Clearing the air: smoke-free homes & cars Dr Laura Jones UKNSCC 9th June 2016 @drlaurajones

Outline Part 1: Emerging evidence on secondhand smoke & smoke-free homes Part 2: Implementation & enforcement of banning smoking in private vehicles

Secondhand smoke exposure Health risks well-established No safe level of exposure 600,000 global SHS deaths annually Surgeon General 2006; 2014; Oberg et al. 2011

Global exposure to SHS 2004: 192 Countries Exposure in work places, homes & vehicles Ave. global exposure: 40% children, 35% NS women, 33% NS men Highest exposure: Europe, Western Pacific, South East Asia 2009-13 : 21 Countries (GATS data) Children’s exposure at home Range 4.5% (Panama) to 79% (Indonesia) China, India, Bangladesh, Indonesia & Philippines accounts for 85% of exposure ~508 million children exposed to SHS in the home across 21 countries Mbulo et al. 2016; Oberg et al. 2011

English children’s exposure to SHS at home Adapted from Jarvis & Feyerabend 2015 English children’s exposure to SHS at home 13000 children 4-15 years

Intervention evidence Rosen et al. 2014 30 studies (17 in intervention meta analysis) 7% more children protected in intervention relative to control groups Conclusion: “Interventions to prevent child [SHSe] are moderately beneficial at the individual level…more research is needed to improve intervention effectiveness and child [SHS] measurement” Baxter et al. 2011 12 studies (2 significant) Conclusion: “mixed-evidence for the effectiveness of interventions to reduce parental environmental tobacco smoke in early infancy” Baxi et al. 2014 57 studies (14 significant) Conclusion: “the review was unable to determine if any one intervention reduced parental smoking and child exposure more effectively than others”

Parental smoking Low socio-economic status Limited education ↑ risk of SHS exposure at home Single parent / separated family More -ve parental attitudes to SHS ↓ risk of SHS exposure at home Conclusion: “this review has identified potential characteristics that may be important for the development of future secondhand smoke and smoke-free home interventions” 41 studies included in the systematic review of the predictors of children’s exposure to SHS at home Children < 18 years of age –majority focussed on 5-18 year olds and not the younger < 5 year group. Undertaken as part of PhD by Sophie Orton in Nottingham Following factors independently & consistently associated with children’s exposure to SHS at home All what we would expect, but prior to this no systematic synthesis of the evidence. Over 90 variables were reported across the 41 studies. Factors which increased the risk of exposure to SHS at home was parental smoking, low SES, limited education and single/separated families One factor which protected children from exposure was where parents has more negative attitudes to SHS.

Intervention recommendations: Target households not just individuals Provide tailored / different support to individuals within the household Promote skill development e.g. negotiation Assets-based approach to harness motivation and steps already taken towards SFH

SHS & SFH Summary Globally, millions of children at risk of SHS exposure in the home 39% of English children regularly exposed Need for novel, targeted interventions to support parental home smoking behaviour change Maximise learning from the evidence base to inform intervention development

Smoking in cars I’m going to move on now to talk about smoking in cars Unlike the home, the car is a place where we can introduce legislation to protect children from the harms of exposure to secondhand smoke

UK children’s exposure to SHS in cars SHS particulate levels (PM2.5) can be much greater in cars than other spaces Exceed WHO 24 hour outdoor air pollution health limits Levels unhealthy even with windows opens/ ventilation system on Levels can remain high for several hours Jones et al. 2014; DoH 2009; ASH 2015; Moore et al. 2015; Kabir e tal. 2009; Bogdanovica et al. 2014

Smoke-free Private Vehicles Regulations: 1st October 2015 Two offences under the Health Act (2006): Applies to both driver and any passengers Applies to private vehicles that are: (a) enclosed, (b) contain more than one person, (c) moving or stationary, (d) located on roads or private land (e.g. driveway) Offence for someone to smoke* in a private vehicle with a person under age 18 present Offence for a driver not to stop someone smoking* in a private vehicle with a person under age 18 present *ECs and nicotine vaporisers not included in definition of smoking

Penalties & enforcement approach Advice / verbal warning Fixed penalty notice (£50) Proceed to prosecution (fine) Police and local authorities have the power to enforce the law “It is a matter for the discretion of the authorised officer to decide whether or not to take formal enforcement action. The legislation provides that authorised officers may issue FPN to alleged offenders but does not require them to do so” (CIEH, 2016) DoH statement Local authorities and police both enforcement authorities Police Automated system to issue PFN is not configured to issue (the reduced) fines for smoking in private cars carrying children System will not be changed dd ASH, 2016; CIEH, 2016; Personal Communication Ian Gray May 2016

Anticipated compliance Positive learning & experience from 2007 smoke-free legislation implementation High levels of public support High levels of voluntary compliance & self-enforcement Minimal need for enforcement DoH statement Local authorities and police both enforcement authorities Police Automated system to issue PFN is not configured to issue (the reduced) fines for smoking in private cars carrying children System will not be changed dd Can this be applied to smoke-free private vehicles (2015) regulations? DoH Smoke-free England 2008

High levels of public support pre smoke-free private vehicles (2015) legislation Image: HISIC 2016 pg. 26; ASH YouGov Survey 2015

Measuring success Department of Health: “measure of success [will be] changes in attitude and behaviour, not the number of enforcement actions”

Evaluation National Police Chiefs Council: “in the first three months, police forces will be taking an educational, advisory and non-confrontational approach when enforcing the new legislation…to help build high level of compliance” No formal evaluation to date Few, in any, other countries with legislation have undertaken robust evaluations BBC Radio 5 FOI request “No fines or court summonses were issued in the first three months of the law” Early in post-implementation period Need time to explore if changes to prevalence, attitude and behaviour McNeill et al. (2013); Sendzik et al. unpublished data; BBC News, 2016

Summary Non-smokers were at risk of exposure to SHS in private vehicles Legislation introduced in October 2015 Need time to assess impact: prevalence of exposure, attitudes and behaviour CIEH guidance available to support the public and authorised officers in England

Acknowledgments L.L.Jones@bham.ac.uk Linda Bauld Ian Gray Ann McNeill Amanda Farley Andy McEwen L.L.Jones@bham.ac.uk @drlaurajones