Wingston Felix Ng’ambi1, Jobiba Chinkhumba2, Michael Mphatso Udedi3, Cosmas Zyambo4, Adamson Sinjani Muula5,6,7*
1Health Economics and Policy Unit, Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences, Lilongwe, Malawi
2Department of Health Systems and Policy, School of Global and Public Health, Kamuzu university of Health Sciences, Blantyre, Malawi
3Division of Non-Communicable Diseases, Injuries and Mental Health, Africa CDC, Addis Ababa, Ethiopia
4Department of Community and Family Medicine, School of Public Health, University of Zambia, Lusaka, Zambia
5Africa Centre of Excellence in Public Health and Herbal Medicine (ACEPHEM), Kamuzu University of Health Sciences, Blantyre, Malawi
6Department of Community and Environmental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
7Professor and Head, Department of Community and Environmental Health, School of Global and Public Health, Kamuzu university of Health Sciences, Blantyre, Malawi *Corresponding author email: adamsonmuula@yahoo.com
Abstract
As of 2026, the most recent Malawi National Global Youth Tobacco Survey and Global School-based Health Survey were conducted in 2009, focusing on adolescents aged 10–14 years. These surveys documented adolescent substance use within the target age group. The absence of relevant successor surveys leaves a data gap on substance use status. Adolescent substance use surveillance allows for early risk detection, policy prioritization, and monitoring of national and global commitments to prevention and control of substance use. This commentary draws on a narrative review of global and African literature, policy frameworks, and national strategies to examine the implications of this monitoring void. We synthesize the scope and utility of the Global Youth Tobacco Survey and Global School-based Health Survey instruments, review trends in youth substance use across sub-Saharan Africa, and assess Malawi’s current policy readiness. Regional evidence highlights increasing adolescent exposure to aggressive tobacco industry marketing; the growing availability of new products such as shisha and electronic cigarettes; and persistent harmful alcohol consumption driven by cheap and illicit beverages and drugs. In the absence of current data, policymakers are unable to detect emerging risks, tailor interventions, or evaluate progress toward national and global targets. Drawing on global and African examples, we argue that renewed youth substance use surveillance is an urgent public health priority. We call on the Malawi Government and partners to rapidly restart youth substance use surveys, strengthen enforcement of Framework Convention on Tobacco Control and alcohol control measures. We propose integrated screening, brief intervention and referral to treatment in appropriate health services to protect a generation from preventable substance-related harm.
Key words: Adolescent substance use, youth surveillance, non-communicable diseases, tobacco and alcohol control, SBIRT, Malawi
MALAWI’S 15-YEAR UNMONITORED HEALTH THREAT
Tobacco use and harmful alcohol consumption remain among the leading global preventable risks for non-communicable diseases (NCDs) accounting for substantial morbidity and premature mortality1. Evidence consistently shows that initiation of both smoking and alcohol use typically occurs during adolescence, underscoring the importance of robust youth surveillance systems and early preventive interventions2–4. In Malawi, however, routine national monitoring of youth substance use has been largely absent for more than a decade. Malawi conducted the last nationwide Global Youth Tobacco Survey (GYTS) 5 and the Global School-based Health Survey (GSHS)6 in 2009. As a result, the country has effectively been navigating adolescent tobacco and alcohol use interventions without up-to-date epidemiological evidence.
This prolonged data gap is particularly concerning given Malawi’s recent ratification of the WHO Framework Convention on Tobacco Control (FCTC) in August 20237 and its commitments under the United Nations 2030 Agenda for Sustainable Development, including Target 3.5 to strengthen the prevention and treatment of substance abuse8. In the absence of current surveillance data, policymakers and programme implementers are constrained in their ability to design, implement, and evaluate the very interventions required under these global frameworks. The challenge is further compounded by the rapid evolution of substance use environments, including the emergence of novel tobacco and nicotine products, changing alcohol marketing strategies, and persistent weaknesses in regulatory enforcement. As highlighted in expert reviews, the lack of adolescent substance use data in many African countries continues to limit the implementation of evidence-based policies9,10. Against this backdrop, this commentary examines the public health and policy implications of Malawi’s youth substance use surveillance gap and issues an urgent call to action for government and international partners to reinvigorate routine monitoring and evidence-informed prevention efforts. Reviving and sustaining youth surveillance infrastructure is the practical condition under which almost every other adolescent health strategy rests. Given how quickly the country’s youth population is growing, the cost of continued inaction compounds with every year that passes without it.
