Jeffrey Ariesta Putra, Dianita Angeline

Healthcare worker perspectives on tobacco harm reduction in perioperative care: a mixed-methods study from Indonesian hospitals

Introduction

Healthcare worker perspectives on tobacco harm reduction in perioperative care: a mixed-methods study from indonesian hospitals . Explore Indonesian healthcare workers' views on Tobacco Harm Reduction in perioperative care. A mixed-methods study reveals limited knowledge but strong support for education and protocol development.

Abstract

Background: Tobacco Harm Reduction (THR) has been proposed as a pragmatic approach to reduce combustible tobacco-related harm among smokers who cannot achieve immediate abstinence before surgery. However, its perioperative implementation remains controversial, particularly where clinician knowledge, institutional guidance, and regulatory clarity are limited. This study assessed healthcare workers’ knowledge, attitudes, practices, and perceived barriers regarding THR in Indonesian perioperative settings. Methods: An explanatory sequential mixed-methods study was conducted from October 2025 to April 2026 in six hospitals in Yogyakarta, Indonesia. The quantitative phase included a cross-sectional survey of 186 perioperative healthcare workers using a validated self-administered questionnaire. Data were analyzed using descriptive statistics, chi-square tests, and multivariable logistic regression. The qualitative phase comprised two focus group discussions with 16 surgeons and nurses, analyzed thematically to explore perceptions, ethical concerns, and implementation barriers. Results: Understanding of THR and nicotine-related risk differentiation was limited. Only 41.3% of respondents correctly identified electronic cigarettes as less harmful than combustible cigarettes, and 22.6% recognized that nicotine is not the primary cause of most smoking-related cancers. Nevertheless, 82.3% supported THR-related clinician training, 74.2% supported piloting a hospital THR protocol, and 68.8% were willing to consider THR for selected patients. The main barriers were lack of knowledge, regulatory uncertainty, cost or product availability, and concern about being perceived as promoting smoking. Accurate e-cigarette risk knowledge and belief in potential perioperative benefit were independently associated with protocol support. Qualitative findings showed conditional acceptance after conceptual clarification, if implementation was supported by institutional policy, clear protocols, and practical educational tools. Conclusion: Indonesian perioperative healthcare workers had limited baseline THR knowledge but showed substantial openness toward education and structured protocol development. Future implementation should prioritize clinician education, institutional governance, and context-specific counseling frameworks before evaluating clinical outcomes.

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