Secondhand tobacco smoke concentrations in motor vehicles: a pilot study

Exposure to secondhand and thirdhand smoke in private vehicles: Measurements in air and dust samples

BACKGROUND

This study aimed to estimate airborne nicotine concentrations and nicotine, cotinine, and tobacco-specific nitrosamines (TSNAs) in settled dust from private cars in Spain and the UK.

METHODS

We measured vapor-phase nicotine concentrations in a convenience sample of 45 private cars from Spain (N = 30) and the UK (N = 15) in 2017-2018. We recruited non-smoking drivers (n = 20), smoking drivers who do not smoke inside the car (n = 15), and smoking drivers who smoke inside (n = 10). Nicotine, cotinine, and three TSNAs (NNK, NNN, NNA) were also measured in settled dust in a random subsample (n = 20). We computed medians and interquartile ranges (IQR) of secondhand smoke (SHS) and thirdhand smoke (THS) compounds according to the drivers' profile.

RESULTS

24-h samples yielded median airborne nicotine concentrations below the limit of quantification (LOQ) (IQR:

CONCLUSIONS

All cars of smokers had measurable SHS and THS pollution, the exposure levels markedly higher in vehicles of drivers where smoking took place. Our results evidence the need for policies to prohibit smoking in vehicles, but also urge for more comprehensive strategies aiming towards the elimination of tobacco consumption.

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Key Words

• Airborne nicotine
• Automobile
• Dust
• Thirdhand smoke
• Tobacco smoke pollution
• Tobacco-specific nitrosamines

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MESH Headings

• Nicotine/analysis
• Cotinine
• Tobacco Smoke Pollution/analysis
• Dust
• Nitrosamines/analysis
• Tobacco

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Affiliation(s)

Xavier Continente Agència de Salut Pública de Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain; Centre for Biomedical Research in Epidemiology and Public Health (CIBERESP), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 28029, Madrid, Spain; Sant Pau Institute of Biomedical Research (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain.
Elisabet Henderson Agència de Salut Pública de Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain; Sant Pau Institute of Biomedical Research (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain.
Laura López-González Agència de Salut Pública de Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain.
Esteve Fernández Unitat de Control de Tabac, Institut Català d'Oncologia, Av. Granvia de l'Hospitalet 199-203, 08908, L'Hospitalet de Llobregat, Spain; Institut D'Investigació Biomèdica de Bellvitge, Av. Granvia de l'Hospitalet 199, 08908, L'Hospitalet de Llobregat, Spain; Department of Clinical Sciences, Campus de Bellvitge, School of Medicine and Health Sciences, University of Barcelona, Feixa Llarga, S/n, 08907, L'Hospitalet de Llobregat, Spain; Centre for Biomedical Research in Respiratory Diseases (CIBERES), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 28029, Madrid, Spain.
Olena Tigova Unitat de Control de Tabac, Institut Català d'Oncologia, Av. Granvia de l'Hospitalet 199-203, 08908, L'Hospitalet de Llobregat, Spain; Institut D'Investigació Biomèdica de Bellvitge, Av. Granvia de l'Hospitalet 199, 08908, L'Hospitalet de Llobregat, Spain; Department of Clinical Sciences, Campus de Bellvitge, School of Medicine and Health Sciences, University of Barcelona, Feixa Llarga, S/n, 08907, L'Hospitalet de Llobregat, Spain; Centre for Biomedical Research in Respiratory Diseases (CIBERES), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 28029, Madrid, Spain.
Sean Semple Institute for Social Marketing, University of Stirling, Stirling, FK9 4LA, Scotland, UK.
Rachel O'Donnell Institute for Social Marketing, University of Stirling, Stirling, FK9 4LA, Scotland, UK.
Ana Navas-Acién Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY, 10032, United States.
Núria Cortés-Francisco Agència de Salut Pública de Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain; Centre for Biomedical Research in Epidemiology and Public Health (CIBERESP), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 28029, Madrid, Spain; Sant Pau Institute of Biomedical Research (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain.
Noelia Ramírez Institut d'Investigació Sanitària Pere Virgili, Dr. Mallafré Guasch, 4, 43007, Tarragona, Spain; Universitat Rovira i Virgili, Department of Electronic Engineering, Escorxador, s/n, 43003, Tarragona, Spain; Centre for Biomedical Research in Diabetes and Associated Metabolic Diseases (CIBERDEM), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 28029, Madrid, Spain.
Ruaraidh Dobson Institute for Social Marketing, University of Stirling, Stirling, FK9 4LA, Scotland, UK.
Maria José López Agència de Salut Pública de Barcelona, Pl. Lesseps, 1, 08023, Barcelona, Spain; Centre for Biomedical Research in Epidemiology and Public Health (CIBERESP), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 28029, Madrid, Spain; Sant Pau Institute of Biomedical Research (IIB Sant Pau), Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain; Departament de Ciències Experimentals i de la Salut (DCEXS), Universitat Pompeu Fabra, Doctor Aiguader, 88, 08003, Barcelona, Spain.

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Impact of different ventilation conditions on tobacco smoke-associated particulate matter emissions in a car cabin using the TAPaC platform

Despite antagonizing attempts from the tobacco industry, passive inhalation of tobacco smoke is known to be cancerogenic and toxic to human health for decades. Nonetheless, millions of non-smoking adults and children are still victims of second-hand smoke. Accumulation of particulate matter (PM) in confined spaces such as the car are particularly harmful due to high concentrations. We here aimed to analyze the specific effects of ventilation conditions in the setting of a car. By the use of the measuring platform TAPaC (tobacco-associated particulate matter emissions inside a car cabin), 3R4F reference cigarettes, Marlboro red, and Marlboro gold were smoked in a car interior with a volume of 3.709 m3. Seven different ventilation conditions (C1-C7) were analyzed. Under C1, all windows were closed. Under C2-C7, the car ventilation was turned on power level 2/4 with the air directed towards the windshield. Only the passenger side window was opened, where an outer placed fan could create an airstream speed of 15.9-17.4 km/h at one meter distance to simulate a driving car. C2: Window 10 cm opened. C3: Window 10 cm opened with the fan turned on. C4: Window half-opened. C5: Window half-opened with the fan turned on. C6: Window fully opened. C7: Window fully opened with the fan turned on. Cigarettes were remotely smoked by an automatic environmental tobacco smoke emitter and a cigarette smoking device. Depending on the ventilation condition the cigarettes emitted different mean PM concentrations after 10 min under condition C1 (PM10: 1272-1697 µg/m3, PM2.5: 1253-1659 µg/m3, PM1: 964-1263 µg/m3) under C2, C4, and C6 (PM10: 68.7-196.2 µg/m3, PM2.5: 68.2-194.7 µg/m3, PM1: 66.1-183.8 µg/m3) C3, C5, and C7 (PM10: 73.7-139 µg/m3, PM2.5: 72-137.9 µg/m3, PM1:68.9-131.9 µg/m3). Vehicle ventilation is insufficient to protect passengers from toxic second-hand smoke completely. Brand-specific variations of tobacco ingredients and mixtures markedly influence PM emissions under ventilation conditions. The most efficient ventilation mode to reduce PM exposure was achieved by opening the passenger´s window 10 cm and turning the onboard ventilation on power level 2/4. In-vehicle smoking should be banned to preserve innocent risk groups (e.g., children) from harm.

