Smoke-Free Policies and 30-Day Readmission Rates for Chronic Obstructive Pulmonary Disease

Published:September 27, 2019DOI:


      Previous evidence has shown that smoke-free policies reduce hospital admissions due to respiratory causes, but the impact on 30-day readmission has not been determined. As 25 states in the U.S. have not adopted comprehensive smoke-free legislation, it is likely that patients return to an environment that increases risk of a secondary event. The aim of this study is to investigate the impact of smoke-free policies on 30-day readmission rates for adults aged ≥65 years following hospitalization for chronic obstructive pulmonary disease in the U.S.


      Data from the U.S. Tobacco Control Laws Database, Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program, American Hospital Association, Area Health Resource File, and U.S. Census Bureau Current Population Survey were merged at the county level for years 2013–2016 and analyzed in 2018. Hierarchical Poisson regression models were utilized to calculate incidence rate ratios to determine the impact of full, partial, and no smoke-free policies on 30-day readmission rates after chronic obstructive pulmonary disease hospitalization.


      Multivariable analysis adjusting for both county and hospital characteristics revealed that the presence of full (incidence rate ratio=0.81, 95% CI=0.76, 0.88) and partial (incidence rate ratio=0.87, 95% CI=0.81, 0.92) smoke-free policies were associated with fewer 30-day readmissions for chronic obstructive pulmonary disease–related hospitalizations when compared with counties with no smoke-free policy.


      The implementation of smoke-free policies is an effective measure for reducing 30-day readmissions following hospitalization due to chronic obstructive pulmonary disease, with stronger policies resulting in decreased risk. Efforts to reduce chronic obstructive pulmonary disease–related 30-day readmissions should include the implementation of smoke-free policies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Galan I
        • Simon L
        • Boldo E
        • et al.
        Changes in hospitalizations for chronic respiratory diseases after two successive smoking bans in Spain.
        PLoS One. 2017; 12e0177979
        • Naiman A
        • Glazier RH
        • Moineddin R
        Association of anti-smoking legislation with rates of hospital admission for cardiovascular and respiratory conditions.
        CMAJ. 2010; 182: 761-767
        • Tan CE
        • Glantz SA
        Association between smoke-free legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases: a meta-analysis.
        Circulation. 2012; 126: 2177-2183
        • Kent BD
        • Sulaiman I
        • Nicholson TT
        • Lane SJ
        • Moloney ED
        Acute pulmonary admissions following implementation of a national workplace smoking ban.
        Chest. 2012; 142: 673-679
        • Vander Weg MW
        • Rosenthal GE
        • Vaughan Sarrazin M
        Smoking bans linked to lower hospitalizations for heart attacks and lung disease among Medicare beneficiaries.
        Health Aff (Millwood). 2012; 31: 2699-2707
        • Dusemund F
        • Baty F
        • Brutsche MH
        Significant reduction of AECOPD hospitalisations after implementation of a public smoking ban in Graubunden, Switzerland.
        Tob Control. 2015; 24: 404-407
        • Hahn EJ
        • Rayens MK
        • Adkins S
        • et al.
        Fewer hospitalizations for chronic obstructive pulmonary disease in communities with smoke-free public policies.
        Am J Public Health. 2014; 104: 1059-1065
        • Stallings-Smith S
        • Zeka A
        • Goodman P
        • Kabir Z
        • Clancy L
        Reductions in cardiovascular, cerebrovascular, and respiratory mortality following the national Irish smoking ban: interrupted time-series analysis.
        PLoS One. 2013; 8: e62063
        • American Nonsmokers’ Rights Foundation
        U.S. Tobacco Control Laws Database: Smokefree Lists and Maps.
        Published 2019
        • Ferrante D
        • Linetzky B
        • Virgolini M
        • Schoj V
        • Apelberg B
        Reduction in hospital admissions for acute coronary syndrome after the successful implementation of 100% smoke-free legislation in Argentina: a comparison with partial smoking restrictions.
