A capacity-readiness gap in tobacco harm reduction and smoking cessation: a multicenter cross-sectional study of frontline healthcare workers in Malawi

A capacity-readiness gap in tobacco harm reduction and smoking cessation: a multicenter cross-sectional study of frontline healthcare workers in Malawi | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A capacity-readiness gap in tobacco harm reduction and smoking cessation: a multicenter cross-sectional study of frontline healthcare workers in Malawi Alexander Thomas Mboma, Bright Sibale, Dziwenji Makombe, Elias Peter Mwakilama, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9281739/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version 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. tobacco harm reduction smoking cessation health systems workforce capacity Malawi implementation readiness Figures Figure 1 1. Introduction Tobacco use remains a major cause of preventable morbidity and mortality worldwide, with an increasingly disproportionate burden in low- and middle-income countries (LMICs) ( 1 ). Although effective tobacco harm reduction (THR) and smoking cessation (SC) interventions are well established, their integration into routine health service delivery remains limited in many resource-constrained settings ( 2 ). Frontline healthcare workers are central to this response because they are often the first point of contact for patients and are well positioned to assess tobacco use, deliver brief advice, support quit attempts, and facilitate referral where appropriate. Despite this critical role, evidence from LMICs suggests that healthcare workers frequently lack adequate preparation to provide evidence-based cessation support ( 3 ). Deficiencies in formal training ( 4 ), limited familiarity with structured counseling frameworks ( 5 ), insufficient access to cessation tools ( 6 ), and weak organizational support ( 7 ) can all reduce the likelihood that tobacco cessation is addressed consistently in routine care. In such contexts, provider motivation alone may be insufficient to translate into effective practice. This study was informed by a health systems readiness perspective, which conceptualizes implementation readiness as a function of provider capacity, organizational support, and system-level enabling conditions ( 8 ). In this framework, training is expected to strengthen provider knowledge, improved knowledge is expected to enhance practice, and the translation of knowledge into practice is influenced by broader structural conditions, including access to resources, clinical protocols, and institutional support. Figure 1 presents the conceptual framework underpinning the study. Training exposure is hypothesized to improve provider capacity, which in turn influences cessation-related clinical practice and overall service delivery readiness. System-level enabling conditions and individual-level modifiers may shape the extent to which knowledge is translated into practice. In Malawi, limited evidence exists on the preparedness of frontline healthcare workers to deliver THR and SC services. Understanding these gaps is essential for designing capacity-building interventions and strengthening health system responses to tobacco use. This study therefore assessed the knowledge, practices, and readiness of frontline healthcare workers in Malawi to deliver THR and SC interventions at baseline, prior to implementation of a structured training intervention. 2. Methods 2.1. Study design This study presents a baseline cross-sectional analysis of a larger multicenter capacity-building project on tobacco harm reduction and smoking cessation among frontline healthcare workers in Malawi. 2.2. Study setting and participants The study was conducted in Lilongwe and Mzimba North districts in Malawi. A total of 335 frontline healthcare workers were recruited from participating health facilities. Participants represented multiple healthcare cadres involved in routine patient care, including Health Surveillance Assistants, nurses, clinicians, and other staff engaged in service delivery. 2.3. Data collection Data were collected using a structured, self-administered digital questionnaire developed specifically for this study and implemented through Kobo Collect. The questionnaire was designed to assess sociodemographic and professional characteristics, prior training exposure, knowledge of tobacco harm reduction and smoking cessation, clinical practices, confidence, and perceived barriers. The full English-language questionnaire is provided as Supplementary File 1. 2.4. Measures The primary explanatory variable was prior training exposure in THR and/or SC, categorized as yes or no. Knowledge-related measures included understanding of nicotine addiction, familiarity with the 5A approach, and awareness of selected cessation strategies such as behavioral counseling, nicotine replacement therapy, motivational interviewing, group counseling, and prescription medications. Practice-related measures included frequency of smoking-status assessment in routine care, discussion of tobacco cessation with clients, tracking of clients’ smoking habits, and referral to cessation services or resources. Confidence was measured using self-reported confidence in helping clients quit smoking, and perceived barriers included lack of knowledge, lack of time, client unwillingness to quit, and lack of resources. Composite knowledge and practice scores were constructed by summing item-level responses across predefined domains. The composite knowledge score ranged from 0 to 11, and the composite practice score ranged from 0 to 13, with higher scores indicating greater knowledge and better cessation-related practice. For regression analyses, higher knowledge was defined as a score at or above the 75th percentile (score ≥6), and higher practice was defined as a score at or above the 75th percentile (score ≥7). 2.5. Data analysis Descriptive statistics were used to summarize participant characteristics and key study variables. Categorical variables were reported as frequencies and percentages, while continuous variables were summarized using means and standard deviations or medians and interquartile ranges, as appropriate. Bivariate comparisons were used to examine differences in knowledge, practice, confidence, and smoking-status assessment by prior training exposure. Multivariable logistic regression models were fitted to examine factors associated with higher knowledge, higher practice, high confidence, and routine smoking-status assessment. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported. Models were fitted using complete-case analysis, with sample size varying slightly across models because of item-level missingness. All statistical analyses were conducted using Stata version 17.0 (StataCorp, College Station, TX, USA), with statistical significance set at a two-sided p < 0.05. Ethical considerations Ethical approval was obtained from the University of Malawi Research Ethics Committee (UNIMAREC), Malawi (Approval number: P.11/24/485). The study was conducted in accordance with the Declaration of Helsinki and relevant national regulations. All participants provided written informed consent for participation and for use of anonymized engagement data for research purposes. Administrative authorization was also obtained from the District Health Offices (Lilongwe and Mzimba North). 3. Results 3.1. Participant characteristics A total of 335 frontline healthcare workers were included in the analysis. The mean age was 38.0 ± 9.5 years, and the mean duration of professional experience was 10.9 ± 8.8 years. Slightly more than half of participants were female (52.5%), and 56.1% were based in Lilongwe district. Health Surveillance Assistants (37.6%) and nurses (32.2%) constituted the largest professional groups. Nearly half of participants held a certificate-level qualification (49.9%), and most were working in outpatient departments (46.6%) (Table 1 ). Table 1 Sociodemographic and professional characteristics of frontline healthcare workers in Malawi (N = 335) Characteristic Value Age, years, mean ± SD 38.0 ± 9.5 Years of professional experience, mean ± SD 10.9 ± 8.8 District, n (%) Lilongwe 188 (56.1) Mzimba North 147 (43.9) Sex, n (%) Female 176 (52.5) Male 159 (47.5) Professional cadre, n (%) Health Surveillance Assistant (HSA) 126 (37.6) Nurse 108 (32.2) Clinician 99 (29.6) Other 2 (0.6) Highest professional qualification, n (%) Certificate 167 (49.9) Diploma 125 (37.3) Bachelor’s degree 35 (10.4) Master’s degree 2 (0.6) Other 6 (1.8) Current department/unit, n (%) Outpatient department (OPD) 156 (46.6) Outreach 76 (22.7) Wards 44 (13.1) Tuberculosis clinic 19 (5.7) Other 39 (11.6) Missing 1 (0.3) SD, standard deviation; HSA, Health Surveillance Assistant; OPD, outpatient department . 3.2. Training exposure, confidence, and knowledge Training exposure in tobacco harm reduction and smoking cessation was limited. Only 7.5% of participants reported prior THR training, while 6.9% reported prior SC training. Despite this limited training exposure, 48.4% reported being very confident in helping clients quit smoking. Knowledge levels were modest. Although 43.3% reported basic understanding of nicotine addiction and 40.6% reported moderate understanding, only 8.4% reported advanced understanding. The mean composite knowledge score was 4.21 ± 2.27 out of a possible 11, with a median score of 4 (IQR 3–6). Only 26.6% met the threshold for higher knowledge. Awareness of evidence-based cessation techniques was uneven. Behavioral counseling was the most commonly recognized intervention (68.4%), but awareness of nicotine replacement therapy (30.1%), group counseling (30.7%), motivational interviewing (26.6%), and prescription medications (10.4%) was substantially lower. In addition, 42.1% of participants reported no familiarity with the 5A approach. The findings on prior training exposure, confidence, and knowledge are summarized in Table 2 . Table 2 Prior training, confidence, and knowledge related to tobacco harm reduction and smoking cessation among frontline healthcare workers (N = 335) Variable Value Prior tobacco harm reduction (THR) training, n (%) Yes 25 (7.5) No 310 (92.5) Prior smoking cessation (SC) training, n (%) Yes 23 (6.9) No 312 (93.1) Confidence in helping clients quit smoking, n (%) Very confident 162 (48.4) Moderately confident 94 (28.1) Slightly confident 63 (18.8) Not confident 16 (4.8) Understanding of nicotine addiction, n (%) Advanced understanding 28 (8.4) Moderate understanding 136 (40.6) Basic understanding 145 (43.3) No understanding 26 (7.8) Familiarity with the 5A approach, n (%) Very familiar 44 (13.1) Moderately familiar 71 (21.2) Slightly familiar 79 (23.6) Not familiar 141 (42.1) Knowledge of smoking cessation techniques*, n (%) Behavioral counseling 229 (68.4) Group counseling 103 (30.7) Nicotine replacement therapy (NRT) 101 (30.1) Motivational interviewing 89 (26.6) Prescription medications 35 (10.4) Selected “Don’t know” 31 (9.3) Composite knowledge score (0–11), mean ± SD 4.21 ± 2.27 Composite knowledge score (0–11), median (IQR) 4 ( 3 – 6 ) Higher knowledge (score ≥ 6), n (%) 89 (26.6) THR, tobacco harm reduction; SC, smoking cessation; NRT, nicotine replacement therapy; IQR, interquartile range. * Multiple responses allowed; percentages may not sum to 100%. 