Advancing the Science

Mayo Clinic Medical Science Blog – an eclectic collection of research- and research education-related stories: feature stories, mini news bites, learning opportunities, profiles and more from Mayo Clinic.

January 29, 2020

A case for public health initiatives

By Elizabeth Zimmermann
medical illustration of COPD, with the parts of the lung and diseased areas identified

COPD is a chronic lung disease that makes it difficult to breath. According to the American Lung Association, COPD is the third leading cause of death in the U.S., with more than 15 million people currently living with the disease. It also increases the likelihood that people will develop heart disease, lung cancer and other debilitating conditions.

In a recent study, health care delivery researchers at Mayo Clinic, the University of North Florida, Jacksonville, and McMaster University, Hamilton, Ontario, found a relationship between hospitalizations among patients with COPD and anti-smoking laws where they live. Specifically, in counties where smoke-free policies covered the workplace, restaurants and bars, people with COPD were 19% less likely (than where no such policies existed) to be readmitted for COPD complications within 30 days of a previous hospitalization. In counties with partial smoke-free policies (one or two of the three locations were not required to be smoke-free) patients were 13% less likely to be re-hospitalized.

The team used the American Nonsmokers’ Rights Foundation Tobacco Control Laws Database to identify U.S. counties with partial, full, or no smoke-free policies. During the time frame of the study (July 1, 2013 to June 30, 2016), the database contained information on smoke-free laws for 1,788 counties.

a close-up of a No Smoking symbol on a sign along a busy city sidewalk

Despite the well-known risks associated with smoking in the workplace, some 21% of the counties had no smoke-free policies.

“We were surprised to find out how many counties didn’t have a smoking policy,” says Aaron Spaulding, Ph.D., a health services researcher in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. “We also found it notable that there were significant variations in the policies that existed.”

The research team combined hospital and county demographic information from several other data sources, overlaying it with the smoke-free policy information to examine associations between county-level smoke-free policies and average hospital COPD readmission rates.

In addition to learning that lacking smoke-free policies was clearly linked to COPD readmissions, the team made other observations about the counties that didn’t have policies. The researchers found that on average, these counties had fewer hospital beds, were more likely to be rural, had the highest levels of poverty and diversity and tended to have the lowest adult education and median population age.

“30-day readmissions are a key quality indicator used by the Center for Medicare and Medicaid Services to drive reimbursement,” says Dr. Spaulding. “Further, the Affordable Care Act requires nonprofit hospitals to conduct an assessment of the health needs of the people in the communities they serve and take steps toward addressing those needs.

“It follows that hospitals should actively lobby for smoke-free policies in their regions.”

However, the research team also notes problems with quality and reimbursement models that penalize hospitals for aspects of health they don’t control.

“Ideally, aspects such as county smoke-free policies should be used in risk adjustment, and local, state, and federal governments should consider how such policies could influence health care costs as well as improve the health of their constituents,” adds Sericea Stallings-Smith, Dr.P.H., an assistant professor of public health in the Brooks College of Health at the University of North Florida.

Although this is a focused study of one health outcome associated with smoke-free policies, Dr. Stallings-Smith says it provides important insight into the critical role played by social determinants of health. Better understanding of social determinants – particularly among decision makers – can lead to advancements in public health practice and policy, and improvements in local and even global health.

Other researchers on the team were:

  • Hanadi Hamadi, Ph.D., and Breck Peterson (M.P.H. candidate), University of North Florida
  • Emma Apatu, Dr.P.H., McMaster University


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Tags: Aaron Spaulding, Center for the Science of Health Care Delivery, collaboration, COPD, Findings, health care policy, lung disease, News, population health, public health, pulmonology, readmissions, tobacco cessation, University of North Florida

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