Tobacco use patterns and socioeconomic disparities in Malawi based on the 2024 Demographic and Health Survey

As Malawi implements the WHO Framework Convention on Tobacco Control (FCTC) following its 2023 ratification, a comprehensive understanding of the national landscape of tobacco use is essential for evidence-based health planning. This study investigated the prevalence and socioeconomic determinants of tobacco use across the Malawian adult population. A secondary analysis was conducted using data from the 2024 Malawi Demographic and Health Survey (MDHS). The Individual Recode and Men’s Recode datasets were appended, yielding an analytical sample of 30,500 respondents; survey weights were applied to generate nationally representative estimates. Tobacco use was categorised into four mutually exclusive groups: exclusive combustible use, exclusive smokeless use, dual use of both combustible and smokeless tobacco, and non-use. Multinomial logistic regression was employed to estimate relative risk ratios (RRR), adjusting for age, sex, educational attainment, household wealth, place of residence, and administrative region. The weighted national prevalence of exclusive combustible tobacco use was 3.71%, exclusive smokeless use 0.12%, and dual use of both products 0.26%, with 95.90% of the population reporting no current use. A pronounced sex disparity was observed: 11.80% of men reported exclusive combustible use compared with 0.39% of women. Prevalence was highest among individuals in the poorest wealth quintile (5.63%) and those with no formal education (5.39%). Tobacco users were significantly older than non-users (mean age 34.20 vs. 28.40 years for exclusive combustible users and non-users, respectively). In the adjusted model, the relative risk of exclusive combustible use increased by 5.2% per additional year of age (RRR = 1.052; 95% CI 1.045–1.060; p < 0.001). Residents of the Central Region were significantly more likely to smoke than those in the Northern Region (RRR = 1.341; 95% CI 1.046–1.718; p = 0.021). Although dual use was rare (0.26%; n = 91), the adjusted model identified education as a particularly strong protective factor, with higher substantially lower relative risk of dual use (RRR = 0.058; p = 0.008). Tobacco use in Malawi is characterised by deep socioeconomic inequality, disproportionately affecting low-income men with limited education. Policy efforts should prioritise equitable access to tobacco cessation services, particularly for older, low-income men and individuals with limited education who experience the greatest burden of combustible tobacco use.