3.3. Clinical practices, attitudes, and perceived barriers Clinical practices related to smoking cessation were suboptimal. Only 21.8% of participants reported assessing smoking status often or always during routine care, while 39.1% did so sometimes and 39.1% rarely or never. A similar pattern was observed for discussion of tobacco cessation with clients, with only 24.1% reporting that they discussed cessation often or always. Tracking of clients’ smoking habits was uncommon, reported by 31.3% of participants, and only 9.9% had ever referred a client to a smoking cessation program or resource. Although 89.9% of participants considered it very important for healthcare providers to address tobacco use, only 14.6% considered their current approach to be very effective. More than half (56.1%) reported that the necessary resources or support for cessation care were not available. The most commonly reported barriers were lack of knowledge of cessation techniques (60.6%), client unwillingness to quit (45.7%), and lack of resources such as medications or support materials (30.1%). The mean composite practice score was 5.34 ± 2.93 out of 13, with a median of 5 (IQR 3–7). Only 31.1% met the threshold for higher practice. Table 3 summarizes the clinical practices, attitudes, and perceived barriers related to smoking cessation care among frontline healthcare workers. Table 3 Clinical practices, attitudes, and perceived barriers related to smoking cessation care among frontline healthcare workers in Malawi (n = 335). Variable Value Frequency of smoking-status assessment during routine care, n (%) Always 42 (12.5) Often 31 (9.3) Sometimes 131 (39.1) Rarely 81 (24.2) Never 50 (14.9) Frequency of discussing smoking cessation with clients, n (%) Always 37 (11.0) Often 44 (13.1) Sometimes 120 (35.8) Rarely 95 (28.4) Never 35 (10.4) Other 3 (0.9) Tracks clients’ smoking habits, n (%) Yes 105 (31.3) No 229 (68.4) Ever referred a client to a smoking cessation program/resource, n (%) Yes 33 (9.9) No 301 (89.9) Perceived effectiveness of current approach to smoking cessation, n (%) Very effective 49 (14.6) Moderately effective 69 (20.6) Slightly effective 141 (42.1) Not effective 75 (22.4) Perceived importance of healthcare providers addressing tobacco use, n (%) Very important 301 (89.9) Moderately important 19 (5.7) Slightly important 12 (3.6) Not important 2 (0.6) Availability of necessary resources/support for smoking cessation care, n (%) Yes 71 (21.2) Not sure 74 (22.1) No 188 (56.1) Other 1 (0.3) Interest in further training/support, n (%) Very interested 321 (95.8) Moderately interested 11 (3.3) Slightly interested 2 (0.6) Reported barriers to discussing smoking cessation*, n (%) Lack of knowledge of cessation techniques 203 (60.6) Client unwillingness to quit 153 (45.7) Lack of resources (medications/support materials) 101 (30.1) Lack of time 41 (12.2) Composite practice score (0–13), mean ± SD 5.34 ± 2.93 Composite practice score (0–13), median (IQR) 5 ( 3 – 7 ) Higher practice (score ≥ 7), n (%) 103 (31.1) IQR, interquartile range. * Multiple responses allowed; percentages may not sum to 100%. 3.4. Association of training with knowledge and practice Participants with prior THR/SC training demonstrated substantially better outcomes than those without prior training. Mean knowledge scores were higher among trained participants than untrained participants (5.96 ± 2.14 vs 4.06 ± 2.22; p < 0.001), and mean practice scores were also higher (8.23 ± 3.19 vs 5.09 ± 2.77; p < 0.001). The proportion achieving higher knowledge was nearly three times greater among trained participants (66.7% vs 23.1%; p < 0.001), and the proportion achieving higher practice was more than twice as high (69.2% vs 27.9%; p < 0.001). Trained participants were also more likely to report routine smoking-status assessment, defined as often or always, than untrained participants (48.1% vs 19.5%; p = 0.002). Although the proportion reporting high confidence was greater among trained participants (63.0% vs 47.1%), this difference was not statistically significant (p = 0.159). The comparison of knowledge, practice, confidence, and smoking status assessment by prior training exposure is presented in Table 4 . Table 4 Knowledge, practice, confidence, and smoking-status assessment according to prior tobacco harm reduction and/or smoking cessation training Measure No prior THR/SC training (n = 308) Any prior THR/SC training (n = 27) P value Knowledge score, mean ± SD 4.06 ± 2.22 5.96 ± 2.14 < 0.001 Practice score, mean ± SD 5.09 ± 2.77 8.23 ± 3.19 < 0.001 Higher knowledge (score ≥ 6), n (%) 71 (23.1) 18 (66.7) < 0.001 Higher practice (score ≥ 7), n (%) 85 (27.9) 18 (69.2) < 0.001 High confidence (very confident), n (%) 145 (47.1) 17 (63.0) 0.159 Routine smoking-status assessment (often/always), n (%) 60 (19.5) 13 (48.1) 0.002 THR, tobacco harm reduction; SC, smoking cessation; SD, standard deviation. P values were derived from appropriate bivariate comparisons between participants with and without any prior THR/SC training. 3.5. Multivariable regression analysis In multivariable logistic regression analyses, prior THR/SC training was strongly associated with higher knowledge (aOR 7.05, 95% CI 2.96–16.75). None of the other covariates in this model showed statistically significant associations with higher knowledge. Higher knowledge scores were independently associated with higher practice (aOR 1.36 per one-point increase, 95% CI 1.20–1.53). Prior THR/SC training also remained significantly associated with higher practice (aOR 3.96, 95% CI 1.52–10.33). In the model for high confidence, higher practice scores were associated with increased odds of reporting very high confidence (aOR 1.20, 95% CI 1.09–1.32), while HSA cadre was also positively associated with high confidence compared with clinician cadre (aOR 1.83, 95% CI 1.01–3.30). In the model for routine smoking-status assessment, prior THR/SC training was associated with greater odds of reporting frequent assessment (aOR 3.67, 95% CI 1.45–9.30), while high confidence was also positively associated with routine assessment (aOR 1.87, 95% CI 1.05–3.33). Participants in Mzimba North and those in HSA cadre had lower odds of routine smoking-status assessment than their respective reference groups. The multivariate logistic regression results are presented in Table 5 . Table 5 Multivariable logistic regression models of knowledge, practice, confidence, and smoking-status assessment among frontline healthcare workers Predictor aOR (95% CI) P value Model 1. Higher knowledge (score ≥ 6/11; n = 333) Mzimba North vs Lilongwe 0.90 (0.53–1.53) 0.697 Male vs female 0.77 (0.45–1.33) 0.350 HSA vs clinician 0.58 (0.31–1.10) 0.098 Nurse vs clinician 0.73 (0.39–1.39) 0.339 Any prior THR/SC training 7.05 (2.96–16.75) < 0.001 Years of experience, per additional year 1.00 (1.00-1.01) 0.342 Model 2. Higher practice (score ≥ 7/13; n = 329) Mzimba North vs Lilongwe 0.70 (0.41–1.19) 0.190 Male vs female 0.70 (0.41–1.21) 0.205 HSA vs clinician 0.63 (0.33–1.18) 0.147 Nurse vs clinician 0.63 (0.33–1.21) 0.168 Knowledge score, per 1-point increase 1.36 (1.20–1.53) < 0.001 Any prior THR/SC training 3.96 (1.52–10.33) 0.005 Years of experience, per additional year 1.00 (0.99-1.00) 0.509 Model 3. High confidence (very confident; n = 329) Mzimba North vs Lilongwe 1.44 (0.90–2.31) 0.130 Male vs female 0.92 (0.57–1.50) 0.752 HSA vs clinician 1.83 (1.01–3.30) 0.046 Nurse vs clinician 1.03 (0.57–1.85) 0.923 Knowledge score, per 1-point increase 1.10 (0.98–1.23) 0.093 Any prior THR/SC training 0.83 (0.33–2.07) 0.686 Practice score, per 1-point increase 1.20 (1.09–1.32) < 0.001 Years of experience, per additional year 0.99 (0.97–1.02) 0.629 Model 4. Routine smoking-status assessment (often/always; n = 333) Mzimba North vs Lilongwe 0.52 (0.29–0.95) 0.033 Male vs female 0.98 (0.54–1.78) 0.954 HSA vs clinician 0.34 (0.17–0.71) 0.004 Nurse vs clinician 0.76 (0.39–1.47) 0.410 Knowledge score, per 1-point increase 1.11 (0.98–1.26) 0.090 Any prior THR/SC training 3.67 (1.45–9.30) 0.006 High confidence (very confident) 1.87 (1.05–3.33) 0.033 Years of experience, per additional year 1.00 (0.99-1.00) 0.659 aOR, adjusted odds ratio; CI, confidence interval; HSA, Health Surveillance Assistant; THR, tobacco harm reduction; SC, smoking cessation. Reference categories were Lilongwe district, female sex, and clinician cadre. 4. Discussion This study provides important baseline evidence on the preparedness of frontline healthcare workers in Malawi to deliver tobacco harm reduction and smoking cessation interventions. The findings reveal a pronounced capacity-readiness gap, characterized by very low levels of formal training, limited knowledge of evidence-based cessation approaches, and suboptimal clinical practices, despite high motivation and perceived confidence among providers. 