Addressing Tobacco Screening and Treatment Among Racially and Ethnically Minoritized Parents in Pediatric Clinics: Barriers and Facilitators

Abstract

Introduction

Household secondhand smoke (SHS) exposure remains a significant health issue for racially and ethnically minoritized children in the United States. Delivering parental tobacco treatment during pediatric primary care visits can reduce children’s SHS exposure. This study examined current tobacco screening practices and health system stakeholder perceptions of facilitators and barriers to addressing tobacco use during pediatric visits among racially and ethnically minoritized parents.

Methods

We conducted 25 semistructured interviews with clinicians, staff, and health system leaders from five pediatric primary care clinics in Minneapolis–St. Paul, Minnesota. The study was informed by the Health Equity Implementation Framework. Interviews were analyzed using both directed content and thematic analysis.

Results

Participants identified multilevel facilitators and barriers to addressing parental tobacco use in minoritized families. Within the clinical encounter, barriers included linguistic and cultural barriers, health system navigational challenges, medical mistrust, low levels of clinician and staff knowledge, skills, and confidence, time constraints, and lack of alignment with external metrics. Facilitators centered on leveraging interpreters’ cultural knowledge and the presence of culturally congruent clinicians and staff to reduce medical mistrust and stigma, developing linguistically and culturally relevant resources, and integrating prompts and resources into the electronic health record. Participants described how lessons from previous system change mechanisms would facilitate this work.

Conclusions

Addressing health system, training and resources, and linguistic and cultural barriers among clinicians and staff is essential to strengthen their capacity to address household SHS exposure among racially and ethnically minoritized populations as a component of pediatric preventive care.

Implications

Clinicians and health system staff perceive unique barriers to identifying and addressing parental tobacco use among racially and ethnically minoritized parents during pediatric primary care visits. Solutions to expand tobacco treatment access to minoritized parents in pediatric settings must attend to clinician training needs on tobacco treatment, embedding clinical encounter resources and reminders that match the linguistic and cultural needs and preferences of their patient populations, and increasing access to high-quality interpreting services and culturally congruent staff.

Introduction

Household secondhand smoke (SHS) exposure remains prevalent among children living in the United States. Approximately 25%–29% of United States middle and high school students report SHS exposure in the home or car.^1,2 While overall levels of pediatric SHS exposure have declined in the past decade,¹ racially and ethnically minoritized children (hereafter referred to as minoritized) and those growing up in households with lower socioeconomic status continue to face high levels of SHS exposure.^3–5 For example, non-Hispanic Black middle and high school students in 2016 were 1.7 times more likely than White students to report home or car SHS exposure.² Though less well documented, SHS exposure is an issue for children in many U.S. immigrant communities amid rising prevalence of adult tobacco.^6,7

These pediatric disparities in SHS exposure stem from structural influences that directly contribute to and perpetuate commercial tobacco-related inequities, including, but not limited to, tobacco industry practices that specifically and disproportionately targeted these communities, barriers to accessing health care, and other social and economic influences.⁸ Consequently, Black, Hispanic, American Indian, and Asian adults are less likely than White adults to receive clinician-delivered cessation counseling and resources.^9–12 Minoritized adults experience many barriers to accessing clinic-delivered tobacco treatment, including inadequate health insurance coverage, limited access to clinicians who are skilled in tobacco cessation, a lack of linguistically or culturally relevant treatment resources,¹³ and general mistrust of clinicians.¹⁴

Clarifying barriers and facilitators to addressing household tobacco use within pediatric primary care settings serving minoritized populations provides an opportunity to reduce household SHS exposure and cessation disparities in these groups. SHS has been tied to higher lifetime levels of cardiovascular disease and cancer and short-term increased risk for pediatric respiratory illness and sudden infant death syndrome.¹⁵ Moreover, parental tobacco use behaviors, attitudes, and expectations^16,17 and the home tobacco environment¹⁸ shape children’s tobacco use behaviors into adolescence. Promoting parental tobacco cessation has the potential to dramatically improve the health outcomes for all family members by decreasing SHS exposure and the likelihood that children in the home will smoke.^19,20

