After twenty years of anti-smoking campaigns, graphic warnings, and stricter regulations, the message that tobacco causes lung cancer has clearly landed. But a major new study suggests that the cardiovascular dangers of smoking—and of second-hand smoke—remain dangerously under-appreciated, both in Europe and globally.
Research published in BMJ Open draws on data from more than 240,000 adult smokers across 46 countries, collected between 2002 and 2022. The findings show that while over 90% of respondents knew smoking can cause lung cancer, only about 80% identified heart disease as a consequence, and even fewer were aware of the elevated risk of stroke or the dangers posed to non-smokers by second-hand smoke.
“Knowledge gaps about the major health effects of smoking and second-hand smoke are deeply concerning,” said Janet Chung-Hall, lead author and research scientist at the University of Waterloo’s International Tobacco Control Policy Evaluation Project (ITC Project). With smoking responsible for more than two million cardiovascular deaths worldwide each year, she added, “low awareness of the cardiovascular harms of smoking and second-hand smoke is particularly troubling.”
Cardiovascular diseases are the leading cause of premature death from non-communicable diseases globally, and smoking is one of the most significant modifiable risk factors. The study’s authors argue that closing these knowledge gaps could be a crucial step toward reducing smoking rates and protecting non-smokers.
Mixed progress across Europe
The study included several European countries, and the results are far from uniform. Awareness that smoking causes lung cancer rose significantly in the Netherlands, but declined in Germany, France, and Romania. Knowledge about the harms of second-hand smoke also fell on some measures in Germany, France, and the Netherlands.
These trends come despite the European Union’s progressive tightening of tobacco rules, including mandatory health warnings and restrictions on advertising. Previous research in six EU countries found that smokers with greater knowledge of smoking-related risks were more likely to report that package warnings had a stronger impact on them.
“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 professor of psychology and public health sciences at 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.”
The study’s authors stress that awareness alone is not enough, but it is a necessary foundation for behaviour change. They call for renewed public health messaging that goes beyond cancer to emphasise the immediate and long-term damage smoking does to the heart and blood vessels.
Europe’s tightening tobacco rules
The findings arrive as several European countries move to restrict tobacco and nicotine products further, particularly to curb youth uptake. In April, the United Kingdom passed an anti-tobacco bill that will permanently ban the sale of tobacco products to anyone born on or after 2008, aiming to create a “smoke-free” generation.
Belgium and Latvia banned disposable vapes in January 2025, citing their appeal to young people and environmental concerns. Spain and France introduced new restrictions on outdoor smoking in public spaces last year. The European Commission has set a goal of a “tobacco-free generation” by 2040, aiming to reduce smoking rates to below 5% from the current level of around 25%.
The EU has already banned flavoured traditional cigarettes and roll-your-own tobacco, including menthol, under the Tobacco Products Directive. It is currently running a consultation on new tobacco and nicotine products, which closes on Friday.
For health campaigners, the new study is a reminder that regulation alone may not be enough. As daily stair climbing has been linked to lower heart disease risk, the contrast between simple protective measures and the persistent dangers of smoking is stark. The authors argue that sustained, well-funded public education campaigns—especially those that highlight cardiovascular risks—must remain a priority alongside legislative measures.
“The fact that awareness has barely budged in two decades is a wake-up call,” said Chung-Hall. “We need to rethink how we communicate the risks, not just repeat the same messages.”
