Children and Families Bill

Memorandum submitted by British Lung Foundation (CF 84)

British Lung Foundation submission supporting proposed amendment NC1 (banning smoking in cars with children) to the Children and Families Bill

About us

One person in five in the UK is affected by lung disease with millions more at risk. The British Lung Foundation (BLF) is the UK’s lung charity and we are here for every one of them, whatever their condition. Lung disease can be frightening and debilitating. We offer hope and support at every step so that no one has to face it alone. We promote greater understanding of lung disease and we campaign for positive change in the nation’s lung health. We fund vital research, so that new treatments and cures can help save lives.


The particular harm that passive smoke causes to children’s health is well documented. Although members of the public are protected by smokefree legislation in public transport and in work vehicles, large numbers of children remain exposed to high concentrations of second-hand smoke when confined in family cars. The BLF takes an evidence-based approach to its work and campaigns for the introduction of legislation making it illegal to smoke in cars with children present. We outline the reasons behind our position below.

1. Medical evidence

i. Passive smoking and children

Smoking near children can cause a range of respiratory illnesses such as asthma, bronchitis and reduced lung function. Passive smoking results each year amongst children in more than 165,000 new episodes of disease of all types, 300,000 primary care consultations, 9,500 hospital admissions and around 40 sudden infant deaths. This comes at a total cost of more than £23 million per year in primary care visits, asthma treatment and hospital admissions in the UK. [1]

Children are particularly vulnerable to second-hand smoke, as they have smaller lungs, faster breathing and less developed immune systems, which make them more susceptible to respiratory and ear infections triggered by passive smoking. [2]

Children and young people are also affected by witnessing smoki ng as a normal adult behaviour . Evidence suggests that children exposed to second-hand smoke in places other than the home are more likely to start smoking than those not exposed, [3] and children exposed to a high degree of second-hand smoke in vehicles have been found to exhibit symptoms of nicotine dependence . [4] More generally, t he RCP has found that children who grow up with smoking parents or siblings are around 90% more likely to become smokers themselves. 23,000 young people in England and Wales start smoking by the age of 15 each year as a result of domestic exposure to smoking. [5]

ii. Toxicity levels in cars

A number of studies have examined the effect of smoking on toxicity levels within cars in a variety of scenarios (e.g. windows open and shut, air conditioning on and off, vehicle stationary and in motion), with largely comparable results.

Research from the University of Waterloo found that a single cigarette smoked in a moving car with the window half open exposes a child in the centre of the back seat to around two thirds as much second-hand smoke as in an average smoke-filled pub. Levels increase to over eleven times those of a smoky pub when the cigarette is smoked in a stationary car with the windows closed. [6]

Meanwhile, research from the Chartered Institute of Environmental Health has found that smoking in cars continues to be dangerous even after the cigarette is extinguished. [7]

iii. Disease burden specifically associated with second-hand smoke in cars

The BLF is aware of two studies that have looked at this issue.

· One study found a tendency towards increased likelihood of both respiratory and allergic symptoms in Irish schoolchildren aged 13-14 who were exposed to cigarette smoke in cars. After adjustment for home smoking, those exposed in cars were found to have significantly increased wheeze and hay fever symptoms, and non-significantly increased risk of bronchitis and asthma. [8]

· An Australian cohort study found that children who were exposed to second-hand smoke in cars at the age of 14 had increased risk of both current wheeze and persistent wheeze. Interestingly, the risks were found to be higher for those exposed in the car than for those exposed in the home. [9]

2. Opinion evidence

i. BLF and stakeholder opinion data and public compliance

Research conducted on the impact of smokefree public places legislation in the UK has found that strong public support and awareness is associated with compliance as soon as legislation has been implemented. Furthermore, public support as well as compliance increases further once legislation has been introduced and implemented. [10]

The BLF and other stakeholders have conducted a number of surveys in the UK to gauge public opinion on possible car smoking legislation outlined below-

ii. Survey data

Extent of children’s exposure to second-hand smoke in cars

· 19% of children aged 11 to 15 reported often being exposed to second-hand smoke in cars (survey of 6971 boys and girls aged 11 to 15, conducted in 2010 on behalf of the NHS Information Centre) . [11]

· 51% of children aged 8 to 15 reported that they had at some point been exposed to cigarette smoke in a car (BLF/TNS UK-wide omnibus survey of 1001 children aged 8 to 15, conducted in January 2011; full data available if required, including regional/national breakdown). [12]

Children’s attitudes to exposure to cigarette smoke in cars

· BLF/TNS survey data suggests that many children feel unable to influence the smoking behaviours of adults around them. For example, 31% of children aged 8 to 15 who had been exposed to second-hand smoke in the car reported having asked the smoker to stop, with 34% not asking because they were either too frightened or embarrassed.

