy, with the

majority of smokers generally compelled by nicotine-

withdrawal symptoms to smoke on multiple occasions

throughout their waking hours. The survey data detailed

above on smokers well-being (Gruber & Mullainathan,

2002) suggests that smokers may be benefiting from the

autonomy-enhancing effects of taxation as a self-

commitment device (Gruber & Koszegi, 2002).

Tobacco-related illness also erodes autonomy when it

causes conditions that damage the brain (eg., strokes)

due to the loss of intellectual abilities. Such illness can

also reduce autonomy by restricting mobility and

increasing dependence on others (eg., as a result of

respiratory disease such as emphysema, cardiovascular

disease, and limb amputations due to peripheral

vascular disease). Perhaps the ultimate constraint on

autonomy from tobacco is premature death from

smoking-related disease, which occurs for around half

of long-term smokers (Peto, Lopez, Boreham, Thun, &

Heath, 1994). The costs of this life lost to smokers has

been estimated at $US 35 per pack of cigarettes (Gruber

& Koszegi, 2002).

Tobacco taxation also tends to reduce the exposure of

non-smokers to SHS (especially in settings with inade-

quate smoke-free environments legislation). This reduc-

tion can be considered autonomy enhancing for those

consequently protected from the harmful effects of SHS,

which reduces their autonomy. Reduced smoking also

increases the opportunities for those who avoid entering

certain venues, due to either the risks of SHS or the

discomfort. Gruber (2002) has noted that if each US

non-smoker valued the cost of not dealing with smokers

at $US 10 per year, then this would amount to more

than 10 cents per pack of cigarettes sold.

Reduced autonomy for those who continue smoking

Tobacco taxation that is set at a higher level than for

general consumption taxes can be seen as an infringe-

ment on the autonomy of those who wish to start or

continue smoking (Klein, 1997). Others have argued

that the costs of smoking are largely a matter for

individual concern only, and there is no basis for

taxation for amounts above the costs to others (Hersch

& Viscusi, 1998; Viscusi, 1998, 1999). Quantifying the

impact of a large tax increase can give some indication

of the imposition involved. For example, in the OECD

country currently with the least affordable tobacco (the

UK), a 20% price increase for tobacco that was

attributable just to tax, would require an additional

40min work per week by the average worker (based on

the data in Guindon, Tobin, & Yach, 2002). This is

1.7% of a 40-h working week.

However, the theory of the smoker as a ‘‘rational

consumer’’ may be problematic (Laux, 2000; Bask &

Melkersson, 2001). Once addicted to nicotine, there is

some neuroscientific evidence that many smokers are

limited in their choices (Tate, Pomerleau, & Pomerleau,

1994; Stolerman & Jarvis, 1995; Pontieri, Tanda, Orzi, &

Di Chiara, 1996). Thus, the potential reduction in

autonomy for smokers via tobacco taxation needs to be

qualified by the degree to which their autonomy is

already limited.

Furthermore, the autonomy arguments around smok-

ing are limited by the imperfect information on the risks

of nicotine addiction and health risks from smoking that

is available to smokers and to youth experimenting with

smoking (Slovic, 2001; Borland, 1997; Schoenbaum,

1997; Hanson & Kysar, 1999; Jamieson & Romer, 2001).

Assumptions of rationality in youth risk-taking have

also been questioned (Bergler, 1995; Cook & Bellis,

2001). There is also the evidence that the uptake and

cessation of smoking is largely formed by social context

(Buller et al., 2003; Barbeau, Krieger, & Soobader, 2004;

Dedobbeleer, Beland, Contandriopoulos, & Adrian,

2004; Jefferis et al., 2004).

Justice

In this analysis, the term ‘‘justice’’ is considered to be

synonymous with ‘‘fairness’’ and as involving an

obligation ‘‘to act on the basis of fair adjudication

between competing claims’’ (Gillon, 1994). Justice issues

arise because the predominant pattern in developed

countries is for lower socioeconomic status (SES) men

and women to have higher smoking prevalence rates

(eg., Stellman & Resnicow, 1997). The consequence of

these unequal rates and exposures are higher rates of

lung cancer among low SES groups (Stellman &

Resnicow, 1997) and significantly lower life expectancy

(Tobias & Cheung, 2001). The general pattern in

poorer developing countries is also for lower SES

men and women to have higher smoking prevalence

rates (Blakely, Hales, Kieft, Wilson, & Woodward,

in press).

