Last updated: July 2020
Suggested citation: Greenhalgh, EM, Purcell, K, Hanley-Jones, S & Winstanley, MH. 3.34 Public perceptions of tobacco as a drug, and knowledge and beliefs about the health consequences of smoking. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2020. Available from https://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-34-public-perceptions-of-tobacco-as-a-drug-and-k
3.34.1 Australian attitudes to tobacco as a drug
Although the prevalence of smoking is declining in Australia, the impact of smoking remains substantial. As outlined in Section 3.30, tobacco continues to be responsible for the vast majority of drug-related deaths in Australia—more than alcohol and illicit drug use combined. Findings from the National Drug Strategy Household Survey in 2019, however, show a decline in the proportion of people agreeing with the (correct) statement that tobacco is the drug that causes the most deaths in Australia (decreasing from 36% of Australians 14 and over in 2010 to 32% in 2013 to 24% in 2016 and 19% in 2019).1 The drug perceived in 2019 to be associated with the most deaths was alcohol (34%), followed by meth/amphetamine (20%) and tobacco (19%)—see Table 3.34.1. Males were more likely to nominate tobacco than females (21% compared with 17%), and people aged in their 60s were the most likely to nominate tobacco (24%), while people aged 14-17 were the least likely to nominate tobacco (13%).1
Drugs thought either to directly or indirectly cause the most deaths in Australia, population aged 14 and over, Australia 2010, 2013, 2016 and 2019
Source: Source: National Drug Strategy Household Survey 2019 key findings, Table 9.31
Note: # indicates statistically significant change between 2013 and 2016, or between 2016 and 2019.
Tobacco also does not rank highly as ‘the drug thought to be of most serious concern for the community,’ presumably reflecting the greater social disruption caused by alcohol and illegal drugs (Table 3.34.2). Alongside a substantial increase between 2013 and 2016 and a slightly higher increase again in 2019 in the proportion of people selecting meth/amphetamine (40.3%) as the drug of most concern, there was a significant decrease from 2013 to 2016 and then again from 2016 to 2019 among those nominating tobacco. For the first time, fewer than eight percent of people thought tobacco smoking was of most concern to the general community. Teenagers (aged 14–17) were more concerned about tobacco (14.8%) than any other age group.1
Drug thought to be of most concern for the general community, people aged 14 years or older, Australia—2010, 2013, 2016 and 2019
Source: Source: National Drug Strategy Household Survey 2019 key findings, Table 9.51
Note: (a) For non-medical purposes
# indicates statistically significant change between 2013 and 2016, or between 2016 and 2019.
Again presumably reflecting the social disruption caused by other drug use, very few Australians think of tobacco when they think of a ‘drug problem’ (Table 3.34.3).1
Drug first nominated when asked about a specific drug problem, people aged 14 years or older, Australia—2010, 2013, 2016 and 2019
Source: National Drug Strategy Household Survey 2019 key findings, Table 9.11
Note: # indicates statistically significant change between 2013 and 2016 and between 2016 and 2019.
Of all drugs used in Australia, alcohol had the greatest degree of personal approval in 2019, followed by cannabis, tobacco , and prescription pain-killers (used for non-medical purposes)(Table 3.34.4). Between 2013 and 2016, there was a significant increase in the proportion of Australians who approve of the use of tobacco (15.7%), this decreased slightly in 2019 to 15.4%. People in the lowest socioeconomic area approved of regular tobacco use by adults more often than those in the highest socioeconomic area (20.1% compared with 11.9%). Unsurprisingly, recent users of tobacco were substantially more likely to approve of its regular use.1
Personal approval of the regular use by an adult of selected drugs, population aged 14 and over, Australia—2010, 2013, 2016 and 2019
Source: National Drug Strategy Household Survey 2019 key findings, Table 9.71
Note: (a) For non-medical purposes
# indicates statistically significant change between 2013 and 2016, or between 2016 and 2019
3.34.2 Public awareness of the health effects of smoking
Although most Australian smokers have a general understanding that smoking poses health risks, many are unaware of the breadth and likelihood of disease caused by smoking. Australian research conducted in 2005 found that most smokers lacked a thorough understanding of smoking-related disease. When asked about diseases that are caused by smoking, smokers spontaneously identified lung cancer most often (55%), followed by emphysema (35%), and heart disease/attack (35%). Less than 10% of smokers spontaneously identified stroke/vascular disease, eye problems, and mouth/oral cancer, and less than 1% of smokers spontaneously identified gangrene and pregnancy complications. However, when prompted, most smokers accepted that smoking causes a wide range of illnesses, with the exception of miscarriage and gangrene.2 A more recent study found that in 2017, Australians still had limited awareness of many serious harms of tobacco. When asked if smoking increases a person’s risk of 23 smoking-related conditions, only nine conditions were selected by more than two-thirds of participants (lung cancer; throat cancer; mouth cancer; disease of the teeth and gums; heart disease; emphysema; stroke; oesophageal cancer; and poor outcomes after surgery). Six cancers were selected by fewer than two-thirds, and rheumatoid arthritis had the lowest level of awareness.3