Physician-delivered parental tobacco screening, brief intervention, and referral to treatment (SBIRT) during pediatric visits is highly acceptable to American parents^21,22 and can be feasibly integrated into busy pediatric clinic, hospital, and emergency department contexts.^23–26 Furthermore, physician-led SBIRT interventions have increased parental access to cessation resources and the likelihood of parental tobacco cessation in several randomized controlled trials,^23,27 including one trial with a predominantly Black and low-income population.^28,29 The American Academy of Pediatrics advises addressing household tobacco use in pediatric primary care through the implementation of SBIRT systems for caregivers who smoke or use other tobacco products,³⁰ and the American Academy of Family Physicians encourages screening for and counseling caregivers about tobacco smoke exposure during pediatric visits.³¹ Despite these recommendations, levels of screening for and treating parental tobacco use in pediatric clinics have remained low (between 17% and 52%) over the past two decades.^32–34 Delivery of parental tobacco treatment during pediatric visits varies widely; cessation counseling is most common (9%–56%), while quitline referrals (9%–18%) and nicotine replacement therapy (NRT) prescriptions (6%–20%) lag.^21,35 Though they report similar levels of screening,^34,36 family medicine physicians are more likely to provide cessation counseling, quitline referrals, and NRT,³⁶ whereas pediatricians are more likely to discuss home/car smoke-free rules.³⁴

Clinician-level barriers to parental tobacco treatment during pediatric visits include limited training in tobacco cessation^36,37 and low confidence levels in delivering tobacco treatment^38,39 or in the clinician’s ability to promote effective parental cessation.^36,40 Prior research has also highlighted health systems-level challenges such as time constraints within pediatric visits.^37,39,40 Potential facilitators include incorporating electronic referrals^27,28 and clinical decision support systems^33,41 into pediatric visits. Yet this body of research has largely sought physician views on parental tobacco use treatment without incorporating broader health systems and interdisciplinary team members’ perspectives.³⁷ Furthermore, while Black and Hispanic parents are more likely to be screened for tobacco use than White parents,^42,43 few studies have explicitly examined how the racial and ethnic composition of the clinic population influences parental tobacco screening and treatment delivery in pediatric primary care.^28,29

The purpose of this study was to (1) describe current parental tobacco screening and treatment in pediatric primary care and (2) examine the multilevel determinants of addressing parental tobacco use through screening and treatment during pediatric visits among racially and ethnically minoritized parents in one health system. This information will inform tailored implementation strategies for evidence-based parental tobacco use screening and treatment interventions to improve tobacco-related health equity outcomes for minoritized parents.

Methods

Study Setting

This study took place in a large Midwestern health care system affiliated with an academic health center (AHC) in the United States. The health system serves a racially and ethnically diverse population of pediatric patients (>50% non-White), inclusive of several large immigrant groups, across family medicine and pediatric academic and nonacademic primary care clinics. The two most prevalent immigrant groups, Somali and Hmong, each comprised about 5% of the approximately 58 000 unique pediatric visits in the prior calendar year. This study was reviewed and approved by the AHC’s institutional review board and the participating health system.

Participants and Recruitment

We identified five primary care clinics (one pediatric, two family medicine, and two mixed family medicine and pediatric) within the health system with large proportions of racially and ethnically minoritized (including immigrant) pediatric populations. Among these participating clinics, 49% of pediatric patients identified as White, 24% as Black or African American, 23% as Asian, and 6% as Hispanic/Latino, with significant variation by site (ie, 65% of patients at one clinic identified as Asian, whereas 63% of patients at another clinic identified as Black or African American). We recruited a mix of clinicians, staff, and health system leaders using emails distributed to clinic listservs, flyers in clinic workspaces, study team presentations at clinic-wide team meetings, and snowball sampling.