The unjust taxation burden and unjust use of revenue

As with many consumption taxes, tobacco taxation is

generally considered to be regressive, with low-income

groups being taxed disproportionately, relative to those

on higher incomes (Jha & Chaloupka, 1999; Remler,

2004). For example, in Britain, households with smokers

in the lowest income decile spend a 600% greater

proportion of their income on tobacco compared to

those in the highest decile (Acheson, 1998). Tobacco

taxation therefore violates the ‘‘ability-to-pay’’ principle

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659654

of tax policy in two ways. First, poorer households,

which are less able to pay tax, are generally made to pay

a greater proportion of their income through tobacco

taxation than richer households of the same size and

composition (vertical inequity). Secondly, households

with the same composition and income are treated

differently, depending whether they pay tobacco taxes or

not (horizontal inequity).

In contrast, some economists consider that tobacco

taxation is probably progressive overall, when the

benefits of taxation as a self-control device are appro-

priately accounted for (Gruber & Koszegi, 2002).

However, this conclusion is sensitive to relative price

sensitivities, values of life, degree of time inconsistency,

and degree of impatience across income groups.

In most countries, governments do not dedicate

tobacco tax revenue for specific tobacco control

purposes, with the revenue being added to other

government income for use in general government

spending. This can be considered unfair, as the harm

to smokers who provide the tax revenue is not

appropriately addressed—a point previously made by

Goodin (1989). It is also unfair that non-smoking

households may benefit from the general government

spending that comes from tobacco taxation. This is

particularly so, given that smoking is an addictive

activity that has great health costs to smokers and their

households.

Reduction in long-term health inequalities

There is some evidence that poor consumers are more

responsive to price increases than rich consumers, so

their consumption of cigarettes will fall more sharply

following a tax increase (eg., Farrelly & Bray, 1998;

Townsend, Roderick, & Cooper, 1994; Biener, Aseltine

Jr., Cohen, & Anderka, 1998). This is also the pattern

for less-well-educated individuals (eg., Chaloupka &

Wechsler, 1997). For these reasons, tobacco taxation

increases have been described as being ‘‘a progressive

public health policy’’ (Warner, 2000) and as such they

may contribute to reductions in health inequalities and

therefore contribute to greater justice. Nevertheless, this

pattern may not always hold, as shown, for the most

disadvantaged smokers in the UK (Marsh & McKay,

1994; Dorsett & Marsh, 1998).

Reducing the conflict between benefits and harms of

tobacco taxation

The benefits from tobacco tax to public health (via

decreased smoking uptake and decreased smoking

prevalence and consumption) contrast with the addi-

tional harm to health and welfare from tax-related

financial hardship for those who continue to smoke. In

the only analysis to date that attempts to compare the

harms of tax and smoking, it was estimated that for the

total New Zealand population, the loss of life expec-

tancy attributable to tobacco tax ranged from 42 to 257

times less than that attributable to smoking, and 119 to

460 times less than that attributable to deprivation

(Wilson et al., 2004). This finding suggests that the

benefits of taxation are probably vastly greater than the

harm at a population level in this particular setting.

However, there is a need for a broader research basis to

better assess the marginal benefits and costs of addi-

tional taxation increases. Also, relatively few studies

address the problem of the effect on households when

smokers do not quit or do not reduce smoking

sufficiently to cut their tobacco spending. Various policy

options that could further shift the balance to maximis-

ing benefits, while minimising harms of tobacco tax,

include the following:

(1)

The rapid and substantial reduction of smoking

prevalence in all sectors of society. This is possible

through comprehensive evidence-based tobacco

control programmes that include taxation, smoke-

free environments legislation, mass media campaigns

and providing support for smoking cessation

(all of which are supported by evidence from

systematic reviews—Hopkins et al., 2001). For

instance, a fairly comprehensive approach allowed

Canada to reduce the smoking prevalence (for those

aged 15 years plus) from 30% to 20% during 1991 to

2003 (Health Canada, 2003). During the year

2002–2003, smoking prevalence declined in New

York City from 21.6% to 19.3% as a result of

taxation increases and other interventions (Gottlieb,

2004).

