Documentation of Cigarette Smoke Odor
Yes, it is acceptable and clinically appropriate to document that a patient smells of cigarette smoke, as this objective observation can serve as an important clinical indicator of current tobacco use that should be systematically assessed and recorded in the medical record.
Rationale for Documentation
Tobacco Status as a Vital Sign
Multiple clinical practice guidelines emphasize that tobacco use status must be documented in the medical record as a vital sign at every healthcare encounter 1. The ACC/AHA guidelines specifically recommend that tobacco use status be "recorded as a vital sign to facilitate tobacco cessation" 1. This systematic documentation approach has been shown to significantly increase physician counseling rates, with one study demonstrating an increase from 47% to 86% in smoking-related discussions when smoking status was added as a vital sign 2.
Objective Clinical Observations Matter
Documenting the smell of cigarette smoke represents an objective physical finding that can be clinically relevant for several reasons:
Discrepancy detection: Patients may underreport or deny tobacco use when asked directly. The ACC/AHA guidelines note that "many people who use tobacco do not report it" and recommend using multiple assessment questions to improve accuracy and disclosure 1. An objective observation like cigarette odor can prompt more thorough assessment.
Current use indicator: The odor of cigarette smoke on a patient suggests very recent tobacco use, which is clinically significant since guidelines define current smokers as those who have used tobacco "within the past 30 days, even a puff" 1.
Documentation completeness: NCCN guidelines explicitly state that "all information should be recorded in the medical record" regarding smoking status 1.
How to Document Appropriately
When documenting this observation, use clear, objective, non-judgmental language that focuses on the clinical finding:
- Appropriate phrasing: "Patient has odor of cigarette smoke on clothing/breath" or "Cigarette smoke odor noted during examination"
- Context: This observation should prompt direct assessment questions about tobacco use: "Have you smoked any tobacco product in the past 30 days, even a puff?" 1
- Avoid judgmental language: Guidelines emphasize using language that is "compassionate, nonjudgmental, and personalized" when addressing tobacco use 1
Clinical Importance
The documentation serves multiple clinical purposes:
- Triggers intervention: Identifying current smokers allows providers to offer evidence-based cessation treatments, which have substantial benefits for morbidity and mortality 1
- Risk stratification: Tobacco use significantly impacts treatment outcomes, side effects, and disease progression, particularly in oncology settings 1
- Continuity of care: Proper documentation ensures all team members are aware of the patient's tobacco status for coordinated cessation efforts 1
Important Caveats
- Follow up with direct questioning: The odor observation alone is insufficient. You must still ask standardized tobacco assessment questions 1
- Consider secondhand exposure: The smell could potentially indicate secondhand smoke exposure rather than personal use, which should be clarified through patient interview 1
- Maintain therapeutic relationship: The goal is to facilitate treatment, not to create adversarial documentation. Frame the observation as part of comprehensive health assessment 1
The evidence strongly supports that systematic documentation of tobacco-related findings, including objective observations like cigarette odor, is both appropriate and necessary for delivering guideline-concordant care that reduces tobacco-related morbidity and mortality 1.