TAPaC-tobacco-associated particulate matter emissions inside a car cabin: establishment of a new measuring platform

Background

Particulate matter (PM) emission caused by tobacco combustion leads to severe health burdens worldwide. Second-hand smoke exposure is extraordinarily high in enclosed spaces (e.g., indoor rooms, car cabins) and poses a particular threat to the health of vulnerable individuals (e.g., children, elderly, etc.). This study aimed to establish a new measuring platform and investigate PM emissions under four different ventilation conditions inside a car cabin without exposing any person to harmful tobacco smoke.

Methods

PM concentrations were measured during the smoking of 3R4F reference cigarettes in a Mitsubishi Space Runner (interior volume 3.709 m³). The cigarettes were smoked with a machine, eliminating exposure of the researchers. Cigarettes were extinguished 4.5 min after ignition, and PM measurements continued until 10 min after ignition.

Results

High mean PM concentrations were measured for cigarettes without ventilation after 4.5 min (PM₁₀: 1150 µg/m³, PM_2.5: 1132 µg/m³, PM₁: 861.6 µg/m³) and after 10 min (PM₁₀: 1608 µg/m³, PM_2.5: 1583 µg/m³, PM₁: 1133 µg/m³). 3R4F smoked under conditions with turned on ventilation resulted in reduction of PM compared to those smoked without ventilation after 4.5 min (PM₁₀:-47.5 to -58.4%, PM_2.5:-47.2 to -58%, PM₁:-39.6 to -50.2%) and after 10 min (PM₁₀:-70.8 to -74.4%, PM_2.5:-70.6 to -74.3%, PM₁:-64.0 to -68.0%). Cigarettes smoked without ventilation generated high PM peaks at 4.5 min (PM₁₀: 2207 µg/m³, PM_2.5: 2166 µg/m³, PM₁: 1421 µg/m³) and at 10 min (PM₁₀: 1989 µg/m³, PM_2.5: 1959 µg/m³, PM₁: 1375 µg/m³). PM peaks of cigarettes smoked under different ventilation modes varied at 4.5 min (PM₁₀: 630-845 µg/m³, PM_2.5: 625-836 µg/m³, PM₁: 543 - 693 µg/m³) and 10 min (PM₁₀: 124 - 130 µg/m³, PM_2.5: 124 - 129 µg/m³, PM₁: 118 - 124 µg/m³).

Conclusion

The new measuring platform provides a safer way for researchers to investigate PM emissions of cigarettes. These data are comparable to published research and show that smoking in a parked vehicle with the windows closed generates harmful PM emissions even when the vehicle ventilation is in operation. Future studies should be carried out using the new measuring platform investigating PM exposure and PM distribution of in-vehicle smoking under a wide range of conditions.

Do smokers want to protect non-smokers from the harms of second-hand smoke in cars? Findings from the EUREST-PLUS ITC Europe Surveys

BACKGROUND

There is currently no comprehensive legislation protecting non-smokers and children from second-hand smoke (SHS) exposure in private cars at the European Union (EU) level. This study aims to assess smokers' support for smoke-free cars legislation in six EU countries.

METHODS

Data come from the EUREST-PLUS ITC Europe Surveys: Wave 1 (2016, n = 6011) and Wave 2 (2018, n = 6027) conducted in Germany, Greece, Hungary, Poland, Romania and Spain. Support for smoke-free cars carrying pre-school children and non-smokers and voluntary implementation of smoke-free cars were assessed among adult smokers. Generalized estimating equations models were used to assess changes in support between waves.

RESULTS

In 2018, 96.3% [95% confidence interval (CI) 95.4-97.0%] of the overall sample supported smoke-free legislation for cars carrying pre-school children, representing an increase of 2.4 percentage points in comparison to 2016. Smoke-free legislation for cars transporting non-smokers was supported by 85.2% (95% CI 83.1-87.1%) of smokers' in 2016 and 90.2% (95% CI 88.6-91.7%) in 2018. Among smokers who owned cars, there was a significant 7.2 percentage points increase in voluntary implementation of smoke-free cars carrying children from 2016 (60.7%, 95% CI 57.2-64.0%) to 2018 (67.9%, 95% CI 65.1-70.5%). All sociodemographic groups of smokers reported support higher than 80% in 2018.

CONCLUSION

The vast majority of smokers in all six EU countries support smoke-free legislation for cars carrying pre-school children and non-smokers. This almost universal support across countries and sociodemographic groups is a clear indicator of a window of opportunity for the introduction of comprehensive legislation to protect non-smokers and children from SHS exposure in cars.

Malaysian adolescents' exposure to secondhand smoke in the car of their parents/guardians: A nationwide cross-sectional school-based study

INTRODUCTION

We investigated the prevalence of children's exposure to secondhand smoke (SHS) in the car of their parents/guardians and the associated factors.

METHODS

A self-administered validated questionnaire was used to obtain data from the nationally representative samples of school-going adolescents aged 11-19 years in Malaysia. Prevalence rates were computed and chi-squared tests and multiple logistic regression were conducted.

RESULTS

Of the participants, 23.3% reported exposure to SHS at least once in the car of their parents/guardians during the last 7 days before the survey. The prevalence and likelihood of SHS exposure were significantly higher in Malays, descendants of natives of Sabah and Sarawak, schools in rural areas, females, and current smokers. However, age group and knowledge on the harmful effects of SHS were not significant after adjusting for confounding effects.

CONCLUSIONS

A substantial proportion of school-going adolescents were exposed to secondhand smoke in the car of their parents/guardians. This highlights the need for effective tobacco control measures to include health promotion and smoke-free car regulations to be introduced to prevent severe health hazards and to reduce smoking initiation among non-smoking adolescents.

Exposure to secondhand smoke in vehicles among Canadian adolescents: Years after the adoption of smoke-free car laws

Exposure to secondhand smoke (SHS) can result in several adverse health consequences. SHS concentrations in vehicles can significantly exceed levels present in other enclosed spaces. Years after the adoption of smoke-free car laws, this study examined the prevalence of exposure to SHS in vehicles among adolescents. Data were utilized from the 2016-2017 Canadian Student Tobacco, Alcohol and Drugs Survey (n = 48,444). The prevalence of exposure to SHS in cars was estimated by grade level and demographic characteristics. The results showed a gradient by grade level in exposure to SHS with students in upper-grade levels reporting a higher prevalence of SHS in cars. SHS varied by province, with the lowest rate found in British Columbia (15.6%) and the highest in Saskatchewan (36.9%). The provinces with laws that extend protections to older children also had high rates of SHS exposure among students in upper-grade levels. Students exposed to SHS were more likely to engage in risky behaviors, including the use of marijuana, alcohol, cigarettes, and e-cigarettes. Despite laws prohibiting smoking in vehicles carrying children, SHS prevalence remains high. While enforcement of these laws may be challenging, persuasion campaigns highlighting that children are especially vulnerable to the health risks of SHS may be beneficial.

