Clarifying categories

Dear ONC,

As a physician and tobacco control researcher, I agree it would be useful to eliminate the redundant categories of "light smoker" and "heavy smoker" as many electronic health records do not help providers with definitions.  The additional information about smokeless tobacco and quit date is helpful.  However, it is not clear how electronic tobacco products are represented, as many people may consider themselves as "vapers" instead of "smokers."  This may be something to consider in future.

I would strongly recommend that "passive smoker" (nonsmoker exposed to secondhand smoke) be included as well.  The Surgeon General has determined there is no risk-free level of exposure to tobacco smoke.  Not only is this important for the pediatric population, but it is important to determine if adult nonsmokers are at risk for disease and death related to secondhand smoke exposure as well.

Elisa Tong, MD

Associate Professor of Internal Medicine

University of California, Davis

Comments from American Association for Cancer Research

Please see the attached for comments from the American Association for Cancer Research (AACR)

2018 AACR ONC Smoking Status EHR V1.pdf

NCPDP Comment

  1. Tobacco Use reporting via SNOMED codes is available in the NCPDP SCRIPT Standard Version 2017071.

Type-Implementation Specification

Standard Implementation/Specification- NCPDP SCRIPT Standard, Implementation Guide, Version 2017071

Standards Process Maturity – Final

Implementation Maturity- Pilot

Adoption Level – 1

Federally Required – No

Cost – $

Test Tool Availability – Yes.

Smoking status - need for second hand smoke exposure status

Dear ONC:

As a pediatrician and a member of the American Academy of Pediatrics Section on Tobacco Control, I have worked considerably to address second hand smoke exposure (SHSE)  in children, and to educate resident physicians in training to address SHSE as well.

I feel strongly that a code documenting SHSE should be added to this list. SHSE is still a huge issue that affects children; not having a code to document it makes it much easier for people to forget to ask and address the issue.

Thank you.

Rachel Boykan, MD, FAAP

Clinical Associate Professor of Pediatrics

Stony Brook University Department of Pediatrics, Stony Brook Children's Hospital

HSC T11-060

Stony Brook, NY 11794


The Massachusetts General…

The Massachusetts General Hospital’s Tobacco Research and Treatment Center is a multidisciplinary team that pairs tobacco dependence treatment counselors who provide service to smokers cared for in our 1100-bed teaching hospital with academic researchers studying effective ways to deliver tobacco cessation interventions in health care settings.   

The current Smoking status EHR classifications are overlapping and duplicative, causing confusion and discouraging clinical staff from filling them out.  A simpler, non-overlapping set of responses is needed.

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.

We advocate for a slightly simpler version.  We propose a new smoking status classification set as follows:

  • Current Smoker
  • Former Smoker
  • Never Smoker
  • Smoking Status Unknown

Nancy Rigotti, MD, Professor of Medicine, Harvard Medical School; Associate Chief, Division of General Internal Medicine, Massachusetts General Hospital

Updates to EMR Tobacco History

Thank you for the opportunity to provide feed back. I work with Tobacco Treatment Specialists, whom are providers, to increase opportunities to provide our patients with resources for successful quit attempts. Upon updating the options to record patient tobacco use and history there was much confusion about the definitions of light and heavy smoker. Streamlining the choices would simplify and lead to more precise record keeping. We also see many patients for smokeless tobacco. We would suggest:

Current everyday Smoker

Current someday Smoker

Former Smoker, smoke free for 30 days or more (30 days smoke free is the range that those that are trained to be Certified Tobacco Treatment Specialists are trained to be the time elapsed to consider the quit attempt successful.)

Never Smoker

Current, smokeless tobacco use

Never, smokeless tobacco use

Passive smoke exposure, non user

Passive smoke exposure, former user

Being that this section is driven from national recommendations, inserting any type of work flows or scripting directly in the patent tobacco history section is virtually impossible. When asking about tobacco use, best practice is to approach in a motivational interviewing manner. We would see better results if national recommendations encouraged adding scripting to the EMR in the history section rather then directing to add it to an outside section of the EMR.

Smoking status - add secondhand smoke exposure

I am a pediatrician, and many of my pediatric patients are exposed to secondhand smoke (SHS). Given the clear health impacts of SHS exposure, I request a "secondhand smoke exposure" category also be added so that we can track those patients exposed to secondhand smoke.

Thank you.
Jyothi Marbin MD

A popular and widely used…

A popular and widely used smoking measure is pack years (also in LOINC):
8663-7 Cigarettes smoked current (pack per day) - Reported 
8664-5 Cigarettes smoked total (pack per year) - Reported 

This question is probably best measure of strength of nicotine addition also a LOINC .code
63636-5 How soon after you wake up do, or did, you smoke your first cigarette [FTND] 
Within 5 minutes (3 points); 6-30 minutes (2 points); 31-60 minutes (1 point); After 60 minutes (0 points).

Smoking status classifications

Thank you for the opportunity to provide feedback on this important issue.

The current overlap and confusion could be avoided with two simple questions requiring yes/no answers, which I have provided below. These questions address combustible tobacco use, the majority of which in the general population consists of cigarette smoking, and which causes the majority of smoking-related illnesses.

If desired, the EHR can ask standard follow-up questions such as what form of tobacco is used (cigarettes? cigars? etc.), and more specific questions such as how often they are used (e.g., how many cigarettes per day). However, I believe the EHR simply wants to know how to classify people into simple categories. If responses to the suggested questions are entered into the EHR, a basic algorithm should be able to use the responses to yield the broad classifications that a health care provider can use in discussion and intervention.

Here are my two suggested questions:

  1. Do you smoke cigarettes or other forms of tobacco that involve burning tobacco (e.g., cigars, cigarillos, roll-your-own, pipe, hookah, etc.)
    1. everyday (yes/no)?
    2. somedays (yes/no)?
  2. Did you ever smoke cigarettes or other forms of tobacco that involve burning tobacco (e.g., cigars, cigarillos, roll-your-own, pipe, hookah, etc.)
    1. everyday (yes/no)
    2. somedays? (yes/no)

“Yes” to 1a = Current everyday tobacco smoker.

“Yes” to 1b = Current someday tobacco smoker.

 “No” to 1a and 1b, AND “Yes” to 2a or 2b = Former tobacco smoker

 “No” to ALL (1a, 1b, 2a, 2b) = Never tobacco smoker.

No responses to both questions= Unknown.

Can further specify former tobacco smokers as everyday or someday former tobacco smokers based on responses to 2a and 2b:

everyday former tobacco smoker = “yes” to 2a

someday former tobacco smoker = ”yes” to 2b, and “no” to 2a.

 J. Lee Westmaas, PhD
Scientific Director, Tobacco Research
American Cancer Society