(2)

In addition to the above, the potential harm from

tobacco-tax-related financial hardship to low-in-

come households can be reduced by maximising

quit rates among this population. This is possible

through targeted mass media campaigns (with

appropriate thematic content and use of media

such as television), subsidised nicotine replace-

ment therapy, free Quitline services, and the use of

quit and win contests. There is evidence from the

UK that smoking cessation services can reduce

inequalities (Lowey, Tocque, Bellis, & Fullard,

2003).

(3)

The potential harm from financial hardship to low-

income households can also be reduced by ensuring

an overall government taxation and spending

pattern which is progressive. That is, progressive

income, capital gains and asset taxes, and spending

on health and social services that favours low-

income households.

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659 655

Reducing the conflicts around the autonomy issues

The conflict around autonomy relates to the potential

role of tobacco tax in enhancing autonomy for some

(i.e., those exposed to SHS, those not starting, and those

valuing taxation in terms of self-control and quitting)

versus an erosion of autonomy for those who wish to

continue to smoke. Given the serious harms involved

and the impact of addiction on reducing autonomy, we

suggest that tobacco taxation (and tobacco control in

general) maximises overall autonomy for the popula-

tion. Other authors have also considered the asymmetry

between the rights of non-smokers and smokers on the

issue of SHS—and have strongly favoured non-smokers’

rights to clean air (Goodin, 1989; Butler, 1993).

More generally, it has been argued that promoting

health and protecting lives can be an overriding value,

justifying the limitation of individual freedom for some

for the common good (Callahan & Jennings, 2002).

Public health values assume that societal action is

needed for the good of society, and that such action

may need to be at some cost to individual rights (Kass,

2001). Nevertheless, possible ways in which any reduc-

tion in the autonomy of persisting smokers might be

further minimised, include the following:

(1)

Strengthening the overall taxation and spending

pattern by government to favour low-income popu-

lations (in which smokers are over-represented)—as

detailed above.

(2)

Improving the quality of information surrounding

nicotine addiction provided to smokers (eg., via

mass media campaigns). This may facilitate smokers

having a better understanding of how ‘‘autonomy’’

arguments might differ for addictive products (such

as tobacco) relative to other consumer products, and

the consequent appropriate role of government.

Goodin (1989) argues that ‘‘helping addicts who

want to break the habit is not offensively paterna-

listic; nor is helping people avoid acquiring addic-

tions they would later want to renounce’’.

Governments could also make more explicit the

potential autonomy-enhancing self-control benefits

of tobacco taxation (as suggested by Gruber &

Koszegi, 2002). They could explicitly advertise this

reason and link any tobacco tax increases with

enhanced programmes for tobacco control.

(3)

Enhancing the quality of public information around

the role of government in protecting public health in

a democracy. Governments could be more explicit

about the trade-offs being made between policies

that have overall population benefit but entail a

potential loss of autonomy for some individuals.

Such issues are the clearest where a public health

intervention protects the autonomy of others (Call-

ahan, 2003; Gostin, 2000). So in regards to tobacco,

there is a particularly strong argument for govern-

ment interventions that help to protect non-smokers

exposed to SHS, and which protect the fetus (in the

case of reducing smoking during pregnancy). Gov-

ernments also need to describe tobacco control

interventions in the context of other public health

interventions that involve externality issues (eg.,

driving speed restrictions, limits on alcohol levels

and driving, and limitations on those with highly

communicable diseases).

When a democracy has publicly funded health

services, there may also be a role for government to

clearly articulate the issues around it having policies to

contain the cost burden of public services to itself (and

therefore the financial burden on tax payers). That is,

such governments can justifiably argue that they can

promote safer behaviour among their citizens to reduce

costs (eg., promoting quitting to both save lives and to

lower health sector costs).

Reducing the conflicts around the justice issues

Tobacco taxes can promote justice through reducing

inequalities in health status, but they can contribute to a

more unjust taxation burden for those who continue to

smoke. There are also injustices associated with in-

appropriate use of tobacco taxation revenue for general

government spending. As detailed above, the strength-

ening of the overall taxation and spending pattern by

government to favour low-income populations may

reduce the financial hardship borne by low-income

populations. This would help decrease injustice. Focuss-

ing tobacco control interventions on such populations is

also highly desirable.

