Case studies of tobacco harm reduction research and innovation led by THRSP scholars in LMICs

Case Study 1: Community-Led Tobacco Harm Reduction in Rural Pakistan

Shaheen N, Ngoma C, Adebisi YA, Glover M. Lady health workers smoking cessation initiative in rural Pakistan. Discover Global Society. 2024 Nov 12;2(1):88.

In rural Pakistan, tobacco smoking and indoor smoke exposure remain major public health risks, particularly within households. The Lady Health Worker (LHW) programme, which forms the backbone of community-based primary healthcare, provided an existing delivery platform for tobacco harm reduction (THR). Rather than creating a new intervention structure, THR education was integrated into routine household outreach, using trusted female health workers already embedded within communities.

More than 170 LHWs were trained on tobacco-related health risks, indoor smoke exposure, and basic THR principles, and provided with simple, culturally appropriate educational materials. Over a 24-week period, these workers reached 25,760 households across Gujranwala district. Around half of households visited included at least one person who smoke, and 90% reported smoking indoors. Following the intervention, awareness of tobacco-related harms increased, and a subset of participants demonstrated readiness to change behaviour, with 51 women and 146 men agreeing to try safer nicotine or THR alternatives. Health workers and supervisors judged the programme to be feasible, low-cost, and compatible with existing community health responsibilities.

The key lesson from this case is that integrating THR into established community health systems significantly expands reach while maintaining trust and sustainability. Training existing health workers reduces costs, avoids parallel programme structures, and enables gender-sensitive engagement, particularly where women play a central role in household health decision-making. Local leadership and community ownership were critical to uptake and acceptability.

An example of a brochure used in Pakistan in PDF version

Case Study 2: Training Health Workers to Deliver THR in Mental Health Services in Malawi

Kondowe T, Ngoma C, Adebisi YA, Lungu S. A structured training intervention on tobacco harm reduction for mental health workers across two psychiatric hospitals in Malawi: a quasi-experimental pre-post study. Intern Emerg Med. 2025 Nov 1.

People with mental health conditions experience disproportionately high smoking prevalence and tobacco-related harm, yet mental health services in many LMICs lack capacity to address this burden. In Malawi, a structured tobacco harm reduction training was delivered to mental health workers across two psychiatric hospitals, focusing on improving knowledge, confidence, and attitudes toward smoking cessation and THR within routine care.

Using a quasi-experimental pre–post design, 48 mental health professionals received a brief, structured THR training. At baseline, only 25% had received any prior THR training. Post-intervention results showed a statistically significant improvement in knowledge scores and a marked shift toward “good” THR knowledge, with poor knowledge virtually eliminated. Participants reported improved confidence in discussing harm reduction with patients, and the intervention was considered practical and scalable within existing mental health services.

This case highlights how targeted capacity-building among frontline health workers can rapidly close knowledge gaps and strengthen THR delivery for high-risk populations. Importantly, the intervention required no new infrastructure and aligned with existing service delivery, demonstrating how THR can be embedded within specialised care settings in LMICs.

Case Study 3: Building THR Communication Capacity Among Emerging Public Health Advocates in Nigeria

Oke GI, Ademola PS, Utaka EN, John E, Adam MF, Okereke B, Onyia IM, Adebisi YA. Knowledge, perception, and willingness of emerging Public Health Advocates to effectively communicate about smoking cessation and Tobacco Harm Reduction in Africa. Discover Psychology. 2024 Jan 16;4(1):6.

Effective THR depends not only on products and policy, but on the ability of advocates and communicators to explain harm reduction accurately and credibly. In Nigeria, a multi-method study examined the knowledge, perceptions, and communication readiness of emerging public health advocates, including healthcare students, health communicators, and aspiring journalists aged 18–30. The study highlights a critical but often overlooked gap in LMIC-led THR implementation: limited understanding of THR among those expected to communicate it to the public.

Among 415 participants, nearly three-quarters lacked prior knowledge or a clear understanding of THR. While most respondents recognised nicotine replacement therapy as a harm reduction strategy, fewer identified e-cigarettes as lower risk than smoking, and uncertainty remained around nicotine dependence and product safety. Despite these gaps, the majority agreed that THR products can support smoking cessation and expressed strong interest in advocacy and awareness activities, particularly those targeting young people and people who smoke themselves.

Importantly, participants identified locally relevant solutions to improve THR communication, including peer-led advocacy, campus-based ambassador programmes, engagement of people who smoke as champions, and simplified messaging delivered through youth-friendly media channels. Barriers such as misinformation from health professionals, cultural and religious concerns, and difficulties reaching remote populations were also highlighted. This case demonstrates that strengthening THR in LMICs requires deliberate investment in communication capacity, not just evidence generation.

The key lesson is that local innovation must include building a knowledgeable and confident cadre of educators who can translate THR evidence into clear, culturally appropriate messages. Empowering young public health leaders enhances credibility, counters misinformation, and supports long-term sustainability of harm reduction efforts across LMIC settings.

Cross-Cutting Lessons for LMIC-Led THR Innovation

Across these cases, effective THR implementation relied on three common principles: integration into existing systems, investment in local health worker capacity, and context-sensitive delivery. Whether at community or facility level, locally led interventions proved more credible, more feasible, and more sustainable than externally designed models. These examples reinforce that local innovation, rather than policy transfer, is the primary driver of effective THR in LMICs.