National Analysis Reveals Shifting Tobacco Use Patterns in South Korea

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Key Points:

• Study Overview: Preventive Medicine Reports analysis of 2013–2021 Korea National Health and Nutrition Examination Survey data tracks cigarette and non-combustible product use in South Korea.

• Major Shift: Exclusive smoking fell 26.4 percent (46.1 percent → 33.9 percent), while dual use with e-cigs or heated tobacco rose from 1.05 percent to 12.76 percent.

• Dual User Profile: Younger, urban, higher income/education, more stress, poorer health perceptions, higher alcohol use.

• Health Outcomes: Dual users had higher odds of depression, allergic rhinitis, and atopic dermatitis; no difference in cardiovascular/metabolic diseases vs. smokers.

• Long-Term Trends: Smoking dropped from 35 percent in 2000 to 19 percent in 2022; growth in heated tobacco (2.6 million users) and e-cigarettes (1.6 million users) linked to steep cigarette sales declines.

• Quit Motivation: 45.2 percent of e-cig users and 15 percent of heated tobacco users cited quitting smoking as their primary reason for use.

• Global Parallel: Patterns mirror U.S. and U.K., where safer alternatives have coincided with record drops in smoking.

• Policy Takeaway: Harm reduction products can accelerate smoking declines if policies and education maximize their cessation potential.

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A new study in Preventive Medicine Reports provides further evidence of tobacco harm reduction products replacing traditional cigarette use.

Researchers analyzed nationwide trends in South Korea to “evaluate the characteristics, trends, and health outcomes of exclusive combustible cigarette users and dual users of combustible cigarettes and non-combustible nicotine or tobacco products (NNTPs).” NNTPs – such as e-cigarettes and heated tobacco products – have become increasingly popular in recent years in South Korea.

Using data from the Korea National Health and Nutrition Examination Survey (KNHANES) from 2013 to 2021, the researchers identified more than 16,000 exclusive cigarette users (defined as current cigarette use with no use of non-combusted products) and 2,142 dual users. They assessed various health outcomes, including stroke, angina, hypertension, dyslipidemia, type 2 diabetes, rheumatoid arthritis, allergic rhinitis, atopic dermatitis, and depression.

Exclusive smoking declined by 26.4 percent, from 46.1 percent in 2013 to 33.9 percent in 2021, while dual use rose sharply from 1.05 percent in 2013 to 12.76 percent in 2021, remaining above 10 percent since 2019. Dual users were more likely to be younger (ages 19–39), live in urban areas, have higher incomes and educational attainment, report more stress and poorer subjective health, and consume alcohol more frequently. Compared to exclusive smokers, dual users had higher odds of depression, atopic dermatitis, and allergic rhinitis, but there were no significant differences for type 2 diabetes, rheumatoid arthritis, dyslipidemia, stroke, hypertension, or angina.

The authors note these trends mirror patterns seen in the U.S. and U.K. Dual users tend to be younger and wealthier and may be more health-conscious, yet also exhibit riskier behavioral patterns. The elevated risks of depression and allergic conditions could be related to younger initiation ages, combined exposure to both products, and nicotine’s neurological effects on mood.

The study has limitations: it is cross-sectional and cannot prove causality, relies on self-reported data, includes a small number of exclusive NNTP users, and does not distinguish between e-cigarettes and heated tobacco products. Nonetheless, it is one of the first large-scale national analyses of dual use compared to exclusive smoking in South Korea, using a nationally representative sample.

South Korea has made significant progress in reducing smoking rates. In 2000, 35 percent of adults smoked; by 2015, this had dropped by 34.2 percent to 23 percent, and as of 2022, only 19 percent of South Koreans used tobacco. At the same time, tobacco harm reduction product use has grown. In 2022, there were 7.9 million smokers, 2.6 million heated tobacco users, and 1.6 million e-cigarette users.

The introduction and growing popularity of these products have coincided with rapid decreases in combustible cigarette use, with many adults reporting using them to quit smoking. A 2024 KNHANES analysis found that among heated tobacco users, the most common reason for use was the absence of cigarette odor (46.7 percent), while 15 percent were using them to quit smoking. Among e-cigarette users, 45.2 percent cited quitting as their primary motivation. The introduction of one particular heated tobacco product also coincided with steep declines in cigarette sales, though that trend has slowed in recent years.

The latest findings add to the growing body of evidence supporting the role of tobacco harm reduction in accelerating declines in combustible cigarette use. While governments have spent decades attempting to reduce smoking through tax hikes and bans, the availability of safer alternatives has produced rapid changes in consumer behavior.

In the United States, for example, e-cigarettes – introduced around 2006–2007 – have been linked to historic drops in young adult smoking. Between 2007 and 2023, the percentage of 18- to 24-year-olds who smoked fell by 81.8 percent, from 30.6 percent to 5.6 percent, with some states now below the World Health Organization’s “smoke-free society” threshold of 5 percent.

The latest South Korean data highlight a clear shift away from exclusive cigarette smoking toward dual use with non-combustible products, reflecting both the appeal and potential of tobacco harm reduction strategies.

While some health concerns remain, especially among dual users, the correlation between the growth of these products and the sharp decline in smoking suggests they can play a vital role in reducing the public health burden of combustible tobacco, provided that policies and education efforts are designed to maximize their harm reduction potential and support full cessation over time.

Nothing in this analysis is intended to influence the passage of legislation, and it does not necessarily represent the views of Tobacco Harm Reduction 101.