· The same survey found alarming results when children were asked to describe how they felt when adults smoked around them with 58% reporting that it made them smell of smoke, 49% said it made them feel sick and 44% said it made them cough. A mere 7% of children surveyed said that it did not bother them when adults smoked around them.

Opinion data on car smoking laws

· In the 2011 BLF/TNS survey, 86% of children aged 8 to 15 said that they want the Government to stop people smoking when children are in the car.

· In a BLF-commissioned UK-wide survey of 1,020 parents using, 86% of respondents said that they would support ban on smoking in private cars when minors are present - including 83% of respondents who were themselves smokers. Substantially fewer - 45% - said that they would support a ban in all private vehicles. [13]

· In an ASH/YouGov survey of 10238 adults in March 2011, 78% of respondents (62% of respondents who were smokers) said they would support a ban on smoking in cars when children under 18 are present. This number fell to 43% (17% of respondents who were smokers) of respondents who would support a ban in all private vehicles.

· Data from the International Tobacco Control Four Country Survey indicate that the level of support amongst UK smokers for legislation banning smoking in cars carrying children is on a par with countries in which state and local legislation has been introduced. Support was highest in Australia, with 83% of smokers supporting legislation for cars carrying children, followed by the UK (75% of smokers) and Canada (74%). Support was slightly lower in the USA (60%). [14]

iii. BLF-stakeholder views on car smoking legislation with children present

The BLF launched its Children’s Charter in June 2010, setting out 12 key areas for improvement in children’s respiratory health. Foremost amongst these is reducing children’s exposure to second-hand smoke in cars. Since the launch of the Charter, the BLF has advocated legislation to ban smoking in cars when children are present, alongside educational campaigns to raise awareness of the health impact of passive smoking in the confines of the car. The BLF supports legislation alongside educational campaigns as the best possible means of making everyone aware of the health risks of smoking in cars with children present, and of urging responsible behaviour.

In May 2012, Lord Ribeiro introduced a Private Member’s Bill to prohibit smoking in private vehicles when children are present. The following health and third sector organisations have signed up to support BLF’s position statement:

Action on Smoking and Health (ASH)

Asthma UK

British Heart Foundation

British Thoracic Society

Faculty of Public Health

Family and Parenting Institute

National Centre for Smoking Cessation and Training

National Children’s Bureau

Primary Care Respiratory Society

Royal College of General Practitioners

Royal College of Paediatrics and Child Health

Royal College of Physicians

Smokefree South West

Tobacco Control Collaborating Centre

Tobacco Free Futures

5. Why legislation?

Evidence suggests that educational campaigns in this area are most effective in changing behaviour when accompanied by legislation. A 2011 inquiry into smoking in private vehicles conducted by the All-Party Parliamentary Group on Smoking and Health concluded that legislation will also be needed to reduce exposure to cigarette smoke in cars. [15] Their conclusions were based on existing evidence from previously passed smokefree public places legislation.

The best examples of changing behaviour through legislation in this context are the passing of car seat belt laws and banning smoking in public places.

i. Seat belts

· Efforts to encourage seat belt use in cars were most successful when legislation was introduced. Seat belt wearing rates increased in the UK from 25% to 91% after legislation was introduced alongside pre-existing awareness campaigns. [16]

· Interestingly, many of the concerns raised in debates on seat belt wearing are also raised now in similar form in opposition to car smoking laws – notably those surrounding personal liberties and enforceability (c.f. Government response from the Earl of Avon: Official Report, Lords; col. 956.

