OBJECTIVES

Current screening questions for pediatric tobacco smoke exposure are suboptimal. Factors influencing screening accuracy, particularly in the pediatric inpatient setting, are unknown. Our objective was to identify facilitators of and barriers to parental disclosure of smoke exposure when screened during their child’s hospitalization and strategies to promote accurate disclosure.

METHODS

This qualitative study was conducted with a convenience sample of parents of children admitted to the medical and surgical unit of a Midwest tertiary care children’s hospital. Eligible parents included those with documented disclosure of smoke exposure in the child’s electronic health record. A researcher trained in qualitative methods conducted semistructured, in-depth interviews with parents regarding their experiences with smoke exposure screening in the inpatient pediatric setting. Two researchers independently identified concepts directed at barriers, facilitators, and strategies for effective screening, which were compared and reconciled by a third researcher.

RESULTS

Facilitators of disclosing their child’s smoke exposure included the following: (1) the caregiver’s internal characteristic(s) promoting disclosure, (2) perceived relevance of the screening question to the child’s health, and (3) the questioner being viewed positively. Barriers included the following: (1) fear of negative consequences, (2) a vague question, (3) lack of knowledge, (4) guilt, and (5) unconducive environment and timing. The strategies parents suggested to improve screening for smoke exposure included the following: (1) communicate preemptively, (2) provide specific exposure examples, (3) improve questioner-caregiver rapport, and (4) improve screening environment and timing.

CONCLUSIONS

Parents identified various mechanisms to improve tobacco smoke exposure screening. The facilitators, barriers, and strategies provide opportunities to improve the inpatient pediatric screening process.

Pediatric tobacco smoke exposure (TSE) is a widespread problem in the United States, with ∼38% of children aged 3 to 11 exposed to tobacco smoke.1  TSE has multiple adverse health effects in children, including an increased risk of lower respiratory tract infections,2  middle ear disease,3  and sudden infant death syndrome4,5 ; TSE increases the severity of asthma,6  pneumonia,7  bronchiolitis,8  and influenza.9  TSE is also associated with higher health care use,10  including increasing the risk of hospitalization in children.11  Pediatric hospitalization has been recognized as a unique opportunity to provide smoking cessation interventions, and parents have shown a strong willingness to engage in such interventions.12  However, to intervene with families, providers must first identify the presence of TSE.

Although the ability for providers to routinely screen for TSE has improved, in large part facilitated by standardization in the electronic health record,13,14  screening sensitivity has been shown to be suboptimal in various settings.15  Data on hospitalized children reveal that, when compared with cotinine testing, approximately half of those with TSE are not identified on routine screening,16,17  highlighting the need to improve the screening process. However, contextual factors that promote and inhibit accurate TSE disclosure, particularly in the pediatric inpatient setting, are largely unknown. Given their central role in the screening process, parents can provide valuable insight into these factors as well as strategies to improve the sensitivity of screening.

The objective of this study was to identify parent perspectives of the facilitators of and barriers to TSE disclosure and strategies to increase screening accuracy during pediatric hospitalization. These findings could inform the way pediatric care team members screen for TSE in the inpatient setting and, thereby, improve the identification of caregivers who may benefit from targeted cessation interventions.

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.

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 <$60 000 (56%). Most parents reported smoking >100 cigarettes in their lives (67%); half were current smokers (Table 1). Parents reported breathing issues as the most common cause of their child’s hospitalization (44%). Hospitalized children of parent participants had a median age of 3 years old (range 3 months to 15 years) and had been previously hospitalized a median of 1 time (range 1–15 times). The people most frequently cited as the smoking contact for the child were the father (56%) and mother (56%) (Table 2). TABLE 1 Parent Demographics (n = 18) n% Age, y 18–24 25–34 50 35–44 33 45–64 11 Female sex 15 83 Education High school or GED 44 Some college 28 Associate degree 22 College degree Hispanic, Latino, or Spanish ethnicity Race White 15 83 Black 22 Other Primary language English 17 94 Annual household income,$
<20 000 11
20 000–59 999 44
60 000–99 999 39
>100 000
Smoked >100 cigarettes in lifetime 12 67
Smoked in past 7 d 50
n%
Age, y
18–24
25–34 50
35–44 33
45–64 11
Female sex 15 83
Education
High school or GED 44
Some college 28
Associate degree 22
College degree
Hispanic, Latino, or Spanish ethnicity
Race
White 15 83
Black 22
Other
Primary language English 17 94
Annual household income, \$
<20 000 11
20 000–59 999 44
60 000–99 999 39
>100 000
Smoked >100 cigarettes in lifetime 12 67
Smoked in past 7 d 50

