Cigarette smoking is associated with an increased risk of developing ARDS. However, it is unclear whether changes in smoking patterns or processes of care impact this relationship.Are changes in smoking and resuscitation patterns associated with changes in the relationship between smoking and ARDS?We conducted a prospective cohort study of critically injured adults with blunt trauma from 2005 - 2015. Plasma cotinine, a tobacco biomarker, was measured to categorize patients by smoking status. We used regression to assess the relationship between smoking, resuscitation practices and ARDS over time.In the overall cohort, active (OR: 1.9, 95% CI: 1.0, 3.5, p = 0.046) and passive (OR: 2.6, 95% CI: 1.4, 4.8, p = 0.002) smoking were associated with an increased risk of developing ARDS in multivariate analyses. In contrast to the dose-response relationship in patients enrolled from 2005 - 2008, passive cigarette smoke exposure was associated with the highest risk of developing ARDS in patients enrolled from 2009 - 2015, suggesting a threshold effect. Packed red blood cell (pRBC) and fresh frozen plasma (FFP) transfusion were associated with an increased risk of developing ARDS, particularly in active smokers (pRBC: OR: 5.6, p < 0.001; FFP: OR: 4.5, p < 0.001) compared to passive smokers or nonsmokers. Blood product transfusion and smoking patterns changed over time.Despite changes in resuscitation and smoking patterns, cigarette smoking remains associated with an increased risk of developing ARDS. However, this relationship changed over time, with passive smokers at particularly increased risk of developing ARDS in later years, which may be related to changes in smoking patterns or transfusion practices over time. These findings highlight the need for additional mechanistic and epidemiologic studies of the effects of low levels of cigarette smoke exposure on lung health.