Clinical Documentation of Tobacco and Cannabis Use

Tobacco Use Documentation

Document smoking status (current, former, never) as a vital sign at every healthcare visit, as recommended by the American Heart Association (Circulation, 2019)【4】.
Classify tobacco use as current (use within the past 30 days), former (no use for > 30 days), or never smoker, following NCCN guidelines (JNCCN, 2016)【7】.
Quantify tobacco exposure in pack‑years (1 pack‑year = 20 cigarettes per day for 1 year) as outlined by the American College of Cardiology (JACC, 2020)【1】.
Assess nicotine dependence severity with validated screening tools (e.g., Fagerström Test for Nicotine Dependence) per Mayo Clinic Proceedings (2009)【8】.

Record cannabis use history as a binary variable (yes/no/unknown) in the patient’s record, as advised by the American College of Cardiology (JACC, 2020)【1】.
Determine frequency of cannabis use: current user, recent user (within the past year), or former user (no use for > 1 year) per American College of Cardiology guidance (2020)【1】.

Diagnose cannabis use disorder using DSM‑5 criteria, categorizing severity as mild (2‑3 criteria), moderate (4‑5 criteria), or severe (≥6 criteria), according to the American Psychiatric Association (American Journal of Psychiatry, 2013)【5】.
Identify physiological dependence on cannabis by documenting tolerance and withdrawal symptoms (insomnia, irritability, anxiety, physical discomfort) that emerge within 24‑72 hours of cessation, as described by the American Psychiatric Association (2013)【5】.
Recognize that cannabis withdrawal syndrome occurs in approximately 50‑95 % of heavy users, based on Praxis Medical Insights (2025)【6】.