CURRENT TOOLS FOR SUBSTANCE USE SURVEILLANCE IN ADOLESCENTS
The GYTS is a school-based survey system designed to enhance the capacity of countries to monitor tobacco use among youth and to guide the implementation and evaluation of tobacco prevention and control programs10. The GYTS questionnaire is composed of 58 core questions designed to gather data on the following seven key domains: (1) prevalence of cigarette smoking and other tobacco use, (2) access to cigarettes, (3) cessation, (4) environmental tobacco smoke (ETS), (5) electronic cigarette use, (6) role of the media and advertising in young people’s use of cigarettes, and (7) knowledge and attitudes of young people towards cigarette smoking. Additionally, the questionnaire includes optional modules covering electronic cigarettes, shisha, heated tobacco products (HTPs), bidis, smokeless tobacco, and oral nicotine products. The GYTS questionnaire is available at: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/global-youth-tobacco-survey/questionnaire.
The GSHS is a school-based survey system designed to provide data on health behaviors and protective factors among students aged 13-17 years6. The GSHS questionnaire comprises 10 core modules addressing the leading causes of morbidity and mortality among children and adults worldwide: (1) alcohol use, (2) dietary behaviours, (3) drug use, (4) hygiene, (5) mental health, (6) physical activity, (7) protective factors, (8) sexual behaviours, (9) tobacco use, and (10) violence and unintentional injury. Countries must select at least six of the 10 core modules in their country-specific questionnaire. The GSHS questionnaire is available at: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/global-school-based-student-health-survey/questionnaire. The GYTS typically targets adolescents aged 13–15 years, while the GSHS includes students aged 13–17 years, allowing complementary age-stratified analysis.
EVIDENCE SYNTHESIS AND REVIEW
We conducted a narrative review of published literature, policy documents, and data repositories related to youth tobacco and alcohol use in Malawi and sub-Saharan Africa. Sources included WHO/UN frameworks (FCTC11, SDGs12, WHO Global NCD Action Plan13), Malawi’s health and NCD strategies (HSSP8, NCD Action Plan14), and recent studies of adolescent substance use15–24. Key findings from global reports, Africa-wide surveys, and Malawi-specific research were synthesized. Recommendations leverage evidence from Screening, brief intervention and referral to treatment (SBIRT) implementation in Africa and policy success stories elsewhere to propose actionable interventions. Representative sampling strategies are essential to ensure national and subnational policy relevance.
Substance use data captured by GYTS and GSHS
Both the GYTS and GSHS questionnaires provide comprehensive frameworks for assessing youth substance use, with complementary strengths. The GYTS questionnaire offers in-depth tobacco-specific assessments across seven core domains25. It captures detailed information on tobacco use prevalence patterns, including cigarettes and alternative products, and examines the critical dimensions of youth access to tobacco products, cessation behaviors, and exposure to environmental tobacco smoke. The questionnaire also includes specific modules on emerging products such as electronic cigarettes, shisha, and heated tobacco products, along with assessments of media influences and advertising exposure. Knowledge and attitude domains provide insights into youth perceptions that can inform prevention strategies. In contrast, the GSHS questionnaire adopts a broader public health approach, covering ten core health domains that include substance use (alcohol, tobacco, and illicit drug use) alongside other critical health behaviors and protective factors26. The alcohol use module complements the tobacco focus of GYTS, allowing for integrated assessment of multiple overall substance use patterns. The inclusion of protective factors, mental health, and other behavioral domains enables understanding of the broader context in which substance use occurs, including risk and protective factors. The drug use module captures information on illicit substances beyond tobacco and alcohol, providing a more comprehensive substance use assessment.
