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

The rationale behind EXIT begins with a candid assessment of why conventional cessation programs fail this population. The researchers identify structural inequities as central barriers: the lack of stable housing, limited access to treatment services, and the fragmentation of care that forces people to navigate multiple disconnected systems. Layered on top of these structural obstacles are high rates of serious mental illness and substance use disorders among homeless smokers, which compound the physiological grip of nicotine dependence. Existing cessation treatments, the authors note, are often brief in duration, rarely integrated into community service settings, and short on the kind of ongoing behavioral support that sustained quitting demands. A single counseling session and a starter pack of patches, in other words, is poorly matched to the realities of life without a home.

EXIT was engineered around two design principles that distinguish it from prior efforts. The first is duration: rather than offering weeks of support, the intervention extends pharmacotherapy and coaching across a full six months, reflecting evidence that longer treatment courses improve cessation odds. The second is accessibility: the intervention routes treatment through community pharmacies and delivers behavioral support by telephone, so participants do not need to travel to clinics, keep rigid appointments, or negotiate unfamiliar healthcare bureaucracies. Community pharmacies have long been recognized as a promising venue for expanding access to evidence-based tobacco treatment, because pharmacists are numerous, trusted, geographically distributed, and empowered in many states to prescribe or recommend nicotine replacement products. Until now, however, pharmacy-based approaches have mostly been tested in short-duration interventions, leaving open the question of whether they can sustain quitting over the long term.

The trial itself is a two-arm, parallel-group randomized controlled trial conducted in transitional shelters in Los Angeles and San Francisco, two cities where homelessness has reached crisis scale. The investigators plan to enroll 150 adults experiencing homelessness who smoke at least five cigarettes per day, whose tobacco exposure is confirmed objectively by an expired carbon monoxide reading of at least 8 parts per million, and who report an intention to quit within six months. That carbon monoxide threshold is an important methodological safeguard, ensuring that self-reported smoking status is corroborated by a biochemical marker before randomization. Participants will then be allocated, in equal numbers, either to the full EXIT intervention or to a pharmacist-only comparator condition, allowing the trial to isolate the added value of extended pharmacotherapy and wellness coaching.

The comparator arm is deliberately pragmatic. Dubbed the pharm-only condition, it consists of a single pharmacist-delivered telephone session structured around the 5As framework, the established clinical sequence of asking about tobacco use, advising cessation, assessing readiness, assisting with a quit plan, and arranging follow-up, plus three months of nicotine replacement therapy. This condition represents a reasonable standard of care that a person might receive through a well-functioning pharmacy-based service, making it a meaningful benchmark against which to measure EXIT’s incremental benefits. Any advantage observed for the full intervention can therefore be attributed with some confidence to the additional months of medication and the intensive coaching component, rather than to mere contact with the healthcare system.

EXIT builds on that foundation in two decisive ways. Participants in the intervention arm receive the same initial 5As session, but their nicotine replacement therapy extends to a full six months, doubling the comparator’s treatment duration. More distinctive still is the behavioral component: 14 wellness-focused telephone coaching sessions delivered over six months by trained health coaches. The framing of these sessions as wellness-focused rather than narrowly cessation-focused is a deliberate design choice. Coaching conversations encompass broader health behaviors, including diet and physical activity, alongside smoking cessation goals. The investigators anticipate that this holistic approach may improve engagement and retention among participants for whom smoking is only one of many competing health and survival concerns, and for whom a single-issue intervention may feel disconnected from their priorities.

The trial’s primary outcome is adherence itself, an unusually honest choice for a feasibility-stage study. Adherence will be measured by the number of coaching sessions attended and by participants’ adherence to the nicotine replacement regimen, since an intervention only works if people actually use it. Secondary outcomes include biochemically verified seven-day point prevalence abstinence at three and six months, again confirmed by carbon monoxide readings of 5 parts per million or below. Assessment visits occur at baseline and at one, three, and six months, capturing a rich panel of measures: tobacco use and nicotine dependence, health behaviors such as diet and physical activity, mental health, substance use, and adherence to nicotine replacement therapy. This longitudinal design allows the team to track not only whether people quit, but how the intervention reshapes the broader health landscape that sustains addiction.