Interview Procedures

We developed interview guides using an adaptation of the Health Equity Implementation Framework (HEIF) to focus on clinician and staff factors and their interactions with parents within the clinical encounter, alongside the clinic, health system, and broader societal contexts.^44,45 The HEIF blends concepts from the Health Care Disparities Framework and the Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework to create a framework that is specifically geared towards identifying multilevel determinants at the patient, clinician, health system, and broader societal levels that affect the implementation of a clinical practice change.^44,45 Questions focused on participants’ professional understanding of these multilevel influences on their and their colleagues’ screening for and addressing parental tobacco use during pediatric visits with minoritized families (Supplementary Appendix 1).

After obtaining verbal consent, AKW and KB conducted semistructured individual interviews via Zoom between November 2022 and March 2023. Participants completed a demographic survey prior to the interview with characteristics as summarized in Table 1. Participants received a $50 gift card. Interviews were recorded and transcribed verbatim.

Table 1.

Interview Participant Demographic Characteristics (N = 25)

	N	%
Age (years)
20–30	15	60
40–50	9	36
60+	1	4
Gender identity
Male	4	16
Female	21	84
Race/ethnicity
Asian	3	12
Black or African	6	24
White	16	64
U.S. born
Yes	21	84
No	4	16
Professiona
Physicianb	9	36
APRN/PAc	2	8
Clinic rooming staffd	13	52
Health system leadere	4	16
Personal smoking history
Current use	1	4
Previous use	5	20
Never use	19	76

^aDoes not sum to 100% due to overlapping roles between physicians and health system leaders.

^bIncludes pediatricians (N = 3) and family medicine physicians (N = 6).

^cAdvanced practice registered nurse/physician assistant (one pediatric and one family medicine).

^dIncludes certified medical assistants, certified nursing assistants, and emergency medical technicians who regularly roomed pediatrics patients during their office visits.

^eIncludes one clinic manager, two clinic medical directors, and one primary care service line leader.

Analyses

Our team used a three-step group coding process to analyze all interviews. First, KB and AKW coded five interview transcripts line-by-line using a combination of content analysis⁴⁶ in which we deductively applied a priori codes developed from the HEIF and inductively coded when we identified concepts not clearly contained within the framework using a grounded theory approach described by Charmaz.⁴⁷ KB and AKW then met to review coding and refine the codebook definitions through consensus discussion. In the second stage of coding, KB and AKW applied the codebook to the remainder of the interviews with regular meetings to resolve coding discrepancies and to update the codebook. The study team reviewed and discussed the main themes and sub-themes to achieve group consensus. NVivo⁴⁸ facilitated the analysis. We used descriptive statistics to summarize the documented health system screening levels for household tobacco use.

Results

Current Parental Tobacco Use Screening and Treatment Practices

The final sample included 25 individuals: 11 clinicians (nine physicians and two nurse practitioners, which included two health system leaders), 13 clinic staff, and one clinic manager (Table 1). Of these, 84% identified as female, 12% as Asian, 24% as Black or African, and 24% reported current or former cigarette use. Documented parental tobacco screening among participating pediatric clinics ranged from 69% to 80% (Table 2). Many clinician participants across clinics generally voiced a lack of awareness about whether parental tobacco screening and treatment routinely occurred and where to find this information. Only a small number of clinicians, primarily clinic leaders, were aware of processes to collect and document this information. Rooming staff, while more familiar with parental tobacco screening processes since they were primarily tasked with them, often lacked knowledge about clinicians’ responses following a positive screen.

Table 2.

Documented Household Tobacco Screening^a Levels in the Health System and Participating Clinics

	N (%)
Health system	43 472 (75)
Clinic 1b	3671 (80)
Clinic 2c	6558 (69)
Clinic 3b	647 (80)
Clinic 4d	1268 (71)
Clinic 5d	712 (80)

^aDefined as pediatric patients with an office visit in the health system during the study period (total N = 58 045) between November 1, 2021 and October 31, 2022 with documentation of parental and/or household tobacco use in the problem list and/or patient history sections.

^bMixed pediatric and family medicine clinic.

^cPediatric-only clinic.

^dFamily medicine-only clinic.

