Study Population
1,258 smokers were recruited in three districts of Malawi, comprising men and women aged between 15 and 55 years. Participant demographic characteristics are presented in Table 1. In each district the study registered a higher number of male smokers than female smokers. However, Balaka district had a higher number of female smokers than other districts. Most smokers were married and not educated. The highest level of education completed ranges from senior primary to senior secondary. Only a few smokers had attended tertiary education.
Factors Affecting Access and Use of Tobacco Harm Reduction Products
Lack of Information
The smokers expressed that they lack information on Safer Nicotine Products (SNP) and had low levels of understanding of safer alternatives to smoking tobacco. They thought that such products were unavailable and more likely to be addictive and deadly compared to tobacco cigarettes.
…“I do not know of tobacco harm reduction products, but I use chewing gum or sweets, which are available on the market”….a smoker in Balaka district.
… "Source of information is not available to everyone”… a smoker in Ntcheu.
…”Those products may be worse than the products that are advertised e.g. embassy”… a smoker in Chitipa.
Geographical location
Smokers in Ntcheu district stressed that geographical location plays a vital role in their ability to gain information on issues concerning their health. Smokers perceived that living in a remote geographical area is a barrier to accessing information concerning tobacco harm reduction products and services.
…“Area where am coming from, difficult to receive information"… smokers in Ntcheu.
Lack of Media Influence
The media does not advertise safer alternatives to smoking tobacco or their potential to reduce harm. This further gives the smokers an impression that SNP are bad.
…“ It means the products are not available in Malawi and it suggests that the products are bad ones”… “They hazardous”… smokers in Chitipa
Smokers emphasized that the media corporations are restricted by the tobacco companies. Since tobacco harm reduction products are safer compared to cigarettes, they have the potential to threaten the tobacco and cigarette industries.
…“They are afraid of killing the business of tobacco”…“harmful to human”… “Maybe the companies that produce cigarettes restricts”… smokers in Ntcheu.
…“I think the government is not providing enough effort”…and…“Lack of seriousness of the companies”… smokers in Balaka.
Poverty and High Levels of Cigarettes
High levels of poverty and the availability of cheap tobacco cigarettes in regional markets are facilitators for smoking tobacco.
…“Cigarettes are everywhere so I cannot stop smoking”… a smoker in Chitipa district.
…“Poverty, don't have materials that I can get the information”... a smoker in Ntcheu.
…“Remove some companies that make tobacco”… a smoker in Balaka.
Availability of Local Tobacco Harm Reduction Resources and Addiction
The smokers perceived that they are familiar with (or even habituated to) the locally-available tobacco harm reduction resources and products, and they are unaware that they can still get the effect of nicotine with the use of novel tobacco harm reduction products, when compared to those that are easily available.
…“used to the locals” …“fear of addiction...and recovery is very expensive in Malawi”… smokers in Chitipa.
Lack of Tobacco Harm Reduction Access points/Clinics
The smokers articulated that the existence of smoking cessation clinics or tobacco harm reduction services would encourage a number of smokers to seek out these services and attempt to quit smoking. They thought that the government should introduce ways to ensure that tobacco harm reduction products are available and accessible.
…“Introduce a department in the hospital to handle all issues related to tobacco harm reduction”… a smoker in Chitipa.
…“Government should make them available on the market for free”… a smoker in Ntcheu.
…“Publicizing/GVT should allow this harm reduction be on public”… a smoker in Balaka.
There was prevalent belief that tobacco harm reduction products or safer alternatives such as electronic cigarettes, nicotine replacement therapies (NRT), heat not burn (HNB), snus and pharmacotherapies are not available on the market. This is statistically significant, with Ρ = 0.041 for Chitipa district, Ρ = 0.038 for Ntcheu district and Ρ = 0.040 for Balaka district, see Table 2.
Tobacco Harm Reduction Methods, Resources and Products Available
Tobacco harm reduction methods, resources and products used include; fruits like malambe (baobab), banana, masau (jujube); mtera (local herbs); janus (sweets) and chocolate; fried maize; milk; chewing gum and consuming soaked tobacco in tea or juice.
Some smokers replaced smoking tobacco with using preparations such as solutions made from sugar, cigarette filters mixed with water, and a mixture of pig milk, tobacco and drinking water. These solutions are perceived to have the potential to reduce the appetite for cigarettes. They are perceived to provide tobacco harm reduction since there is no smoke or tar production, although nothing is known about their efficacy or toxicity.
…“I don’t know tobacco harm reduction products…but I sell chingambwe myself”… a smoker in Chitipa district.
…“ Mostly I use Sweets like Janus, The appetite of smoking was reduced"… a smoker in Ntcheu district.
Smokers also use smokeless tobacco products (STP) such as Chingambwe and Ngirimbo. Chingambwe is raw tobacco that is dried and pounded into small tablets for easy consumption. It is consumed by snuffing, put in the nose and placed between the lower lip and gum. Sometimes it is soaked in water and taken as a drink. Again, it is perceived as a tobacco harm reduction product due to the absence of combustion.
…“Chingambwe mainly when it's smokeless, ngirimbo, Chocolate sweets”… smoker in Chitipa.
The absence of safer nicotine products on the market indicates that smokers rarely use them; which is statistically significant in Chitipa (Ρ = 0.030), Ntcheu (Ρ = 0.033) and Balaka (Ρ = 0.023) in Table 3.
Awareness of Smokers on Tobacco Harm Reduction Products
Smokers clearly said that they are not aware of the existence of tobacco harm reduction products.
… “Do not have any knowledge, and are not locally available”… a smoker in Balaka.
…“Lack of knowledge and poverty”… a smoker in Chitipa.
…“I don't know them"… a smoker in Ntcheu.
Perceptions and Attitude of Smokers towards Tobacco Harm Reduction Products
The widespread use of tobacco harm reduction products depends on consumer preference, experience, availability of the products and the ability to alleviate the health issues associated with smoking cigarettes.
…“I think they may help reduce cases of TB and lung Cancer”… a smoker in Ntcheu District.
…“I think it's because they are developed to reduce the risks that someone can have when smoking”... a smoker in Chitipa.
“I know the smoke in cigarettes is bad for my health”…“Maybe if they adopt tobacco harm reduction products”… a smoker in Balaka.
Smokers articulated that it is not easy to quit smoking but approved the notion of tobacco harm reduction products as safer alternatives; since they may provide smokers a higher chance of being able to quit smoking tobacco.
…“I would love to see these products in shops as they will help us improve our health”… a smoker in Chitipa district.
…“It can help because I once got sick because of smoking it can help me stop”… a smoker in Ntcheu District.
…“It’s hard to quit, Maybe if they adopt tobacco harm reduction products”… a smoker in Balaka District.