Methodologically, the protocol reflects the iterative logic of modern behavioral intervention science. Rather than leaping directly to a large, fully powered effectiveness trial, the EXIT team is first testing feasibility, acceptability, and preliminary efficacy in the very settings where a scalable program would ultimately operate. This staged approach guards against the familiar failure mode of cessation interventions that perform well in controlled academic clinics but collapse when transplanted into community environments with high participant mobility, competing survival needs, and limited staffing. By embedding the trial within transitional shelters and partnering with pharmacy infrastructure from the outset, the investigators are stress-testing the delivery model under real-world conditions. The findings are explicitly intended to inform a future fully powered trial that could establish a scalable model for delivering tobacco cessation treatment to people experiencing homelessness nationwide.

The scientific significance of the trial extends beyond its immediate population. Smoking among homeless adults is a major driver of the stark mortality gap between housed and unhoused populations, contributing to cardiovascular disease, respiratory illness, and cancer at rates that dwarf the risks posed by many problems that receive far more public attention. Yet tobacco is frequently deprioritized in homeless services, treated as a concern to be addressed only after housing, addiction, and mental health needs are met. EXIT challenges that triage logic by demonstrating that evidence-based tobacco treatment can be woven directly into homeless services and pharmacy systems rather than deferred. The trial is funded by the California Tobacco-Related Disease Research Program, with additional support to the first author from the National Institute on Drug Abuse, and it is registered at ClinicalTrials.gov under identifier NCT07148232.

If EXIT proves feasible, acceptable, and even preliminarily effective, the implications could ripple across public health practice. A model that pairs six months of nicotine replacement with sustained telephone coaching, initiated through a pharmacist visit and anchored in transitional shelters, could be replicated in cities across the country at comparatively low cost, since it relies on existing pharmacy networks and remote coaching rather than new clinics. The trial also contributes a methodological template for studying cessation in transient populations, combining biochemical verification, extended follow-up, and outcome measures that respect participants’ full health context. For the roughly seven in ten homeless adults who smoke, most of whom express a desire to quit but lack access to sustained treatment, EXIT represents a rigorous test of whether the healthcare system can finally meet them where they are, for as long as quitting truly takes.

Subject of Research: A randomized controlled trial testing an extended pharmacy-linked tobacco cessation intervention with telephone coaching for adults experiencing homelessness.

Article Title: Extended Intervention for Tobacco Use (EXIT) for people experiencing homelessness: study protocol for a randomized controlled trial

Article References: Extended Intervention for Tobacco Use (EXIT) for people experiencing homelessness: study protocol for a randomized controlled trial. (n.d.). https://doi.org/10.1186/s13722-026-00720-z

Image Credits: AI Generated

DOI: 10.1186/s13722-026-00720-z

Keywords: tobacco cessation, homelessness, nicotine replacement therapy, randomized controlled trial, community pharmacies, telephone coaching, health inequity, smoking prevalence, transitional shelters, public health, clinical trial protocol, addiction science

The patch works through transdermal delivery, a process in which nicotine passes gradually through the skin and enters the bloodstream. Unlike a cigarette, which sends nicotine to the brain within seconds and produces sharp rises and falls in concentration, a patch is designed to create a relatively stable level over many hours. This steadier exposure can reduce the intense withdrawal symptoms that occur when a person stops smoking, including irritability, difficulty concentrating, restlessness, and strong cravings.

