Whether it’s Molly Ringwald in the Breakfast Club, cigarette in hand and mischief on her face or the image of Hunter S. Thompson, creator of Gonzo journalism, nearly blowing up Nixon’s plane on the campaign trail in 1972 with one of his many cigarette butts, many images of cigarettes create an appeal that was never about nicotine or addiction. It was about the act of defiance and the sweet smell of being different.

Even banned from restaurants, parks, and public spaces, cigarettes and the people who smoke them have always seemed cool.

As Gregor Hans explained in his book Nicotine, “every cigarette that I’ve ever smoked served a purpose—they were a signal, medication, a stimulant or a sedative, they were a plaything, an accessory, a fetish object, something to help pass the time, a memory aid, a communication tool or an object of meditation. Sometimes…all at once.”

So good and yet so bad

May was Anti-Tobacco Campaign Month, and the 31^stof that month saw the World Health Organization (WHO) focus World No Tobacco Day 2018 on the impact that tobacco has on the cardiovascular system – namely how tobacco use is linked to cardiovascular diseases (CVDs), including the development of coronary heart disease, stroke and peripheral vascular disease.

Though the WHO has long been advocating for the end of tobacco use globally – now that the events of last month have passed, we can see that support from governments does not really mean widespread support. In 2003 the WHO got 168 countries to sign the Framework Convention on Tobacco Control (FCTC), which is designed to reduce the effects of tobacco through legislation. Though governments in 181 countries have now signed the treaty, there are still places throughout the world where smoking in public places is acceptable, including cities in the EU and the US.

Why is it so hard to go without?

So the question that must be asked is, despite the best of intentions, why is smoking still viewed as acceptable?

Earlier this year, Bloomberg Philanthropies’ Michael Bloomberg opened an agency that will monitor the tobacco industry, its advertising and behaviours, especially in low and middle-income countries. This new agency’s purpose is to monitor deceptive tobacco industry tactics and practices that undermine public health.

A study in more than 22 countries found that though the tobacco companies have stopped advertising, promotion, and sponsorship of their products in regulated areas such as television and radio, point of sale advertising occurs worldwide, often near schools, daycares and parks. And the evidence is clear: 14% of children between 13 and 15 years old use tobacco products, and 4% smoke cigarettes, the majority of them in low- and middle-income countries.

Advertising and product placements are considered the norm. Children see actors in movies and on television smoking. They see bright coloured posters when they go into small stores for sweets and they are enchanted by the coolness of smoking, led on by peer pressure and influenced by some of the adults in their life.

The thing is, it seems like tobacco manufacturers have more worldwide influence then even the WHO and healthcare workers. A researcher on the history of science who looked at how tobacco companies spread confusion about the health ramifications of their products created a word to describe this: Agnotology.

Despite having to put images of rotting teeth, cancerous sores and other gruesome things on cigarette boxes, people still seem to not know that cigarettes and tobacco products cause harm. The WHO has been bringing attention to the health risks of tobacco use since the 1980s – World No Tobacco Day was first celebrated in 1988, on the WHO’s 40^thanniversary.

CVDs are the largest causes of death worldwide today and tobacco product use makes up about 12% of all heart disease deaths. Tobacco use kills more than 7 million people each year, including almost 900 000 people who breathe in second-hand smoke. Nearly 80% of the more than 1 billion smokers worldwide live in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest.

How to fight the agnotologists?

Though there is legislation throughout the world that is supposed to make smoking more difficult and less of a cultural icon, the reality is that some governments are not strong enough, or have other priorities then fighting tobacco companies.

In 2015, Dr Margaret Chan, the then Director-General of WHO, called on governments to take the easiest option and increase taxes on tobacco sales. Recently the Lancet published a series of articles on the economics of NCDs and one of the conclusions it came to was that increasing taxes helps public health and in the long-term is actually pro poor.

The best case scenario would be for governments to put these tax funds into campaigns to control tobacco, which would include price increases on all tobacco products, educational media, public policy with follow through at the local level, and free services to help smokers quit. Though unlikely, even higher taxes could lead to people understanding that tobacco use causes everything from cancer to erectile dysfunction. Hopefully a change in social norms is just around the corner.