Smoke Exposure Disclosure: Parental Perspectives of Screening in the Inpatient Setting

In this qualitative study, semistructured interviews were conducted with parents of children admitted to a medical-surgical unit in a Midwest tertiary care children’s hospital from November 2019 to March 2020. One-on-one, in-depth interviews were chosen to encourage parent comfort with speaking given the potentially sensitive nature of inquiries on personal behavior.¹⁸ 

Children admitted to the hospital were screened for TSE by a nurse, during a series of intake questions, using the prompt “Does anyone in your household smoke?” in the electronic medical record. Children are also screened by a physician as part of the history and physical, although this is not a requirement and not documented in a standardized way.

All charts of children on the medical-surgical unit were screened for documented TSE 2 times per week during the study period. A purposeful sampling strategy¹⁹  was used to recruit parents of children hospitalized with respiratory and nonrespiratory illnesses. Parents were eligible if their child was admitted to the medical-surgical unit and had TSE documented in their chart. Parents were first approached by their child’s nurse and provided a study information sheet. A researcher then approached parents who reported they were willing to learn more about the study and obtained informed consent. One parent from each family was eligible and chosen on the basis of who self-identified as the most likely to attend the child’s medical visits. Participants were recruited until data reached saturation,²⁰  the point at which no new barriers, facilitators, or strategies arose. This study was approved by the university’s institutional review board.

A semistructured interview guide was developed and refined after piloting with parents on 2 occasions. A semistructured interview format allowed for a more natural flow of conversation, in which questions and probes can be asked in any order.¹⁸  A nonclinician researcher trained in qualitative methods conducted the interviews using the guide. Parents were first asked about their experiences with the inpatient tobacco screening process and then asked how they responded to our institution’s TSE screening question. This was followed by probes to identify factors that may have promoted or inhibited disclosure. Participants were then asked about situations in which they had not disclosed TSE and asked why they had not disclosed it. Finally, participants were asked for suggestions on strategies to improve accurate smoke disclosure targeting each elicited barrier. Before completing the interview, parents were given the opportunity to add any additional comments. Interviews occurred at a location of the parents’ choice, either in the patient’s room or a private hospital conference room, and lasted between 20 and 50 minutes. Interviews were audio-recorded and transcribed verbatim by a professional transcription service. At the conclusion of the interview, parents completed a 14-item survey to assess parent smoking behavior, parent and child demographics, and child health status, including admission diagnoses, previous hospitalizations, and specifics regarding sources of child tobacco exposure. When parents listed a diagnosis in “other” as a reason for hospitalization that actually fit in a specific organ system (ie, pneumonia = respiratory), we placed that diagnosis in the appropriate disease category.

Interview transcript data were uploaded to Dedoose (www.dedoose.com, v8.3.17; SocioCultural Research Consultants, LLC, Los Angeles, CA) to assist with qualitative data management. Three researchers trained in qualitative methods analyzed data using conventional inductive content analysis.²¹  Two researchers, one clinician and another nonclinician, first read all interview transcripts independently, identifying any barriers, facilitators, and strategies mentioned by interview participants. These researchers met and created a preliminary codebook with definitions of codes and exemplary quotes. This codebook was refined iteratively with a senior researcher after coding 3 interviews. After finalizing the codebook, the 2 researchers then independently coded all transcripts, meeting 7 times (every 2–3 interviews) to review and reconcile coded excerpts. Any unresolved differences in coding were evaluated and resolved by the senior researcher. Codes were subsequently grouped into common categories. Survey results were analyzed by using descriptive statistics.

Eighteen parents were interviewed for this study. The median parent age was 31 years old (range 23–50 years), and participants were primarily female (83%) and non-Hispanic white (83%) and had at least some college education (56%) and a household income of <$60 000 (56%). Most parents reported smoking >100 cigarettes in their lives (67%); half were current smokers (Table 1). Parents reported breathing issues as the most common cause of their child’s hospitalization (44%). Hospitalized children of parent participants had a median age of 3 years old (range 3 months to 15 years) and had been previously hospitalized a median of 1 time (range 1–15 times). The people most frequently cited as the smoking contact for the child were the father (56%) and mother (56%) (Table 2).