Female non-smokers' environmental tobacco smoking exposure by public transportation mode

Background

This study aimed to analyze environmental tobacco smoking exposure in female nonsmokers by public transportation mode using representative data of Koreans.

Methods

Data from the Second Korean National Environmental Health Survey (2012–2014) were analyzed. Urine cotinine was analyzed by public transport behavior, secondhand smoke exposure, socioeconomic factors, and health-related factors. Participants were 1322 adult females; those with the top 75% urine cotinine concentrations were assigned to the high exposure group. A logistic regression analysis was performed considering appropriate weights and stratification according to the sample design of the Second Korean National Environmental Health Survey.

Results

The geometric mean of urine cotinine concentrations differed according to public transportation modes: subway (1.66 μg/g creatinine) bus (1.77 μg/g creatinine), and taxi (1.94 μg/g creatinine). The odds ratio [OR] was calculated for the high exposure group. The OR of the taxi (2.39; 95% confidence interval, 1.00–5.69) was statistically significantly higher than the subway value (reference), and marginally significant after adjusted with life style, sociodemographic factors and involuntary smoking frequency (2.42, 95% confidence interval, 0.97–6.04).

Conclusions

The odds ratio of passengers who mainly used taxis was marginally significantly higher than those of passengers who used subways and buses after adjusted with life style and sociodemographic factors. Implementation of supplementary measures and further studies on exposure to environmental tobacco smoking in taxis are warranted.

Towards smoke-free cars in the Republic of Korea: Evidence from environmental and biochemical monitoring of third-hand smoke exposure in taxis

INTRODUCTION

To evaluate the level of tobacco smoke exposure in taxis in Korea using tobacco specific environmental markers.

METHODS

From June to September 2012, cross-sectional measurements of air nicotine levels and dust nicotine-derived nitrosamine ketone (NNK) concentrations were conducted in 17 taxis in Goyang, Korea. Field investigators completed an observational questionnaire on building characteristics, smoking policies and evidence of smoking. Descriptive statistics including geometric means (GMs) ± standard deviations were produced for air nicotine levels and dust NNK concentrations.

RESULTS

There was no evidence of active smoking in the 17 taxis monitored, despite the fact that 10 drivers were current smokers. The overall GMs of air nicotine and dust NNK concentration were 0.42 μg/m3 and 6.78 pg/mg, respectively. These levels were 3.4-fold and 2.6-fold higher in taxis whose drivers were current smokers compared to the taxis of nonsmokers (GM of air nicotine: 0.65 μg/m3 vs 0.19 μg/m3; GM of dust NNK: 10.07 pg/mg vs 3.85 pg/mg).

CONCLUSIONS

The present study shows that air nicotine and dust NNK were detected in all taxis regardless of whether the taxi driver was smoking or not, which indicates the potential for exposure to SHS or THS. It suggests that an appreciable level of SHS and TSH exposure might occur if the environment is not completely smoke-free and enforcement is lacking.

ABBREVIATIONS

THS: third-hand smoke, SHS: second-hand smoke, FCTC: Framework Convention Alliance for Tobacco Control, NNK: 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone, LOD: limit of detection, GM: geometric mean, GSD: geometric standard deviation.

A Casino goes smoke free: a longitudinal study of secondhand and thirdhand smoke pollution and exposure

Background

Secondhand smoke (SHS) in US casinos is common, but little is known about the residue of tobacco smoke pollutants left behind in dust and on surfaces, commonly referred to as thirdhand smoke (THS). We examined SHS and THS pollution and exposure before and during a casino smoking ban and after smoking resumed.

Methods

A casino was visited nine times over a 15-month period to collect dust, surface and air samples in eight locations. Finger wipe and urine samples were collected from non-smoking confederates before and after a 4-hour casino visit. Samples were analysed for markers of SHS and THS pollution and exposure.

Results

Exceptionally high levels of THS were found in dust and on surfaces. Although the smoking ban led to immediate improvements in air quality, surface nicotine levels were unchanged and remained very high for the first month of the smoking ban. Surface nicotine decreased by 90% after 1 month (P<0.01), but nicotine and tobacco-specific nitrosamines in dust decreased more slowly, declining by 90% only after 3 months (P<0.01). Exposure was significantly reduced after the ban, but the benefits of the ban were reversed after smoking resumed.

Conclusions

Long-term smoking in a casino creates deep THS reservoirs that persist for months after a smoking ban. A complete smoking ban immediately improves air quality and significantly reduces exposure to SHS and THS. However, THS reservoirs contribute to continued low-level exposure to toxicants. To accelerate the effect of smoking bans, remediation efforts should address specific THS reservoirs, which may require intensive cleaning as well as replacement of carpets, furniture and building materials.

Smoke-free homes and attitudes towards banning smoking in vehicles carrying children in Spain (2016)

OBJECTIVE

To describe the voluntary adoption of smoke-free homes and social attitudes in Spain towards banning smoking in vehicles in which children are present.

METHODS

Cross-sectional study of a representative sample of the adult Spanish population age range, 18-75 years (n=1036). The field work was conducted via a computer-assisted telephone survey in March and April 2016. Survey respondents answered questions about smoking rules at home and attitudes towards a smoking ban in cars with or without children. Home smoking rules were defined as complete (smoking not allowed anywhere in the house), partial (smoking allowed in some areas inside the house) or absent (smoking allowed everywhere).

RESULTS

Most (83.0%) of the surveyed population had some type of smoking restriction in place at home (45.6% complete and 37.5% partial). There were significant differences between groups according to age group (the highest prevalence was 86.1% from 66 to 75 years and the lowest prevalence was 77.8% from 46 to 65 years) and smoking status (the highest prevalence was 89.4% in people who had never been smokers and the lowest prevalence was 75.0% in current smokers) with regards to the prevalence of smoke-free homes (p<0.05), with partial bans more prevalent in smoking households (49.0%). Most (61.6%) of the population favored banning smoking in cars, and 90.1% supported a ban in cars carrying minors. Attitudes towards smoking regulation in cars (with or without children) varied significantly by age group (the highest prevalence was 81.9% from 66 to 75 years and the lowest prevalence was 54.5% from 18 to 45 years) and smoking status (the highest prevalence was 71.4% in people who had never been smokers and the lowest prevalence was 46.0% in current smokers). However, no significant differences were found with regard to attitudes towards smoking regulation in cars carrying children, regardless of sex, age, social class, or smoking status.

