Smokers know tobacco causes cancer. They’re less clear on the heart risks

A new research covering more than 240,000 smokers across 46 countries finds little progress in understanding the cardiovascular damage caused by tobacco — raising questions about whether decades of health warnings are getting through. After two decades of tobacco-control efforts, smokers know that cigarettes can cause lung cancer. Far fewer appear to know that the same cigarettes can trigger heart disease, heart attacks and strokes — not only in smokers but also in people around them. A major international study published in BMJ Open found that awareness of the health consequences of smoking has barely improved over the past two decades, despite years of tobacco-control policies, graphic warnings and public-health campaigns. “Knowledge gaps about the major health effects of smoking and second-hand smoke are deeply concerning,” Janet Chung-Hall, Research Scientist for the International Tobacco Control Policy Evaluation Project (ITC Project) at the University of Waterloo and the lead author of the study, said in a press release. With smoking being responsible for over 2 million cardiovascular deaths worldwide each year, “low awareness of the cardiovascular harms of smoking and second-hand smoke is particularly troubling,” Chung-Hall added, calling on authorities to increase public awareness. Cardiovascular diseases are the leading cause of premature death from non-communicable diseases worldwide, and smoking is one of the major modifiable risk factors. Researchers analysed data from more than 240,000 adults who smoke across 46 countries, drawing on the International Tobacco Control Project and the World Health Organization’s Global Adult Tobacco Survey. The research covers surveys conducted between 2002 and 2022. While over 90% of respondents knew that smoking can cause lung cancer, only about 80% identified heart disease as a consequence of smoking and even fewer knew about the stroke risk as well as second-hand smoke risks. Getting the message through in Europe The study involved European countries too. Researchers found that awareness that smoking causes lung cancer increased significantly in the Netherlands, but declined in Germany, France and Romania, among others. Knowledge of the dangers of second-hand smoke also fell for some measures in Germany, France and the Netherlands. The European Union has progressively tightened its tobacco rules, including requirements for health warnings and restrictions on tobacco advertising and promotion. Previous research in six EU countries found that smokers who had greater knowledge of smoking-related risks were also more likely to report stronger effects from cigarette-package warnings. “Knowledge is an important first step toward quitting smoking and protecting others from second-hand smoke,” said Geoffrey T. Fong, Principal Investigator of the ITC Project and University Professor of Psychology and Public Health Sciences at the University of Waterloo. “Our findings highlight the need for governments to implement stronger, sustained public education about the cardiovascular as well as cancer risks of smoking and second-hand smoke. Tobacco ban in Europe The findings come as several European countries tighten restrictions on tobacco and nicotine products, as part of a broader push to reduce smoking rates among youth. In April, the United Kingdom passed an anti-tobacco bill, permanently restricting sales of tobacco products to anyone born on or after 2008 to create a ‘smoke-free’ generation. Belgium and Latvia banned the sale of disposable vapes in January 2025, citing concerns about their appeal to young people and environmental impact. Meanwhile, Spain and France introduced new regulations to restrict outdoor smoking in public spaces last year. The European Commission aims for a "tobacco-free generation" by 2040, reducing smoking rates to less than 5%, compared to around 25%, which it stands at today. The European Commission banned flavoured traditional cigarettes and roll-your-own tobacco with characterising flavours, including menthol, in the past decade under the EU Tobacco Products Directive. It is currently running a consultation on new tobacco and nicotine products, which ends on Friday. Tobacco use is the leading preventable cause of disease and death worldwide. According to the World Health Organization (WHO), it kills more than 7 million people each year, including over 1.6 million non-smokers who are exposed to second-hand smoke.