4.1. Capacity-readiness gap in tobacco cessation service delivery The most striking finding was the mismatch between confidence and demonstrated preparedness. Nearly half of participants reported being very confident in helping clients quit smoking, yet knowledge scores were low, in line with regional estimates ( 9 ) familiarity with structured cessation frameworks was limited, and routine tobacco-related clinical practices were inconsistently implemented as is the case elsewhere ( 10 – 12 ). This discordance likely reflects a form of perceived self-efficacy decoupled from technical competence, a phenomenon observed in under-resourced systems where exposure to standardized training is limited. In such contexts, confidence maybe shaped more by routine patient interaction than by mastery of evidence-based cessation protocols, which ultimately constrains intervention fidelity. The extremely low prevalence of prior THR and SC training represents a critical bottleneck in health system readiness. Training was the strongest predictor of higher knowledge, supporting the view that structured educational exposure is a foundational input for building provider readiness. In settings where tobacco cessation is not systematically incorporated into preservice or in-service professional development, frontline healthcare workers are unlikely to acquire the competencies required for consistent, evidence-based care ( 13 ). 4.2. Knowledge deficits and limitations in evidence-based care Consistent with literature, knowledge gaps were especially pronounced in pharmacological ( 14 ) and structured behavioral interventions ( 15 ). Furthermore, although behavioral counseling was relatively well recognized, awareness of nicotine replacement therapy, motivational interviewing, and prescription medications was much lower. This pattern suggests that provider knowledge may be limited to general advice-giving rather than a broader understanding of comprehensive cessation care. This disparity in awareness between behavioral support and pharmacological or advanced interventions is also reported in other study ( 16 ), and is a recognized issue in smoking cessation efforts. The low average knowledge score further reinforces this concern. With only about one quarter of participants meeting the threshold for higher knowledge, the findings suggest that substantial proportions of frontline healthcare workers may not be adequately prepared to provide even basic cessation support. In practical terms, this may reduce the quality, consistency, and effectiveness of tobacco-related counseling within routine clinical care. 4.3. From knowledge to practice: evidence of a capacity-knowledge-practice pathway The results support a clear pathway from training to knowledge and from knowledge to practice. Higher knowledge scores were significantly associated with improved cessation-related practices, and training remained independently associated with both higher knowledge and higher practice. These findings support the conceptual model underpinning the study and suggest that investment in training can have downstream effects on day-to-day clinical behavior ( 17 , 18 ). However, practice gaps remained substantial even among trained participants. Routine smoking-status assessment was uncommon overall, referral to cessation resources was rare, and many participants lacked familiarity with the 5A approach. These findings suggest that knowledge, while necessary, may not be sufficient on its own. The translation of knowledge into practice likely depends on additional organizational and system-level conditions that support implementation in routine care ( 19 ). 4.4. Structural and system-level barriers The study also highlights important structural barriers that constrain implementation. More than half of participants reported lack of resources or support for cessation care, and nearly one third cited lack of medications or support materials as a barrier. These findings suggest that even motivated and knowledgeable providers may struggle to deliver effective cessation interventions when health systems do not provide the tools, protocols, and infrastructure required for sustained practice ( 20 – 22 ). Readiness should therefore be understood as a multilevel construct. At the provider level, it includes training, knowledge, and confidence. At the organizational level, it includes supervision, protocols, and workflow integration. At the system level, it includes access to cessation tools, referral pathways, and broader institutional support. Interventions that focus exclusively on training without addressing these structural conditions may achieve only partial or short-lived gains. 4.5. Implications for policy and health systems strengthening in LMICs These findings have several implications for tobacco control policy and health systems strengthening in Malawi and similar LMIC settings. First, the strong associations between training, knowledge, and practice indicate that competency-based training programs for frontline healthcare workers should be prioritized. Second, training should be embedded within broader efforts to integrate cessation support into routine service delivery, including use of standardized counseling frameworks such as the 5A approach. Third, facility-level and district-level support systems should be strengthened to ensure availability of educational materials, clinical protocols, referral options, and, where feasible, cessation aids. The very high level of expressed interest in further training is especially encouraging. It suggests that frontline healthcare workers are receptive to capacity-building efforts and that implementation initiatives are likely to encounter less resistance at the provider level than might otherwise be expected. Harnessing this motivation may be critical for closing the gap between willingness and preparedness. 4.6. Strengths and limitations This study has several strengths. It used a multicenter design, included a relatively large sample of frontline healthcare workers, and generated real-world baseline evidence from routine health system settings in Malawi. The use of both descriptive and multivariable analyses also allowed examination of potential pathways linking training, knowledge, and practice. Several limitations should be acknowledged. The cross-sectional design precludes causal inference, and all measures were self-reported, raising the possibility of recall and social desirability bias. The study was conducted in two districts and may therefore not fully represent all healthcare settings in Malawi. In addition, the composite knowledge and practice measures, while analytically useful, may not capture all dimensions of provider readiness. These limitations notwithstanding, the study offers a valuable baseline assessment of frontline workforce preparedness for tobacco cessation service delivery. 5. Conclusion Frontline healthcare workers in Malawi are highly motivated to support tobacco harm reduction and smoking cessation but remain insufficiently prepared to deliver these services effectively. A clear capacity-readiness gap exists, driven by limited formal training, low knowledge of evidence-based cessation strategies, inconsistent clinical practices, and inadequate system support. Addressing this gap will require integrated interventions that combine targeted workforce training with organizational and structural reforms to support routine delivery of tobacco cessation care. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the University of Malawi Research Ethics Committee (UNIMAREC), Malawi (Approval number: P.11/24/485). The study was conducted in accordance with the Declaration of Helsinki and relevant national regulations. All participants provided written informed consent for participation in the study and for the use of anonymized survey data for research purposes. Administrative authorization was also obtained from the District Health Offices (Lilongwe and Mzimba North). Consent for publication Not applicable, as no individual person’s data or quotations are reported in this manuscript. Availability of data and materials The datasets generated during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Global Action to End Smoking, Inc., under Grant Number UNS-001-004. The funder had no role in study design, data collection, analysis, interpretation of data, or writing of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency. Authors’ contributions ATM conceived the study and drafted the manuscript. EPM led data analysis. SBM contributed to interpretation of findings. BS, DM, HP and SBM contribution to study implementation, manuscript review, and critical revisions. 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Barriers to smoking interventions in community healthcare settings: a scoping review. Health Promot Int. 2024;39(2). Tan MM, Veluz-Wilkins A, Styrczula P, McBrayer S. Gaps in Knowledge and Practice in Treating Tobacco Use Among Non-physician Healthcare Professionals and Lay Health Workers in Chicago, Illinois. Cancer Control. 2022;29:10732748221105310. Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;3(3):Cd008286. Gilbert P, Dowd B-A, Dabney BW, Linton M. Educating Providers on Proactive Smoking Cessation Treatments in Primary Care. The Journal for Nurse Practitioners. 2025;21(1):105239. Onda M, Horiguchi M, Domichi M, Sakane N. Effect of a Smoking Cessation Education Program on the Knowledge, Attitude, and Self-Efficacy of Community Pharmacists in Japan: A Quasi-Experimental Study. Tob Use Insights. 2024;17:1179173x241272362. Baliunas D, Ivanova A, Tanzini E, Dragonetti R, Selby P. Impact of comprehensive smoking cessation training of practitioners on patients' 6-month quit outcome. Can J Public Health. 2020;111(5):766-74. Kgadima MR, Coetzee IM, Heyns T. Factors influencing knowledge translation into critical care practice: The reality facing intensive care nurses in Limpopo Province. South Afr J Crit Care. 2024;40(2):e1282. Al-Worafi YM. Smoking Cessation in Developing Countries: Challenges and Recommendations. In: Al-Worafi YM, editor. Handbook of Medical and Health Sciences in Developing Countries : Education, Practice, and Research. Cham: Springer International Publishing; 2023. p. 1-20. Gichuki JW, Opiyo R, Mugyenyi P, Namusisi K. Healthcare Providers' Level of Involvement in Provision of Smoking Cessation Interventions in Public Health Facilities in Kenya. J Public Health Afr. 2015;6(2):523. Visser JEM, Nur FA, Rozema AD, Kunst AE, Kuipers MAG. Facilitators and barriers to smoking cessation support among professionals in social and community service settings: a systematic review and thematic synthesis. Health Educ Res. 2025;40(5). Additional Declarations No competing interests reported. Supplementary Files QuestionnaireAcapacityreadnessgapintobaccoharmreductionandsmokingcessationamulticentercrosssectionalstudyoffrontlinehealthcareworkersinMalawi.