Abstract

Abstract Background: Frontline healthcare workers play a critical role in delivering tobacco harm reduction (THR) and smoking cessation (SC) interventions. However, their preparedness to implement these services in low-resource settings remains poorly understood. This study assessed the knowledge, practices, and readiness of frontline healthcare workers in Malawi to deliver THR and SC interventions. Methods: We conducted a multicenter baseline cross-sectional survey among 335 frontline healthcare workers in Lilongwe and Mzimba North districts, Malawi. Data were collected using a structured digital questionnaire capturing sociodemographic characteristics, prior training exposure, knowledge of nicotine addiction and cessation techniques, clinical practices, confidence in delivering cessation support, and perceived barriers. Composite knowledge and practice scores were constructed by summing item-level responses across predefined domains, with higher scores indicating greater knowledge and better cessation-related practice. Descriptive statistics and multivariable logistic regression analyses were performed. Models were fitted using complete-case analysis, with sample size varying slightly because of item-level missingness. Results: Only 7.5% and 6.9% of participants reported prior training in THR and SC, respectively. Knowledge gaps were substantial: although 43.3% demonstrated basic understanding of nicotine addiction, only 8.4% reported advanced understanding. Awareness of evidence-based cessation strategies was limited, including nicotine replacement therapy (30.1%), motivational interviewing (26.6%), and prescription medications (10.4%). Practice gaps were also evident: only 21.8% reported assessing smoking status often or always during routine care, 42.1% reported no familiarity with the 5A approach, and only 9.9% had ever referred a client to a cessation resource. Lack of knowledge was the most frequently reported barrier (60.6%). Despite these gaps, 48.4% reported being very confident in helping clients quit smoking, and 95.8% expressed strong interest in receiving further training. Prior THR/SC training was strongly associated with higher knowledge (aOR 7.05, 95% CI 2.96-16.75), while higher knowledge was associated with improved practice (aOR 1.36 per one-point increase, 95% CI 1.20-1.53). Conclusion: Frontline healthcare workers in Malawi are highly motivated but insufficiently prepared to deliver effective tobacco harm reduction and smoking cessation interventions. Addressing critical gaps in training, knowledge, and system support represents an important opportunity to strengthen tobacco control efforts in Malawi and similar low-resource settings.

Original language	en
Publication status	Published - 2026