The facilitators to TSE disclosure identified by parents included the following: (1) the parent’s internal characteristics promoting disclosure, (2) perceived relevance of the screening question to their child’s health, and (3) having a positive view of the person screening for TSE (Table 3). The most common internal characteristic parents identified was a desire to be honest as a general principle. This was discussed in 11 of 18 interviews and illustrated by one parent: “I was always honest…because I’m not going to lie about [smoke exposure]” (parent 5). Another characteristic facilitating TSE was a personal lack of guilt, for example, when the parent being asked was not the child’s source of TSE: “I have no problem answering [the screening question] because I’m not guilty of [smoking], and I’m not the [person] exposing her” (parent 7).

The perceived relevance of the screening question to their child’s health also influenced disclosure, particularly for parents of children admitted with respiratory illnesses (eg, asthma, bronchiolitis, pneumonia). In these cases, parents recognized that TSE could be contributing to the disease process and, therefore, felt doctors should know about this when caring for their child. Finally, parents reported being more likely to disclose exposure when they viewed the questioner in a positive light, for instance, when the person screening seemed relaxed, had a nonjudgmental demeanor, or was able to develop rapport with the parent: “And I guess that’s why I was so open about it and talking about it more, because she didn’t make me feel, like, bad about it” (parent 6).

Parents identified multiple barriers to TSE disclosure, including the following: (1) fear of negative consequences, (2) a vague screening question, (3) lack of knowledge (either of TSE itself or the different types of TSE), (4) guilt, and (5) an unconducive screening environment and timing (Table 4). Parents often mentioned declining to discuss TSE status for fear of negative consequences, such as judgment by the medical team and/or getting a lecture on why they should quit smoking: “I knew as soon as I mentioned [smoke exposure], they’re just going to bombard me with all of these, you know, quit smoking options” (parent 1).

Parents also felt that the wording of the question itself could hinder accurate disclosure. Some believed that the question was too vague, in that it did not apply exactly to their child’s situation, for example, when parents were asked about smoking in the home, they were uncertain if that meant smoking inside of the home or by members who lived in the home:

Parent 5

Others felt that the questioner or the question itself incorrectly assumed that parents had knowledge about what secondhand or thirdhand TSE was: “I take the time [to] go outside and smoke, my child is not getting exposed to that smoke, so I don’t have to answer that” (parent 2).

Parents identified that guilt about their child’s TSE also impaired disclosure: “Nobody wants to admit that they smoke around their child, because it is really bad for your kid” (parent 13). Finally, factors in the screening environment and timing acted as barriers to disclosure, such as when the setting was too loud or crowded or when screening occurred when their child needed urgent medical care:

Parent 5

Parents reported the following strategies to improve the accuracy of TSE disclosure when screening: (1) communicate preemptively about screening, (2) provide specific examples of types of TSE, (3) improve questioner-caregiver rapport, and (4) improve the screening environment and timing (Table 5). Parents most often suggested using preemptive communication to improve the likelihood of disclosure. Preemptive communication included various strategies, such as explaining why the questioner was asking, outlining the risks of TSE, gauging parents’ knowledge of exposure types, defining different types of exposure, emphasizing the benefits of disclosure, reassuring against consequence or judgment, and offering smoking cessation materials.

Parent 5

Another parent described the importance of assessing parent knowledge:

Parent 16

Parents also frequently recommended that the question itself include specific examples of TSE types, potential locations of TSE, and people who might smoke around their child:

Parent 13

Another parent described the importance of providing examples: “[Specific examples] actually makes somebody stop and think about what your child’s routine is and where they are every day when you’re not around” (parent 7). Parents also suggested that improved rapport with the questioner would encourage TSE disclosure. Finally, parents felt that optimizing the screening environment and timing would encourage disclosure, such as asking when the child’s health is not felt to be acutely at risk: “I think that [screening] would be something left all the way at the end of registration once…their loved one is stabilized” (parent 14).

In this qualitative study, parents provided insight into contextual factors that may inhibit accurate disclosure of pediatric TSE in the inpatient setting. These parents also identified facilitators, modifiable actions, and tangible strategies that may be employed to improve pediatric TSE screening.

Our study findings support the notion that stigma plays a strong role in inhibiting parental disclosure of TSE. This is captured by both guilt and fear of negative consequences barriers, with parents identifying both a fear of judgment by the questioner and of being lectured on smoking cessation if they were to disclose TSE. Previous studies reveal that smokers who perceive a high smoker-related stigma are less likely to reveal their smoking status.²²  Smoker-related stigma is hypothesized to explain the discrepancy between parent-reported pediatric TSE and biomarker results.^15,16  This may be amplified in sick children and explain the even lower sensitivity of screening questions in the inpatient population. Previous studies have suggested that assuring confidentiality to parents may be associated with increased rates of TSE reporting¹⁶  and support the idea that smoker-related stigma is modifiable.