CONCLUSION

Approximately half of the adult population in Spain have implemented a complete smoke-free rule at home. More than 9 out of 10 adults favor regulating smoking in cars in the presence of minors. These findings support the expansion of smoke-free regulations to include private vehicles, particularly when minors are in the car.

Smoke-Free Rules and Secondhand Smoke Exposure in Vehicles among U.S. Adults-National Adult Tobacco Survey, 2009-2010 and 2013-2014

In the United States (U.S.), secondhand smoke (SHS) exposure causes more than 41,000 deaths among nonsmoking adults annually. Adoption of smoke-free laws in public areas has increased, but private settings such as vehicles remain a source of SHS exposure. This study assessed change in voluntary smoke-free vehicle rules and SHS exposure in personal vehicles among U.S. adults between two periods, 2009–2010 and 2013–2014, using data from the National Adult Tobacco Survey (NATS). NATS is a national landline and cellular telephone survey of non-institutionalized adults aged ≥18 years in the 50 U.S. states and the District of Columbia. We assessed percentage change in the prevalence of smoke-free vehicle rules among all adults and SHS exposure in vehicles among nonsmoking adults, overall, by sociodemographic factors (sex, age, race/ethnicity, education, marital status, annual household income, U.S. region), and by cigarette smoking status. During 2009–2010 to 2013–2014, the percentage of adults with a 100% smoke-free vehicle rule increased from 73.6% to 79.5% (% change = +8.0%; p < 0.05). Among nonsmokers, SHS exposure in vehicles in the previous 7 days decreased from 9.2% to 8.2% (% change = −10.9%; p < 0.05). Smoke-free rules in private settings such as vehicles, in coordination with comprehensive smoke-free policies in indoor public settings, can help reduce SHS exposure and promote smoke-free norms.

Trends in adult exposure to secondhand smoke in vehicles: Findings from the 2009-2012 Canadian Tobacco Use Monitoring Survey

INTRODUCTION

A growing number of jurisdictions have implemented smoke-free vehicles when children are present due to the substantial health effects of secondhand smoke (SHS). Prior studies on the prevalence of SHS exposure in vehicles have mainly focused on adolescents. This study examined the prevalence and socio-demographic correlates of SHS exposure in vehicles among Canadian adults.

METHODS

A repeated cross-sectional data on youth and adult data were drawn from the 2009-2012 Canadian Tobacco Use Monitoring Survey (n=58, 195). Multivariable logistic regression analysis was used to examine the socio-demographic correlates of exposure to SHS in vehicles.

RESULTS

Overall, 19% in 2009 and 18% in 2012 of adults reported SHS exposure in vehicles in the past month. Disparities in the SHS exposure prevalence were observed, with a higher SHS exposure among current smokers, former smokers, males, younger adults, living in a household with smoking-related exposure, and those with less education. The multivariable analyses showed significant associations between socio-demographic characteristics and SHS exposure. Higher odds SHS exposure was found for those younger (aged 20-24, OR=16.27, CI=11.09-23.88; 25-44, OR=6.12, CI=4.14-9.06; 45-64, OR=2.79, CI=1.95-4.02) compared to those aged 65 and over. Likewise, those with less education had greater odds of SHS exposure.

CONCLUSIONS

Findings suggest that adults SHS exposure is high, especially for young adults and those with less education. Adult passengers may need protection from SHS given that no level of SHS exposure is safe.

A systematic review of secondhand smoke exposure in a car: Attributable changes in atmospheric and biological markers

Exposure to secondhand smoke (SHS) has been linked to disease, disability, and premature death. While several countries have enacted smoke-free legislations, exposure to SHS may still occur in unregulated private environments, such as in the family car. We performed a systematic review of peer-reviewed literature in PubMed and Web of Science up to May 2013. Articles were selected if they provided a quantitative measure of SHS exposure (biological or atmospheric markers); the study was conducted inside a car; and the assessed exposure was attributable to cigarette combustion. From 202 articles identified, 12 met the inclusion criteria. Among all studies that assessed smoking in cars with at least one window partially open, the particulate matter 2.5 μm or less in diameter (PM2.5) concentrations ranged from 47 μg/m(3) to 12,150 μg/m(3). For studies with all windows closed, PM2.5 ranged from 203.6 μg/m(3) to 13,150 μg/m(3). SHS concentration in a car was mediated by air-conditioning status, extent of airflow, and driving speed. Smoking in cars leads to extremely high exposure to SHS and increased concentration of atmospheric markers of exposure-even in the presence of air-conditioning or increased airflow from open windows. This clearly shows that the only way to protect nonsmokers, especially children, from SHS within cars is by eliminating tobacco smoking.

Reduction of Secondhand Smoke Exposure in the Cars of Children With Cancer

This study examined whether an intervention designed to reduce secondhand smoke exposure (SHSe) among children being treated for cancer had effects in the specific setting of a motor vehicle. The parents or guardians (n = 71) of children being treated for cancer were randomized to either a behavioral secondhand smoke (SHS) reduction program or a standard care control group. Parental reports of SHSe were collected over the course of 12 months. Younger children were exposed at baseline more than their older counterparts. The greatest initial declines in car exposure were observed among children ≤5 years old in the intervention group compared with same-aged peers in the control group. After the 3-month time point, the control group showed greater reductions in car exposure in comparison with the intervention group. Interventions that teach parents strategies to manage their smoking while driving in their personal vehicles may produce even greater reductions in child exposure and should be developed. Based on the age-specific results reported here, future studies should account for effects of child age and use setting-specific measures of SHS.

Portuguese children's exposure to second-hand tobacco smoke in the family car

OBJECTIVES

To assess the prevalence of children's exposure to second-hand smoke in the family car; to compare exposure among children with smoking and non-smoking parents.

METHODS

In 2011, a self-administered questionnaire was applied to a 4th grade Portuguese children national sample (N=3187, mean age 9.5 ± 0.7, 51.1% boys). Prevalence rates and chi-square tests were computed.

RESULTS

Of the participants, 52.0% reported having, at least, one smoking parent. Overall exposure in the car was 28.9% (95% CI 27.3-30.5). Children's exposure among those reporting smoking parents was 46.9% (95% CI 44.4-49.4); and 8.6% (95% CI 7.1-10.1) among those reporting non-smoking parents (p<.001). Therefore, children with smoking parents were 5.44 times more likely to be exposed.

CONCLUSIONS

Children's exposure to second-hand smoke in the family car is frequent, especially if one or both parents smoke. This highlights the need for effective tobacco control measures to prevent this severe health hazard.

Intake of toxic and carcinogenic volatile organic compounds from secondhand smoke in motor vehicles

BACKGROUND

Volatile organic compounds (VOC) from tobacco smoke are associated with cancer, cardiovascular, and respiratory diseases. The objective of this study was to characterize the exposure of nonsmokers to VOCs from secondhand smoke (SHS) in vehicles using mercapturic acid metabolites.