The use of all tobacco tax revenue for tobacco control

programmes would reduce the injustice of using smokers

as a captive revenue source, where the means of capture

(tobacco) is extremely dangerous. A number of jurisdic-

tions already relate tobacco control spending to higher

tobacco taxes (Guindon et al., 2002). The notable

reductions in smoking prevalence in states such as

California and Massachusetts (CDC (Centers for Dis-

ease Control and Prevention), 1996) provide evidence

favouring the adoption of dedicated tobacco taxes for

improved tobacco control.

Limitations of the ethical framework used and other

possible approaches

A major limitation of the framework used may be the

weight given to the issue of individual autonomy. We

have described some of the limitations of the concept of

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659656

autonomy in the context of incomplete knowledge of

risks and in terms of addiction. But other fundamental

challenges to the concept of autonomy come from the

psychological literature, which suggests that people have

fairly limited knowledge of themselves and the causes of

their own behaviour (eg., Wegner, 2002; Wilson, 2002).

Some findings from neuroscience are also pointing in

this direction, by suggesting the illusory nature of the

conscious self (Metzinger, 2003).

Ethicists have tried to construct a conception of

respect for autonomy that is ‘‘not excessively individua-

listic (neglecting the social nature of individuals and the

impact of individual choices and actions on others)’’

(Beauchamp & Childress, 2001). Some philosophers

have even argued for a reformulation of the notion of

autonomy towards ‘‘a balanced relationship between the

needs and rights of the individual with due consideration

of the interests of the group’’ (Tauber, 2003). This type

of autonomy requires respect for the rights of others,

and the placing of a premium on ‘‘the cooperative

nature of morality from which justice must be derived’’.

The framework used in this analysis also fails to fully

consider the insights of other ethical systems, such as

communitarian ethics, the ethics-of-care, and virtue

ethics (Roberts & Reich, 2002). For example, a

communitarian approach may argue for tobacco taxa-

tion as a means to achieve the social value of a smoke-

free society, and to minimise the overall social burden of

smoking-related harm. An analysis from an ethics-of-

care perspective might give much more emphasis to the

importance of reducing the smoking-created psycholo-

gical and social burden on families and friends. In

particular, the burden associated with caring for

smokers suffering from chronic tobacco-related diseases

might be emphasised (where this burden could have been

prevented through improved tobacco taxation policy).

An ethics-of-care analysis may also give more weight to

the need to prevent financial hardship on families, where

smokers continue to smoke in the context of tobacco tax

increases.

This analysis also does not specifically address the

issue of intergenerational justice. Such a perspective

could emphasise the importance of stronger tobacco

control programmes (including taxation) so as to

minimise the risk of suffering from nicotine dependence

and its adverse health consequences in future genera-

tions.

Another ethical perspective that could be used when

considering tobacco taxation comes from environmental

ethics. Using that framework might also emphasise the

use of strong tobacco control measures over concern for

individual human autonomy, given the adverse impact

of tobacco on consumption and production waste, the

harm to biodiversity associated with smoking-related

forest fires, and from deforestation to produce tobacco

(eg., Geist, 1999).

Finally, the ethical framework used in this analysis is

a secular one. Analyses based on other cultural or

religious contexts might give additional emphasis to

such aspects as the role of tobacco control measures in

protecting the sanctity of human life (including reducing

the risk of death to the fetus from maternal smoking).

To the extent that the human body is considered in some

way sacred (Smith, 2003)—this too might give emphasis

to protecting it from the pollutants in tobacco smoke

(eg., via stronger tobacco control measures). Some

cultural or religious perspectives might also favour

stronger tobacco control in terms of their general

opposition to addictive substances (eg., Whooley, Boyd,

Gardin, & Williams, 2002).

Despite the various potential limitations with the

framework used for this analysis, it has allowed for some

of the major ethical issues associated with tobacco

taxation to be identified and contrasted with each other.

Although further analysis using different frameworks is

desirable, the priority for further work is probably to

refine the extent that the ethical dilemmas identified to

date can be further reduced, through the implementation

of strong tobacco control programmes, and supportive

social policies.

Acknowledgements

The authors wish to thank Louise Delany, Dr Kevin

Dew, Anne Tucker and two anonymous referees for

their very helpful comments on the draft manuscript.

George Thomson was supported for this work by

funding from the New Zealand Heart Foundation and

the Wellington Division of the New Zealand Cancer

Society.

References

Acheson, D. (1998). Independent Inquiry into Inequalities in

Health Report (p. 84). London; The Stationary Office.

Barbeau, E. M., Krieger, N., & Soobader, M. J. (2004).

