3.34 Public perceptions of tobacco as a drug, and knowledge and beliefs about the health consequences of smoking

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 2022-23, 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, 24% in 2016, 19% in 2019, and 17% in 2022-23).¹ The drug perceived in 2022-23 to be associated with the most deaths was alcohol (39%), followed by tobacco (17%) and meth/amphetamine (15%)—see Table 3.34.1. Males were more likely to nominate tobacco than females (20% compared with 17%) and people aged in their 60s were the most likely to nominate tobacco (24%), while people aged 18-24 were the least likely to nominate tobacco (10%).¹

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). Consistent with results from 2019, fewer than eight percent of people thought tobacco smoking was of most concern to the general community in 2022–2023. Teenagers (aged 14–17) were more concerned about tobacco (14.8%) than any other age group.¹

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

Of all drugs used in Australia, alcohol had the greatest degree of personal approval in 2022-23, followed by cannabis, tobacco, hallucinogens, and tranquilisers/sleeping pills (Table 3.34.4). Between 2013 and 2016, there was a significant increase in the proportion of Australians who approved of the use of tobacco (15.7%), this decreased slightly in 2019 to 15.4% and remained much the same in 2022-23 at 15.5%. People in the lowest socioeconomic area approved of regular tobacco use by adults more often than those in the highest socioeconomic area (18.5% compared with 12.4%). Unsurprisingly, recent users of tobacco were substantially more likely to approve of its regular use.¹

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 full scope and probability of disease caused by smoking. Australian research conducted in 2005 found that most people who smoke lacked a thorough understanding of smoking-related disease. When asked about diseases that are caused by smoking, people who smoke spontaneously identified lung cancer most often (55%), followed by emphysema (35%), and heart disease/attack (35%). Less than 10% spontaneously identified stroke/vascular disease, eye problems, and mouth/oral cancer, and less than 1% spontaneously identified gangrene and pregnancy complications. However, when prompted, most people who smoke accepted that smoking causes a wide range of illnesses, with the exception of miscarriage and gangrene.² A 2018 study found that  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

Research conducted in 2024⁴ indicated that many Australians who smoke underestimate the harm of low-rate or occasional smoking, influenced by a common misbelief that reducing smoking significantly lowers health risks. Research shows that low-rate or occasional smoking still carries substantial health risks; for example, smoking just one cigarette per day can result in nearly half the cardiovascular risk associated with smoking 20 cigarettes per day, and low levels of smoking still significantly increase risks of cancer and overall mortality.⁵ The misbelief that reducing smoking significantly lowers health risks is particularly prevalent among those who smoke infrequently or use both cigarettes and e-cigarettes. Overall, 72% of people who smoke viewed reducing the number of cigarettes smoked as an effective way to lower risk, a misperception more common among individuals smoking fewer than five cigarettes per day or smoking occasionally, compared with those smoking more than five cigarettes daily. Additionally, 67.9% underestimated the risks associated with smoking a single cigarette per day, with this perception more prevalent among low-rate smokers (77.6%) than those smoking five or more cigarettes daily (63.1%).⁴ See Section 3.36 for more on the health effects of occasional (“social”) smoking and cutting down.

International research has shown wide variation in people who smoke’s 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 people who smoke 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.^6,7 Research in the US found that the proportion of people who perceived that people who smoke place themselves at great risk of harm declined between 2006 and 2015, both among people who smoke and non-smokers.⁸ 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 people considerably underestimated the relative risk of smoking.⁹ In a 2021 nationally representative study,¹⁰ researchers found that while most US adults recognised smoking as a cause of lung cancer, awareness of its link to other health issues varied widely. Those who were older, less educated, or had limited exposure to anti-tobacco campaigns were generally less likely to recognise that an established health effect was caused by smoking. People who smoke with lower nicotine dependence and worse health were generally more likely to agree that an established health effect was caused by smoking.¹⁰

Beliefs about the addictiveness of smoking also vary. Although most adults who smoke 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.¹¹ Young people especially tend to be optimistic about their ability to quit before their smoking became problematic, and many young people who smoke do not believe that they are addicted.¹² (See Sections 6.13 and 6.14)

Even when informed about health risks, many people who smoke tend to believe that they personally are at lesser risk than others who smoke.¹³ Further, even after acknowledging the harms of smoking, people who smoke may adopt beliefs that serve to minimise the severity, importance, or impact of such risks, and to rationalise the behaviour^14,15 (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) or 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 knowledge and quitting behaviours see InDepth 12A and Chapter 14. 

Relevant news and research

For recent news items and research on this topic, click here. (Last updated December 2024)

References

1. Australian Institute of Health Welfare. National Drug Strategy Household Survey 2022–2023. Canberra: AIHW, 2024. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey.

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. Brennan E, Nuss T, Haynes A, Scollo M, Winnall WR, et al. Misperceptions about the effectiveness of cutting down and low-rate daily smoking for reducing the risk of tobacco-caused harm. Nicotine and Tobacco Research, 2024. Available from: https://doi.org/10.1093/ntr/ntae263

5. Hackshaw A, Morris JK, Boniface S, Tang JL, and Milenkovic D. Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports. Bmj, 2018; 360:j5855. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29367388

6. 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. Tob Control, 2006; 15 Suppl 3(suppl 3):iii65–70. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16754949

7. 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

8. 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

9. 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

10. Mills SD and Wiesen CA. Beliefs About the Health Effects of Smoking Among Adults in the United States. Health Education and Behavior, 2021:10901981211004136. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33870757

11. 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 and Tobacco Research, 2017; 20(9):1038–46. Available from: https://doi.org/10.1093/ntr/ntx186

12. 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

13. 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

14. 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

15. 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