Even low levels of smoking in- crease risks of acute MI; thus, reducing the number of cigarettes per day does not totally eliminate risk.S4.5-8 Healthy People 2020 recommends that cessation treat- ment in clinical care settings be expanded, with access to proven cessation treatment provided to all tobacco Electronic Nicotine Delivery Systems (ENDS), often called e-cigarettes,S4.5-10 are a new class of tobacco product that emit aerosol containing fine and ultrafine particulates, nicotine, and toxic gases that may increase risk of cardiovascular and pulmonary diseases.S4.5-11 Ar- rhythmias and hypertension with e-cigarette use have also been reported.S4.5-12 Chronic use is associated with persistent increases in oxidative stress and sympathetic stimulation in young, healthy subjects.S4.5-13 Recommendation-Specific Supportive Text 1. On the basis of on the US Public Health Service s Clinical Practice Guideline for Treating Tobacco Use and Dependence,S4.5-14,S4.5-15 the USPSTF rec- ommended (Grade A) in 2003 and reaffirmed in 2009 that clinicians ask all adults about tobacco Treating tobacco use status as a vital sign and recording tobacco use status in the health record at every healthcare visit not only increases the rate of tobacco treatment but also improves Office-wide screen- ing systems (eg, chart stickers, computer prompts) that expand the vital signs to include tobacco use status (current, former, never) can facilitate Because many people who use tobacco do not report it, using multiple ques- tions to assess tobacco use status may improve accuracy and disclosure. For example, clinicians should ask, Have you smoked any tobacco prod- uct in the past 30 days, even a puff? Have you vaped or juuled in the past 30 days, even a puff? Have you used any other tobacco product in the past 30 days? If these questions are answered with yes, the patient is considered a current smoker. 