Twenty-year trends in nicotine exposure and educational disparities in Brazil.

Background Tobacco use remains the primary modifiable risk factor for cardiovascular disease (CVD). Despite Brazil’s recognized leadership in tobacco control, recent stabilization of smoking prevalence and the emergence of electronic smoking devices (ESD) present a new public health challenge. It remains to be fully elucidated whether educational attainment, acting as a proxy for health literacy, influences these evolving patterns of nicotine exposure and the adoption of alternative nicotine delivery systems. Purpose To describe the epidemiological profile and temporal trends of conventional cigarette smoking and ESD use among Brazilian adults between 2006 and 2024, focusing on stratification by educational level. Methods We conducted a time-series analysis using data from VIGITEL (2006–2024), an annual representative telephone survey of adults (n = 833,217) (age above 18 years) across 27 Brazilian capital. Current smoking was defined by self-reported cigarette use; ESD use (daily or occasional) was monitored from 2019 onwards. Annual prevalence and average annual variation (AAV) were estimated via linear regression. Data were stratified into four educational tiers (0–8, 9–11,12–14, and > 15 years of formal education), with sampling weights adjusted to the 2024 projected population demographics. Results From 2006 to 2024, 833,217 interviews were completed. Overall smoking prevalence declined from 15.7% (2006) to 11.5% (2024) (AAV: -0.69 pp/year, CI: 95% -0.85 to -0.53), though a plateau was observed after 2019. A persistent educational gradient was observed: in 2024, prevalence was 16.6% in the lowest education group (>8 years) vs. 7.8% in the highest (>15 years). Heavy smoking (> 20 cigarettes/day) was twice as frequent in the least educated (4.1% vs 2.0%). Conversely, ESD use exhibited a "literacy paradox," with higher prevalence among the adults with the most years of formal education (2.7% vs. 0.7% in the lowest). Notably, ESD use among young adults (18–24 years) reached 10.1% in 2024. Combined nicotine use (smoking + ESD) showed a rising trend in middle-education groups (9–11 years), peaking at 18.3%. Conclusion Despite historical gains in tobacco control, smoking prevalence in Brazil has plateaued, and current data reveal a socioeconomic difference in consumption patterns. Conventional smoking remains concentrated among lower-education cohorts, while ESD use predominates among more educated young adults. Addressing these disparate nicotine exposure profiles through health literacy-targeted cessation strategies is imperative to mitigate future cardiovascular risk.Nicotine landscape and the "litery paradox".Smoking prevalence by education level.