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 May, 2026 Reviewers agreed at journal 15 May, 2026 Reviewers agreed at journal 15 May, 2026 Reviews received at journal 09 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers invited by journal 06 May, 2026 Editor invited by journal 13 Apr, 2026 Editor assigned by journal 09 Apr, 2026 Submission checks completed at journal 09 Apr, 2026 First submitted to journal 09 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9281739","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":639891615,"identity":"6ce718ef-a2f4-450f-bbbc-f2515deac7e1","order_by":0,"name":"Alexander Thomas Mboma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYDACCTBpAWNLyIEYBx4Q1gInLYzBWhJI0FKR2ABi4dOiO7v56IYfNRJyBsfPHrzxcY9E+vywww+BttjJ6TZg12J251jazZ5jEsaSPXnJljOeSeRuvJ1mANSSbGx2AIeWGzlmN3jYJBL7GXLMpHkOALXMTgBpOZC4DY+Wm3/+SdS38b8xk/5zQCLdcHb6B4JabvO2SSTwSwBtYTggkSAvnUPAFqBfbsv2SRjOnPHG2LLngIThBumcggMJBnj8crv52M0332zkDc7nGN74caBOXn52+uYPHyrs5HBpwQQGYJUGxCoHAfkGUlSPglEwCkbBSAAAuLVko1XBUqAAAAAASUVORK5CYII=","orcid":"","institution":"Center for Development Management, Consulting and Learning Facility","correspondingAuthor":true,"prefix":"","firstName":"Alexander","middleName":"Thomas","lastName":"Mboma","suffix":""},{"id":639891616,"identity":"bc33dc97-034b-4610-97b1-93ad2f29ee27","order_by":1,"name":"Bright Sibale","email":"","orcid":"","institution":"Center for Development Management, Consulting and Learning Facility","correspondingAuthor":false,"prefix":"","firstName":"Bright","middleName":"","lastName":"Sibale","suffix":""},{"id":639891617,"identity":"63a17103-2a6c-4b29-8caa-923851cce098","order_by":2,"name":"Dziwenji Makombe","email":"","orcid":"","institution":"Sub-Sahara Health and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Dziwenji","middleName":"","lastName":"Makombe","suffix":""},{"id":639891618,"identity":"5d8bafa7-3569-4034-a195-ba673cc4ee19","order_by":3,"name":"Elias Peter Mwakilama","email":"","orcid":"","institution":"University of Malawi","correspondingAuthor":false,"prefix":"","firstName":"Elias","middleName":"Peter","lastName":"Mwakilama","suffix":""},{"id":639891619,"identity":"6594bf08-958a-4fad-a99b-62521bd44024","order_by":4,"name":"Hlupekile Phiri","email":"","orcid":"","institution":"Center for Development Management, Consulting and Learning Facility","correspondingAuthor":false,"prefix":"","firstName":"Hlupekile","middleName":"","lastName":"Phiri","suffix":""},{"id":639891620,"identity":"a0b20395-39a5-4848-8609-4783691b1a15","order_by":5,"name":"Samson Banankhu Mhango","email":"","orcid":"","institution":"Sub-Sahara Health and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Samson","middleName":"Banankhu","lastName":"Mhango","suffix":""}],"badges":[],"createdAt":"2026-03-31 15:09:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9281739/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9281739/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109303834,"identity":"8b40f941-d79c-45d3-b0db-118c5c17e7c6","added_by":"auto","created_at":"2026-05-15 09:40:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":175990,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual framework illustrating the capacity-readiness pathway for delivery of tobacco harm reduction and smoking cessation interventions among frontline healthcare workers.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9281739/v1/89495c15f1b9aaad8e904a5c.png"},{"id":109405410,"identity":"0d8f46d6-aed6-486d-86cb-4b4bd7ba7d41","added_by":"auto","created_at":"2026-05-17 13:17:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":486798,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9281739/v1/e139f1bf-5729-4f3d-a980-41197cd80ef2.pdf"},{"id":109303781,"identity":"a50d7d3d-a6ad-4d61-91f8-654c44a4e52d","added_by":"auto","created_at":"2026-05-15 09:40:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":118275,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnaireAcapacityreadnessgapintobaccoharmreductionandsmokingcessationamulticentercrosssectionalstudyoffrontlinehealthcareworkersinMalawi.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9281739/v1/4b9dd2d7fe2800eddbab8940.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A capacity-readiness gap in tobacco harm reduction and smoking cessation: a multicenter cross-sectional study of frontline healthcare workers in Malawi","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eTobacco use remains a major cause of preventable morbidity and mortality worldwide, with an increasingly disproportionate burden in low- and middle-income countries (LMICs) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although effective tobacco harm reduction (THR) and smoking cessation (SC) interventions are well established, their integration into routine health service delivery remains limited in many resource-constrained settings (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Frontline healthcare workers are central to this response because they are often the first point of contact for patients and are well positioned to assess tobacco use, deliver brief advice, support quit attempts, and facilitate referral where appropriate.\u003c/p\u003e \u003cp\u003eDespite this critical role, evidence from LMICs suggests that healthcare workers frequently lack adequate preparation to provide evidence-based cessation support (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Deficiencies in formal training (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), limited familiarity with structured counseling frameworks (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), insufficient access to cessation tools (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and weak organizational support (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) can all reduce the likelihood that tobacco cessation is addressed consistently in routine care. In such contexts, provider motivation alone may be insufficient to translate into effective practice.\u003c/p\u003e \u003cp\u003eThis study was informed by a health systems readiness perspective, which conceptualizes implementation readiness as a function of provider capacity, organizational support, and system-level enabling conditions (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In this framework, training is expected to strengthen provider knowledge, improved knowledge is expected to enhance practice, and the translation of knowledge into practice is influenced by broader structural conditions, including access to resources, clinical protocols, and institutional support. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the conceptual framework underpinning the study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTraining exposure is hypothesized to improve provider capacity, which in turn influences cessation-related clinical practice and overall service delivery readiness. System-level enabling conditions and individual-level modifiers may shape the extent to which knowledge is translated into practice.\u003c/p\u003e \u003cp\u003eIn Malawi, limited evidence exists on the preparedness of frontline healthcare workers to deliver THR and SC services. Understanding these gaps is essential for designing capacity-building interventions and strengthening health system responses to tobacco use. This study therefore assessed the knowledge, practices, and readiness of frontline healthcare workers in Malawi to deliver THR and SC interventions at baseline, prior to implementation of a structured training intervention.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1. Study design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study presents a baseline cross-sectional analysis of a larger multicenter capacity-building project on tobacco harm reduction and smoking cessation among frontline healthcare workers in Malawi. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Study setting and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Lilongwe and Mzimba North districts in Malawi. A total of 335 frontline healthcare workers were recruited from participating health facilities. Participants represented multiple healthcare cadres involved in routine patient care, including Health Surveillance Assistants, nurses, clinicians, and other staff engaged in service delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using a structured, self-administered digital questionnaire developed specifically for this study and implemented through Kobo Collect. The questionnaire was designed to assess sociodemographic and professional characteristics, prior training exposure, knowledge of tobacco harm reduction and smoking cessation, clinical practices, confidence, and perceived barriers. The full English-language questionnaire is provided as Supplementary File 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary explanatory variable was prior training exposure in THR and/or SC, categorized as yes or no. Knowledge-related measures included understanding of nicotine addiction, familiarity with the 5A approach, and awareness of selected cessation strategies such as behavioral counseling, nicotine replacement therapy, motivational interviewing, group counseling, and prescription medications. Practice-related measures included frequency of smoking-status assessment in routine care, discussion of tobacco cessation with clients, tracking of clients’ smoking habits, and referral to cessation services or resources. Confidence was measured using self-reported confidence in helping clients quit smoking, and perceived barriers included lack of knowledge, lack of time, client unwillingness to quit, and lack of resources.\u003c/p\u003e\n\u003cp\u003eComposite knowledge and practice scores were constructed by summing item-level responses across predefined domains. The composite knowledge score ranged from 0 to 11, and the composite practice score ranged from 0 to 13, with higher scores indicating greater knowledge and better cessation-related practice. For regression analyses, higher knowledge was defined as a score at or above the 75th percentile (score ≥6), and higher practice was defined as a score at or above the 75th percentile (score ≥7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5. Data analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to summarize participant characteristics and key study variables. Categorical variables were reported as frequencies and percentages, while continuous variables were summarized using means and standard deviations or medians and interquartile ranges, as appropriate. Bivariate comparisons were used to examine differences in knowledge, practice, confidence, and smoking-status assessment by prior training exposure.