        Tob Control. 2012; 21: 402-406
        • Aguero F
        • Degano IR
        • Subirana I
        • et al.
        Impact of a partial smoke-free legislation on myocardial infarction incidence, mortality and case-fatality in a population-based registry: the REGICOR Study.
        PLoS One. 2013; 8: e53722
        • Pechacek TF
        • Babb S
        How acute and reversible are the cardiovascular risks of secondhand smoke?.
        BMJ. 2004; 328: 980-983
        • Pope 3rd, CA
        • Burnett RT
        • Krewski D
        • et al.
        Cardiovascular mortality and exposure to airborne fine particulate matter and cigarette smoke: shape of the exposure–response relationship.
        Circulation. 2009; 120: 941-948
        • Flouris AD
        • Metsios GS
        • Carrillo AE
        • et al.
        Acute and short-term effects of secondhand smoke on lung function and cytokine production.
        Am J Respir Crit Care Med. 2009; 179: 1029-1033
        • Glantz SA
        • Parmley WW
        Passive smoking and heart disease. Mechanisms and risk.
        JAMA. 1995; 273: 1047-1053
        • Niemann B
        • Rohrbach S
        • Miller MR
        • et al.
        Oxidative stress and cardiovascular risk: obesity, diabetes, smoking, and pollution: part 3 of a 3-part series.
        J Am Coll Cardiol. 2017; 70: 230-251
        • Lee W
        • Hwang SH
        • Choi H
        • Kim H
        The association between smoking or passive smoking and cardiovascular diseases using a Bayesian hierarchical model: based on the 2008‒2013 Korea Community Health Survey.
        Epidemiol Health. 2017; 39e2017026
        • Ali M
        • Li Y
        • O'Neal WT
        • Soliman EZ
        Tobacco exposure as determined by serum cotinine and subclinical myocardial injury in individuals free from cardiovascular disease.
        Am J Cardiol. 2017; 120: 1114-1117
        • Diez-Izquierdo A
        • Cassanello-Penarroya P
        • Lidon-Moyano C
        • et al.
        Update on thirdhand smoke: a comprehensive systematic review.
        Environ Res. 2018; 167: 341-371
        • Acuff L
        • Fristoe K
        • Hamblen J
        • Smith M
        • Chen J
        Third-hand smoke: old smoke, new concerns.
        J Commun Health. 2016; 41: 680-687
        • Croft JB
        • Wheaton AG
        • Liu Y
        • et al.
        Urban–rural county and state differences in chronic obstructive pulmonary disease - United States, 2015.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 205-211
        • CDC, National Center for Health Statistics
        Chronic obstructive pulmonary disease (COPD): Includes chronic bronchitis and emphysema.
        Published 2017
        Date accessed: June 21, 2019
        • Goto T
        • Faridi MK
        • Gibo K
        • et al.
        Trends in 30-day readmission rates after COPD hospitalization, 2006‒2012.
        Respir Med. 2017; 130: 92-97
        • Hartl S
        • Lopez-Campos JL
        • Pozo-Rodriguez F
        • et al.
        Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit.
        Eur Respir J. 2016; 47: 113-121
        • Hunter LC
        • Lee RJ
        • Butcher I
        • et al.
        Patient characteristics associated with risk of first hospital admission and readmission for acute exacerbation of chronic obstructive pulmonary disease (COPD) following primary care COPD diagnosis: a cohort study using linked electronic patient records.
        BMJ Open. 2016; 6e009121
        • Goto T
        • Faridi MK
        • Gibo K
        • Camargo Jr., CA
        • Hasegawa K
        Sex and racial/ethnic differences in the reason for 30-day readmission after COPD hospitalization.
        Respir Med. 2017; 131: 6-10
        • Shah T
        • Churpek MM
        • Coca Perraillon M
        • Konetzka RT
        Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion.
