Documentation of Electronic Nicotine Delivery System, Nicotine Pouch and Combustible Tobacco Product Use in Electronic Health Record Clinical Notes

Background: Due to the lack of standardized codes, documentation of electronic nicotine delivery system (ENDS) use is non-existent in healthcare claims data and severely limited in structured electronic health record (EHR) data. We conducted a comprehensive assessment on the documentation and distribution of terms related to ENDS, nicotine pouch, and combustible tobacco use in unstructured EHR clinical notes to assess the feasibility of conducting real-world evidence studies. Methods: Utilizing retrospective data from Optum’s EHR and Clinical Notes Databases (2007-2023), 13.6 million patients had ≥1 diagnosis code for combustible tobacco use history, and 5.2 million also had ≥1 clinical note. Searches were conducted for terms for ENDS, nicotine pouches, or combustible tobacco in the clinical notes. Results: There were 4.4 million patients with ≥1 clinical note containing a term for ENDS, nicotine pouches, or combustible tobacco, with 66.1 million notes. Seventy-seven ENDS-related terms were identified, in addition to 27 ENDS brand terms. The terms used evolved over time concurrently with the dramatic increase in their documentation in recent years. There were 8 terms and 10 brand names for nicotine pouches. 118 combustible tobacco-related terms were identified, with 49 and 34 indicating current and former cigarette smoking, respectively: 21 for cigar and 14 for water pipe use. Conclusions: Extensive ENDS use data are available in the unstructured EHR clinical notes that can be extracted for research; however, nicotine pouch use documentation was very limited during the study period. When combined with additional data sources (structured EHR, claims, and survey linkage), these data may enable robust studies on the health impacts associated with the use of ENDS. Standardization and consistent documentation practices will further enhance the utility of these data for research. Trial Registration: Not applicable