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

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

3. 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

4. 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
: 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

5. 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

6. 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”

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

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

17. 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

18. 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

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