GED, general equivalency diploma.

TABLE 2

Child Demographics (n = 18)

Value
Age, n (%)
0–12 mo 5 (28)
13–24 mo 1 (6)
2–5 y 4 (22)
6–11 y 4 (22)
12–18 y 4 (22)
General health, n (%)
Excellent 3 (17)
Very good 4 (22)
Good 7 (39)
Fair 4 (22)
Poor 0 (0)
Previous hospitalizations, median (range) 1 (1–15)
Breathing problem 10 (55.6)
Fever 2 (11.1)
Gastrointestinal 1 (5.6)
Otherb 6 (33.3)
Smoker contact, n (%)a
Mother 10 (55.6)
Father 10 (55.6)
Grandmother 4 (22.2)
Grandfather 4 (22.2)
Aunt 2 (11.1)
Uncle 1 (5.6)
Brother 1 (5.6)
Value
Age, n (%)
0–12 mo 5 (28)
13–24 mo 1 (6)
2–5 y 4 (22)
6–11 y 4 (22)
12–18 y 4 (22)
General health, n (%)
Excellent 3 (17)
Very good 4 (22)
Good 7 (39)
Fair 4 (22)
Poor 0 (0)
Previous hospitalizations, median (range) 1 (1–15)
Breathing problem 10 (55.6)
Fever 2 (11.1)
Gastrointestinal 1 (5.6)
Otherb 6 (33.3)
Smoker contact, n (%)a
Mother 10 (55.6)
Father 10 (55.6)
Grandmother 4 (22.2)
Grandfather 4 (22.2)
Aunt 2 (11.1)
Uncle 1 (5.6)
Brother 1 (5.6)
a

Not mutually exclusive.

b

Other included abscess, surgery, paralysis, autoimmune disease, rash, and cardiac arrest

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).

TABLE 3

Facilitators: Definitions and Illustrative Parent Quotes

FacilitatorDefinitionIllustrative Quote
Caregiver’s internal characteristic(s) promoting disclosure Parent more likely to disclose smoke exposure because they valued being honest and/or had a lack of personal guilt about smoking “Probably just because I don’t like to lie. Like I just don’t, period…I feel it’s my responsibility to be honest about [smoke exposure].” (Parent 5)
“I don’t care how you look at me…if I smoke.” (Parent 14)
Perceived relevance of the screening question to their child’s health Caregiver more likely to disclose child’s smoke exposure because of perceived relevance to child’s acute health problem “I know she’s sick, and she’s having trouble breathing. I know that that’s bad. So it’s good for them to know that…[smoke exposure] is affecting it more.” (Parent 18)
Questioner was viewed positively Caregiver more likely to disclose child’s smoke exposure because of favorable opinion of questioner (eg, good questioner-caregiver rapport, questioner perceived as nonjudgmental, questioner made caregiver feel relaxed) “It’s the talking all before that…I’m not being dismissed as dumb mom or anything like that. I have that rapport with the nurse or the doctor where…they’re making me feel real comfortable. And to me, I’m looking at them as, you know, you’re really sweet, you’re genuine, you know. So when they ask, it’s not, I’m up here, you’re down here when they ask.” (Parent 11)
FacilitatorDefinitionIllustrative Quote
Caregiver’s internal characteristic(s) promoting disclosure Parent more likely to disclose smoke exposure because they valued being honest and/or had a lack of personal guilt about smoking “Probably just because I don’t like to lie. Like I just don’t, period…I feel it’s my responsibility to be honest about [smoke exposure].” (Parent 5)
“I don’t care how you look at me…if I smoke.” (Parent 14)
Perceived relevance of the screening question to their child’s health Caregiver more likely to disclose child’s smoke exposure because of perceived relevance to child’s acute health problem “I know she’s sick, and she’s having trouble breathing. I know that that’s bad. So it’s good for them to know that…[smoke exposure] is affecting it more.” (Parent 18)
Questioner was viewed positively Caregiver more likely to disclose child’s smoke exposure because of favorable opinion of questioner (eg, good questioner-caregiver rapport, questioner perceived as nonjudgmental, questioner made caregiver feel relaxed) “It’s the talking all before that…I’m not being dismissed as dumb mom or anything like that. I have that rapport with the nurse or the doctor where…they’re making me feel real comfortable. And to me, I’m looking at them as, you know, you’re really sweet, you’re genuine, you know. So when they ask, it’s not, I’m up here, you’re down here when they ask.” (Parent 11)