Barriers and Facilitators to Parental Tobacco Screening and Treatment

Barriers

Linguistic and Cultural Influences.

Most participants acknowledged the diversity of their patient populations and strove to provide equal care to all families regardless of their background. However, participants across roles highlighted several linguistic and cultural influences among their immigrant patients that impacted the clinical encounter and parental tobacco screening and treatment. This included interpreter use, which was widely viewed as a barrier to addressing parental tobacco use. Interpretation was seen as taking more time, leading to questionnaires being skipped during the rooming process, yet visits requiring interpretation were not scheduled additional time to accommodate this need. Several participants also described concerns or distrust with the accuracy of interpretation and reported how virtual interpreting services have further disrupted the flow of clinic visits in the wake of the COVID-19 pandemic.

Cultural barriers included the stigmatization of tobacco use, which was perceived to be a significant influence for women from Muslim faiths and in the Hmong American community. Additionally, one health system leader shared that a desire to provide socially pleasing responses to the clinician among some groups, especially Hmong Americans, might limit parents’ willingness to disclose their smoking habits.

Health Literacy & Knowledge Gaps Hinder Ability to Navigate the System and Access Resources.

Several participants across roles described how lower levels of health literacy and less knowledge of preventive care, especially among immigrant populations, influenced parents’ ability to navigate the health care system, and to engage in tobacco treatment during a pediatric visit. Many interviewees described scenarios in which parents had fundamental misunderstandings about what tobacco products could result in harmful exposure, how to more effectively mitigate the risks to their children, and potential cessation resources, particularly among immigrant parents. Several clinicians and staff shared how these limitations underscored the importance of addressing parental tobacco use during pediatric visits.

Legacy of Medical Mistrust Impedes Parental Tobacco Screening and Treatment for Some Groups.

Several participants also described mistrust of health systems among parents as a barrier, one that stemmed from the impact of historical events and structural racism within health care, which negatively impacted the clinician-parent relationship and the ability of clinicians to incorporate parental tobacco treatment into pediatric visits. Related to this, participants shared that parents expressed concern about why tobacco screening questions were performed and how this information would be used.

There is a mistrust of the healthcare system, [...] especially with the immigrant community. If mom smokes, I will say it would be very, very difficult for her to admit to me that she smokes. Because who knows [who has] access to their healthcare record. [...] So, I mean there is a lot of taboo among those families. And I feel like those things actually impact them seeking help in terms of smoking. (Physician 04)

Knowledge, Skills, and Attitudinal Barriers.

Most participants shared the belief that regular screening for tobacco use among parents/caregivers should be a clinic priority, that relating tobacco use questions to the child’s health makes screening easier at pediatric visits, and that repetition of these questions can be effective in conveying that the issue is important. Despite this, several clinicians shared that they only prioritize addressing parental tobacco use if it appeared that their patient had health issues directly related to SHS exposure, such as frequent upper respiratory infections or asthma attacks, or if they noticed visible signs of parental tobacco use. Additionally, several clinicians, largely pediatricians, and staff shared that they were hesitant to address parental tobacco if they felt parents were not ready to quit smoking or if they viewed questions related to parental tobacco use as invasive. In addition, most participants were not aware of the degree to which household SHS exposure was occurring amongst their patients, how this varied by patient demographics (especially race/ethnicity), and felt ill prepared to address relatively new types of tobacco products such as vaping. Many clinicians, especially pediatricians, noted a lack of skills in and comfort with providing tobacco cessation to adults that was compounded by a lack of knowledge to properly address tobacco use in groups of a culture different from their own.

Needing more Time to Effectively Address Tobacco Use Disparities.

Clinicians discussed how time constraints, which had been further exacerbated due to the impact of the COVID-19 pandemic, limited the potential to discuss a topic like parental tobacco use effectively. Many participants shared how time pressure can create an environment that is not conducive to the trust-building needed to address a potentially sensitive topic like parental tobacco use, particularly when providing care across cultures.