Nicotine acts primarily by binding to nicotinic acetylcholine receptors, proteins found on nerve cells throughout the brain and body. These receptors normally respond to the neurotransmitter acetylcholine, which helps regulate attention, arousal, muscle activity, and several automatic bodily functions. Repeated nicotine exposure changes the sensitivity and number of these receptors, contributing to tolerance and dependence. When nicotine intake suddenly stops, the altered nervous system can react with withdrawal symptoms, helping explain why quitting is difficult even when a person understands the health risks of smoking.

The medical logic behind nicotine replacement therapy is harm reduction. Cigarette smoke contains thousands of chemicals produced by burning tobacco, including substances that damage blood vessels, irritate the lungs, and contribute to cancer. A nicotine patch does not generate smoke or combustion products, and it avoids the rapid delivery pattern that reinforces smoking behavior. Nevertheless, nicotine remains pharmacologically active. It can affect the cardiovascular and nervous systems, and the patch may cause unwanted effects even when used exactly as directed.

Skin reactions are among the most recognizable problems associated with the patch. Redness, itching, irritation, or a rash can develop where the adhesive has been placed. Rotating application sites may help reduce repeated irritation, but persistent or severe reactions should not be ignored. Some symptoms may reflect sensitivity to the adhesive or another component of the product rather than nicotine itself. The patient information emphasizes the importance of following product instructions and discussing troublesome reactions with a health professional.

Because nicotine is absorbed continuously, excessive exposure can produce symptoms that signal toxicity. Nausea, dizziness, headache, sweating, weakness, shakiness, or a rapid or irregular heartbeat may occur when the body receives more nicotine than it can comfortably process. Sleep disturbances and vivid dreams are also reported by some users, reflecting nicotine’s effects on brain activity during the night. The severity of symptoms can vary according to the patch strength, the person’s previous nicotine use, and whether nicotine is being received from other products at the same time.

Accidental exposure is an especially important concern. A patch that has been discarded improperly may still contain nicotine, creating a risk if it is handled, chewed, swallowed, or placed on the skin by another person. Children are particularly vulnerable because a small body can receive a relatively large dose. Pets may also be harmed by chewing or swallowing a patch. Used patches should be folded so the adhesive sides stick together and discarded according to local safety guidance, rather than left where children or animals can find them.

Contact with the patch can also occur unintentionally when a patch is transferred from one person to another or remains attached after it should have been removed. Anyone who develops concerning symptoms after accidental exposure should seek urgent medical advice or contact a poison control service where available. The JAMA Patient Page underscores that nicotine poisoning is a medical issue, not merely an inconvenience, and that people should not wait for symptoms to become severe before requesting guidance.

Dependence is another reason the patch requires informed use. Nicotine replacement therapy is intended to reduce the harms of tobacco use and support cessation, but it still supplies the drug that drives addiction. Some people may continue using nicotine products longer than planned, or combine a patch with cigarettes, vaping products, nicotine gum, lozenges, or other sources. Such combinations may sometimes be part of a supervised quitting strategy, but unsupervised stacking can increase total nicotine exposure. A clinician or pharmacist can help determine how products should be used and how treatment can eventually be reduced.

The broader message is not that nicotine patches are unsafe or that smokers should avoid evidence-based cessation treatment. Rather, the patient information places the patch in its proper scientific context: it is a controlled drug-delivery system with a substantially different risk profile from combustible tobacco, but it is not risk-free. Used according to instructions and with professional support when needed, it can help stabilize nicotine levels and make quitting more achievable. Understanding its pharmacology, recognizing side effects, preventing accidental exposure, and treating dependence as a medical condition can help ensure that a tool designed to end nicotine addiction does not create new risks along the way.

Subject of Research: Nicotine patch use, potential harms and side effects, accidental exposure, and nicotine dependence.

Web References: https://doi.org/10.1001/jama.2026.12580

References: JAMA, doi:10.1001/jama.2026.12580

Keywords: Nicotine patches, nicotine replacement therapy, smoking cessation, nicotine dependence, addiction, side effects, accidental exposure, tobacco, smoke, medical treatments.