\u003c/p\u003e\n\u003cp\u003eMultivariable logistic regression models were fitted to examine factors associated with higher knowledge, higher practice, high confidence, and routine smoking-status assessment. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported. Models were fitted using complete-case analysis, with sample size varying slightly across models because of item-level missingness. All statistical analyses were conducted using Stata version 17.0 (StataCorp, College Station, TX, USA), with statistical significance set at a two-sided p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the University of Malawi Research Ethics Committee (UNIMAREC), Malawi (Approval number: P.11/24/485). The study was conducted in accordance with the Declaration of Helsinki and relevant national regulations. All participants provided written informed consent for participation and for use of anonymized engagement data for research purposes. Administrative authorization was also obtained from the District Health Offices (Lilongwe and Mzimba North).\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Participant characteristics\u003c/h2\u003e \u003cp\u003eA total of 335 frontline healthcare workers were included in the analysis. The mean age was 38.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5 years, and the mean duration of professional experience was 10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 years. Slightly more than half of participants were female (52.5%), and 56.1% were based in Lilongwe district. Health Surveillance Assistants (37.6%) and nurses (32.2%) constituted the largest professional groups. Nearly half of participants held a certificate-level qualification (49.9%), and most were working in outpatient departments (46.6%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and professional characteristics of frontline healthcare workers in Malawi (N\u0026thinsp;=\u0026thinsp;335)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of professional experience, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistrict, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLilongwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e188 (56.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMzimba North\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147 (43.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176 (52.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159 (47.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional cadre, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Surveillance Assistant (HSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126 (37.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108 (32.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (29.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest professional qualification, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCertificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167 (49.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125 (37.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent department/unit, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient department (OPD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156 (46.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutreach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (22.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (13.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTuberculosis clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (5.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (11.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSD, standard deviation; HSA, Health Surveillance Assistant; OPD, outpatient department\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Training exposure, confidence, and knowledge\u003c/h2\u003e \u003cp\u003eTraining exposure in tobacco harm reduction and smoking cessation was limited. Only 7.5% of participants reported prior THR training, while 6.9% reported prior SC training. Despite this limited training exposure, 48.4% reported being very confident in helping clients quit smoking.\u003c/p\u003e \u003cp\u003eKnowledge levels were modest. Although 43.3% reported basic understanding of nicotine addiction and 40.6% reported moderate understanding, only 8.4% reported advanced understanding. The mean composite knowledge score was 4.21\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27 out of a possible 11, with a median score of 4 (IQR 3\u0026ndash;6). Only 26.6% met the threshold for higher knowledge.\u003c/p\u003e \u003cp\u003eAwareness of evidence-based cessation techniques was uneven. Behavioral counseling was the most commonly recognized intervention (68.4%), but awareness of nicotine replacement therapy (30.1%), group counseling (30.7%), motivational interviewing (26.6%), and prescription medications (10.4%) was substantially lower. In addition, 42.1% of participants reported no familiarity with the 5A approach. The findings on prior training exposure, confidence, and knowledge are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrior training, confidence, and knowledge related to tobacco harm reduction and smoking cessation among frontline healthcare workers (N\u0026thinsp;=\u0026thinsp;335)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior tobacco harm reduction (THR) training, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e310 (92.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrior smoking cessation (SC) training, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (6.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e312 (93.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConfidence in helping clients quit smoking, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162 (48.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (28.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (18.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnderstanding of nicotine addiction, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvanced understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (8.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (40.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (43.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamiliarity with the 5A approach, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (13.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (21.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (23.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot familiar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141 (42.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of smoking cessation techniques*, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavioral counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229 (68.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (30.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNicotine replacement therapy (NRT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (30.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotivational interviewing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (26.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrescription medications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelected \u0026ldquo;Don\u0026rsquo;t know\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComposite knowledge score (0\u0026ndash;11), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.21\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComposite knowledge score (0\u0026ndash;11), median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigher knowledge (score\u0026thinsp;\u0026ge;\u0026thinsp;6), n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (26.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eTHR, tobacco harm reduction; SC, smoking cessation; NRT, nicotine replacement therapy; IQR, interquartile range. * Multiple responses allowed; percentages may not sum to 100%.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Clinical practices, attitudes, and perceived barriers\u003c/h2\u003e \u003cp\u003eClinical practices related to smoking cessation were suboptimal. Only 21.8% of participants reported assessing smoking status often or always during routine care, while 39.1% did so sometimes and 39.1% rarely or never. A similar pattern was observed for discussion of tobacco cessation with clients, with only 24.1% reporting that they discussed cessation often or always.\u003c/p\u003e \u003cp\u003eTracking of clients\u0026rsquo; smoking habits was uncommon, reported by 31.3% of participants, and only 9.9% had ever referred a client to a smoking cessation program or resource. Although 89.9% of participants considered it very important for healthcare providers to address tobacco use, only 14.6% considered their current approach to be very effective. More than half (56.1%) reported that the necessary resources or support for cessation care were not available.\u003c/p\u003e \u003cp\u003eThe most commonly reported barriers were lack of knowledge of cessation techniques (60.6%), client unwillingness to quit (45.7%), and lack of resources such as medications or support materials (30.1%). The mean composite practice score was 5.34\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93 out of 13, with a median of 5 (IQR 3\u0026ndash;7). Only 31.1% met the threshold for higher practice. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the clinical practices, attitudes, and perceived barriers related to smoking cessation care among frontline healthcare workers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical practices, attitudes, and perceived barriers related to smoking cessation care among frontline healthcare workers in Malawi (n\u0026thinsp;=\u0026thinsp;335).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of smoking-status assessment during routine care, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOften\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131 (39.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (24.