When you recognize that you have to build up that trust a little bit more, it’s not as easy [as] hey I’m going to insert this quick [...] there’s more of this like okay, maybe I do need to see this family a couple more times for me to then have that trust to then say, hey let me ask about this a little bit more. Maybe that trust building […] doesn’t fit into the efficient model as easily as a one and done counseling thing. (Physician 01)

Lack of Alignment with External Metrics Limits Parental Tobacco Screening.

Most participants acknowledged that few clinics were engaging in initiatives to address parental tobacco use and that this was related to a lack of inclusion in externally driven metrics for quality care or requirements for children’s preventive visits. Thus, these questions are not integrated into preventive visit questionnaires or asked systematically and are not prioritized during otherwise busy pediatric primary care visits.

So, around here if something is important, we measure it [...] And I think it would probably lump into all these other things we ask about that people say, yeah, they’re important but I don’t know that we spend as much time on them. (Physician 03)

Interviewees further described how external regulatory frameworks and policies drove the selection of quality improvement goals, such as the Child and Teen Checkup criteria, Minnesota’s Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program developed to meet Medicaid requirements for preventive care delivery to children and adolescents,⁴⁹ which does not include household SHS assessments.

Several clinicians described how working in a large health system that emphasizes operationalizing all of these requirements, particularly through best practice alerts in the EHR, which were noted as absent for SHS screening, limited their personal ability to incorporate their own priorities into patient visits.

I think the one thing that stinks about being at such a big corporation […] is even just making tiny changes like adding a different questionnaire for parents I feel like could be really hard to do. (Physician 07)

Facilitators

Culturally congruent staff and clinicians and interpreters were frequently cited as valued cultural brokers to navigate this landscape, as illustrated here:

I’ve had a few interpreters laugh because they explained to me culturally so I was aware [...] a lot of females in the Hmong culture don’t smoke. So like when we’re asking the moms, like hey do you smoke? I always get the chuckle… (Staff 01)

However, a shared identity was not a panacea; even participants who shared a cultural background or spoke a common non-English language did not feel that this alone prepared them to address tobacco use in these groups. In fact, another participant perceived having a shared identity with patients as being a potential barrier, as it may be easier to talk about stigmatized behaviors with people outside of their culture.

Obviously, because they can see I speak the same language and all those things. They open up to me. But again, they still see me as part of the system. Because I work in the system [...] like all the other providers and all the things that they say goes into the computer. So, I mean again, I am one of them. But [...] it does not mean they can open up completely to me. (Physician 04)

Participants also raised the challenge of a lack of readily available resources to address parental tobacco use during a visit, particularly for parents whose preferred language was not English. They voiced a need for additional language options for screening and cessation materials that fit their patients’ linguistic literacy needs and that reflected their identities in the materials.

Participants raised two main areas to leverage technology in addressing parental tobacco use among their diverse patient populations. They suggested that incorporating prompts to alert them of a positive parental tobacco screen that connected to readily available resources would increase the likelihood that they could integrate this into their busy pediatric visits. Additionally, they advised about potential technological solutions to more easily enable parental tobacco treatment, such as linking to the parent’s EHR record in the child’s chart or sharing tobacco treatment resources through the after visit summary materials for parents.

It’s not as easy to give [parents] those resources when it’s the kid because it’s built into the patient record [...] In order to give the parent other resources like the Get Quit program and those other things we talked about, we actually would have to open a chart for them and there’s not time for that. (Physician 02)

Finally, two potential health system change solutions included identifying system champions to promote this work and integrating parental tobacco screening and treatment into care using analogous approaches to how they had previously implemented routine screening of mothers for postpartum depression during infant well visits in the first year of life.

Discussion

In this study, we found a high level of variation in awareness and operationalization of parental tobacco screening and treatment practices during pediatric visits in one health system serving a large number of racially and ethnically minoritized families. Clinicians, staff members, and health system leaders described multilevel barriers and facilitators to addressing parental tobacco use during pediatric primary care visits with their minoritized patients.

