Representing Patient Tobacco Use (Smoking Status)

WA State Department of Health Tobacco/Smoking/Vaping Comments

In 2018, e-cigarette products with nicotine concentrations of five percent or greater comprised approximately two-thirds of the e-cigarette market, while zero-nicotine products accounted for less than one percent.[1] To more accurately assess nicotine intake and potential nicotine dependence among patients, Washington State Department of Health recommends distinguishing e-cigarette use by nicotine concentration, rather than e-cigarette liquid with nicotine versus e-cigarette liquid without nicotine. Additionally, Washington State Department of Health concurs with the recommendation submitted on September 19, 2018 by Dr. Michael Fiore and Robert Adsit to implement non-overlapping values for smoking status. [1] Romberg AR, Miller Lo EJ, Cuccia AF, Willet JG, Xiao H, Hair EC . . . King BA (2019). Patterns of nicotine concentrations in electronic cigarettes sold in the United States, 2013-2018, Drug and Alcohol Dependence, 203, 1-7. doi:10.1016/j.drugalcdep.2019.05.029.

NCPDP Comments

1. Substance use fields are available in NCPDP SCRIPT Standard Version 2017071 to allow tobacco use information to be transmitted via SNOMED codes
2. Add the following:

Type-Implementation Specification Standard Implementation/Specification- NCPDP SCRIPT Standard, Implementation Guide, Version 2017071 Standards Process Maturity – Final Implementation Maturity- Production Adoption Level – 5 Federally Required – Yes Cost – $ Test Tool Availability – Yes

3. Include Test Tool Link: https://tools.ncpdp.org/erx/#/home

NCPDP Comment

1. Substance use fields are available in NCPDP SCRIPT Standard Version 2017071 to allow tobacco use information to be transmitted via SNOMED codes
2. Add the following:

Type-Implementation Specification Standard Implementation/Specification- NCPDP SCRIPT Standard, Implementation Guide, Version 2017071 Standards Process Maturity – Final Implementation Maturity- Production Adoption Level – 1 Federally Required – Yes Cost – $ Test Tool Availability – Yes

3. Include Test Tool Link: https://tools.ncpdp.org/erx/#/home

The AMA requests that the…

The AMA requests that the Current Procedural Terminology (CPT) code set be added to the standards listed in Section I: Representing Patient Tobacco Use (Smoking Status). CPT codes 99406 and 99407 identify the patient as a tobacco user and that cessation counseling was provided. In addition, CPT Category II codes identify assessment of tobacco use (1000F), current tobacco user with asthma (1032F), current tobacco user with heart disease (1034F), tobacco use cessation counseling (4000F), tobacco use cessation pharmacologic therapy (4001F), and patient screened as a tobacco user and received cessation intervention (4004F). CPT is a comprehensive and regularly curated uniform language that accurately describes medical, surgical, and diagnostic services and provides for reliable communication among users. It has an extremely robust and mature development process with open and transparent meetings and clinical input from national medical specialties and relevant stakeholders. It is the most widely adopted outpatient procedure code set. Use of the CPT code set is federally required under HIPAA.

NCPDP Comment

1. The SubstanceUse fields will be available in NCPDP SCRIPT Standard Version 2017071 to allow tobacco use information to be transmitted via SNOMED codes.

Support smoking status clarification

Dear ONC,

I support eliminating the redundant terminology of "light" and "heavy" smoker, as keeping these would require some standard definition to reference.

I would also support that "passive smoker - nonsmoker exposed to secondhand smoke" be included.  The Surgeon General has determined that there is no risk-free level of smoke exposure.

Elisa Tong, MD, MA Associate Professor of Internal Medicine University of California, Davis

Final SRNT comment

Attached please find the final comment from the Society for Tobacco Research and Intervention (SRNT).  The version submitted previously by Bruce Wheeler was a draft document.

Sincerely,

Megan Piper, SRNT Treasurer

SRNT smoking status comments letter - FINAL.docx

RE: smoking status

Reproduced from the attached letter:

October 1, 2018

Office of the National Coordinator for Health Information Technology

U.S. Department of Health and Human Services

330 C St SW, Floor 7

Washington, DC 20201  

Re: Representing Patient Tobacco Use (Smoking Status)

Dear Colleagues, 

The Tobacco Treatment Program at the Medical University of South Carolina appreciates the opportunity to provide input on the Interoperability Standards Advisory (ISA) process for representing patient tobacco use.  We commend the Office of the National Coordinator for Health Information Technology (ONC) on their commitment to ensuring the ISA process facilitates interoperability for clinical, public health, and research purposes. It is our hope that smoking status can be more documented in Electronic Health Records (EHR) in a way that provides more consistency to allow for interoperability and streamlines categories to reduce confusion and improve providers’ workflow. 

One concern with the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) EHR smoking status classification is that the categories are open to interpretation and importantly are not mutually exclusive which adds confusion to the process of correctly classifying patients smoking status. The current value set includes:

Current every day smoker

Current some day smoker

Former smoker

Never smoker

Smoker, current status unknown

Unknown if ever smoked

Heavy tobacco smoker

Light tobacco smoker

The overlap in values, lack of definitions for categories that are open to interpretation (e.g., light and heavy smoker), and risk of different interpretations of the record between different healthcare settings reduces the potential for tobacco use data to be organized, queried, and analyzed for the benefit of individuals, institutions, and populations.

To address overlap and interpretation challenges, we propose ONC address the following through the ISA process:

1. Simplify the smoking status choices/classifications. 
2. Remove overlapping smoking status classifications.

We recommend adoption of the following simplified categories:

Current Every Day Smoker

Current Some Day Smoker

Former Smoker

Never Smoker

Smoking Status Unknown

A second concern has to do with fully capturing smoking status in a meaningful way to direct interventions to those who are current smokers.  We have found that asking a follow-up question of CURRENT and FORMER smokers beyond the one recommended above, improves capture by about 25% of those who may be in need of help with quitting and remaining off cigarettes.   

ASK OF CURRENT AND FORMER SMOKERS: 

When did you last smoke a cigarette (even one or two puffs)?

•         I smoked a cigarette today (at least one puff)

•         1 to 7 days ago

•         8 days to 1 month ago

•         More than 1 month ago to 1 year ago

•        More than 1 year ago

•        Don't know/don't remember

Thank you for considering our input on this important issue. These comments are based on careful discussion by members of our Tobacco Treatment Program. If we at MUSC can provide any additional information or assistance to ONC, please do not hesitate to contact Benjamin Toll, PhD, Professor of Public Health Sciences, at toll@musc.edu.

Sincerely,

Kathleen Cartmell, Ph.D.

K. Michael Cummings, Ph.D.

Georges El Nahas, Ph.D.

Phil Smeltzer, Ph.D.

Benjamin Toll, Ph.D.

Graham Warren, M.D., Ph.D.

MUSC ONC Smoking Status FINAL.pdf

Smoking Status Documentation

Please see attached for the American Lung Association's comments.

American Lung Association Comments - Smoking Status Documentation .pdf