Association between health literacy, tobacco use patterns, and cessation behaviors among Korean adults: a population-based cross-sectional study

Tobacco use remains a major preventable cause of disease and premature death worldwide, and identifying modifiable factors influencing tobacco-related behaviors is essential for public health policy. Health literacy has been associated with tobacco use and cessation outcomes; however, evidence from South Korea remains limited, despite the recent stalling of smoking decline, the increasing diversity of tobacco product use, and the substantial proportion of Korean adults with inadequate health literacy. We examined the associations between health literacy, tobacco use patterns, and cessation behaviors among Korean adults. Data from the 2023 and 2024 Korea National Health and Nutrition Examination Survey (KNHANES) were analyzed. The analytic sample comprised 11,346 adults aged 19 years or older. Health literacy was assessed using a 10-item self-reported instrument, with scores ≥ 30 classified as adequate. Tobacco use was categorized into non-current, single-product, and multiple-product use based on the current use of conventional cigarettes, heated tobacco products, and electronic cigarettes. Cessation behaviors included past-year quit attempts and intention to quit within 6 months. Complex sample multinomial and binomial logistic regression analyses were conducted, adjusting for sex, age, educational attainment, household income, survey year, perceived stress, weight status, and chronic disease status. Sensitivity analyses were also conducted to assess the robustness of the findings. Inadequate health literacy was associated with a higher likelihood of single-product use (relative risk ratio [RRR] = 1.24, 95% confidence interval [CI]: 1.09–1.42) and multiple-product use (RRR = 1.43, 95% CI: 1.13–1.82) relative to non-current use. No significant associations were found between health literacy and quit attempts or intention to quit. The findings remained robust in the sensitivity analyses. These findings suggest that the role of health literacy may differ across tobacco-related outcomes. Tailoring tobacco-related health communication to different health literacy levels, together with comprehensive cessation support, may contribute to more effective tobacco control.