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We conducted individual-level analyses of the ITC and GATS data separately, without combining the datasets or analysing previously published summary statistics. Generalised estimating equations and weighted multinomial regression models assessed country-level prevalence of knowledge for three smoking and two SHS outcomes. Multilevel models estimated mean prevalence across all countries and tested within-country linear trends over time for five disease indicators by survey. Across 12 countries with data from both surveys, correlations between ITC and GATS assessed consistency across indicators.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Knowledge that smoking causes lung cancer was highest (ITC=92.2%, GATS=91.9%), followed by heart disease (ITC=84.7%)\/heart attack (GATS=80.0%) and stroke (ITC=75.0%, GATS=66.1%). Knowledge that SHS causes lung cancer (ITC=77.3%, GATS=82.1%) was highest, followed by heart attack (ITC=61.8%)\/heart disease (GATS=72.5%) (all p&lt;0.0001). In ITC and GATS countries, the average change in knowledge across the five diseases was +0.14% per year. There was agreement between the ITC and GATS data (range: Pearson correlations=0.60\u20130.81 across the five indicators).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>There is a need to improve and sustain people\u2019s knowledge of diseases caused by smoking and SHS, especially CVD risks.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-107667","type":"journal-article","created":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T11:55:47Z","timestamp":1785844547000},"page":"e107667","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Changes in knowledge of the major harms of tobacco smoking and secondhand smoke exposure among adults who smoke: findings from 26 countries of the International Tobacco Control (ITC) Project (2002\u20132022) and 32 countries of the Global Adult Tobacco Survey (GATS) (2008\u20132020)"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9139-8100","authenticated-orcid":false,"given":"Janet","family":"Chung-Hall","sequence":"first","affiliation":[{"name":"School of Psychology, University of Waterloo, Waterloo, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9098-6472","authenticated-orcid":false,"given":"Geoffrey T","family":"Fong","sequence":"additional","affiliation":[{"name":"School of Psychology, University of Waterloo, Waterloo, Ontario, Canada"},{"name":"School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada"},{"name":"Ontario Institute for Cancer Research, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7771-7881","authenticated-orcid":false,"given":"Gang","family":"Meng","sequence":"additional","affiliation":[{"name":"School of Psychology, University of Waterloo, Waterloo, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorraine V","family":"Craig","sequence":"additional","affiliation":[{"name":"School of Psychology, University of Waterloo, Waterloo, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-0732-8419","authenticated-orcid":false,"given":"Eunice O","family":"Indome","sequence":"additional","affiliation":[{"name":"School of Psychology, University of Waterloo, Waterloo, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"for the ITC Project Collaborators","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6601-7097","authenticated-orcid":false,"given":"Alissa C","family":"Kress","sequence":"additional","affiliation":[{"name":"National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-7782-5323","authenticated-orcid":false,"given":"Jing","family":"Shi","sequence":"additional","affiliation":[{"name":"National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Georgia, USA"},{"name":"Noninfectious Disease Programs, CDC Foundation Inc, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5985-3356","authenticated-orcid":false,"given":"Indu B","family":"Ahluwalia","sequence":"additional","affiliation":[{"name":"National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,4]]},"reference":[{"key":"2026080404551364000_16.8.e107667.1","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(20)30752-2"},{"key":"2026080404551364000_16.8.e107667.2","unstructured":"World Health Organization . 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