METHODS

Fourteen nonsmokers were individually exposed in the backseat to one hour of SHS from a smoker seated in the driver's seat who smoked three cigarettes at 20-minute intervals in a stationary car with windows opened by 10 cm. Baseline and 0- to 8-hour postexposure mercapturic acid metabolites of nine VOCs were measured in urine. Air-to-urine VOC ratios were estimated on the basis of respirable particulate matter (PM2.5) or air nicotine concentration, and lifetime excess risk (LER) of cancer death from exposure to acrylonitrile, benzene, and 1,3-butadiene was estimated for adults.

RESULTS

The greatest increase in 0- to 8-hour postexposure concentrations of mercapturic acids from baseline was MHBMA-3 (parent, 1,3-butadiene; 2.1-fold), then CNEMA (acrylonitrile; 1.7-fold), PMA (benzene; 1.6-fold), MMA (methylating agents; 1.6-fold), and HEMA (ethylene oxide; 1.3-fold). The LER of cancer death from exposure to acrylonitrile, benzene, and 1,3-butadiene in SHS for 5 hours a week ranged from 15.5 × 10(-6) to 28.1 × 10(-6) for adults, using air nicotine and PM2.5 to predict air VOC exposure, respectively.

CONCLUSION

Nonsmokers have significant intake of multiple VOCs from breathing SHS in cars, corresponding to health risks that exceed the acceptable level.

IMPACT

Smoking in cars may be associated with increased risks of cancer, respiratory, and cardiovascular diseases among nonsmokers.

Association between current asthma and secondhand smoke exposure in vehicles among adults living in four US states

OBJECTIVE

Many states have implemented laws prohibiting tobacco smoking in indoor public places. However, private settings remain a major source of secondhand smoke (SHS) exposure for many people. We assessed the association between current asthma and SHS exposure in vehicles among adult never-smokers in Indiana, Kentucky, Louisiana and Mississippi.

METHODS

Data came from the 2011 Behavioral Risk Factor Surveillance System, a state-based telephone survey of US adults aged ≥18 years. Analyses were restricted to states (n=4) that administered an optional SHS module. Prevalence of self-reported asthma and past 7-day SHS exposure in vehicles was calculated by demographics, voluntary smoke-free vehicle rules and SHS exposure in homes, public places and workplaces. Logistic regression was used to assess the adjusted association between asthma and SHS exposure in vehicles.

RESULTS

Among 17 863 never-smoking adults, 7.4% reported having current asthma, whereas 12.3% reported past 7-day SHS exposure in vehicles. Among adults with asthma, SHS exposure in vehicles was lower among those with voluntary smoke-free rules compared with those without voluntary smoke-free rules (9.5% vs 56.7%, p<0.0001). Following adjustment, adults exposed to SHS in a vehicle had a higher odds of having current asthma compared with unexposed adults (OR=2.01, 95% CI 1.18 to 3.40).

CONCLUSIONS

Never-smoking adults recently exposed to SHS in a vehicle had higher odds of having current asthma compared with unexposed adults. Efforts are warranted to warn about the dangers of SHS and to encourage voluntary smoke-free rules in vehicles, especially among adults with asthma.

Biomarkers of secondhand smoke exposure in automobiles

OBJECTIVES

The objectives of this study were: (1) to characterise the exposure of non-smokers exposed to secondhand smoke (SHS) in a vehicle using biomarkers, (2) to describe the time course of the biomarkers over 24 h, and (3) to examine the relationship between tobacco biomarkers and airborne concentrations of SHS markers.

METHODS

Eight non-smokers were individually exposed to SHS in cars with fully open front windows and closed back windows over an hour from a smoker who smoked three cigarettes at 20 min intervals. The non-smokers sat in the back seat on the passenger side, while the smoker sat in the driver's seat. Plasma cotinine and urine cotinine, 3-hydroxycotinine (3HC) and 4-(methylnitrosoamino)-(3-pyridyl)-1-butanol (NNAL) were compared in samples taken at baseline (BL) and several time-points after exposure. Nicotine, particulate matter (PM2.5) and carbon monoxide (CO) were measured inside and outside the vehicle and ventilation rates in the cars were measured.

RESULTS

Average plasma cotinine and the molar sum of urine cotinine and 3HC (COT+3HC) increased four-fold, urine cotinine increased six-fold and urine NNAL increased ∼27 times compared to BL biomarker levels. Plasma cotinine, urine COT+3HC and NNAL peaked at 4-8 h post-exposure while urine cotinine peaked within 4 h. Plasma cotinine was significantly correlated to PM2.5 (Spearman correlation rs=0.94) and CO (rs=0.76) but not to air nicotine. The correlations between urine biomarkers, cotinine, COT+3HC and NNAL, and air nicotine, PM2.5 and CO were moderate but non-significant (rs range =  0.31-0.60).

CONCLUSIONS

Brief SHS exposure in cars resulted in substantial increases in levels of tobacco biomarkers in non-smokers. For optimal characterisation of SHS exposure, tobacco biomarkers should be measured within 4-8 h post-exposure. Additional studies are needed to better describe the relationship between tobacco biomarkers and environmental markers of SHS.

Impact of a multi-level intervention to prevent secondhand smoke exposure in schoolchildren: a randomized cluster community trial

OBJECTIVE

To assess the effectiveness of a multi-level (individual, family, and school) school-based intervention to prevent the exposure to secondhand smoke (SHS) in a population of schoolchildren (12-14 years old).

METHOD

This was a community trial with cluster randomization of schools to an intervention and comparison group (ClinicalTrials.Gov identifier NCT01881607). The intervention targeted schoolchildren in Terrassa (Catalonia, Spain). We assessed SHS exposure in different settings and tobacco consumption by means of a questionnaire before and one year after the intervention.

RESULTS

We analyzed data from 1734 students with both baseline and follow-up data. The crude analysis showed that SHS exposure among students in the intervention group significantly decreased at school (-14.0%), at home (-19.9%), and on transportation (-21.8%). In the comparison group, SHS exposure significantly decreased only at home (-16.9%). After adjustment for potential confounders, the good accomplishment of the activities showed a possible trend towards a non-significant reduction in exposure at home, transportation, and leisure time.

CONCLUSION

While this school-based multi-level intervention had no overall effect in SHS exposure, the improvement of the activities focused on preventing SHS would be needed in order to achieve a significant decrease in the proportion of children exposed to SHS.

Secondhand smoke exposure and smoking behavior among young adult bar patrons

OBJECTIVES

We described frequency of secondhand smoke (SHS) exposure among young adults patronizing bars and associations between SHS exposure, attitudes, and smoking behavior.

METHODS

We collected cross-sectional surveys from randomized time-location samples of bar patrons aged 18 to 26 years in San Diego, California, and Oklahoma City and Tulsa, Oklahoma, in 2010 to 2011. Multivariate logistic regression evaluated associations between SHS exposure, attitudes about dangers of SHS, susceptibility to smoking initiation among nonsmokers, and quit attempts among current smokers.

