Provider Perspectives on Adding Biomarker Screening for Tobacco Smoke Exposure to Lead Screening at Well-Child Visits

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

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.

Ask about smoking, not quitting: a chronic disease approach to assessing and treating tobacco use

Tobacco use is a chronic relapsing disease, and remains the leading cause of preventable death in much of the world. Increasingly, tobacco use, chiefly cigarette smoking, is being framed as a chronic disease, with periods of use and periods of abstinence. An implicit component of this conceptualization is that treatment—both counseling and pharmacotherapy—may be needed at various intervals for extended periods of time, perhaps over an individual’s lifetime. This would mirror the treatment of other chronic conditions, such as diabetes, hypertension, or hyperlipidemia. Yet, clinical trials of tobacco dependence treatment still generally model outcome measures in terms of cessation, abstinence, or quitting, measured at discrete time points. This reinforces the notion that smoking, or tobacco dependence, is a dichotomous condition, and that one is either “cured,” or not. Although the goal of treating tobacco dependence is to ensure long-term abstinence (i.e. “quitting”), this model is discordant with clinical reality, in which of periods of tobacco use are interspersed with periods of abstinence. Hence, the goal of treatment is to lengthen the duration of the latter, while shortening the duration of the former. In the clinical arena, this dichotomous model of tobacco use is reflected in electronic health records, where smoking is generally categorized as current, former, or never. We propose that clinicians move away from the dichotomous categorization of tobacco use, and adopt methods used to categorize the status of other chronic conditions. Specifically, biomarkers such as carbon monoxide, cotinine, and anabasine, measured at regular intervals, can provide clinicians with much clearer, clinically relevant and actionable assessments of current tobacco use by their patients. This can be done without making reference to dichotomous states such as current or former use of tobacco. In psychological terms, one can frame tobacco use in terms of states, attributes in specific situations at discrete moments in time, rather than the more durable traits.