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).

TABLE 4

Barriers: Definitions and Illustrative Parent Quotes

BarriersDefinitionIllustrative Quote
Fear of negative consequences Caregiver less likely to disclose child’s smoke exposure because of fear of negative consequence (eg, judgment, a lecture, legal consequences) “If I tell these guys that I smoke with my kid in the car, you know, am I going to get a ticket? Is social services going to end up at my door?” (Parent 1)
Vague question Caregiver less likely to disclose child’s smoke exposure because of question ambiguity (eg, does not specify various locations, exposure types, people involved) “I would have never in one million years thought to answer that and say, ‘oh, well, we go to grandma’s every now and then, and grandma smokes in the house when we’re not there.’… I guess I should have thought ‘grandma,’ because we were actually there this last week.” (Parent 5)
Lack of knowledge Caregiver less likely to disclose child’s smoke exposure because of knowledge gaps (eg, unaware that thirdhand smoke is an exposure, unaware of sources of exposure, or unaware of relevance to health) “My mom smokes. My sister smokes. My baby-sitter, she smokes. I mean, no, I don’t believe they do it around my children. Can I guarantee that when I’m not there? Absolutely not.” (Parent 13)
Guilt Caregiver less likely to disclose child’s smoke exposure because of they feel guilty about their behavior and/or its effect on their child’s health “I possibly, at that time, didn’t want somebody to say like, well, if there was no smoke around, she wouldn’t be in this situation.” (Parent 7)
Unconducive environment and timing Caregiver less likely to disclose child’s smoke exposure as a result of hospital environment or timing of screening (eg, stressful, loud, crowded room) “Well, honestly, I just said no because it was so, there was so much going on. There were so many people in [the hospital room].” (Parent 9)
BarriersDefinitionIllustrative Quote
Fear of negative consequences Caregiver less likely to disclose child’s smoke exposure because of fear of negative consequence (eg, judgment, a lecture, legal consequences) “If I tell these guys that I smoke with my kid in the car, you know, am I going to get a ticket? Is social services going to end up at my door?” (Parent 1)
Vague question Caregiver less likely to disclose child’s smoke exposure because of question ambiguity (eg, does not specify various locations, exposure types, people involved) “I would have never in one million years thought to answer that and say, ‘oh, well, we go to grandma’s every now and then, and grandma smokes in the house when we’re not there.’… I guess I should have thought ‘grandma,’ because we were actually there this last week.” (Parent 5)
Lack of knowledge Caregiver less likely to disclose child’s smoke exposure because of knowledge gaps (eg, unaware that thirdhand smoke is an exposure, unaware of sources of exposure, or unaware of relevance to health) “My mom smokes. My sister smokes. My baby-sitter, she smokes. I mean, no, I don’t believe they do it around my children. Can I guarantee that when I’m not there? Absolutely not.” (Parent 13)
Guilt Caregiver less likely to disclose child’s smoke exposure because of they feel guilty about their behavior and/or its effect on their child’s health “I possibly, at that time, didn’t want somebody to say like, well, if there was no smoke around, she wouldn’t be in this situation.” (Parent 7)
Unconducive environment and timing Caregiver less likely to disclose child’s smoke exposure as a result of hospital environment or timing of screening (eg, stressful, loud, crowded room) “Well, honestly, I just said no because it was so, there was so much going on. There were so many people in [the hospital room].” (Parent 9)