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrequency of discussing smoking cessation with clients, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (11.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOften\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (13.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (35.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (28.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTracks clients\u0026rsquo; smoking habits, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (31.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229 (68.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver referred a client to a smoking cessation program/resource, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e301 (89.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived effectiveness of current approach to smoking cessation, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (14.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (20.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141 (42.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (22.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived importance of healthcare providers addressing tobacco use, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e301 (89.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (5.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAvailability of necessary resources/support for smoking cessation care, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (21.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (22.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e188 (56.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInterest in further training/support, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery interested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e321 (95.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately interested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly interested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReported barriers to discussing smoking cessation*, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of knowledge of cessation techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e203 (60.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClient unwillingness to quit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (45.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of resources (medications/support materials)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (30.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComposite practice score (0\u0026ndash;13), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.34\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComposite practice score (0\u0026ndash;13), median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigher practice (score\u0026thinsp;\u0026ge;\u0026thinsp;7), n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (31.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eIQR, interquartile range. * Multiple responses allowed; percentages may not sum to 100%.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Association of training with knowledge and practice\u003c/h2\u003e \u003cp\u003eParticipants with prior THR/SC training demonstrated substantially better outcomes than those without prior training. Mean knowledge scores were higher among trained participants than untrained participants (5.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14 vs 4.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.22; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and mean practice scores were also higher (8.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19 vs 5.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe proportion achieving higher knowledge was nearly three times greater among trained participants (66.7% vs 23.1%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the proportion achieving higher practice was more than twice as high (69.2% vs 27.9%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Trained participants were also more likely to report routine smoking-status assessment, defined as often or always, than untrained participants (48.1% vs 19.5%; p\u0026thinsp;=\u0026thinsp;0.002). Although the proportion reporting high confidence was greater among trained participants (63.0% vs 47.1%), this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.159). The comparison of knowledge, practice, confidence, and smoking status assessment by prior training exposure is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge, practice, confidence, and smoking-status assessment according to prior tobacco harm reduction and/or smoking cessation training\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo prior THR/SC training (n\u0026thinsp;=\u0026thinsp;308)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAny prior THR/SC training (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge score, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice score, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher knowledge (score\u0026thinsp;\u0026ge;\u0026thinsp;6), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher practice (score\u0026thinsp;\u0026ge;\u0026thinsp;7), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh confidence (very confident), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (63.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoutine smoking-status assessment (often/always), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eTHR, tobacco harm reduction; SC, smoking cessation; SD, standard deviation.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eP values were derived from appropriate bivariate comparisons between participants with and without any prior THR/SC training.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Multivariable regression analysis\u003c/h2\u003e \u003cp\u003eIn multivariable logistic regression analyses, prior THR/SC training was strongly associated with higher knowledge (aOR 7.05, 95% CI 2.96\u0026ndash;16.75). None of the other covariates in this model showed statistically significant associations with higher knowledge.\u003c/p\u003e \u003cp\u003eHigher knowledge scores were independently associated with higher practice (aOR 1.36 per one-point increase, 95% CI 1.20\u0026ndash;1.53). Prior THR/SC training also remained significantly associated with higher practice (aOR 3.96, 95% CI 1.52\u0026ndash;10.33).\u003c/p\u003e \u003cp\u003eIn the model for high confidence, higher practice scores were associated with increased odds of reporting very high confidence (aOR 1.20, 95% CI 1.09\u0026ndash;1.32), while HSA cadre was also positively associated with high confidence compared with clinician cadre (aOR 1.83, 95% CI 1.01\u0026ndash;3.30). In the model for routine smoking-status assessment, prior THR/SC training was associated with greater odds of reporting frequent assessment (aOR 3.67, 95% CI 1.45\u0026ndash;9.30), while high confidence was also positively associated with routine assessment (aOR 1.87, 95% CI 1.05\u0026ndash;3.33). Participants in Mzimba North and those in HSA cadre had lower odds of routine smoking-status assessment than their respective reference groups. The multivariate logistic regression results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable logistic regression models of knowledge, practice, confidence, and smoking-status assessment among frontline healthcare workers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel 1. Higher knowledge (score\u0026thinsp;\u0026ge;\u0026thinsp;6/11; n\u0026thinsp;=\u0026thinsp;333)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMzimba North vs Lilongwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.90 (0.53\u0026ndash;1.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale vs female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.77 (0.45\u0026ndash;1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.350\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHSA vs clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.58 (0.31\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse vs clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.73 (0.39\u0026ndash;1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.339\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny prior THR/SC training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.05 (2.96\u0026ndash;16.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience, per additional year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00 (1.00-1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 2. Higher practice (score\u0026thinsp;\u0026ge;\u0026thinsp;7/13; n\u0026thinsp;=\u0026thinsp;329)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMzimba North vs Lilongwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.70 (0.41\u0026ndash;1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale vs female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.70 (0.41\u0026ndash;1.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHSA vs clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.63 (0.33\u0026ndash;1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.147\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse vs clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.63 (0.33\u0026ndash;1.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge score, per 1-point increase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.36 (1.20\u0026ndash;1.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny prior THR/SC training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.96 (1.52\u0026ndash;10.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience, per additional year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.99-1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 3. High confidence (very confident; n\u0026thinsp;=\u0026thinsp;329)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMzimba North vs Lilongwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.44 (0.90\u0026ndash;2.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.130\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale vs female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.92 (0.57\u0026ndash;1.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.752\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHSA vs clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.83 (1.01\u0026ndash;3.