Documented Tobacco Cessation Care and Patient Outcomes in Malawi: Analysis of Post-Training Clinical Records

Healthcare worker training programs for tobacco cessation in low- and middle-income countries (LMICs) often evaluate isolated service indicators. Tobacco cessation care is inherently multi-component, yet the association between the breadth of documented care (as recorded in routine clinical records) and patient outcomes has rarely been examined in LMIC settings.

We conducted a secondary analysis of 640 patient assessments collected over nine months following a tobacco harm reduction and smoking cessation training program for frontline healthcare workers in Lilongwe and Mzimba North districts, Malawi. A documented-care index (0-4) was constructed by summing four binary indicators: tobacco-use screening, cessation counseling, prior quit attempt, and cessation service utilization. The index measures the extent to which these interventions were documented in clinical records, not independently verified care delivery. Multivariable linear regression identified predictors of index score. Logistic regression estimated associations between index score and two outcomes: improved tobacco-use status at follow-up and follow-up attendance. Dose-response patterns were assessed using Spearman rank correlation and chi-square tests.

Scores of 3 or 4 were observed in 70.9% of records. Daily tobacco use was the strongest predictor of higher index scores (β=1.08, p<0.001), followed by Mzimba North district (β=0.24, p=0.001) and older age (β=0.01, p=0.007). Among 261 follow-up assessments, improvement rates increased from 47.1% (index 0-1) to 76.6% (index 4). Each one-unit increase in index score was associated with nearly twice the odds of improvement (aOR 2.04, 95% CI 1.43-2.92, p<0.001) and follow-up attendance (aOR 2.19, 95% CI 1.78-2.70, p<0.001). A significant dose-response pattern was observed (Spearman ρ=0.24, p<0.001; chi-square p=0.002).

Higher documented-care index scores were associated with better cessation-related outcomes and greater re-engagement in care. These findings are exploratory; the index has not yet been prospectively validated. Prospective validation with independently verified cessation outcomes is warranted.