Background <p>Hispanic patients with cancer who smoke are less likely to quit after diagnosis and underutilize evidence-based tobacco treatment. Understanding the complex factors influencing their engagement is crucial for developing effective and tailored interventions.</p> Methods <p>Semi-structured individual interviews were conducted with 12 adult patients with cancer who self-identified as Hispanic or Latino referred between June 1, 2023, and June 30, 2024, to a tobacco treatment program embedded within a cancer center. Interviews were conducted via phone or video in English or Spanish. Transcripts were thematically analyzed, guided by the Socio-ecological Model, assessing individual, interpersonal, organizational, community, and policy barriers and facilitators affecting treatment engagement.</p> Results <p>Median age was 65 and most participants (10) were women. Four multilevel themes emerged from the data: (1) Socio-Cultural Drivers and the Psychological Barrier of Fatalism; (2) Provider–Patient Relationship Enhances Engagement; (3) Community and Cultural Contexts Shaping Tobacco Use and Support Needs; and (4) Structural, Economic, And Policy-Level Determinants Constrain Access; Implementation and Enforcement are Key Levers. Additionally, the decision to accept or decline treatment further distinguished by differences in age/fatalism, provider relationship/trust, and the view of willpower versus external support.</p> Conclusion <p>Engagement in tobacco treatment among Hispanic patients with cancer is shaped by the intersection of individual, cultural, and structural barriers and facilitators. Findings highlight the need for culturally and linguistically congruent interventions that address fatalism, integrate family support, reduce financial barriers, and leverage the patient-provider relationship to improve access and outcomes.</p>