Working class matters: socioeconomic disadvantage, race/

ethnicity, gender, and smoking in NHIS 2000. American

Journal of Public Health, 94(2), 269–278.

Bask, M., & Melkersson, M. (2001). Rationally addicted to

drinking and smoking? Umea, Umea University: Swedish

Working Papers in Economics. October 2001. http://

www.econ.umu.se/ues/ues567.html.

Bates, C. (2001). Study shows that smoking costs 13 times more

than it saves. British Medical Journal, 323(7319), 1003.

Beauchamp, T. L., & Childress, J. F. (2001). Principles of

biomedical ethics. Oxford: Oxford University Press.

Bergler, R. (1995). Irrationalitat und risko—eine problemana-

lyse (Irrationality and risk—a problem analysis) (N. Grey,

Trans.). Zentralbl Hyg Umweltmed, 197(1–3), 260–275.

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659 657

Biener, L., Aseltine, R. H., Jr., Cohen, B., & Anderka, M.

(1998). Reactions of adult and teenaged smokers to the

Massachusetts tobacco tax. American Journal of Public

Health, 88(9), 1389–1391.

Blakely, T., Hales, S., Kieft, C., Wilson, N., & Woodward, A.

The global distribution of risk factors by poverty. Bulletin of

the World Health Organization, in press.

Borland, R. (1997). What do people’s estimates of smoking

related risk mean? Psychology and Health, 12, 513–521.

Buller, D., Borland, R., Woodall, W., Hall, J., Burris-Woodall,

P., & Voeks, J. (2003). Understanding factors that influence

smoking uptake. Tobacco Control, 11(Suppl. 1), 181–191.

Butler, K. (1993). The moral status of smoking. Social Theory

and Practice, 19(1), 1–26.

California EPA (Environmental Protection Agency), Office of

Environmental Health Hazard Assessment. (1997). Health

effects of exposure to environmental tobacco smoke. Sacra-

mento: California EPA.

Callahan, D. (2003). Individual good and common good: a

communitarian approach to bioethics. Perspectives in

Biology and Medicine, 46(4), 496–507.

Callahan, D., & Jennings, B. (2002). Ethics and public health:

forging a strong relationship. American Journal of Public

Health, 92(2), 169–176.

Calman, K. C., & Downie, R. S. (1997). Ethical principles and

ethical issues in public health. In R. Detels, W. W. Holland,

J. McEwan, & G. S. Omenn (Eds.), The practice of public

health, oxford textbook of public health. New York: Oxford

University Press.

CDC (Centers for Disease Control and Prevention). (1996).

Cigarette smoking before and after an excise tax

increase and an anti-smoking campaign—Massachusetts,

1990–1996. Morbidity and Mortality Weekly Report, 45(44),

966–970.

CDC (Centers for Disease Control and Prevention). (1997).

Cigarette smoking among adults—United States, 1995.

Morbidity and Mortality Weekly Report, 46(51), 1217–1220.

Chaloupka, F. J., & Wechsler, H. (1997). Price, tobacco control

policies and smoking among young adults. Journal of

Health Economics, 16(3), 359–373.

Chaloupka, F. J., Cummings, K. M., Morley, C. P., & Horan,

J. K. (2002). Tax, price and cigarette smoking: evidence

from the tobacco documents and implications for tobacco

company marketing strategies. Tobacco Control, 11(Suppl.

1), I62–I72.

Cook, P., & Bellis, M. (2001). Knowing the risk: relationships

between risk behaviour and health knowledge. Public

Health, 115(1), 54–61.

Dedobbeleer, N., Beland, F., Contandriopoulos, A., & Adrian,

M. (2004). Gender and the social context of smoking

behaviour. Social Science & Medicine, 58(1), 1–12.

Dorsett, R., & Marsh, A. (1998). The health trap: poverty,

smoking and lone parenthood. London: Policy Studies

Institute.

Emmons, K. M., Hammond, S. K., Fava, J. L., Velicer, W. F.,

Evans, J. L., & Monroe, A. D. (2001). A randomized trial to

reduce passive smoke exposure in low-income households

with young children. Pediatrics, 108(1), 18–24.

Farrelly, M. C., & Bray, J. W. (1998). Office on smoking and

health. Response to increases in cigarette prices by race/

ethnicity, income and age groups—United States,

1976–1993. Morbidity and Mortality Weekly Report,

47(29), 605–609.

