Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Posted: 10/30/2019
Home » Tobacco Use Status

Release Notes:
Data Element
Version 2020A2

Name:Tobacco Use Status
Collected For: TOB-2, TOB-3
Definition:Documentation within the first day of admission (by the end of Day 1) of the adult patient’s tobacco use status within the past 30 days prior to the day of hospital admission. Tobacco use includes all forms of tobacco including cigarettes, smokeless tobacco products, pipe, and cigars. A tobacco use screen should identify the type of tobacco product used, the volume used, and the time frame of use.
Question:What is the patients tobacco use status?
Allowable Values:

1    The patient has during the last 30 days
  • smoked, on average, 5 or more cigarettes(>=¼ pack)daily, and/or
  • Smoked cigars and/or pipes daily

2    The patient has during the past 30 days
  • smoked, on average, 4 or less cigarettes(<¼ pack) daily and/or
  • Smoked cigarettes, cigars and/or pipes, but not daily, and/or
  • Used smokeless tobacco, regardless of frequency

3    The patient has not used any forms of tobacco in the past 30 days.

4    The patient refused the tobacco use screen within the first day of admission (by the end of Day 1).

5    The patient was not screened for tobacco use within the first day of admission (by the end of Day 1) or unable to determine the patient’s tobacco use status from medical record documentation.

6    The patient was not screened for tobacco use within the first day of admission (by end of Day 1) because of cognitive impairment.
Notes for Abstraction:
  • The tobacco use status screening must have occurred within the first day of admission (by the end of Day 1). This includes the day of admission which is defined as Day 0, and the day after admission which is defined as Day 1
    . If the screening was performed within 3 days prior to admission, i.e., at the transferring facility, in another inpatient hospital unit, emergency department or observation unit, the screening documentation must be present in the current medical record.
  • If there is any conflicting documentation about the patient’s tobacco use status, e.g., RN assessment states patient has not used any tobacco products in the past 30 days prior to admission, but there is also physician documentation in the H & P that the patient is a “smoker,” select Value “5” since tobacco use status is unable to be determined.
  • Documentation of "nicotine" use is not acceptable to determine tobacco use status. The documentation of "nicotine" use needs to be supported by language showing it was in the form of cigarettes, cigars, pipes and/or smokeless tobacco.
  • If there is documentation that the patient has not used any tobacco products during the past 30 days prior to admission, continued assessment for the type, volume and frequency does not need to be performed.
  • If there is documentation that the patient has used smokeless tobacco AND has also smoked cigarettes daily on average in a volume of five or more cigarettes (=>¼ pack) per day and/or cigars daily and/or pipes daily during the past 30 days, select Value “1.”
  • There is no requirement to capture volume and frequency of use for patients using only smokeless tobacco.
  • For the History and Physical (H&P) source, use only the H&P report for the current admission. The H&P may be a dictated report, a handwritten report on an H&P form, or a separate entry labeled as the H&P in the progress notes.
  • Classify a form as a nursing admission assessment if the content is typical of nursing admission assessment (e.g., med/surg/social history, current meds, allergies, physical assessment) AND the form is completed/reviewed by a nurse or labeled as a “nursing form.”
  • Disregard documentation of tobacco use history if the current tobacco use status or time frame that patient quit is not defined (e.g., “20 pk/yr smoking history,” “History of tobacco abuse”).
  • Do not include documentation of smoking history referenced as a “risk factor” (e.g., “risk factor: tobacco,” “risk factor: smoking,” “risk factor: smoker”), where current tobacco use status is indeterminable.
  • When there is conflicting information in the record with regard to volume, for instance, one document indicates patient is a light smoker and another indicates patient is a volume greater than light smoking; select Value “1” indicating the heaviest usage.
  • If the medical record indicates the patient smokes cigarettes and the volume is not documented or is unknown, assume smoking at the heaviest level and select Value “1.”
  • Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for tobacco use due to the impairment (e.g., comatose, obtunded, confused, memory loss) within the first day of admission (by end of Day 1).
  • If there is documentation within the first day of admission (by end of Day 1) that the patient was psychotic, symptoms of psychosis, e.g., hallucinating, non-communicative, catatonic, etc., must also be documented for the patient to be considered cognitively impaired.
  • If there is documentation to “rule out” a condition/diagnosis related to cognitive impairment, Value “6” cannot be selected unless there is documentation of symptoms.
    • Patient actively hallucinating, rule out psychosis. (Select Value “6”).
    • Rule out psychosis. (Cannot select Value “6”).
  • If there is documentation of any of the examples of cognitive impairment below within the first day of admission (by the end of Day 1), select Value “6” regardless of conflicting documentation.
    Examples of cognitive impairment include:
    • Altered Level of Consciousness (LOC)
    • Altered Mental Status
    • Cognitive impairment
    • Cognitively impaired
    • Cognitive impairment due to acute substance use; overdose, acute intoxication
    • Confused
    • Dementia
    • Intubation and patient is intubated through the end of Day 1
    • Memory loss
    • Mentally handicapped
    • Obtunded
    • Psychotic/psychosis with documented symptoms
    • Sedation
  • Documentation of cognitive impairment overrides documentation of a tobacco screen and therefore would not be considered "conflicting documentation." Even if the family or others tell staff the patient uses tobacco, the patient could not be appropriately screened and subsequently counseled due to cognitive impairment. Select Value “6.”
Suggested Data Sources:
  • Emergency department record
  • History and physical
  • Nursing admission assessment
  • Nursing admission notes
  • Physician progress notes
  • Respiratory therapy notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Chewing (spit) Tobacco
  • Dry snuff
  • Moist snuff
  • Plug tohbacco
  • Redman
  • Smokeless Tobacco
  • Snus
  • Twist
  • E-cigarettes
  • Hookah pipe
  • Marijuana use only
  • Nicotine delivery system
  • Vaping or nicotine vaporizer use

Tobacco Use Status
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.