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse vs clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.03 (0.57\u0026ndash;1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.923\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge score, per 1-point increase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.10 (0.98\u0026ndash;1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny prior THR/SC training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.83 (0.33\u0026ndash;2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice score, per 1-point increase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.20 (1.09\u0026ndash;1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience, per additional year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.99 (0.97\u0026ndash;1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.629\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 4. Routine smoking-status assessment (often/always; n\u0026thinsp;=\u0026thinsp;333)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMzimba North vs Lilongwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.52 (0.29\u0026ndash;0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale vs female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.54\u0026ndash;1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHSA vs clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.34 (0.17\u0026ndash;0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse vs clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.76 (0.39\u0026ndash;1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge score, per 1-point increase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.11 (0.98\u0026ndash;1.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny prior THR/SC training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.67 (1.45\u0026ndash;9.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh confidence (very confident)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.87 (1.05\u0026ndash;3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience, per additional year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.99-1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.659\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eaOR, adjusted odds ratio; CI, confidence interval; HSA, Health Surveillance Assistant; THR, tobacco harm reduction; SC, smoking cessation. Reference categories were Lilongwe district, female sex, and clinician cadre.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study provides important baseline evidence on the preparedness of frontline healthcare workers in Malawi to deliver tobacco harm reduction and smoking cessation interventions. The findings reveal a pronounced capacity-readiness gap, characterized by very low levels of formal training, limited knowledge of evidence-based cessation approaches, and suboptimal clinical practices, despite high motivation and perceived confidence among providers.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Capacity-readiness gap in tobacco cessation service delivery\u003c/h2\u003e \u003cp\u003eThe most striking finding was the mismatch between confidence and demonstrated preparedness. Nearly half of participants reported being very confident in helping clients quit smoking, yet knowledge scores were low, in line with regional estimates (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) familiarity with structured cessation frameworks was limited, and routine tobacco-related clinical practices were inconsistently implemented as is the case elsewhere (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This discordance likely reflects a form of perceived self-efficacy decoupled from technical competence, a phenomenon observed in under-resourced systems where exposure to standardized training is limited. In such contexts, confidence maybe shaped more by routine patient interaction than by mastery of evidence-based cessation protocols, which ultimately constrains intervention fidelity.\u003c/p\u003e \u003cp\u003eThe extremely low prevalence of prior THR and SC training represents a critical bottleneck in health system readiness. Training was the strongest predictor of higher knowledge, supporting the view that structured educational exposure is a foundational input for building provider readiness. In settings where tobacco cessation is not systematically incorporated into preservice or in-service professional development, frontline healthcare workers are unlikely to acquire the competencies required for consistent, evidence-based care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Knowledge deficits and limitations in evidence-based care\u003c/h2\u003e \u003cp\u003eConsistent with literature, knowledge gaps were especially pronounced in pharmacological (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and structured behavioral interventions (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Furthermore, although behavioral counseling was relatively well recognized, awareness of nicotine replacement therapy, motivational interviewing, and prescription medications was much lower. This pattern suggests that provider knowledge may be limited to general advice-giving rather than a broader understanding of comprehensive cessation care. This disparity in awareness between behavioral support and pharmacological or advanced interventions is also reported in other study (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and is a recognized issue in smoking cessation efforts.\u003c/p\u003e \u003cp\u003eThe low average knowledge score further reinforces this concern. With only about one quarter of participants meeting the threshold for higher knowledge, the findings suggest that substantial proportions of frontline healthcare workers may not be adequately prepared to provide even basic cessation support. In practical terms, this may reduce the quality, consistency, and effectiveness of tobacco-related counseling within routine clinical care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.3. From knowledge to practice: evidence of a capacity-knowledge-practice pathway\u003c/h2\u003e \u003cp\u003eThe results support a clear pathway from training to knowledge and from knowledge to practice. Higher knowledge scores were significantly associated with improved cessation-related practices, and training remained independently associated with both higher knowledge and higher practice. These findings support the conceptual model underpinning the study and suggest that investment in training can have downstream effects on day-to-day clinical behavior (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, practice gaps remained substantial even among trained participants. Routine smoking-status assessment was uncommon overall, referral to cessation resources was rare, and many participants lacked familiarity with the 5A approach. These findings suggest that knowledge, while necessary, may not be sufficient on its own. The translation of knowledge into practice likely depends on additional organizational and system-level conditions that support implementation in routine care (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Structural and system-level barriers\u003c/h2\u003e \u003cp\u003eThe study also highlights important structural barriers that constrain implementation. More than half of participants reported lack of resources or support for cessation care, and nearly one third cited lack of medications or support materials as a barrier. These findings suggest that even motivated and knowledgeable providers may struggle to deliver effective cessation interventions when health systems do not provide the tools, protocols, and infrastructure required for sustained practice (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReadiness should therefore be understood as a multilevel construct. At the provider level, it includes training, knowledge, and confidence. At the organizational level, it includes supervision, protocols, and workflow integration. At the system level, it includes access to cessation tools, referral pathways, and broader institutional support. Interventions that focus exclusively on training without addressing these structural conditions may achieve only partial or short-lived gains.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.5. Implications for policy and health systems strengthening in LMICs\u003c/h2\u003e \u003cp\u003eThese findings have several implications for tobacco control policy and health systems strengthening in Malawi and similar LMIC settings. First, the strong associations between training, knowledge, and practice indicate that competency-based training programs for frontline healthcare workers should be prioritized. Second, training should be embedded within broader efforts to integrate cessation support into routine service delivery, including use of standardized counseling frameworks such as the 5A approach. Third, facility-level and district-level support systems should be strengthened to ensure availability of educational materials, clinical protocols, referral options, and, where feasible, cessation aids.\u003c/p\u003e \u003cp\u003eThe very high level of expressed interest in further training is especially encouraging. It suggests that frontline healthcare workers are receptive to capacity-building efforts and that implementation initiatives are likely to encounter less resistance at the provider level than might otherwise be expected. Harnessing this motivation may be critical for closing the gap between willingness and preparedness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.6. Strengths and limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. It used a multicenter design, included a relatively large sample of frontline healthcare workers, and generated real-world baseline evidence from routine health system settings in Malawi. The use of both descriptive and multivariable analyses also allowed examination of potential pathways linking training, knowledge, and practice.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. The cross-sectional design precludes causal inference, and all measures were self-reported, raising the possibility of recall and social desirability bias. The study was conducted in two districts and may therefore not fully represent all healthcare settings in Malawi. In addition, the composite knowledge and practice measures, while analytically useful, may not capture all dimensions of provider readiness. These limitations notwithstanding, the study offers a valuable baseline assessment of frontline workforce preparedness for tobacco cessation service delivery.