RESULTS

More than 80% of respondents reported past 7-day exposure to any SHS, and more than 70% reported exposure at a bar. Current smokers reported more SHS exposure in cars and their own homes than did nonsmokers. Among nonsmokers, SHS exposure was associated with susceptibility to initiation, but those who believed that SHS exposure is harmful were less susceptible. Belief that SHS is dangerous was associated with quit attempts among smokers.

CONCLUSIONS

Smoke-free environments and education about the harms of SHS may decrease tobacco use among young adults who frequent bars, where they are heavily exposed to SHS.

Smoke-free rules and secondhand smoke exposure in homes and vehicles among US adults, 2009-2010

INTRODUCTION

An increasing number of US states and localities have implemented comprehensive policies prohibiting tobacco smoking in all indoor areas of public places and worksites. However, private settings such as homes and vehicles remain a major source of exposure to secondhand smoke (SHS) for many people. This study assessed the prevalence and correlates of voluntary smoke-free rules and SHS exposure in homes and vehicles among US adults.

METHODS

We obtained data from the 2009-2010 National Adult Tobacco Survey, a landline and cellular-telephone survey of adults aged 18 years or older residing in the 50 US states or the District of Columbia. We calculated national and state estimates of smoke-free rules and past-7-day SHS exposure in homes and vehicles and examined national estimates by sex, age, race/ethnicity, and education.

RESULTS

The national prevalence of voluntary smoke-free home rules was 81.1% (state range, 67.9%-92.9%), and the prevalence of household smoke-free vehicle rules was 73.6% (state range, 58.6%-85.8%). Among nonsmokers, the prevalence of SHS exposure was 6.0% in homes (state range, 2.4%-13.0%) and 9.2% in vehicles (state range, 4.8%-13.7%). SHS exposure among nonsmokers was greatest among men, younger adults, non-Hispanic blacks, and those with a lower level of education.

CONCLUSION

Most US adults report having voluntary smoke-free home and vehicle rules; however, millions of people remain exposed to SHS in these environments. Disparities in exposure also exist among certain states and subpopulations. Efforts are needed to warn about the dangers of SHS and to promote voluntary smoke-free home and vehicle rules.

[The prevalence of exposure of children under the age of 18 to second-hand smoke inside motor vehicles]

INTRODUCTION

The objective of the study was to estimate the level of exposure of children under the age of 18 to second-hand smoke (SHS) inside motor vehicles.

METHODS

A prevalence study was conducted on the exposure of children under the age of 18 to SHS in motor vehicles in Lleida (Spain). The population was the users of private motor vehicles. The sample was random, and the data were collected by direct observation. The study variables were: the age and sex of the driver, whether the driver was smoking, and the presence of an exposed passenger under the age of 18.

RESULTS

A total of 1600 vehicles were observed, 134 of which (8.4%) were carrying a child. In 8 of these 134 vehicles (6%; 95% CI: 2.5-11.0) a child was exposed to SHS. In all these cases, the driver was a male (P=0.02), and in 75% of cases he was over 40 years old.

CONCLUSIONS

The rate of child exposure to SHS is very high. There is, therefore, a case for organising campaigns to prevent smoking tobacco inside motor vehicles in the presence of children in Spain.

Private space second-hand smoke exposure and the mental health of non-smokers: a cross-sectional analysis of Canadian adults

INTRODUCTION

The aim of this paper was to examine the association between exposure to second-hand smoke (SHS) among non-smokers, in the home and the vehicle, and poor mental health outcomes (mood disorder, anxiety disorder, poor/fair mental health, and high stress).

METHODS

Data were drawn from the 2010 Canadian Community Health Survey, a representative sample of 62,909 Canadians 12years and older. Measures of SHS exposure are drawn from self-reported daily or near daily exposure in the home or in the vehicle. Mental health indicators include self-reported diagnosed mood and anxiety disorders, and self-report measures of overall mental health and experiences of stress. Associations between SHS exposure and poor mental health among non-smokers were examined in a series of logistic regression models. Additional analyses stratified on respondent's smoking status, physical health, and gender.

RESULTS

Analyses revealed that SHS exposure among non-smokers was associated with increased anxiety disorders, poor/fair mental health, and high stress, with no association to mood disorders. Stratified analyses demonstrated that associations between SHS and poor mental health are contextualized by respondent's gender, physical health, and smoking status.

CONCLUSIONS

Beyond changes to physical health, SHS exposure in private spaces was negatively associated with the mental health of non-smokers. Public health efforts to reduce SHS exposure in private spaces are warranted. Findings also reveal additional targets for decreasing and eliminating the societal burden of mental health disorders. Further research is needed to examine causality and to explore associations between SHS exposure and specific mental health outcomes.

Compliance and enforcement of a partial smoking ban in Lisbon taxis: an exploratory cross-sectional study

Background

Research evaluating enforcement and compliance with smoking partial bans is rather scarce, especially in countries with relative weak tobacco control policies, such as Portugal. There is also scarce evidence on specific high risk groups such as vehicle workers. In January 2008, Portugal implemented a partial ban, followed by poor enforcement. The purpose of this study was to explore the effectiveness of a partial smoking ban in a pro-smoking environment, specifically transportation by taxi in the city of Lisbon. Ban effectiveness was generally defined by ban awareness and support, compliance and enforcement.

Methods

Exploratory cross-sectional study; purposive sampling in selected Lisbon streets. Structured interviews were conducted by trained researchers while using taxi services (January 2009-December 2010). Participants: 250 taxi drivers (98.8% participation rate). Chi-square, McNemar, Man Whitney tests and multiple logistic regression were performed.

Results

Of the participants, 249 were male; median age was 53.0 years; 43.6% were current smokers. Most participants (82.8%) approved comprehensive bans; 84.8% reported that clients still asked to smoke in their taxis; 16.8% allowed clients to smoke. Prior to the ban this value was 76.9% (p < 0.001). The major reason for not allowing smoking was the legal ban and associated fines (71.2%). Of the smokers, 66.1% admitted smoking in their taxi. Stale smoke smells were detected in 37.6% of the cars. None of the taxi drivers did ever receive a fine for non-compliance. Heavy smoking, night-shift and allowing smoking prior the ban predicted non-compliance.

Conclusions

Despite the strong ban support observed, high smoking prevalence and poor enforcement contribute to low compliance. The findings also suggest low compliance among night-shift and vehicle workers. This study clearly demonstrates that a partial and poorly-enforced ban is vulnerable to breaches, and highlights the need for clear and strong policies.

Parents smoking in their cars with children present

OBJECTIVE

To determine prevalence and factors associated with strictly enforced smoke-free car policies among smoking parents.

METHODS

As part of a cluster, randomized controlled trial addressing parental smoking, exit interviews were conducted with parents whose children were seen in 10 control pediatric practices. Parents who smoked were asked about smoking behaviors in their car and receipt of smoke-free car advice at the visit. Parents were considered to have a "strictly enforced smoke-free car policy" if they reported having a smoke-free car policy and nobody had smoked in their car within the past 3 months.