International research has similarly shown wide variation in smokers’ understanding of the diseases caused by smoking. Findings from the 2002 International Tobacco Control (ITC) Four Country Survey showed that in Australia, the US, Canada, and the UK most smokers were aware of the association of smoking with heart disease and lung cancer. Awareness that smoking causes other conditions such as stroke and impotence was less common, and aside from carbon monoxide, there was generally poor awareness of the constituents of cigarette smoke. Higher education, as well as living in a country with government mandated health warnings, was associated with higher awareness and knowledge.4, 5 Research in the US found that the perceived risk of smoking declined between 2006 and 2015, both among smokers and non-smokers.6 Another US study found that people naturally think about the health consequences of smoking in terms of relative risk (e.g., “how much more likely is a person to get lung cancer if he/she smokes?”), but most current smokers, former smokers, and never smokers considerably underestimated the relative risk of smoking.7
Beliefs about the addictiveness of smoking also vary. Although most adult smokers acknowledge that smoking is addictive and that they themselves are addicted, some still maintain ambivalence about their own addiction or reject being labelled “addicted”, even if they agree smoking is addictive for others.8 Young people especially tend to be optimistic about their ability to quit before their smoking became problematic, and many young smokers do not believe that they are addicted.9 (See Sections 6.13 and 6.14)
Even when informed about health risks, many smokers tend to believe that they personally are at lesser risk than other smokers.10 Further, even after acknowledging the harms of smoking, smokers may adopt beliefs that serve to minimise the severity, importance, or impact of such risks, and to rationalise the behaviour11, 12 (see Section 7.5.2). Knowledge and awareness of the health risks of smoking, and perceiving such risks as personally relevant, can play an important role in decisions to start smoking (see Section 5.6 ) and decisions to quit smoking (see Section 7.5). Communicating risks and increasing people’s knowledge of the harms of tobacco use is therefore an important aim of governments and public health advocates. For evidence on the effectiveness of public education campaigns and health warnings on smokers’ knowledge and quitting behaviours see InDepth 12A and Chapter 14.
1. Australian Institute of Health and Welfare. Data tables: National Drug Strategy Household Survey 2019 - 9. Perceptions and policy support supplementary tables. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data
2. Brennan E and Durkin S. Perceptions about the health effects of smoking and passive smoking among Victorian adults, 2003–2005. CBRC Research Paper Series No. 25, Melbourne, Australia: Centre for Behavioural Research in Cancer, The Cancer Council Victoria, 2007. Available from: https://www.cancervic.org.au/research/behavioural/research-papers/perceptions_health_smoking_05u.html.
3. Brennan E, Dunstone K, and Wakefield M. Population awareness of tobacco-related harms: Implications for refreshing graphic health warnings in Australia. Medical Journal of Australia, 2018; 209(4):173–4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29976131
4. Siahpush M, McNeill A, Hammond D, and Fong GT. Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: Results from the 2002 international tobacco control (ITC) four country survey. Tobacco Control, 2006; 15 Suppl 3(suppl 3):iii65–70. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16754949
5. Hammond D, Fong GT, McNeill A, Borland R, and Cummings KM. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: Findings from the international tobacco control (ITC) four country survey. 2006; 15(suppl 3):iii19–iii25. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/15/suppl_3/iii19.full.pdf
6. Pacek LR and McClernon FJ. Decline in the perceived risk of cigarette smoking between 2006 and 2015: Findings from a US nationally representative sample. Drug and Alcohol Dependence, 2018; 185:406–10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29496344
7. Krosnick JA, Malhotra N, Mo CH, Bruera EF, Chang L, et al. Perceptions of health risks of cigarette smoking: A new measure reveals widespread misunderstanding. PLoS ONE, 2017; 12(8):e0182063. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28806420
8. Pfeffer D, Wigginton B, Gartner C, and Morphett K. Smokers’ understandings of addiction to nicotine and tobacco: A systematic review and interpretive synthesis of quantitative and qualitative research. Nicotine & Tobacco Research, 2017; 20(9):1038–46. Available from: https://doi.org/10.1093/ntr/ntx186
9. Mantler T. A systematic review of smoking youths’ perceptions of addiction and health risks associated with smoking: Utilizing the framework of the health belief model. Addiction Research & Theory, 2012; 21(4):306–17. Available from: https://doi.org/10.3109/16066359.2012.727505
10. Weinstein ND, Marcus SE, and Moser RP. Smokers’ unrealistic optimism about their risk. 2005; 14(1):55–9. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/14/1/55.full.pdf
11. Fotuhi O, Fong GT, Zanna MP, Borland R, Yong H-H, et al. Patterns of cognitive dissonance-reducing beliefs among smokers: A longitudinal analysis from the international tobacco control (ITC) four country survey. 2013; 22(1):52–8. Available from: https://tobaccocontrol.bmj.com/content/tobaccocontrol/22/1/52.full.pdf
12. Kaufman AR, Coa KI, and Nguyen AB. Cigarette smoking risk-reducing beliefs: Findings from the United States health information national trends survey. Preventive Medicine, 2017; 102:39–43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28658608