Fichtenberg, C. M., & Glantz, S. A. (2000). Association

of the California Tobacco Control Program with

declines in cigarette consumption and mortality from heart

disease. New England Journal of Medicine, 343(24),

1772–1777.

Flynn, B., Goldstein, A., Solomon, L., Bauman, K., Gottlieb,

N., Cohen, J., et al. (1998). Predictors of state legislators’

intentions to vote for cigarette tax increases. Preventive

Medicine, 27(2), 157–165.

Geist, H. J. (1999). Global assessment of deforestation related

to tobacco farming. Tobacco Control, 8(1), 18–28.

Gillon, R. (1994). Medical ethics: four principles plus

attention to scope. British Medical Journal, 309(6948),

184–188.

Glied, S. (2003). Is smoking delayed smoking averted?

American Journal of Public Health, 93(3), 412–416.

Goodin, R. E. (1989). No smoking: the ethical issues. Chicago:

Chicago University Press.

Gostin, L. (2000). Public health law: power, duty, restraint.

Berkeley: University of California Press.

Gottlieb, S. (2004). New York’s war on tobacco produces

record fall in smoking. British Medical Journal, 328(7450),

1222.

Gruber, J. (2002). The economics of tobacco regulation. Only

the costs that smokers impose on others justify a mandate

for government action. Health Affairs (Millwood), 21(2),

146–162.

Gruber, J., & Koszegi, B. (2002). A theory of government

regulation of addictive bads: optimal tax levels and tax

incidence for cigarette excise taxation. Working Paper 8777.

Cambridge, Massachusetts: National Bureau of Economic

Research.

Gruber, J., & Mullainathan, S. (2002). Do cigarette taxes make

smokers happier? Cambridge, Massachusetts: National

Bureau of Economic Research.

Guindon, G. E., Tobin, S., & Yach, D. (2002). Trends and

affordability of cigarette prices: Ample room for tax

increases and related health gains. Tobacco Control, 11(1),

35–43.

Hanson, J., & Kysar, D. (1999). Taking behavioralism

seriously: some evidence of market manipulation. Harvard

Law Review, 112(7), 1420–1572.

Health Canada (2003). Canadian tobacco use monitoring survey

(CTUMS): trends in the prevalence of current smokers.

Ottawa: Health Canada. Accessed April 25, 2004. http://

www.hc-sc.gc.ca/hecs-sesc/tobacco/research/ctums/index.html.

Hersch, J., & Viscusi, W. (1998). Smoking and other risky

behaviors. Journal of Drug Issues, 28(3), 645–656.

Hill, S. E., Blakely, T. A., Kawachi, I., & Woodward, A. (2004).

Mortality among ‘‘never smokers’’ living with smokers: two

cohort studies, 1981–4 and 1996–9. British Medical Journal,

328(7446), 988–989.

Hopkins, D. P., Briss, P. A., Ricard, C. J., Husten, C. G.,

Carande-Kulis, V. G., Fielding, J. E., et al. (2001). Reviews

of evidence regarding interventions to reduce tobacco use

and exposure to environmental tobacco smoke. American

Journal of Preventive Medicine, 20(2S), 16–66.

IARC (International Agency for Research on Cancer). (2002).

Involuntary smoking (Group 1) 5. Summary of Data

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659658

Reported and Evaluation, Vol. 83. http://monographs.

iarc.fr/htdocs/monographs/vol83/02-involuntary.html.

Jamieson, P., & Romer, D. (2001). What do young people think

they know about the risks of smoking? In P. Slovic (Ed.),

Smoking: risk, perception and policy. Thousand Oaks, CA:

Sage Publications.

Jefferis, B., Power, C., Graham, H., & Manor, O. (2004).

Effects of childhood socioeconomic circumstances on

persistent smoking. American Journal of Public Health,

94(2), 279–285.

Jha, P., & Chaloupka, F. J. (1999). Curbing the epidemic:

government and the economics of tobacco control. Washing-

ton DC: The World Bank.

Jha, P., & Chaloupka, F. J. (2000). The economics of global

tobacco control. British Medical Journal, 321(7257),

358–361.

Kass, N. E. (2001). An ethics framework for public

health. American Journal of Public Health, 91(11),

1776–1781.

King, G., Mallett, R. K., Kozlowski, L. T., & Bendel, R. B.