Despite our use of the HEIF to guide our data collection and analysis of the multilevel determinants of health disparities,⁴⁵ we observed that clinicians and staff often focused on individual-level barriers to parental tobacco treatment that are specific to immigrant families, such as linguistic differences in care, the stigmatization of tobacco use in certain cultural groups, and their impacts on health care navigation, rather than structural barriers to tobacco treatment and barriers for racial and ethnic minority groups more broadly. For example, participants described how time constraints in interpreted visits made addressing parental tobacco use difficult, but they generally did not relate this to the broader health system‘s lack of providing additional time for interpreted visits. Similarly, participants were more likely to share parental health literacy challenges that make navigating the health system and resources difficult rather than discussing the lack of resources tailored to the health literacy levels of their families. Participants also shared perceptions of minoritized parental mistrust of the health care system, which resonates with previously described barriers for Black and Indigenous populations.¹⁴ The focus of many participants on linguistic and health system navigational barriers for immigrants may be due to our clinic sample with a large proportion of immigrant families, or it may reflect that examining linguistic structural barriers is easier for clinicians and staff than discussing how implicit bias and structural racism may contribute to inequities for minoritized parents.

Clinicians and staff members described knowledge, skills, and attitudinal barriers to addressing parental tobacco use in minoritized populations that resonated with previously documented clinician obstacles to providing smoking cessation counseling to adults and connecting parents to cessation resources during pediatric visits.^36–40 Participants further reported limited skills for providing cessation treatment across cultural differences, especially about the cultural tobacco practices and beliefs of their patient populations. We also identified similar widespread attitudinal barriers to addressing parental tobacco use, including concerns for alienating parents and disrupting the therapeutic alliance, perceptions that parents were not interested in quitting, and perceptions that clinician cessation treatment efforts would be ineffective, to the prior pediatric literature.^36,38,40 These perceptions contrast with reports of parental openness to cessation interventions by pediatricians that are intended to promote the well-being of their children.⁵⁰

Finally, clinicians and staff highlighted time constraints as the main barrier to identifying and discussing parental tobacco use along many of the same dimensions previously documented, including challenges in prioritizing this issue among a vast number of topics.^38–40 Time challenges may be even more pronounced for minoritized populations, who disproportionately experience disadvantageous social determinants of health that contribute to health care access issues, leaving more urgent issues to address at attended visits.^10,13 Furthermore, participants described that using medical interpreters increased time pressure, making it challenging to conduct even a brief intervention with parents during pediatric visits. This challenge mirrors experiences in adult primary care¹³ and has been exacerbated by the increased reliance on virtual interpreting services implemented after the COVID-19 pandemic. Participants described how a lack of alignment of screening for household tobacco exposure with externally driven metrics further limited their ability to prioritize this care, exemplifying how the system’s prioritization of externally driven metrics can lag behind the evidence base, potentially further delaying research translation into clinical practice. These barriers highlight the importance of identifying interventions to improve pediatric primary care tobacco treatment for parents and to broaden the reach of cessation support for parents from minoritized groups who often visit their children’s clinics more frequently than their own.⁸

Alongside these barriers, participants voiced several opportunities to increase parental tobacco screening in pediatric visits for minoritized families. First, clinicians and staff highlighted the value of interpreters to navigate linguistic and cultural barriers in health care and they identified the role of culturally congruent health care providers to facilitate this care for some parents. Participants also requested more readily available cessation resources that fit the linguistic and literacy needs of their patient populations.^13,37 Alignment with existing health systems and strategies,⁵¹ and the integration of screening and treatment into the EHR using clinical decision support tools and reminder prompts that automate delivery and reduce the number of steps needed to provide NRT and quitline referrals is another approach that our participants identified that has shown promise in the literature to enhance parental tobacco screening and treatment uptake.^41,52 The use of preprinted prescriptions for NRT, as in previous interventions, would address clinician concerns about how to prescribe to parents who are not their patients.⁵²

