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 review comes at a moment when tobacco use is changing rather than disappearing. Cigarette smoking has declined in several high-income countries, but rates remain persistently high in parts of Europe and many other regions. At the same time, commercial markets for alternative nicotine products are expanding worldwide. Modern e-cigarettes can deliver substantial doses of nicotine through highly engineered heating systems, while heated-tobacco products aerosolize processed tobacco without fully burning it. Oral nicotine products, including pouches and other formulations, provide still another route into the bloodstream. Their different designs create different exposure profiles, but all are capable of sustaining nicotine dependence.

The most urgent concern may be the speed with which these products are reaching young people. Compact, discreet devices, sweet flavours, sophisticated branding and high nicotine concentrations can make initiation easier and dependence faster. Some newer systems use nicotine salts, which reduce the harshness of inhaled nicotine and allow users to consume larger quantities without the immediate irritation associated with older products. Early exposure may establish a long-term pattern of nicotine use, even among people who would otherwise never have smoked cigarettes. The review describes youth addiction as an escalating public-health challenge made more serious by regulatory systems that often move more slowly than product innovation.

Nicotine itself acts directly on the cardiovascular system through the sympathetic nervous system, the network responsible for the body’s rapid stress response. By stimulating the release of catecholamines such as adrenaline and noradrenaline, nicotine can increase heart rate, blood pressure and the force with which the heart contracts. This raises haemodynamic stress, requiring the cardiovascular system to work harder. Repeated exposure may impose recurrent episodes of vascular constriction and elevated pressure, particularly in people with underlying hypertension, diabetes, atherosclerosis or other cardiovascular vulnerabilities.

The biological effects extend beyond short-term changes in pulse and blood pressure. The review describes evidence that nicotine promotes oxidative imbalance and inflammation, two processes closely linked to vascular ageing and atherosclerosis. Oxidative stress occurs when reactive oxygen species overwhelm the body’s antioxidant defenses, damaging proteins, lipids and cellular signaling pathways. Inflammation can activate endothelial cells, alter immune-cell behavior and encourage the development of unstable arterial plaques. These effects matter because atherosclerotic disease is not simply the accumulation of cholesterol; it is an active process in which injured vessel walls, immune responses and disrupted blood flow can eventually produce a heart attack or stroke.

One mechanism highlighted by the authors involves endothelial nitric oxide synthase, or eNOS, an enzyme that helps blood vessels produce nitric oxide. Nitric oxide signals the smooth muscle surrounding arteries to relax, supports healthy blood flow and helps prevent platelets and inflammatory cells from adhering excessively to the vessel wall. Under conditions of oxidative stress, eNOS can become “uncoupled,” producing reactive molecules instead of beneficial nitric oxide. The result is endothelial dysfunction, a measurable failure of the inner lining of blood vessels to regulate tone and protect against inflammation and clot formation. This dysfunction is considered an early warning sign of cardiovascular disease and has been observed in studies of people using different nicotine-containing products.

Laboratory and animal research adds to the concern. Experimental studies have associated nicotine exposure with vascular constriction, oxidative injury, inflammatory signaling and changes that may promote plaque instability. Human investigations have reported adverse vascular responses after exposure to cigarettes, e-cigarettes and other nicotine products, although the review emphasizes that these studies must be interpreted carefully. Many are small, use short follow-up periods or examine surrogate markers rather than heart attacks, strokes and cardiovascular deaths. Product formulations also vary widely, making direct comparisons difficult. A device’s effects may depend on nicotine concentration, heating temperature, aerosol composition, frequency of use and whether the user also smokes conventional cigarettes.

That uncertainty does not mean the products are risk-free; it means that the full scale of their long-term danger is still being established. Cigarette smoking has been studied for decades, producing overwhelming evidence of cardiovascular harm. By contrast, many newer devices have existed for too little time to reveal their consequences across an entire lifetime. The absence of definitive long-term outcome data can therefore be misleading, especially when products are marketed as modern, clean or safer alternatives. Reduced exposure to combustion products is biologically meaningful, but it should not be confused with the elimination of vascular toxicity.

