Investigating the effect of England's smoke-free private vehicle regulation on changes in tobacco smoke exposure and respiratory disease in children: a quasi-experimental study

BACKGROUND: Comprehensive tobacco control policies can help to protect children from tobacco smoke exposure and associated adverse respiratory health consequences. We investigated the impact of England's 2015 regulation that prohibits smoking in a private vehicle with children present on changes in environmental tobacco smoke exposure and respiratory health in children. METHODS: In this quasi-experimental study, we used repeated cross-sectional, nationally representative data from the Health Survey for England from Jan 1, 2008, to Dec 31, 2017, of children aged up to 15 years. We did interrupted time series logistic or ordinal regression analyses to assess changes in prevalence of self-reported respiratory conditions, prevalence of self-reported childhood tobacco smoke exposure (children aged 8-15 years only), and salivary cotinine levels (children aged 2 years or older) before and after implementation of the smoke-free private vehicle regulation on Oct 1, 2015. Children who were considered active smokers were excluded from the analyses of salivary cotinine levels. Our primary outcome of interest was self-reported current wheezing or asthma, defined as having medicines prescribed for these conditions. Analyses were adjusted for underlying time trends, quarter of year, sex, age, Index of Multiple Deprivation quintile, and urbanisation level. FINDINGS: 21 096 children aged 0-15 years were included in our dataset. Implementation of the smoke-free private vehicle regulation was not associated with a demonstrable change in self-reported current wheezing or asthma (adjusted odds ratio 0·81, 95% CI 0·62-1·05; p=0·108; assessed in 13 369 children), respiratory conditions (1·02, 0·80-1·29; p=0·892; assessed in 17 006 children), or respiratory conditions probably affecting stamina, breathing, or fatigue (0·75, 0·47-1·19; p=0·220; assessed in 12 386 children). Self-reported tobacco smoke exposure and salivary cotinine levels generally decreased over the study period. There was no additional change in self-reported tobacco smoke exposure in cars among children aged 8-15 years following the legislation (0·77, 0·51-1·17; p=0·222; assessed in 5399 children). We observed a relative increase in the odds of children having detectable salivary cotinine levels post legislation (1·36, 1·09-1·71; p=0·0074; assessed in 7858 children) and levels were also higher (1·30, 1·04-1·62; p=0·020; ordinal variable). Despite introduction of the regulation, one in 20 children still reported being regularly exposed to tobacco smoke in cars and one in three still had detectable salivary cotinine levels. INTERPRETATION: We found no demonstrable association between the implementation of England's smoke-free private vehicle regulation and changes in children's self-reported tobacco smoke exposure or respiratory health. There is an urgent need to develop more effective approaches to protect children from tobacco smoke in various places, including in private vehicles. FUNDING: Netherlands Lung Foundation, Erasmus MC, Farr Institute, Health Data Research UK, Asthma UK Centre for Applied Research, Academy of Medical Sciences, and Newton Fund