        Chest. 2015; 147: 1219-1226
        • Eisner MD
        • Blanc PD
        • Omachi TA
        • et al.
        Socioeconomic status, race and COPD health outcomes.
        J Epidemiol Commun Health. 2011; 65: 26-34
        • Golden SD
        • McLeroy KR
        • Green LW
        • Earp JA
        • Lieberman LD
        Upending the social ecological model to guide health promotion efforts toward policy and environmental change.
        Health Educ Behav. 2015; 42: 8S-14S
        • Herman PM
        • Walsh ME
        Hospital admissions for acute myocardial infarction, angina, stroke, and asthma after implementation of Arizona's comprehensive statewide smoking ban.
        Am J Public Health. 2011; 101: 491-496
        • Ho V
        • Ross JS
        • Steiner CA
        • et al.
        A nationwide assessment of the association of smoking bans and cigarette taxes with hospitalizations for acute myocardial infarction, heart failure, and pneumonia.
        Med Care Res Rev. 2017; 74: 687-704
        • Gaudreau K
        • Sanford CJ
        • Cheverie C
        • McClure C
        The effect of a smoking ban on hospitalization rates for cardiovascular and respiratory conditions in Prince Edward Island, Canada.
        PLoS One. 2013; 8: e56102
        • Humair JP
        • Garin N
        • Gerstel E
        • et al.
        Acute respiratory and cardiovascular admissions after a public smoking ban in Geneva, Switzerland.
        PLoS One. 2014; 9: e90417
        • Centers for Medicare and Medicaid Services
        Readmissions Reduction Program.
        Published 2017
        • Fischer C
        • Lingsma HF
        • Marang-van de Mheen PJ
        • et al.
        Is the readmission rate a valid quality indicator? A review of the evidence.
        PLoS One. 2014; 9e112282
        • American Nonsmokers’ Rights Foundation
        U.S. Tobacco Control Laws Database.
        Published 2018
        Date accessed: June 21, 2019
        • Health Resources & Services Administration
        Area health resources files: county-level data technical documentation.
        Published 2018
        Date accessed: June 21, 2019
        • McIlvennan CK
        • Eapen ZJ
        • Allen LA
        Hospital readmissions reduction program.
        Circulation. 2015; 131: 1796-1803
        • Krumholz HM
        • Keenan PS
        • Lin Z
        • et al.
        Hospital 30-day heart failure readmission measure: methodology. Quality Net.
        Published 2011
        • Nuckols TK
        County-level variation in readmission rates: implications for the Hospital Readmission Reduction Program's potential to succeed.
        Health Serv Res. 2015; 50: 12-19
        • U.S. Office of the Federal Register
        A Guide to the Rulemaking Process.
        Published 2018
        • Williams DR
        • Collins C
        Racial residential segregation: a fundamental cause of racial disparities in health.
        Public Health Rep. 2001; 116: 404-416
        • Iceland J
        The multigroup entropy index (also known as Theil's H or the information theory index).
        U.S. Census Bureau, 2004
        • Parisi D
        • Lichter DT
        • Taquino MC
        The buffering hypothesis: growing diversity and declining black–white segregation in America's cities, suburbs, and small towns?.
        Sociol Sci. 2015; 2: 125
        • Eisner MD
        • Blanc PD
        • Omachi TA
        • et al.
        Socioeconomic status, race and COPD health outcomes.
        J Epidemiol Commun Health. 2011; 65: 26-34
        • Sosunov EA
        • Egorova NN
        • Lin HM
        • et al.
        The impact of hospital size on CMS hospital profiling.
        Med Care. 2016; 54: 373-379
        • Hamadi H
        • Apatu E
        • Spaulding A
        Does hospital ownership influence hospital referral region health rankings in the United States.