The distinction is particularly important for people who use more than one product. Dual use of cigarettes and e-cigarettes or other nicotine systems may preserve much of the exposure associated with smoking while adding a new source of nicotine and aerosol constituents. Even when combustion is eliminated, inhaled particles, flavoring chemicals, thermal degradation products and other components may interact with nicotine to affect the cardiovascular system. Oral products avoid inhalation but still deliver pharmacologically active nicotine, which can produce sympathetic stimulation and haemodynamic stress. No route should be assumed to be cardiovascularly neutral simply because it does not generate tobacco smoke.

The review’s broader message is that public-health policy must keep pace with a market capable of evolving faster than safety research. Leading cardiovascular organizations and regulatory authorities agree that no nicotine-containing product can be considered safe for the cardiovascular system. Effective prevention will require stronger protection for young people, careful oversight of nicotine concentrations and product design, restrictions on marketing that normalizes dependence, and research capable of tracking long-term outcomes. For adults who smoke, switching completely away from combustible tobacco may reduce exposure to some of the most dangerous toxicants, but the safest cardiovascular strategy remains stopping nicotine use altogether. As the nicotine market fragments into increasingly sophisticated forms, the central scientific warning remains consistent: less harmful than cigarettes is not the same as harmless.

Subject of Research: The cardiovascular effects and global health implications of nicotine-containing products, including cigarettes, e-cigarettes, heated-tobacco products and oral nicotine formulations.

Article Title: Nicotine-containing products and the cardiovascular system: mechanisms and global health implications

Article References: Münzel, T., Kuntic, M., Keaney, J.F. et al. Nicotine-containing products and the cardiovascular system: mechanisms and global health implications. Nature Reviews Cardiology (2026). https://doi.org/10.1038/s41569-026-01331-6

Image Credits: AI Generated

DOI: 10.1038/s41569-026-01331-6

Keywords: nicotine, cardiovascular disease, tobacco, e-cigarettes, heated-tobacco products, oral nicotine, endothelial dysfunction, oxidative stress, inflammation, youth addiction, atherosclerosis, public health

The study, published in Tobacco Control, evaluates the FDA’s proposed product standard to cap nicotine in combusted cigarettes at minimally or nonaddictive levels. While a typical cigarette contains about 10 to 14 milligrams of nicotine, the proposal would set the limit at 0.7 milligrams.

Because nicotine is the core driver of addiction, lowering nicotine exposure may reduce initiation and make quitting more achievable. The researchers focused on major depression, a group that experiences smoking at disproportionately higher rates than the general population, and for whom smoking can intensify depressive symptoms.

Using a computational forecasting model, the team projected long-term health and financial outcomes for the U.S. population through 2100. The model tracks how individuals transition between health and substance-use states over time, starting with people born without major depression or smoking history.

To estimate real-world impacts, the authors scaled results to U.S. costs and prevalence using data sources including the Medical Expenditure Panel Survey and the National Survey on Drug Use and Health. This allowed the simulation to translate changes in smoking behavior into measurable mortality prevention, disease burden, and downstream productivity effects.

Results indicate that the policy could drive smoking rates below 1% across population groups by 2040. For individuals with and without major depression, the model projects near elimination of smoking by that horizon, with sustained effects into later decades.

By 2100, the researchers estimate the policy could prevent 1.6 million premature deaths and reduce the number of people who develop major depression by 8 million. The model also suggests that altered tobacco exposure would ripple through public health outcomes over decades.

From an economic perspective, reduced smoking is projected to boost worker productivity by $298 billion and increase consumer spending by $1.3 trillion. The mechanism is straightforward in the model: fewer early deaths translate into more years of work and consumption.

While a federal mandate is uncertain, the researchers argue that states and localities could act now through sales restrictions, similar to existing approaches used for flavored products. Their findings are made explorable through an online interactive policy tool designed to support decision-making.

Subject of Research: People
Article Title:
News Publication Date: 15-Jul-2026
Web References: https://doi.org/10.1136/tc-2025-059896
References: FDA proposed product standard (nicotine cap); Tobacco Control Policy Tool; Medical Expenditure Panel Survey; National Survey on Drug Use and Health
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Keywords: nicotine reduction, combusted cigarettes, major depression, tobacco control, computational simulation, public health disparity, smoking prevalence, FDA standard, productivity