There is a parallel with car smoking laws in respect of privacy and public interest. Drivers are required to ensure that minors in the car are wearing seatbelts. This is an example of state regulation of behaviour within the car, with the primary purpose of guaranteeing the safety of those within the car - not of those outside the car. Another commonality is the need for opportunistic enforcement by police.

ii. Smokefree public places legislation

· Data from the ITC project indicate that prevalence of smoking in bars decreased very slowly, and remained high, before the introduction of smokefree legislation, at a time when mass media campaigns and other educational initiatives were being deployed to educate the public about the dangers of second-hand smoke . When smokefree legislation was implemented in April and July 2007, smoking prevalence in public places decreased dramatically, with public compliance as high as 98%. [17]

6. Developments beyond England

Action has been taken to protect children’s health in a number of jurisdictions. Domestically, the Welsh Assembly has committed to considering legislation if its educational campaign has not succeeded within three years, and the Northern Ireland Executive have consulted formally on options around banning smoking in private vehicles and Scotland has committed to supporting a ban on smoking in cars in their 2013 tobacco strategy. Smoking in cars carrying children is prohibited in 4 US states, 10 of 13 Canadian provinces, 7 of 8 Australian states, and in five countries, including South Africa (for children under 12) and Cyprus.


It should be noted that smokefree legislation already prohibits smoking in public transport, including private rental vehicles, and in work vehicles, even if colleagues who use the vehicle are not present. It is acknowledged that there are concerns about enforcement and intrusion into one’s private doings but the BLF feels that these concerns whilst valid, have already been addressed at the time of the introduction of seat belt legislation in vehicles. It is important to recognise that the issue to be addressed here is one of child protection. It is extremely worrying to see the effects of smoking in cars on children as 49% of those surveyed reported feeling sick and 44% saying it made them cough. Furthermore, with 83% of smokers surveyed expressing their support for a ban on smoking in cars with children present, we see support for anti-smoking measures in cars rising which should be reflected in legislation that protects young people from the risks associated with passive smoking.


[1] Passive smoking and children: A report by the Tobacco Advisory Group . Royal College of Physicians, 2010.

[2] Annual report of the Chief Medical Officer 2002 . Department of Health, 2003

[3] Centers for Disease Control and Prevention. “Exposure to second- hand smoke among students aged 13–15 years – worldwide, 2000– 2007”. Morb Mortal Wkly Rep 2007 ; 56: 497–500

[4] Bélanger, O’Loughlin, Okoli, et al. “ Nicotine dependence symptoms among young never-smokers exposed to secondhand tobacco smoke”. Addict Behav 2008; 33: 1557–1563

[5] Passive smoking and children: A report by the Tobacco Advisory Group . Royal College of Physicians, 2010

[6] Sendzik, Fong, Travers, Hyland. “An experimental investigation of tobacco smoke pollution in cars”. Nicotine Tob Res, 2009; 11(6):627-34

[7] Elaine Clarke MCIEH. “The impact of smoking cigarettes on particulate levels in private vehicles”. Presentation to the Chartered Institute of Environmental Health conference, ‘Public Health, Challenging Norms’, March 2011

[8] Kabir, Manning, Holohan, Keogan, Goodman, Clancy. “Second-hand smoke exposure in cars and respiratory health effects in children”. Eur Respir J 2009;34:629-633

[9] Sly, Deverell, Kusel, Holt. “Exposure to environmental smoke in cars increases the risk of persistent wheeze in adolescents”. Med J Aust 2007; 186:322.

[10] Bauld. The introduction of smokefree legislation in England: evidence review . DH, 2011; Smokefree England: One year on . DH, 2008

[11] 19% in survey of 6971 boys and girls aged 11-15. Smoking, drinking and drug use among young people in England in 2010 . NHS Information Centre, 2010

[12] BLF/ TNS survey of more than 1,000 children aged 8-15, conducted 20-27 January 2011

[13] BLF online survey of 1,020 people through Mumsnet, conducted 29 April-6 May 2010; 127 respondents reported to being current smokers. Variety of breakdowns available

[14] Survey of 6716 adult current smokers from the 2007 Wave of the International Tobacco Control Four Country Survey. Hitchman, Fong, Zanna, Hyland, Bansal- Travers. “Support and correlates of support for banning smoking in cars with children: findings from the ITC Four Country Survey”. Eur J Public Health . 2011 June; 21(3): 360–365

[15] Inquiry into smoking in private vehicles . All-Party Parliamentary Group on Smoking and Health, 2011

[16] Seat-belts and child restraints . World Health Organisation/ FIA Foundation, 2009

[17] Smokefree England: One year on . DH, 2008




[17] April 2013


Prepared 19th April 2013