Specifications Manual for Joint Commission National Quality Measures (v2023B)
Posted: 02/03/2023
Home » Tobacco Use Status

Release Notes:
Data Element
Version 2023B

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. Tobacco use includes all forms of tobacco including cigarettes, smokeless tobacco products, pipe, and cigars.

Question:What is the patients tobacco use status?
Allowable Values:

1    Current everyday tobacco user

2    Current some day tobacco user

3    Former tobacco user

4    Never tobacco user

5    The patient refused the tobacco use screen

6    Tobacco use status unknown

7    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.
  • There is no requirement to capture volume of use.
  • If there is documentation that the patient uses any amount or any type of tobacco product on a daily basis, select Value “1.”
  • Current some day tobacco user is defined as tobacco use that is infrequent, sporadic, use that is not on a daily basis. This is regardless of volume or occurrence of tobacco use.
  • If there is documentation that the patient is not a current tobacco user but used tobacco at any time in the past, regardless of date of last tobacco use, select Value “3.”
  • If 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, select Value “6.”
  • If there is any conflicting documentation about the patient’s tobacco use status, where there is documentation of both tobacco use and no tobacco use, e.g., RN assessment states patient does not use any tobacco products but there is also physician documentation in the H & P that the patient is a “smoker,” select Value “6” since tobacco use status is unable to be determined.
  • When both daily and sporadic ("some day") tobacco use are documented, select Value "1".
  • 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, smokeless tobacco products, pipe, and cigars.
  • 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.”
  • 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 “7” cannot be selected unless there is documentation of symptoms.
    • Patient actively hallucinating, rule out psychosis. (Select Value “7”).
    • Rule out psychosis. (Cannot select Value “7”).
  • 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 “7” 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 “7.”
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 tobacco
  • Redman
  • Smokeless Tobacco
  • Snus
  • Twist
  • E-cigarettes
  • Hookah pipe
  • Marijuana use only
  • Nicotine delivery system
  • Vaping or nicotine vaporizer use

Tobacco Use Status
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Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)


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