Burden of adolescent substance use
A recent meta-analysis found that in SSA roughly one-quarter of young people have ever used some substance (pooled lifetime prevalence of 21%)20. Alcohol is by far the most common (40% lifetime prevalence), followed by khat (25%) and cigarettes (16%)19. In the African setting, the lifetime prevalence of alcohol use typically ranges from 35% to 45%, while tobacco use among males generally falls between 20% and 30%27. New, cheap products are increasingly available: for example, flavored tobacco products like shisha (hookah) and electronic cigarettes are emerging on the youth market. Adolescents often perceive e-cigarettes and heated tobacco as “safer” than cigarettes21, yet evidence shows youth who vape are three times more likely to become smokers21. In Malawi, traditional alcohol sachets and informal brews (e.g. kachasu, busaa) have similarly fueled youth drinking. Adolescents can easily obtain illicit home-brews or illegally re-packaged spirits, undermining alcohol policies and posing a gateway to tobacco smoking and serious health risks.
Policy landscape and gaps
Malawi’s national health policies recognize NCDs and their risk factors. Tobacco use control appears in Malawi’s Health Sector Strategic Plans (HSSP II 2017–2228, and the current HSSP III 2023–308) and NCD Action Plans29. For example, the 2017 WHO STEPS survey in Malawi found that 21% of adults smoke24. The NCD Strategy notes that eliminating shared risk factors (tobacco, alcohol) can prevent up to 80% of heart disease, stroke and diabetes29. However, these plans rely on outdated or adult data, not reflecting today’s adolescent and youth behaviors. Globally and in Africa, evidence-based measures are well-known: WHO’s MPOWER package (tax increases, marketing bans, smoke-free spaces) and SBIRT) 30. Malawi’s ratification of the FCTC in 2023 signals political will to adopt such steps7, but implementation needs robust data. Crucially, FCTC Article 20 calls for “research, surveillance and exchange of information” on tobacco use in adolescents and youth – a commitment unmet in Malawi since 2009. Likewise, the UN Commission on Narcotic Drugs urges member states to strengthen youth prevention under SDG 3.530. Without current surveys, Malawi cannot track progress toward these targets or detect new threats (e.g. vaping). As one pan-African initiative highlights, “existing policy interventions [are] lagging and often based on those of traditional tobacco products,” underscoring the need for updated youth surveillance21.
SBIRT and intervention readiness
Evidence-based interventions exist to address adolescent substance use. The SBIRT is an internationally endorsed approach for risky alcohol and drug use. WHO recommends SBIRT in primary care to reduce harmful drinking and promote referrals30, and it has been shown to be cost-effective in low income settings31. For example, a recent South African rollout of SBIRT training in HIV clinics screened over 41,000 clients for alcohol risk, delivering brief interventions to 86% of positives31. This demonstrates feasibility even in resource-limited African settings. In Malawi, where many adolescents and youths interact with the health system (e.g. clinics, schools), incorporating SBIRT could catch rising substance use early. Moreover, such programs align with Malawi’s health workforce strengthening under HSSP III and global efforts on integrated youth services. Yet SBIRT and other preventive services for adolescents are currently limited. Renewed surveillance would allow Malawi to target SBIRT and other interventions to high-risk groups and measure their impact over time.
Conclusion
Sixteen years without youth surveillance has created a critical blind spot in Malawi’s public health intelligence. The country’s commitment to the FCTC and the SDGs demands better data and action. We strongly urge the Ministry of Health, with WHO, UNICEF, CDC and other partners, to:(a) Using updated data, enforce strong FCTC measures (increase tobacco taxes, ban marketing, regulate e-cigarettes) and strengthen alcohol laws (tighten packaging limits, impose minimum pricing, eliminate sachets) as per WHO recommendations30; (b) Integrate screening and brief intervention for risky substance use into primary health care and school health programs, leveraging WHO’s proven SBIRT protocols31; and (c) Mobilize government sectors (education, agriculture, law enforcement) and development partners (WHO, UNICEF, CDC, NGOs) to support monitoring and youth prevention initiatives. This is an urgent child and adolescent public health imperative. Without prompt action, Malawi risks neglecting a generation on the cusp of avoidable addiction and disease. In light of new global commitments and emerging threats, updating youth substance use surveillance and policy implementation is critical to protect the health of Malawian children and fulfill national and international obligations32.
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