A risk of global stagnation in policies to raise awareness of the dangers of tobacco

Over the past two decades, knowledge among adult smokers about the dangers of tobacco has made little progress internationally. A study published in BMJ Open drew on two major data sources: the International Tobacco Control (ITC) project, which covered 26 countries between 2002 and 2022, and the Global Adult Tobacco Survey (GATS), which covered 32 countries between 2008 and 2020. Researchers observed that, among more than 240,000 adults surveyed, information levels remained high regarding the link between tobacco and lung cancer, but significantly lower for cardiovascular disease and the effects of secondhand smoke.[1].

Well-identified risks such as lung cancer

The main finding of the study is the strong recognition of the link between smoking and lung cancer. In the most recent data available for each country, 92.2% of adult smokers surveyed in ITC countries knew that smoking could cause lung cancer. The proportion reached 91.9% in GATS countries. This result confirms that lung cancer has become the health risk most strongly associated with smoking in the public's awareness. Prevention campaigns, health warnings, and the visibility of this disease in the public sphere have likely contributed to this high level of awareness.

However, this knowledge is not entirely uniform. Within the ITC group, awareness of lung cancer risk increased significantly in China, the Netherlands, Bangladesh, and India. Conversely, it decreased in Japan, Germany, France, Romania, Russia, and Turkey. These trends alone do not allow us to identify the precise causes of the observed changes. They may be related to the frequency and content of awareness campaigns, changes in product warnings, tobacco control policies, or even transformations in social perceptions of smoking.

Cardiovascular risks are less well understood

Knowledge of the cardiovascular effects of tobacco use is significantly lower than knowledge of the risk of lung cancer. In ITC countries, 84.7% of adult smokers knew that smoking could cause heart disease. In GATS countries, 80% knew that it could cause a heart attack. Knowledge of the risk of stroke was even lower: 75% of respondents in ITC countries and 66.1% in GATS countries were aware of it.

This gap in knowledge is significant from a public health perspective. In the public imagination, tobacco is often associated with respiratory illnesses and cancers. Its role in cardiovascular diseases may be less visible, even though the mechanisms involved are multiple: damage to blood vessels, increased risk of thrombosis, elevated blood pressure, and worsening of atherosclerosis.

Passive smoking remains a blind spot

Knowledge of the risks associated with secondhand smoke is generally lower than that concerning active smoking. In ITC countries, 77.3% of adult smokers knew that exposure to secondhand smoke could cause lung cancer in non-smokers. In GATS countries, this proportion reached 82.1%. Knowledge of the cardiovascular effects of secondhand smoke was more limited. In the ITC data, 61.8% of participants knew that this exposure could cause a heart attack. In the GATS data, 72.5% associated secondhand smoke with heart disease in non-smokers.

Here again, the results vary considerably between countries. In the ITC data, awareness of the risk of lung cancer linked to secondhand smoke has increased significantly in Australia, China, India, Bangladesh, and Thailand. However, it has declined in Germany, New Zealand, France, and Uruguay. Regarding awareness of the risk of heart attack associated with secondhand smoke, progress has been observed in Bangladesh, India, the Netherlands, Kenya, and China. Conversely, declines have been recorded in Australia, Malaysia, Japan, and New Zealand.

Among GATS countries, Vietnam is the only country to have recorded significant progress for both indicators related to passive smoking. These results demonstrate a highly heterogeneous trend depending on national contexts.

An average increase of almost no progress

Despite decades of prevention efforts, the overall evolution of knowledge appears very limited. The average net change observed for the five indicators was only 0.14 percentage points per year, which corresponds to virtually no progress. Stroke is the only indicator to have increased on average in both datasets. Conversely, knowledge of the link between smoking and lung cancer decreased slightly in both databases, despite a very high starting level.

In most countries and for the majority of risks studied, no statistically significant changes were observed. National trends therefore fall into three categories: improved knowledge for some risks, sustained stability, and a decline in awareness in some countries and for some indicators.

These results do not mean that information campaigns are ineffective. Rather, they show that a high level of knowledge about a given risk can be difficult to maintain and that general information about the dangers of tobacco does not guarantee a precise understanding of all the diseases involved.

Implications for tobacco prevention policies

The authors believe that tobacco control policies should place greater emphasis on the cardiovascular risks and those of secondhand smoke. Among the many recommendations of the WHO Framework Convention on Tobacco Control (FCTC), clear and visible health warnings, mass media campaigns, and smoke-free environments could be used in a complementary manner.

Prevention messages could include reminders that tobacco not only causes cancer, but also heart attacks and strokes; explaining that cardiovascular diseases can occur without prior respiratory symptoms; specifying that passive smoking also exposes non-smokers to serious risks; regularly renewing messages to avoid trivialization or loss of attention; or adapting campaigns to the levels of knowledge specific to each country and each social group.

However, knowledge alone is not enough to change behavior. A person may know that tobacco is dangerous but continue to smoke due to nicotine addiction, their social environment, stress, economic difficulties or insufficient access to smoking cessation support. The authors therefore emphasize the importance of combining information with support measures, smoke-free environments, and accessible cessation support services.

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[1]Chung-Hall J., Fong GT, Meng G., et al., Changes in knowledge of the major harms of tobacco smoking and secondhand smoke exposure among adults who smoke: findings from 26 countries of the International Tobacco Control (ITC) Project (2002–2022) and 32 countries of the Global Adult Tobacco Survey (GATS) (2008–2020), BMJ Open, published on August 4, 2026, accessed on August 7, 2026

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