(2003). African American’s attitudes toward cigarette excise

taxes. American Journal of Public Health, 93(5), 828–834.

Klein, D. B. (1997). Liberty, dignity, and responsibility.

Independent Review, 1(3), 325–341.

Lando, H., Thai, D., Murray, D., Robinson, L., Jeffery, R.,

Sherwood, N., et al. (1999). Age of initiation, smoking

patterns, and risk in a population of working adults.

Preventive Medicine, 29(6 Part 1), 590–598.

Laux, F. (2000). Addiction as a market failure: using rational

addiction results to justify tobacco regulation. Journal of

Health Economics, 19(4), 421–437.

Liang, L., Chaloupka, F., Nichter, M., & Clayton, R. (2003).

Prices, policies and youth smoking, May 2001. Addiction,

98(Suppl. 1), 105–122.

Lightwood, J. M., & Glantz, S. A. (1997). Short-term economic

and health benefits of smoking cessation: myocardial

infarction and stroke. Circulation, 96(4), 1089–1096.

Lightwood, J. M., Phibbs, C. S., & Glantz, S. A. (1999). Short-

term health and economic benefits of smoking cessation:

low birth weight. Pediatrics, 104(6), 1312–1320.

Lowey, H., Tocque, K., Bellis, M. A., & Fullard, B. (2003).

Smoking cessation services are reducing inequalities. Journal

of Epidemiology and Community Health, 57(8), 579–580.

Marsh, A., & McKay, S. (1994). Poor smokers. London: Policy

Studies Institute.

Max, W. (2001). The financial impact of smoking on health-

related costs: a review of the literature. American Journal of

Health Promotion, 15(5), 321–331.

McLachlan, H. V. (1995). Smokers, virgins, equity and health

care costs. Journal of Medical Ethics, 21(4), 209–213.

McLachlan, H. V. (2002). Tobacco, taxation, and fairness.

Journal of Medical Ethics, 28(6), 381–383.

Metzinger, T. (2003). Being no one: the self-model theory of

subjectivity. Cambridge, Massachusetts: The MIT Press.

Orphaides, A., & Zervos, D. (1998). Myopia and addictive

behaviour. Economic Journal, 108(446), 75–92.

Osinubi, O., & Slade, J. (2002). Tobacco in the workplace.

Occupational Medicine, 17(1), 137–158.

Parrott, A. (1995). Smoking cessation leads to reduced stress,

but why? International Journal of Addiction, 30(11),

1509–1516.

Parrott, A. (1998). Nesbitt’s paradox resolved? Stress and

arousal modulation during cigarette smoking. Addiction,

93(1), 27–39.

Parrott, S., Godfrey, C., & Raw, M. (2000). Cost of employee

smoking in the workplace in Scotland. Tobacco Control,

9(2), 187–192.

Peck, R., Chaloupka, F. J., Jha, P., & Lightwood, J. M. (2000).

A welfare analysis of tobacco use. In P. Jha, & F.

Chaloupka (Eds.), Tobacco control in developing countries.

Oxford: Oxford University Press.

Peto, R., Lopez, A. D., Boreham, J., Thun, M., & Heath, C., Jr.

(1994). Mortality from smoking in developed countries

1950–2000. Oxford: Oxford University Press.

Pontieri, F., Tanda, G., Orzi, F., & Di Chiara, G. (1996).

Effects of nicotine on the nucleus accumbens and similarity

to those of addictive drugs. Nature, 382(6588), 255–257.

Rasmussen, S. R., Prescott, E., Sørensen, T. I. A., & Søgaard, J.

(2004). The total lifetime costs of smoking. European

Journal of Public Health, 14(1), 95–100.

Remler, D.K. (2004). Poor smokers, poor quitters, and

cigarette tax regressivity. American Journal of Public Health,

94(2), 225–229.

Ringel, J. S., & Evans, W. N. (2001). Cigarette taxes and

smoking during pregnancy. American Journal of Public

Health, 91(11), 1851–1856.

Roberts, M. J., & Reich, M. R. (2002). Ethical analysis in

public health. Lancet, 359(9311), 1055–1059.

Schoenbaum, M. (1997). Do smokers understand the mortality

effects of smoking? American Journal of Public Health,

87(5), 755–759.

SCTH (Scientific Committee on Tobacco and Health) (1998).