Taken together, our findings underscore the importance of addressing barriers in clinician and staff training in parental tobacco treatment simultaneously with the structural factors that affect their ability to connect with and provide effective tobacco treatment for parents who smoke from diverse racial and ethnic groups. Training of pediatric clinicians and staff must include the basics of parental tobacco treatment tailored to specific populations. Additionally, our findings highlight the importance of time (both during a visit and through continuity of care) in facilitating effective screening and treatment of parental tobacco use in pediatric primary care for minoritized parents. Reducing structural barriers such as inadequate time and staffing is essential to building trust between health care providers and minoritized parents, bridging longstanding medical mistrust and experiences of societal stigma and bias. Expanding resources beyond the clinic visit to connect parents who smoke with culturally and linguistically congruent staff or community health workers could further support parental tobacco treatment for these groups.⁵³

Limitations

This study has limitations. First, our participants were mainly female, family medicine clinicians and self-identified as White from a single health system, many of whom reported no previous smoking history. There may thus be differences based on gender, smoking history, specialty training, health system, and geography that may not generalize to other groups. Due to the small sample size of participants, we were unable to examine potential interactions in our findings based on demographic characteristics. Future studies with larger sample sizes should explore how demographic factors interact to influence attitudes and perceptions of barriers and facilitators of tobacco screening and intervention. Second, our convenience sample may be subject to self-selection bias. Finally, despite speculating on the experience of the parents they serve, this study does not include the perspectives of those parents themselves, which is an essential next step to identifying opportunities to strengthen delivery of tobacco treatment to parents in pediatric primary care.

Conclusions

This study is one of the first to focus on increasing our understanding of the multilevel barriers and facilitators to screening and providing tobacco treatment to racially and ethnically minoritized parents during pediatric visits. Clinicians and staff identified unique barriers and facilitators to addressing parental tobacco use among racially and ethnically minoritized parents during pediatric primary care visits. Enhancing clinician training on tobacco treatment for these populations and adapting structural solutions to the linguistic and cultural preferences of these patient populations, including through the use of high-quality interpreting services and culturally congruent team members and expanded time for these visits, will be important to more effectively connect parents from these diverse backgrounds to support for tobacco cessation within pediatric primary care. Integrating clinical decision support systems and resources into health systems can enhance the dissemination and implementation of tailored cessation supports. Additionally, considering alternative implementation strategies, such as the use of community health workers to extend parental tobacco treatment beyond the clinic, offers further potential to reduce tobacco-related inequities among minoritized parents.

Supplementary Material

Supplementary material is available at Nicotine and Tobacco Research online.

Declaration of Interests

The authors declare that they have no real or perceived conflicts of interest to report that could have appeared to influence the work reported in this paper. The information and opinions presented are those of the authors and do not represent the official views of the Department of Veterans Affairs (VA) or the United States Government.

Funding

This work was supported by Dr. Wilhelm’s Department of Family Medicine and Community Health at the University of Minnesota research funds. JNdB’s work on this project was supported by the National Institute of Arthritis Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number K12 AR084223.

Author Contributions

April Wilhelm (Conceptualization [lead], Data curation [supporting], Formal analysis [lead], Investigation [lead], Methodology [lead], Project administration [lead], Software [equal], Visualization [supporting], Writing—original draft [lead], Writing—review & editing [lead]), Karen Bauer (Data curation [lead], Formal analysis [equal], Investigation [supporting], Methodology [supporting], Software [equal], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [supporting]), Junia de Brito (Data curation [equal], Formal analysis [equal], Software [equal], Visualization [lead], Writing—original draft [supporting], Writing—review & editing [supporting]), Michele Allen (Conceptualization [supporting], Formal analysis [supporting], Investigation [supporting], Methodology [supporting], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [supporting]), Steven Fu (Conceptualization [supporting], Formal analysis [supporting], Investigation [supporting], Methodology [supporting], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [supporting]), and Rebekah Pratt (Conceptualization [supporting], Formal analysis [equal], Investigation [supporting], Methodology [equal], Software [supporting], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [equal])

Data Availability

The data underlying this article cannot be shared publicly due to the small sample size and potentially identifiable participants. The data will be shared on reasonable request to the corresponding author.