How should I document the complications discussed for a [age]-year-old [male/female] who smokes [number] cigarettes per day for [X] years, including any comorbidities, counseling provided, and the smoking cessation plan?

Documentation of Smoking Complications

Document smoking status as a vital sign at every encounter, including pack-years calculation (cigarettes per day × years smoked ÷ 20), specific complications discussed, counseling provided, and the cessation plan with pharmacotherapy prescribed. 1, 2

Essential Documentation Components

Smoking History Details

• Record the following at every visit: 1, 2
  • Current smoking status (never smoker, former smoker, or current smoker—includes anyone who quit within the last 12 months due to high relapse probability) 1
  • Cigarettes per day and total years of smoking 1
  • Pack-years calculation (daily cigarettes × years ÷ 20) 3, 2
  • Type of tobacco products used (cigarettes, cigars, pipes, chewing tobacco, waterpipe/shisha) 1, 3
  • Secondhand smoke exposure at home and work 1, 2
  • Age at smoking initiation 3, 2

Complications Discussed

Document the specific health risks you counseled the patient about, using quantified data to make the discussion concrete: 1, 3

• Cancer risks: Smoking causes 30% of all cancer deaths and is causally linked to at least 16 cancer types, with 85-90% of lung cancer deaths attributable to cigarette smoking 1, 3
• Cardiovascular risks: The 10-year fatal cardiovascular disease risk is approximately doubled in all smokers regardless of intensity, with no safe threshold for tobacco smoke exposure 3
• Diabetes complications: Smoking 2 packs per day increases diabetes incidence by 45% in men and 74% in women, and exacerbates existing diabetic complications 1
• Surgical outcomes: Document that continued smoking worsens surgical outcomes, though cessation should not delay appropriate timing of cancer resection 1

Readiness to Change Assessment

• Document the patient's current stage using the "5 Rs" framework if not ready to quit: 1

  • Relevance: Personal reasons smoking matters to them
  • Risks: Specific health consequences discussed
  • Rewards: Benefits of quitting relevant to the patient
  • Roadblocks: Barriers identified (weight gain concerns, living with smokers, stress, depression) 1
  • Repetition: Note this is an ongoing conversation 1

• If ready to quit, document the "5 As" intervention: 1

  • Asked about tobacco use
  • Advised to quit in clear, strong, personalized manner
  • Assessed willingness to make quit attempt
  • Assisted with specific quit plan
  • Arranged follow-up 1

Cessation Plan Documentation

Document the specific quit date set (should be within 1-2 weeks) and the complete treatment plan: 1

• Pharmacotherapy prescribed: 1, 3

  • First-line recommendation: Varenicline 1 mg twice daily for 12 weeks (achieves 21.8% quit rate at 6 months versus 9.4% for placebo) 3, 4
  • Alternative first-line: Combination nicotine replacement therapy (patch plus gum/lozenge) with fewer adverse effects than varenicline or bupropion 3
  • Second-line option: Bupropion SR 150 mg twice daily 1, 5
  • Document contraindications checked and side effects counseled 1, 4, 5

• Behavioral counseling plan: 1

  • Individual counseling sessions scheduled (weekly for at least 4 weeks) 1
  • Problem-solving strategies taught: removal of all tobacco products from home/work before quit date, planning for high-risk situations 1
  • Coping skills reviewed: deep breathing for relaxation, changing routines where smoking occurs 1
  • Social support identified: partner for quit attempt, addressing other smokers in household 1

• Relapse prevention strategies: 1

  • Risk factors for relapse documented: frequent/intense cravings, elevated anxiety/stress/depression, living/working with smokers, time since quitting <1 year, drug/alcohol use 1
  • Guidance provided on handling smoking slips 1

Follow-Up Plan

• Document specific follow-up schedule: 1
  • Within 2-3 weeks after therapy begins 1
  • Weekly sessions for at least 4 weeks 1
  • Following 12 weeks of therapy 1
  • Carbon monoxide measurement planned to verify abstinence 1

Benefits of Cessation Discussed

Document the timeline of health improvements you reviewed with the patient: 3

• Cardiac death risk decreases by 37% within just 1 year of cessation 3
• Risk of death from coronary heart disease is 50% lower after 1 year of abstinence 3
• Cardiovascular disease risk approaches that of never-smokers within 10-15 years after quitting 3

Critical Documentation Pitfalls to Avoid

• Never document vague statements like "patient counseled on smoking cessation"—specify exactly what complications were discussed and what plan was made 1, 2
• Avoid suggesting e-cigarettes or shisha as "safer" alternatives, as all smoked tobacco is harmful with no safe threshold 3
• Do not delay documentation of smoking status—it should be recorded as a vital sign at every encounter, not just annual visits 2, 6
• Address weight gain concerns proactively in documentation, noting that average weight gain does not diminish the substantial cardiovascular benefit from cessation 3
• Document objective findings when present (e.g., smell of cigarette smoke on patient), but follow up with direct questioning to clarify current use versus secondhand exposure 2

Special Populations

Patients with Psychiatric History

• Document psychiatric comorbidities, as these patients require closer monitoring: 1, 4
  • Higher risk of relapse (12.2% clinically significant neuropsychiatric events with varenicline versus 9.5% with placebo in psychiatric cohort) 4
  • Consider referral to specialist for management of psychiatric comorbidities 1
  • Document that patient was counseled about monitoring for mood changes, agitation, depression, or suicidal thoughts 4, 5

Patients with Cardiovascular Disease

• Document cardiovascular risk factors, as these patients had higher rates of major adverse cardiovascular events (MACE) in varenicline trials 4
• Emphasize the doubled 10-year fatal cardiovascular disease risk from continued smoking 3