Representing Patient Tobacco Use (Smoking Status)

Consider adding additional tobacco concepts to this standard

Thank you for making the tobacco use (smoking status) codes and value sets a little more clear than previous versions.  We would like to recommend including standard codes for smokeless tobacco, in addition to the smoking status codes.  Clinical quality measures are interested in assessing both forms of tobacco use.  We recently requested a new LOINC code for Smokeless Tobacco Status, and was approved for a future release.  This LOINC code will have the following SNOMED CT answer list:
713914004 User of smokeless tobacco (finding)

451381000124107 Smokeless tobacco non-user (finding)

TBD Former smokeless tobacco user (finding) (this code was recently requested of SNOMED CT and was approved for their next release)

In addition to having standard codes to capture the smoking or smokeless tobacco status, we feel it is also very important to have a standard way to capture the quit date for both smoking and smokeless tobacco. Here are the recommended LOINC codes:

TBD- Date Quit Smokeless Tobacco (this code was recently requested of LOINC and was approved for a future release)

74010-0 Date Quit tobacco smoking 

The rationale for this is important, in that different quality measures may have different time frames for when they consider someone a current tobacco user or not.  For example, The Joint Commission considers a person who has used tobacco products in the past 30 days a current user and someone who needs tobacco cessation interventions.  Other measure stewards may have different thresholds.  In order to capture the data once in order to re-use many times, there needs to be a standard way to codify this data in a more granular fashion.  That way, The Joint Commission eCQM could use logic to ask the tobacco use status, if the person is a "former user", then ask for the quit date, and use logic to determine if that quit date was within the past 30 days or not.  If a measure has a different threshold, the same granular level of data could be used, and their measure could use logic with a different time frame.  This would decrease the burden on implementation, because then every measure steward would not be using a different pre-coordinated term (e.g. LOINC 68535-4 to get the past 30 days, or LOINC 54845-3 to get the past 7 days) to get the information, which forces duplication of documentation just to satisfy a measure. 

NCPDP - Comment

SNOMED – Not currently used in NCPDP MMA mandated standards. Future versions of the NCPDP SCRIPT standard support SNOMED.

Update with specific codes

The Joint Commission has an update to last year's comment.  We have received the following codes, and request these be added for inclusion for smokeless tobacco:

456711000124105 Former smokeless tobacco user (finding)

Smoking Status Classifications

Presently, there is much confusion about the smoking status choices and classifications in EHRs which creates overlap and confusion at the point of care when smoking status is documented.   It would be very beneficial if all EHR vendors could standardize how this important information is classified. It would be better if vendors could:

*Simplify and reduce the smoking status choices/classifications

*Remove overlapping smoking status classifications

*Use clear, non-duplicative language such as below:

           Current Every Day Smoker

           Current Some Day Smoker

           Former Smoker

           Never Smoker

           Smoking Status Unknow

It is also important to be able to assess other tobacco use as well in this same way.  I would recommend the same classifications for "Tobacco User" along with a way to collect "quit date" for those that are "former smokers" or "former tobacco users".  

Smoking status classifications: 2nd hand smoke addition, revis

Firstly, given the links between childhood exposures and development of chronic and acute illness (e.g, asthma, allergies, ear infections) there should be entries for exposure to secondhand smoke as a child, adolescent / adult, and currently.   I hope  these entries will eventually  be seen as the left side of a dose-response curve. 

Further, I think there are advantages to classifying "less than 8 cigarettes" per day as light tobacco use, 8- 16 cigarettes as intermediate tobacco use, and more than 16 cigarettes per day as heavy tobacco use.  If a some is a former tobacco user, the quit date should be listed next to the classfication, along with some indication of the nature of use. 

Lastly, I think EHRs have to explicitly and accurately capture nicotine use in the context of addiction.  For this reason, there should be a linked series of classifications for nicotine delivery devices. And since tobacco use involves a constellation of harms attributable (1) toxic exposure and (2) addiction to nicotine,  there should be entries tracking use of multiple nicotine delivery systems (snus, cigarettes, cigars,  etc) when used simultaneously.  

Scott Matthews MD MPH

Smoking Status Versus Tobacco Use

Increased charting requirements - Consider the degree of clinical value and how that information would actually be employed in the care of the patient versus the increase provider burden required in documenting. Comparing Snomed smoking status versus Tobacco use below. Unless it’s a specific use smoking status is sufficient.

Smoking status versus  Tobacco Use SNOMED versus LOINC

• The only real cost to switching is implementation time and retraining. Is the clinical impact worth the effort/expense?

Smoking status Value Set Name Smoking Status  Code System      SNOMEDCT   OID        2.16.840.1.113883.11.20.9.3

• 8 charting values

Tobacco Use SNOMED 2.16.840.1.113883.11.20.9.41 Contains all values descending from the SNOMED CT 365980008 tobacco use and exposure

• 63 charting values

categories must be mutually-exclusive

Thank you for accepting comments on this important topic. I am an investigator, actively conducting and publishing research in the field of smoking cessation.

My primary concern with the existing standards is that they are not exclusive. Problems that are likely to result from these overlapping categories include:

• Inconsistencies in how data are recorded, which reduce value for patients, clinicians, and researchers
• Confusion on the part of clinicians at the time of data entry, which is likely to reduce use of the field overall

I suggest simplifying to the following five categories: Current Daily Smoker; Current Sometimes Smoker, Former Smoker, Never Smoker, Unknown. These categories have straightforward interpretations, and are mutually exclusive.

Thank you for your time and attention. Please note that these opinions are my own, and do not necessarily reflect the opinions of my employer.

Sincerely,

Michael S. Amato, PhD

Research Investigator

Schroeder Institute

Truth Initiative

Washington, DC 20010

Simpler, non-overlapping Smoking Status classifications

Thank you for the opportunity to provide input on Smoking Status documentation in the EHR.

The major concern with the current smoking status classifications is that the choices are not mutually exclusive, creating overlap and confusion at the point of care when smoking status is documented.

Overlap and confusion is created by:

• Vagueness of “some day” smoker (i.e. what frequency?).
• Vagueness of “heavy” and “light” smoker (i.e. number of cigarettes/day).
• Vagueness of “former smoker” (i.e. how long since quit?).
• Each patient is documented with one smoking status which creates overlap:
  • “Current every day smoker” and “light smoker”.
  • “Current every day smoker” and “heavy smoker”.
  • “Current some day smoker” and “light smoker”.
• Uncertainty that all clinical staff who are identifying and documenting patient smoking status are using consistent definitions for each category.

In an effort to clarify and streamline “Smoking Status” documentation, we recommend that ONC simplify and promote non-overlapping criteria for smoking status documentation in the EHR.  The clear, non-duplicative smoking status classifications that we recommend for the ONC ISA and EHR Certification Program are:

We fully support the continuation of smoking status being documented for each patient age 13 years old and older.

Michael Fiore, MD, MPH, MBA                                              Robert Adsit, MEd

Professor of Medicine, Director                                             Director of Education and Outreach

University of Wisconsin School of Medicine and Public Health Center for Tobacco Research and Intervention