Parents in this study identified several additional strategies that may help overcome smoking-related stigma. They suggested TSE screening questions be preempted with a statement to minimize stigma by specifically explaining (1) why we ask about exposure, (2) the benefits of disclosure, and (3) that the goal of screening is to be nonjudgmental. Messages regarding the impact of parental smoking on a child have been found to have importance in increasing parental smoking cessation treatment, and it is possible that similar messaging could affect disclosure.²³ 

Although our findings suggest that the stigma parents feel may be reduced, overcoming this barrier is likely much more complex and not necessarily resolved with only a prescreening statement. Future studies are needed to test the best ways to incorporate preemptive communication into the screening process, its effect on screening accuracy, and alternative interventions, including education on motivational interviewing, to reduce stigma.

Overwhelmingly, parents in our sample reported a desire to be honest with tobacco screening questions but identified vague questions as a major barrier to accurate exposure reporting. Many parents were unclear as to what defined an exposure and whether exposure outside the home occurred or was meaningful. These uncertainties led parents to interpret the question in a manner that may not have included all of their child’s specific exposures. Because a high percentage of children are known to be exposed to smoke outside the home²⁴  and children in families who only smoke outside the home still have significant cotinine levels,²⁵  identifying these exposures could meaningfully improve screening accuracy. Parents repeatedly recommended using a preemptive statement to define exposure types during screening.

Parents further suggested using specific examples of TSE as a means to limit question ambiguity while also encouraging parents to think of potential exposures outside of the home. The American Academy of Pediatrics policy statement “Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke” suggests using a variety of questions when screening for pediatric TSE.²⁶  Many of these questions were recently evaluated, and it was found that asking about who smoked had a higher sensitivity and predictive value than asking about where smoking occurred.¹⁵  Our parents’ suggested strategies of defining exposures more clearly and listing examples of exposure were consistent with previous work revealing that parents who underwent in-depth interviews reported TSE at a higher rate than those who answered a simple tobacco screening question.¹⁶  Identifying the language most likely to promote accurate disclosure is vital to ensuring that screening remains feasible in a busy inpatient environment.

Parents in our study identified the stress of a sick child, coupled with a care team with whom the parents had no previous relationship, as a barrier to disclosure. These findings support previous work revealing that screening questions have lower sensitivity in children with chronic illness,¹⁵  although the specific effect of acute illness on disclosure remains unknown. Parents suggested that waiting until the child is stabilized may help mitigate the acute stress associated with screening disclosure. Although screening questions are often bundled in a series of admission questions, this may not be the optimal time for such screening, identifying an area for future study.

Regarding the barrier of an unfamiliar provider performing screening, this can potentially be overcome through staff training to improve nonjudgmental communication or performing screening via a self-screener, either in paper or electronic form, to lesson concern of staff judgment.

This study has limitations that should be considered. It was conducted at a single center that uses one standardized question to screen for TSE on admission. Participants were mostly female, a majority had some post–high school education, and many were nonsmokers. Given the need to recruit participants on the basis of their child’s documented TSE, our study sample included parents who had provided accurate answers to screening questions. This approach may introduce biases; these parent participants may or may not have the knowledge and experience necessary to identify all possible factors influencing accurate TSE screening, nor may their perspectives represent those of the general population. Although we did have a few parents who initially answered “no” to the screening question and were later identified as smoke exposed, this was uncommon. Identifying parents who screened negative for TSE yet had a child with a positive cotinine screen result would provide the ideal population for identifying barriers to disclosure.

Although the American Academy of Pediatrics recommends screening for TSE at all pediatric clinical encounters,²⁶  inpatient screening remains complicated, and it appears that a single standardized screening question may not be enough to accurately accomplish this task. Participants in this study identified multiple contextual factors that may act as barriers to a parent’s decision to disclose TSE for their hospitalized child, such as guilt, fear of consequences, vague question language, and an unconducive environment. Parents also provided numerous practical strategies to potentially reduce these barriers, such as communicating preemptively to reduce stigma around disclosure and improve parental understanding of the goal of screening. Findings may inform future TSE screening processes in the inpatient pediatric setting.