Malawi’s Frontline Health Workers Eager to Help Smokers Quit but Lack the Training to Do So

In the fight against tobacco, the most powerful weapon in any health system is often the person standing at the front desk of a rural clinic. Frontline healthcare workers — the nurses, health surveillance assistants, and clinicians who see patients every day — are uniquely positioned to spot smokers, offer advice, and connect them with the support they need to quit. Yet a new study from Malawi suggests that in one of the world’s most resource-constrained health systems, this potential is being left largely untapped, not because of indifference, but because of a striking absence of training and knowledge. The research, published in BMC Health Services Research, offers one of the most detailed portraits to date of how prepared — or unprepared — frontline workers in a low-income country are to deliver smoking cessation support.

The study, led by Alexander Thomas Mboma of the Center for Development Management, Consulting and Learning Facility in Lilongwe, together with colleagues from the Sub-Sahara Health and Research Institute and the University of Malawi, surveyed 335 frontline healthcare workers across two districts: Lilongwe, the capital, and Mzimba North in the country’s north. The team used a structured digital questionnaire to capture a wide range of information, from sociodemographic characteristics and prior training exposure to knowledge of nicotine addiction and cessation techniques, actual clinical practices, confidence in delivering cessation support, and the barriers workers perceive in their daily practice. The survey was designed as a multicenter baseline cross-sectional assessment, meaning it provides a snapshot of readiness at a single point in time — a starting line against which future interventions can be measured.

To make sense of the responses, the researchers constructed composite knowledge and practice scores by summing item-level responses across predefined domains, with higher scores indicating greater knowledge and better cessation-related practice. They then applied descriptive statistics, bivariate comparisons, and multivariate linear and logistic regression analyses to identify which factors were associated with better knowledge and practice. The models were fitted using complete-case analysis, with the sample size varying slightly because of item-level missingness — a common and transparent approach in survey research that ensures only participants with full data on a given variable contribute to that particular estimate.

The headline finding is a sobering one: knowledge gaps were substantial. Only 7.5 percent of participants reported having received any prior training in tobacco harm reduction, and just 6.9 percent had ever been trained in smoking cessation programs. Perhaps most striking, only 8.4 percent reported an advanced understanding of nicotine addiction — the fundamental science that underpins every effective cessation intervention. Awareness of nicotine replacement therapy, a mainstay of cessation support worldwide, stood at just 30.1 percent, while motivational interviewing, a well-established counseling technique for helping people change health behaviors, was recognized by only 26.6 percent of participants. In other words, fewer than one in three workers surveyed knew about the two most widely recommended tools in modern cessation care.

Practice gaps mirrored the knowledge deficits almost exactly. Only 21.8 percent of respondents said they were able to assess smoking status often or always during routine care — a basic first step that international guidelines recommend for every patient encounter. Meanwhile, 42.1 percent reported being unfamiliar with the 5 A approach, the widely used clinical framework of Ask, Advise, Assess, Assist, and Arrange that structures cessation counseling in health systems around the world. Most telling of all, only 9.9 percent of the healthcare workers surveyed had ever referred a client to a cessation resource. Even when workers encounter smokers in their clinics, the pathway from identification to referral appears to be almost entirely absent in practice.

When asked what stood in their way, the answer was unambiguous. Lack of knowledge was the most frequently reported barrier, cited by 60.6 percent of participants. This is a crucial insight for policymakers, because it frames the problem as one that is fundamentally solvable through education rather than one rooted in resistance or lack of concern. The workers themselves, in other words, are not the obstacle — the absence of training infrastructure is. In a health system where tobacco control competes with HIV, malaria, and maternal health for scarce resources and attention, cessation skills have simply never been built into the professional toolkit of the frontline workforce.

Yet the study is far from a story of despair. Despite the deep gaps in knowledge and practice, 48.4 percent of participants reported being very confident in their ability to help clients quit smoking, and an overwhelming 95.8 percent expressed strong interest in receiving further training. That combination — high confidence alongside high demand for education — represents a genuine opportunity. It suggests that frontline workers in Malawi already recognize the importance of addressing tobacco use and believe in their own potential to make a difference; what they lack is not motivation but the technical content that would allow that motivation to translate into effective care.

The regression analyses added an important layer of evidence about what works. Prior smoking cessation training was strongly associated with higher knowledge of tobacco harm reduction interventions, with the association reaching statistical significance at p < 0.001. Moreover, higher knowledge scores were independently associated with improved practice, also at p < 0.001. Taken together, these findings point to a clear causal pathway: training builds knowledge, and knowledge changes what happens in the clinic. For a health ministry deciding where to invest limited tobacco control funds, the implication is direct — every dollar spent on frontline cessation education is likely to be repaid in changed clinical behavior.

The study was conducted with rigorous ethical oversight. Approval was obtained from the University of Malawi Research Ethics Committee, and the research was carried out in accordance with the Declaration of Helsinki and relevant national regulations. All participants provided written informed consent, and administrative authorization was secured from the District Health Offices of both Lilongwe and Mzimba North. The work was supported by the Global Action to End Smoking, Inc., under Grant Number UNS-001-004, with the funder having no role in study design, data collection, analysis, interpretation, or writing of the manuscript — an arrangement that helps safeguard the independence of the findings.

For Malawi, and for low-resource settings across sub-Saharan Africa and beyond, the message of this study is both a warning and an invitation. Tobacco use is rising in many low- and middle-income countries even as it declines in wealthier ones, and health systems that fail to equip their frontline workers will find themselves fighting a growing epidemic with an untrained army. But the near-universal appetite for training documented here suggests the solution may be within reach. Embedding nicotine addiction science, the 5 A framework, motivational interviewing, and referral pathways into pre-service curricula and in-service professional development could transform a workforce that is already willing into one that is truly able. The readiness, in the sense of willingness, is already there. What remains is to build the readiness in the sense of capability — and this study provides the baseline evidence to start.

Subject of Research: Smoking cessation readiness, knowledge, and practices among frontline healthcare workers in Malawi

Article Title: Smoking cessation readiness among frontline healthcare workers in Malawi: a multicenter cross-sectional study

Article References: Mboma, A. T., Sibale, B., Makombe, D., Mwakilama, E. P., Phiri, H., & Mhango, S. B. (2026). Smoking cessation readiness among frontline healthcare workers in Malawi: a multicenter cross-sectional study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15687-5

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15687-5

Keywords: smoking cessation, tobacco harm reduction, frontline healthcare workers, Malawi, nicotine addiction, health services research, tobacco control, 5 A approach, motivational interviewing, nicotine replacement therapy, low-resource settings, cross-sectional study