RESULTS

Of 981 smoking parents, 817 (83%) had a car; of these, 795 parents answered questions about their car smoking policy. Of these 795 parents, 29% reported having a smoke-free car policy, and 24% had a strictly enforced smoke-free car policy. Of the 562 parents without a smoke-free car policy, 48% reported that smoking occurred with children present. Few parents who smoke (12%) were advised to have a smoke-free car. Multivariable logistic regression controlling for parent age, gender, education, and race showed that having a younger child and smoking ≤10 cigarettes per day were associated with having a strictly enforced smoke-free car policy.

CONCLUSIONS

The majority of smoking parents exposed their children to tobacco smoke in cars. Coupled with the finding of low rates of pediatricians addressing smoking in cars, this study highlights the need for improved pediatric interventions, public health campaigns, and policies regarding smoke-free car laws to protect children from tobacco smoke.

Particulate mass and polycyclic aromatic hydrocarbons exposure from secondhand smoke in the back seat of a vehicle

CONTEXT

Exposure to secondhand smoke (SHS) has been reduced in the USA by banning smoking in public places. These restrictions have not had the same effect on children's exposure to SHS as adults suggesting that children are exposed to SHS in locations not covered by bans, such as private homes and cars.

OBJECTIVES

Assess exposure to SHS in the backseat of a stationary vehicle where a child would sit, quantify exposures to fine particulates (PM2.5), polycyclic aromatic hydrocarbons (PAH), carbon monoxide (CO) and nicotine. Estimate the impact on a child's mean daily exposure to PM2.5.

METHODS

SHS exposures in stationary vehicles with two different window configurations were monitored. A volunteer smoked three cigarettes in a one-hour period for twenty-two experiments. PM2.5, CO, nicotine and PAH where measured in the backseat of the vehicle. 16 PAH compounds were measured for in gas and particle phases as well as real-time particle phase concentrations.

RESULTS

The mean PAH concentration, 1325.1 ng/m(3), was larger than concentrations measured in bars and restaurants were smoking is banned in many countries. We estimate that a child spending only ten minutes in the car with a smoker at the mean PM2.5 concentration measured in the first window configuration--1697 mg/m(3)--will cause a 30% increase to the daily mean PM2.5 personal average of a child.

CONCLUSIONS

Estimates made using the measured data and previously reported PM2.5 daily mean concentrations for children in California showing that even short exposure periods are capable of creating large exposure to smoke.

Environmental monitoring of secondhand smoke exposure

The complex composition of secondhand smoke (SHS) provides a range of constituents that can be measured in environmental samples (air, dust and on surfaces) and therefore used to assess non-smokers' exposure to tobacco smoke. Monitoring SHS exposure (SHSe) in indoor environments provides useful information on the extent and consequences of SHSe, implementing and evaluating tobacco control programmes and behavioural interventions, and estimating overall burden of disease caused by SHSe. The most widely used markers have been vapour-phase nicotine and respirable particulate matter (PM). Numerous other environmental analytes of SHS have been measured in the air including carbon monoxide, 3-ethenylpyridine, polycyclic aromatic hydrocarbons, tobacco-specific nitrosamines, nitrogen oxides, aldehydes and volatile organic compounds, as well as nicotine in dust and on surfaces. The measurement of nicotine in the air has the advantage of reflecting the presence of tobacco smoke. While PM measurements are not as specific, they can be taken continuously, allowing for assessment of exposure and its variation over time. In general, when nicotine and PM are measured in the same setting using a common sampling period, an increase in nicotine concentration of 1 μg/m³ corresponds to an average increase of 10 μg/m³ of PM. This topic assessment presents a comprehensive summary of SHSe monitoring approaches using environmental markers and discusses the strengths and weaknesses of these methods and approaches.

Assessing secondhand smoke exposure with reported measures

Non-smokers are exposed to tobacco smoke from the burning cigarette and the exhaled smoke from smokers. In spite of decades of development of approaches to assess secondhand smoke exposure (SHSe), there are still unresolved methodological issues. This manuscript summarises the scientific evidence on the use of SHSe reported measures and their methods, objectives, strengths and limitations; and discusses best practices for assessing behaviour leading to SHSe for lifetime and immediate or current SHSe. Recommendations for advancing measurement science of SHSe are provided. Behavioural measures of SHSe commonly rely on self-reports from children and adults. Most commonly, the methodology includes self, proxy and interview-based reporting styles using retrospective recall or diary-style reporting formats. The reporting method used will vary based upon the subject of interest, assessment objectives and cultural context. Appropriately implemented, reported measures of SHSe provide an accurate, timely and cost-effective method for assessing exposure time, location and quantity in a wide variety of populations.

Predictors of car smoking rules among smokers in France, Germany and the Netherlands

BACKGROUND

As exposure to tobacco smoke pollution (TSP) has been identified as a cause of premature death and disease in non-smokers, and studies have demonstrated that smoking in cars produces high levels of TSP, this study will investigate smokers' rules for smoking in their cars, and predictors of car smoking rules, including potentially modifiable correlates.

METHODS

Data were drawn from nationally representative samples of current smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), and the Netherlands (2008). Smokers in France and Germany were asked about smoking rules in their cars, and smokers in the Netherlands were asked about smoking rules in cars carrying children.

RESULTS

In France and Germany, 59% and 52% of smokers respectively, allowed smoking in their cars. In the Netherlands, 36% of smokers allowed smoking in cars carrying children. Predictors of allowing smoking in cars included: being a daily vs. non-daily smoker, being younger vs. older age, having no (young) children in the home, being a heavier smoker, and allowing smoking in the home. In the Netherlands, smokers who agreed that TSP is dangerous to non-smokers were less likely to allow smoking in cars carrying children.

CONCLUSION

Overall, a sizeable proportion of smokers allowed smoking in their cars across the three countries. Media campaigns with information about the dangers of TSP may increase the adoption of smoke-free cars. These media campaigns could target smokers who are most likely to allow smoking in cars.

Secondhand smoke exposure in cars among middle and high school students--United States, 2000-2009

OBJECTIVES

Exposure to secondhand smoke (SHS) from cigarettes poses a significant health risk to nonsmokers. Among youth, the home is the primary source of SHS. However, little is known about youth exposure to SHS in other nonpublic areas, particularly motor vehicles.

METHODS

Data were obtained from the 2000, 2002, 2004, 2006, and 2009 waves of the National Youth Tobacco Survey, a nationally representative survey of US students in grades 6 to 12. Trends in SHS exposure in a car were assessed across survey years by school level, gender, and race/ethnicity by using binary logistic regression.

RESULTS

From 2000 to 2009, the prevalence of SHS exposure in cars declined significantly among both nonsmokers (39.0%-22.8%; trend P < .001) and smokers (82.3%-75.3%; trend P < .001). Among nonsmokers, this decline occurred across all school level, gender, and race/ethnicity subgroups.

