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

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

Smoking Status Documentation in the EHR

Our group includes researchers, academicians in the area of tobacco, and tobacco dependence treatment counselors. We concur with ATTUD member Rob Adsit and colleagues who advocate to:

• Simplify and reduce the smoking status choices/classifications.
• Remove overlapping smoking status classifications.
• Recommended clear, non-duplicative smoking status classifications.
• Use new smoking status classifications as follows:
  • Current Every Day Smoker
  • Current Some Day Smoker
  • Former Smoker
  • Never Smoker
  • Smoking Status Unknown

In addition, our suggestions and comments also include the following:

1.  Simplified list [5 (above) vs. 8] is definitely better. 
   1. Whatever is decided, the classifications should map to ICD-10 or whatever standardized diagnostic codes are appropriate.
   2. Concurrent other tobacco and e-cigarette use is not captured with these suggested classifications.
2. Question language is needed that allows the provider to funnel the patient according to these suggested categories and best solicit true answers. There is currently no consensus on measurement with regards to how this is conducted.
3. If cigarette use is on the decline, there should be thought given to how overall substance use/abuse is addressed in health/social histories.
4. Research suggests documentation of tobacco using classifications/codes is less frequent than tobacco use documentation occurring in the progress notes. If there is a way that categories can be automatically assigned as the provider asks the patient questions? 

Recent papers:

Challenges with Collecting Smoking Status in Electronic Health Records 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977725/

Validating the use of veterans affairs tobacco health factors for assessing change in smoking status: accuracy, availability, and approach

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5948734/

current smoker…

current smoker

former smoker

never smoker

smokeless tobacco use

there is no safe level of cigarette use so why does it matter if someone is a some day smoker

protocol is to ask each patient every time about tobacco  so "unknown" should not be allowed

Dear ONC,…

Dear ONC,

As a physician scientist with my research focus on smoking cessation, I recommend to simplify and reduce the smoking status choices by removing overlapping smoking status classifications, and presenting clear, non-duplicative smoking status choices.

Please see my letter attached. 

Sincerely, 

Li-Shiun Chen, M.D., M.P.H., Sc.D.

Associate Professor of Psychiatry

Washington University School of Medicine in St. Louis

Campus Box 8134, 660 South Euclid Avenue

St. Louis, Missouri 63110

li-shiun@wustl.edu; Phone: 314-362-3932; Fax: 314-362-4247