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:

I thought that’s what she was asking like literally in the home. But…, it was kind of an open question, because do you mean somebody living in the home that smokes inside the home, literally, or are you just saying is there anybody in the home that smokes, whether inside or outside?

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:

But then again, sometimes you wonder why you need to know this right now? You just got done asking me 600 questions about, you know, things that I, I mean, things that probably you need to know. But at this point, I’m just like I just want to know what’s wrong and just how to fix her. Like can you ask me later?

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.

TABLE 5

Strategies: Definitions and Illustrative Parent Quotes

StrategyDefinitionIllustrative Quote
Communicate preemptively Before screening for child’s smoke exposure, reassure caregiver against judgment or consequences and explain why screening is performed, assess caregiver’s level of education, and provide education if necessary “You should really have the reason why you’re asking the question in the first place to show the importance of the question…because there’s a lot of times where people will not understand why.” (Parent 2)
“Maybe start off with like a question, like do you know how this affects your child? And if they say, well, I don’t know, maybe educate them a little bit.” (Parent 18)
Provide specific exposure examples Include specific examples in the question to help caregiver think more broadly, including smoke exposure type, potential smokers, and locations of exposure “I guess include those things in the question, you know, ‘is your kid exposed to smoke outside the home, including,’ and then list those things like ‘baby-sitter, family member,’ and then ‘outside play area.’” (Parent 6)
Improve questioner-caregiver rapport Improve questioner-caregiver rapport before and during screening for child’s smoke exposure (eg, educate staff on nonjudgmental forms of communication, normalize screening topic, use respectful tone of voice) “Try and set up rapport and be relatable. It’s going to make it a lot easier.” (Parent 11)
“Don’t ever let your face show that that parent did something wrong, especially if they’re already in the hospital worried about their kid.” (Parent 17)
Improve screening environment and timing Increase likelihood of disclosure by improving screening environment and process (eg, perform screening with paper survey, ask caregiver in private, after child’s acute health care needs are met) “Maybe it would help [to ask] when things settle down, to [then] ask those questions.” (Parent 7)
“I feel that [answering on a piece of paper] would have been less invasive…I can be honest with a piece of paper…a piece of paper is not going to judge me.” (Parent 1)
StrategyDefinitionIllustrative Quote
Communicate preemptively Before screening for child’s smoke exposure, reassure caregiver against judgment or consequences and explain why screening is performed, assess caregiver’s level of education, and provide education if necessary “You should really have the reason why you’re asking the question in the first place to show the importance of the question…because there’s a lot of times where people will not understand why.” (Parent 2)
“Maybe start off with like a question, like do you know how this affects your child? And if they say, well, I don’t know, maybe educate them a little bit.” (Parent 18)
Provide specific exposure examples Include specific examples in the question to help caregiver think more broadly, including smoke exposure type, potential smokers, and locations of exposure “I guess include those things in the question, you know, ‘is your kid exposed to smoke outside the home, including,’ and then list those things like ‘baby-sitter, family member,’ and then ‘outside play area.’” (Parent 6)
Improve questioner-caregiver rapport Improve questioner-caregiver rapport before and during screening for child’s smoke exposure (eg, educate staff on nonjudgmental forms of communication, normalize screening topic, use respectful tone of voice) “Try and set up rapport and be relatable. It’s going to make it a lot easier.” (Parent 11)
“Don’t ever let your face show that that parent did something wrong, especially if they’re already in the hospital worried about their kid.” (Parent 17)
Improve screening environment and timing Increase likelihood of disclosure by improving screening environment and process (eg, perform screening with paper survey, ask caregiver in private, after child’s acute health care needs are met) “Maybe it would help [to ask] when things settle down, to [then] ask those questions.” (Parent 7)
“I feel that [answering on a piece of paper] would have been less invasive…I can be honest with a piece of paper…a piece of paper is not going to judge me.” (Parent 1)