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eFrontline healthcare workers in Malawi are highly motivated to support tobacco harm reduction and smoking cessation but remain insufficiently prepared to deliver these services effectively. A clear capacity-readiness gap exists, driven by limited formal training, low knowledge of evidence-based cessation strategies, inconsistent clinical practices, and inadequate system support. Addressing this gap will require integrated interventions that combine targeted workforce training with organizational and structural reforms to support routine delivery of tobacco cessation care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the University of Malawi Research Ethics Committee (UNIMAREC), Malawi (Approval number: P.11/24/485). The study was conducted in accordance with the Declaration of Helsinki and relevant national regulations. All participants provided written informed consent for participation in the study and for the use of anonymized survey data for research purposes. Administrative authorization was also obtained from the District Health Offices (Lilongwe and Mzimba North).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, as no individual person’s data or quotations are reported in this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Global Action to End Smoking, Inc., under Grant Number UNS-001-004. The funder had no role in study design, data collection, analysis, interpretation of data, or writing of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eATM conceived the study and drafted the manuscript. EPM led data analysis. SBM contributed to interpretation of findings. BS, DM, HP and SBM contribution to study implementation, manuscript review, and critical revisions. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the frontline healthcare workers in Lilongwe and Mzimba North districts who participated in this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eTauras JA. Tobacco control in low-income and middle-income countries: findings from WHO FCTC investment cases. Tobacco Control. 2024;33(Suppl 1):s1-s2.\u003c/li\u003e\n \u003cli\u003eShankar A, Parascandola M, Sakthivel P, Kaur J, Saini D, Jayaraj NP. Advancing Tobacco Cessation in LMICs. Current Oncology. 2022;29(12):9117-24.\u003c/li\u003e\n \u003cli\u003eSultana S, Inungu J, Jahanfar S. Barriers and Facilitators of Tobacco Cessation Interventions at the Population and Healthcare System Levels: A Systematic Literature Review. International Journal of Environmental Research and Public Health. 2025;22(6):825.\u003c/li\u003e\n \u003cli\u003eHasan SI, Amer Nordin AS, Hairi FM, Ahmad Tajuddin NAN. Barriers and Facilitators to Smoking Cessation Intervention: Qualitative Insights From Health Care Providers. Asia Pacific Journal of Public Health. 2025;37(6-7):566-77.\u003c/li\u003e\n \u003cli\u003eKnudsen HK, Studts CR, Studts JL. The implementation of smoking cessation counseling in substance abuse treatment. J Behav Health Serv Res. 2012;39(1):28-41.\u003c/li\u003e\n \u003cli\u003eRamanadhan S, Mahtani SL, D\u0026rsquo;Costa M, Mandal G, Jagiasi D, Chawla R, et al. Adaptation drivers of evidence-based brief advice/counselling for tobacco use in high-reach, low-resource settings in Mumbai: a qualitative exploration with patients, practitioners and policymakers. BMJ Open. 2025;15(10):e101969.\u003c/li\u003e\n \u003cli\u003eSiddiqi AD, Britton M, Chen TA, Carter BJ, Wang C, Martinez Leal I, et al. Tobacco Screening Practices and Perceived Barriers to Offering Tobacco Cessation Services among Texas Health Care Centers Providing Behavioral Health Treatment. International Journal of Environmental Research and Public Health. 2022;19(15):9647.\u003c/li\u003e\n \u003cli\u003eWalker TJ, Brandt HM, Wandersman A, Scaccia J, Lamont A, Workman L, et al. Development of a comprehensive measure of organizational readiness (motivation \u0026times; capacity) for implementation: a study protocol. Implement Sci Commun. 2020;1(1):103.\u003c/li\u003e\n \u003cli\u003eMuza LC, Egenasi CK, Steinberg WJ, Benedict MO, Habib T, Mampuya F, et al. Healthcare providers\u0026rsquo; knowledge, attitudes and practices on smoking cessation intervention in the Northern Cape. Health SA Gesondheid. 2024;29.\u003c/li\u003e\n \u003cli\u003eWestmaas JL, Kates I, Makaroff L, Henson R. Barriers to helping patients quit smoking: Lack of knowledge about cessation methods, E-cigarettes, and why nurse practitioners and physician assistants can help. Public Health in Practice. 2023;6:100409.\u003c/li\u003e\n \u003cli\u003eSiddiqui F, Ahmad F, Fieroze F, Lina S, Mazhar L, Nawaz AM, et al. Mixed Methods Process Evaluation of Behavioral Support and Nicotine Replacement Therapy for Smokeless Tobacco Cessation in Bangladesh, India, and Pakistan. Nicotine and Tobacco Research. 2026:ntag004.\u003c/li\u003e\n \u003cli\u003eAlagidede AN, Omole OB. Tobacco use and readiness to treat tobacco users among primary healthcare professionals in Soweto. South African Family Practice. 2024;66(1).\u003c/li\u003e\n \u003cli\u003eColeman C, Ferguson SG, Nash R. Barriers to smoking interventions in community healthcare settings: a scoping review. Health Promot Int. 2024;39(2).\u003c/li\u003e\n \u003cli\u003eTan MM, Veluz-Wilkins A, Styrczula P, McBrayer S. Gaps in Knowledge and Practice in Treating Tobacco Use Among Non-physician Healthcare Professionals and Lay Health Workers in Chicago, Illinois. Cancer Control. 2022;29:10732748221105310.\u003c/li\u003e\n \u003cli\u003eStead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016;3(3):Cd008286.\u003c/li\u003e\n \u003cli\u003eGilbert P, Dowd B-A, Dabney BW, Linton M. Educating Providers on Proactive Smoking Cessation Treatments in Primary Care. The Journal for Nurse Practitioners. 2025;21(1):105239.\u003c/li\u003e\n \u003cli\u003eOnda M, Horiguchi M, Domichi M, Sakane N. Effect of a Smoking Cessation Education Program on the Knowledge, Attitude, and Self-Efficacy of Community Pharmacists in Japan: A Quasi-Experimental Study. Tob Use Insights. 2024;17:1179173x241272362.\u003c/li\u003e\n \u003cli\u003eBaliunas D, Ivanova A, Tanzini E, Dragonetti R, Selby P. Impact of comprehensive smoking cessation training of practitioners on patients\u0026apos; 6-month quit outcome. Can J Public Health. 2020;111(5):766-74.\u003c/li\u003e\n \u003cli\u003eKgadima MR, Coetzee IM, Heyns T. Factors influencing knowledge translation into critical care practice: The reality facing intensive care nurses in Limpopo Province. South Afr J Crit Care. 2024;40(2):e1282.\u003c/li\u003e\n \u003cli\u003eAl-Worafi YM. Smoking Cessation in Developing Countries: Challenges and Recommendations. In: Al-Worafi YM, editor. Handbook of Medical and Health Sciences in Developing Countries : Education, Practice, and Research. Cham: Springer International Publishing; 2023. p. 1-20.\u003c/li\u003e\n \u003cli\u003eGichuki JW, Opiyo R, Mugyenyi P, Namusisi K. Healthcare Providers\u0026apos; Level of Involvement in Provision of Smoking Cessation Interventions in Public Health Facilities in Kenya. J Public Health Afr. 2015;6(2):523.\u003c/li\u003e\n \u003cli\u003eVisser JEM, Nur FA, Rozema AD, Kunst AE, Kuipers MAG. Facilitators and barriers to smoking cessation support among professionals in social and community service settings: a systematic review and thematic synthesis. Health Educ Res. 2025;40(5).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"tobacco harm reduction, smoking cessation, health systems, workforce capacity, Malawi, implementation readiness","lastPublishedDoi":"10.21203/rs.3.rs-9281739/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9281739/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eFrontline 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOnly 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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eFrontline 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.\u003c/p\u003e","manuscriptTitle":"A capacity-readiness gap in tobacco harm reduction and smoking cessation: a multicenter cross-sectional study of frontline healthcare workers in Malawi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-15 09:39:28","doi":"10.21203/rs.3.rs-9281739/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-18T17:07:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320860676465916965896744454723106287805","date":"2026-05-15T11:01:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57439216387818560053422730267337240971","date":"2026-05-15T05:13:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T02:23:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110610945783400184304867479214045931363","date":"2026-05-06T21:02:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-06T09:00:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-13T06:15:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-09T17:15:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-09T08:56:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-04-09T08:08:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0eb9875e-0e3d-43cb-b917-bb2dea16af6e","owner":[],"postedDate":"May 15th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-18T17:07:23+00:00","index":84,"fulltext":""},{"type":"reviewerAgreed","content":"320860676465916965896744454723106287805","date":"2026-05-15T11:01:42+00:00","index":80,"fulltext":""},{"type":"reviewerAgreed","content":"57439216387818560053422730267337240971","date":"2026-05-15T05:13:54+00:00","index":79,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T02:23:38+00:00","index":53,"fulltext":""},{"type":"reviewerAgreed","content":"110610945783400184304867479214045931363","date":"2026-05-06T21:02:02+00:00","index":50,"fulltext":""},{"type":"reviewersInvited","content":"31","date":"2026-05-06T09:00:12+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T09:39:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-15 09:39:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9281739","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9281739","identity":"rs-9281739","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}