        Int J Health Plann Manag. 2018; 33: e168-e180
        • Chen AS
        • Revere L
        • Ratanatawan A
        • Beck CL
        • Allo JA
        A comparative analysis of academic and nonacademic hospitals on outcome measures and patient satisfaction.
        Am J Med Qual. 2019; 34: 367-375
        • Cuellar AE
        • Gertler PJ
        How the expansion of hospital systems has affected consumers.
        Health Aff (Millwood). 2005; 24: 213-219
        • Apatu E
        • Hamadi H
        • Abrams JA
        • Metzger IW
        • Spaulding A
        Association between hospital community services and county population health in the USA.
        J Public Health (Oxf). 2019; 41: 71-79
        • Faseru B
        • Turner M
        • Casey G
        • et al.
        Evaluation of a hospital-based tobacco treatment service: outcomes and lessons learned.
        J Hosp Med. 2011; 6: 211-218
        • Bazzoli GJ
        • Chen HF
        • Zhao M
        • Lindrooth RC
        Hospital financial condition and the quality of patient care.
        Health Econ. 2008; 17: 977-995
        • Wong HS
        • Zhan C
        • Mutter R
        Do different measures of hospital competition matter in empirical investigations of hospital behavior.
        Rev Ind Organ. 2005; 26: 27-60
        • Hamadi H
        • Spaulding A
        • Haley DR
        • et al.
        Does value-based purchasing affect U.S. hospital utilization pattern: a comparative study.
        Int J Healthc Manag. 2019; 12: 148-154
        • Anthonisen NR
        Smoking, lung function, and mortality.
        Thorax. 2000; 55: 729-730
        • White K
        • Borrell LN
        Racial/ethnic residential segregation: framing the context of health risk and health disparities.
        Health Place. 2011; 17: 438-448
        • Yip NH
        • Yuen G
        • Lazar EJ
        • et al.
        Analysis of hospitalizations for COPD exacerbation: opportunities for improving care.
        COPD. 2010; 7: 85-92
        • Wong AW
        • Gan WQ
        • Burns J
        • Sin DD
        • van Eeden SF
        Acute exacerbation of chronic obstructive pulmonary disease: influence of social factors in determining length of hospital stay and readmission rates.
        Can Respir J. 2008; 15: 361-364
        • Bambhroliya AB
        • Donnelly JP
        • Thomas EJ
        • et al.
        Estimates and temporal trend for U.S. nationwide 30-day hospital readmission among patients with ischemic and hemorrhagic stroke.
        JAMA Netw Open. 2018; 1e181190
        • Lai PM
        • Lin N
        • Du R
        Effect of teaching hospital status on outcome of aneurysm treatment.
        World Neurosurg. 2014; 82: 380-385.e6
        • Abusaada K
        • Alsaleh L
        • Herrera V
        • et al.
        Comparison of hospital outcomes and resource use in acute COPD exacerbation patients managed by teaching versus nonteaching services in a community hospital.
        J Eval Clin Pract. 2017; 23: 625-630
        • Syamlal G
        • Doney B
        • Mazurek JM
        Chronic obstructive pulmonary disease prevalence among adults who have never smoked, by industry and occupation - United States, 2013‒2017.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 303-307
        • Burkes RM
        • Gassett AJ
        • Ceppe AS
        • et al.
        Rural residence and Chronic Obstructive Pulmonary Disease exacerbations: analysis of the SPIROMICS cohort.
        Ann Am Thorac Soc. 2018; 15: 808-816
        • Greskevitch M
        • Kullman G
        • Bang KM
        • Mazurek JM
        Respiratory disease in agricultural workers: mortality and morbidity statistics.
        J Agromedicine. 2007; 12: 5-10
        • Hnizdo E
        • Sullivan PA
        • Bang KM
        • Wagner G
        Association between chronic obstructive pulmonary disease and employment by industry and occupation in the U.S. population: a study of data from the third National Health and Nutrition Examination Survey.
        Am J Epidemiol. 2002; 156: 738-746