Report of the scientific committee on tobacco and health

(Publication No. 011322124x). London: Her Majesty’s

Stationery Office.

Shibuya, K., Ciecierski, C., Guindon, E., Bettcher, D. W.,

Evans, D. B., & Murray, C. J. (2003). WHO Framework

Convention on Tobacco Control: development of an

evidence based global public health treaty. British Medical

Journal, 327(7407), 154–157.

Siahpush, M., Borland, R., & Scollo, M. (2003). Smoking and

financial stress. Tobacco Control, 12(1), 60–66.

Siegel, M., & Doner, L. (1998). Marketing public health:

strategies to promote social change. Gaithersberg, Maryland:

Aspen Publishers.

Slovic, P. (2001). Smokers: rational actors or rational fools. In

P. Slovic (Ed.), Smoking: risk, perception, and policy.

London: Sage Publications.

Smith, C. (2003). Theorizing religious effects among American

adolescents. Journal for the Scientific Study of Religion,

42(1), 17–31.

Smith, V. R., & Bopp, A. E. (1999). Smokers and taxes. Journal

of Medical Ethics, 25(5), 419.

Stellman, S. D., & Resnicow, K. (1997). Tobacco smoking,

cancer and social class. IARC Scientific Publications(138),

229–250.

Stolerman, I., & Jarvis, M. (1995). The scientific case

that nicotine is addictive. Psychopharmacology, 117(1),

2–10.

Tate, J., Pomerleau, C., & Pomerleau, O. (1994). Pharmacolo-

gical and non-pharmacological smoking motives: a replica-

tion and extension. Addiction, 89(3), 321–330.

ARTICLE IN PRESSN. Wilson, G. Thomson / Social Science & Medicine 61 (2005) 649–659 659

Tauber, A. I. (2003). A philosophical approach to rationing.

Medical Journal of Australia, 178(9), 454–457.

Thomson, G. W., Wilson, N. A., O’Dea, D., Reid, P. J., &

Howden-Chapman, P. (2002). Tobacco spending and

children in low income households. Tobacco Control,

11(4), 372–375.

Tobias, M., Cheung, J. (2001). Inhaling inequality: tobacco’s

contribution to health inequality in New Zealand. Public

Health Intelligence Occasional Bulletin No. 7. Wellington:

Ministry of Health.

Townsend, J. L., Roderick, P., & Cooper, J. (1994). Cigarette

smoking by socioeconomic group, sex and age: effects of

price, income, and health publicity. British Medical Journal,

309(6959), 923–926.

Tsai, Y. W., Yen, L. L., Yang, C. L., & Chen, P. F. (2003).

Public opinion regarding earmarked cigarette tax in Taiwan.

BMC Public Health, 3(1), 42.

Viscusi, W. (1998). Smoke and mirrors. Brookings Review,

16(1), 14–19.

Viscusi, W. (1999). Using warnings to extend the boundaries of

consumer sovereignty. Harvard Journal of Law & Public

Policy, 23(1), 211–223.

Warner, K. E. (2000). The economics of tobacco: myths and

realities. Tobacco Control, 9(1), 78–89.

Wegner, D. M. (2002). The illusion of conscious will. Cambridge,

Massachusetts: MIT Press.

West, R., & Hajek, P. (1997). What happens to anxiety levels on

giving up smoking? American Journal of Psychiatry, 154(11),

1589–1592.

WHO (World Health Organization) (1999). International

consultation on environmental tobacco smoke (ETS) and

child health. Consultation Report. Geneva: World Health

Organization.

Whooley, M. A., Boyd, A. L., Gardin, J. M., & Williams, D. R.

(2002). Religious involvement and cigarette smoking in

young adults. Archives of Internal Medicine, 162(14),

1604–1610.

Wilson, N., Thomson, G., Tobias, M., & Blakely, T. (2004).

How much downside?: quantifying the relative harm from

tobacco taxation. Journal of Epidemiology and Community

Health, 58(6), 451–454.

Wilson, T. D. (2002). Strangers to ourselves: discovering the

adaptive unconscious. Cambridge, Massachusetts: Belknap

Press of Harvard University Press.

Wiltshire, S., Bancroft, A., Amos, A., & Parry, O. (2001).

‘‘They’re doing people a service’’—qualitative study of

smoking, smuggling, and social deprivation. British Medical

Journal, 323(7306), 203–207.