Yeah, just being more specific and maybe saying why you’re asking this question.… The reason that you’re asking this question isn’t to judge anybody or make, just because we need to know…try to explain why you’re asking the question in the first place, and then be specific about what you’re asking.

Parent 5

Another parent described the importance of assessing parent knowledge:

I think you almost need to put a question in there like, “Are you aware of what thirdhand smoke is?” Because I don’t even think most people realize having [smoke] on your clothes or in your hair or on your coat is a form of smoke exposure”

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:

“I guess it would be something along the lines of, you know, “Is your child exposed to cigarette smoke, whether in the home, you know, at a friend’s home, in the car.” Just add like a few small little things after it just so that way, you know, you’re covering your bases”

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.

FUNDING: Supported by the American Academy of Pediatrics Julius B. Richmond Center of Excellence 2019 New Investigator Grant. The funder/sponsor did not participate in the work.

Dr Williams conceptualized and designed the study, conducted initial analyses, and drafted the initial manuscript; Ms Nacht conducted the acquisition of data and initial analyses and reviewed and revised the manuscript; Dr Fiore contributed to the design of the study and reviewed and revised the manuscript; Dr Kelly contributed to the design of the study, assisted with analysis of data, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

1.
Tsai
J
,
Homa
DM
,
Gentzke
AS
, et al
.
Exposure to secondhand smoke among nonsmokers - United States, 1988-2014
.
MMWR Morb Mortal Wkly Rep
.
2018
;
67
(
48
):
1342
1346
2.
Jones
LL
,
Hashim
A
,
McKeever
T
,
Cook
DG
,
Britton
J
,
Leonardi-Bee
J
.
Parental and household smoking and the increased risk of bronchitis, bronchiolitis and other lower respiratory infections in infancy: systematic review and meta-analysis
.
Respir Res
.
2011
;
12
(
1
):
5
3.
Jones
LL
,
Hassanien
A
,
Cook
DG
,
Britton
J
,
Leonardi-Bee
J
.
Parental smoking and the risk of middle ear disease in children: a systematic review and meta-analysis
.
.
2012
;
166
(
1
):
18
27
4.
Mitchell
EA
,
J
.
Smoking and the sudden infant death syndrome
.
Rev Environ Health
.
2006
;
21
(
2
):
81
103
5.
Anderson
HR
,
Cook
DG
.
Passive smoking and sudden infant death syndrome: review of the epidemiological evidence
.
Thorax
.
1997
;
52
(
11
):
1003
1009
6.
Pyle
RC
,
Divekar
R
,
May
SM
, et al
.
Asthma-associated comorbidities in children with and without secondhand smoke exposure
.
Ann Allergy Asthma Immunol
.
2015
;
115
(
3
):
205
210
7.
Ahn
A
,
Edwards
KM
,
Grijalva
CG
, et al
.
Secondhand smoke exposure and illness severity among children hospitalized with pneumonia
.
J Pediatr
.
2015
;
167
(
4
):
869
874.e1
8.
Behrooz
L
,
Balekian
DS
,
Faridi
MK
,
Espinola
JA
,
Townley
LP
,
Camargo
CA
Jr
.
Prenatal and postnatal tobacco smoke exposure and risk of severe bronchiolitis during infancy
.
Respir Med
.
2018
;
140
:
21
26
9.
Wilson
KM
,
Pier
JC
,
Wesgate
SC
,
Cohen
JM
,
Blumkin
AK
.
Secondhand tobacco smoke exposure and severity of influenza in hospitalized children
.
J Pediatr
.
2013
;
162
(
1
):
16
21
10.
Merianos
AL
,
Jandarov
RA
,
Gordon
JS
,
Lyons
MS
,
Mahabee-Gittens
EM
.
Child tobacco smoke exposure and healthcare resource utilization patterns
.
Pediatr Res
.
2020
;
88
(
4
):
571
579
11.
Merianos
AL
,
Jandarov
RA
,
Mahabee-Gittens
EM
.
Secondhand smoke exposure and pediatric healthcare visits and hospitalizations
.
Am J Prev Med
.
2017
;
53
(
4
):
441
448
12.
Winickoff
JP
,
Hibberd
PL
,
Case
B
,
Sinha
P
,
Rigotti
NA
.
Child hospitalization: an opportunity for parental smoking intervention
.
Am J Prev Med
.
2001
;
21
(
3
):
218
220
13.
Thomas
KEH
,
Kisely
S
,
Urrego
F
.
Electronic heath record prompts may increase screening for secondhand smoke exposure
.
Clin Pediatr (Phila)
.
2018
;
57
(
1
):
27
30
14.
Lindholm
C
,
R
,
Bain
P
, et al
.
A demonstration project for using the electronic health record to identify and treat tobacco users
.
WMJ
.
2010
;
109
(
6
):
335
340
15.
Groner
JA
,
Rule
AM
,
McGrath-Morrow
SA
, et al
.
Assessing pediatric tobacco exposure using parent report: comparison with hair nicotine
.
J Expo Sci Environ Epidemiol
.
2018
;
28
(
6
):
530
537
16.
Wilson
KM
,
Wesgate
SC
,
Best
D
,
Blumkin
AK
,
Klein
JD
.
Admission screening for secondhand tobacco smoke exposure
.
Hosp Pediatr
.
2012
;
2
(
1
):
26
33
17.
Mahabee-Gittens
EM
,
Merianos
AL
,
Gordon
JS
,
Stone
L
,
Semenova
O
,
Matt
GE
.
Electronic health record classification of tobacco smoke exposure and cotinine levels in hospitalized pediatric patients
.
Hosp Pediatr
.
2019
;
9
(
9
):
659
664
18.
Britten
N
.
Qualitative interviews in medical research
.
BMJ
.
1995
;
311
(
6999
):
251
253
19.
Patton
MQ
.
Qualitative Research & Evaluation Methods
. 3rd ed.
Thousand Oaks, CA
:
Sage Publications, Inc
;
2002
20.
Guest
G
,
Bunce
A
,
Johnson
L
.
How many interviews are enough? An experiment with data saturation and variability
.
Field Methods
.
2006
;
18
(
1
):
59
82
21.
Elo
S
,
Kyngäs
H
.
The qualitative content analysis process
.
.
2008
;
62
(
1
):
107
115
22.
Stuber
J
,
Galea
S
.
Who conceals their smoking status from their health care provider?
Nicotine Tob Res
.
2009
;
11
(
3
):
303
307
23.
Jenssen
BP
,
Kelly
MK
,
Faerber
J
, et al
.
Pediatrician delivered smoking cessation messages for parents: a latent class approach to behavioral phenotyping
.
.
2021
;
21
(
1
):
129
138
24.
Torok
MR
,
Winickoff
JP
,
McMillen
RC
,
Klein
JD
,
Wilson
KM
.
Prevalence and location of tobacco smoke exposure outside the home in adults and children in the United States
.
Public Health
.
2017
;
151
:
149
159
25.
Wilson
KM
,
Moss
A
,
Lowary
M
, et al
.
Smoking behaviors among tobacco-using parents of hospitalized children and association with child cotinine level
.
Hosp Pediatr
.
2021
;
11
(
1
):
17
24
26.
Farber
HJ
,
Walley
SC
,
Groner
JA
,
Nelson
KE
;
Section on Tobacco Control
.
Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke
.
Pediatrics
.
2015
;
136
(
5
):
1008
1017

## Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.