CONCLUSIONS

SHS exposure in cars decreased significantly among US middle and high school students from 2000 to 2009. Nevertheless, in 2009, over one-fifth of nonsmoking students were exposed to SHS in cars. Jurisdictions should expand comprehensive smoke-free policies that prohibit smoking in worksites and public places to also prohibit smoking in motor vehicles occupied by youth.

Tobacco consumption and secondhand smoke exposure in vehicles: a cross-sectional study

Objectives To estimate the prevalence of tobacco consumption and secondhand smoke (SHS) exposure in private cars, commercial vehicles and taxis in the city of Barcelona in Spain. Design setting and participants We carried out an observational cross-sectional study in 2011. We selected a systematic sample of 2442 private cars, commercial vehicles and taxis on 40 public roads regulated by traffic lights in all 10 districts of Barcelona. We calculated the prevalence rates and 95% CIs of smoking and SHS exposure in cars, and the corresponding ORs adjusting for the potential confounding variables. Results The prevalence of tobacco consumption was 5.5% (95% CI 4.6% to 6.4%) and was greater for commercial vehicles (9.8%; 95% CI 7.1% to 12.5%). The prevalence of SHS exposure was 5.2% (95% CI 3.8% to 6.6%) and 2.2% (95% CI 0.5% to 3.9%) of passengers under 14 years of age were exposed to SHS in vehicles. Conclusions This study highlights the need to promote public health measures aimed at reducing tobacco consumption in vehicles, especially in the presence of children, as well as enforcement of the current Spanish law against smoking in commercial vehicles and taxis.

Policy guidance on threats to legislative interventions in public health: a realist synthesis

Background

Legislation is one of the most powerful weapons for improving population health and is often used by policy and decision makers. Little research exists to guide them as to whether legislation is feasible and/or will succeed. We aimed to produce a coherent and transferable evidence based framework of threats to legislative interventions to assist the decision making process and to test this through the 'case study' of legislation to ban smoking in cars carrying children.

Methods

We conceptualised legislative interventions as a complex social interventions and so used the realist synthesis method to systematically review the literature for evidence. 99 articles were found through searches on five electronic databases (MEDLINE, HMIC, EMBASE, PsychINFO, Social Policy and Practice) and iterative purposive searching. Our initial searches sought any studies that contained information on smoking in vehicles carrying children. Throughout the review we continued where needed to search for additional studies of any type that would conceptually contribute to helping build and/or test our framework.

Results

Our framework identified a series of transferable threats to public health legislation. When applied to smoking bans in vehicles; problem misidentification; public support; opposition; and enforcement issues were particularly prominent threats. Our framework enabled us to understand and explain the nature of each threat and to infer the most likely outcome if such legislation were to be proposed in a jurisdiction where no such ban existed.

Specifically, the micro-environment of a vehicle can contain highly hazardous levels of second hand smoke. Public support for such legislation is high amongst smokers and non-smokers and their underlying motivations were very similar - wanting to practice the Millian principle of protecting children from harm. Evidence indicated that the tobacco industry was not likely to oppose legislation and arguments that such a law would be 'unenforceable' were unfounded.

Conclusion

It is possible to develop a coherent and transferable evidence based framework of the ideas and assumptions behind the threats to legislative intervention that may assist policy and decision makers to analyse and judge if legislation is feasible and/or likely to succeed.

Recent contributions of air- and biomarkers to the control of secondhand smoke (SHS): a review

Since the publication of the US Surgeon General Reports in 1996 and 2006 and the report of the California Environmental Protection Agency in 1999, many reports have appeared on the contribution of air and biomarkers to different facets of the secondhand smoke (SHS) issue, which are the targets of this review. These recent studies have allowed earlier epidemiological surveys to be biologically validated, and their plausibility demonstrated, quantified the levels of exposure to SHS before the bans in various environments, showed the deficiencies of mechanical control methods and of partial bans and the frequently correct implementation of the efficient total bans. More stringent regulation remains necessary in the public domain (workplaces, hospitality venues, transport sector, etc.) in many countries. Personal voluntary protection efforts against SHS are also needed in the private domain (homes, private cars). The effects of SHS on the cardiovascular, respiratory and neuropsychic systems, on pregnancy and fertility, on cancers and on SHS genotoxicity are confirmed through experimental human studies and through the relationship between markers and prevalence of disease or of markers of disease risk.

Support and correlates of support for banning smoking in cars with children: findings from the ITC Four Country Survey

BACKGROUND

Since 2006, banning smoking in cars with children has become a rapidly growing tobacco control policy. However, to date, there have been few studies examining support and correlates of support for car smoking bans, and none of the existing studies have been international in nature. We conducted such a study among smokers in four countries.

METHODS

6716 adult current smokers from the 2007 Wave of the International Tobacco Control Four Country Survey, a nationally representative, longitudinal cohort telephone survey of smokers in the USA, Canada, UK and Australia. Controlling for demographics, heaviness of smoking, smoking health knowledge/beliefs and quit intentions, we compared support and correlates of support for banning smoking in cars with children across the four countries.

RESULTS

The majority of smokers supported banning smoking in cars with children. Support was highest in Australia (83%), followed by the UK (75%) and Canada (74%); support was lower-but still high-in the USA (60%). Support was highest among smokers who: had stronger quit intentions, were lighter smokers, had lower education, had no children in the home, believed that cigarette smoke is dangerous to non-smokers and could cause asthma in children, and were concerned about modelling smoking to children.

CONCLUSIONS

These findings indicate that a majority of smokers in the four countries support banning smoking in cars with children, and lend support to banning smoking in cars with children. Additionally, they suggest that support may be increased by educating smokers about the dangers of cigarette smoke exposure.

Predictors of smoking in cars with nonsmokers: findings from the 2007 Wave of the International Tobacco Control Four Country Survey

OBJECTIVE

This study examines the proportion and characteristics of smokers who smoke in cars with nonsmokers across four countries and the potentially modifiable correlates of this behavior.

METHODS

Respondents included a total of 6,786 current adult smokers from Wave 6 (September 2007-February 2008) of the International Tobacco Control Four Country Survey, a random digit-dial telephone survey of nationally representative samples of adult smokers in Australia, the United Kingdom, Canada, and the United States.

RESULTS

Reports of smoking in cars with nonsmokers ranged from a low of 29% in Australia and the United Kingdom, to 34% in Canada, and to a high of 44% in the United States. Daily smokers who were from the United States, male, and younger were the most likely to smoke in cars with nonsmokers. Several potentially modifiable factors were also found to be related to this behavior, including smoke-free homes and beliefs about the dangers of cigarette smoke exposure to nonsmokers.

CONCLUSIONS

A considerable proportion of smokers continue to smoke in cars with nonsmokers across the four countries, particularly in the United States. Public health campaigns should educate smokers about the hazards of cigarette smoke exposure and promote the need for smoke-free cars. These findings provide a foundation of evidence relevant for jurisdictions that are considering banning smoking in cars.