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.