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Research paper
Smoking while driving and public support for car smoking bans in Italy
  1. Jose M Martínez-Sánchez1,2,3,
  2. Silvano Gallus4,
  3. Alessandra Lugo4,
  4. Esteve Fernández1,2,3,
  5. Giovanni Invernizzi5,6,
  6. Paolo Colombo7,
  7. Roberta Pacifici8,
  8. Carlo La Vecchia4,9
  1. 1Tobacco Control Unit, Cancer Prevention and Control Program, Institut Català d'Oncologia—ICO, L'Hospitalet de Llobregat, Barcelona, Spain
  2. 2Cancer Control and Prevention Group, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
  3. 3Department of Clinical Sciences, Universitat de Barcelona, Barcelona, Spain
  4. 4Department of Epidemiology, Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italia
  5. 5Laboratorio per la ricerca sull'inquinamento da fumo passivo, Istituto nazionale dei tumori/SIMG-Società italiana di medicina generale, Milan, Italy
  6. 6ISDE Medici per l'ambiente, Sondrio, Italy
  7. 7Istituto DOXA, Gallup International Association, Milan, Italy
  8. 8Dipartimento del Farmaco, Istituto Superiore di Sanità, Rome, Italy
  9. 9Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
  1. Correspondence to Dr Silvano Gallus, Department of Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, Via G. La Masa 12, Milan 20156, Italy; silvano.gallus{at}marionegri.it

Abstract

Objective To analyse the prevalence and correlates of smoking in cars as well as attitudes towards the extension of smoking bans in private vehicles among Italian adults.

Methods We used data from two surveys conducted in 2011 and 2012 on an overall sample of 6167 individuals representative of the Italian population aged ≥15 years.

Results The prevalence of smoking while driving was 65.5% among adult smokers. There was a negative trend with age and a positive one with education level. Smoking while driving was more prevalent among men, heavy smokers and smokers who believe there is little or no increased risk of accidents from smoking while driving. Among smokers who smoke while driving, 20.9% smoke in cars carrying children. Overall, 79.6% of Italians (88.2% non-smokers and 48.8% current smokers) support a ban on smoking in cars, and 92.5% (95.0% non-smokers and 83.5% current smokers) support such a ban in cars carrying children.

Conclusions Despite the high percentage of smokers who smoke in private vehicles, the majority of the Italian population (including smokers) support the introduction of a smoking ban in cars, particularly in cars carrying children. Smoke-free laws should therefore be extended to private vehicles, particularly if they are carrying children. Moreover, warning labels on cigarette packages should include information on the increased risk of accidents when smoking while driving. Mass media campaigns should also consider targeting this topic.

  • Public policy
  • Public opinion
  • Secondhand smoke

https://doi.org/10.1136/tobaccocontrol-2012-050700

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    Introduction

    Exposure to secondhand smoke (SHS) increases the risk of cancer, cardiovascular and respiratory diseases among adults and asthma in children.1 In Italy, legislation banning smoking in public venues and all workplaces came into effect on 10 January 2005.2 A decrease in smoking prevalence,3 ,4 and a substantial decrease in exposure to SHS were observed after this legislation was implemented.5 However, 5 years after the Italian smoking ban there was still frequent SHS exposure in some settings. A high exposure was observed in private vehicles, where 18% of adult and 33% of young (15–24 year old) non-smokers reported that they were exposed to SHS during the previous week.5 Extremely high concentrations of pollutants are present in cars when a smoker lights-up even a single cigarette.6 ,7 The issue is particularly relevant for children, who are more vulnerable than adults to SHS exposure given their faster breathing and their less mature immune system.7–9 The high levels of tobacco pollution that occur inside vehicles where people smoke increase the risk of respiratory and allergic symptoms among children and the young.8 ,9 Fine particulate matter (PM2.5) concentrations in cars can reach peaks over 700 μg/m3 during smoking periods.10 These levels are much greater than those recommended by the EPA air quality index guidelines, which label PM2.5 >150 μg/m3 as ‘very unhealthy’, and >250 μg/m3 as ‘hazardous’.11 A study found that the concentration of PM2.5 found inside cars with people smoking was only exceeded by those found in some British hospitality venues before the smoking ban.7

    In some jurisdictions of the USA, Canada and Australia smoking in cars is banned, at least in vehicles carrying children.12 ,13 Surveys in those countries show that smoking regulations in cars are highly accepted among non-smokers (80–95%) and smokers (60–80%).13 ,14 However, in most countries smoking in private vehicles is unregulated.

    The issue is relevant in Italy, a country where smoking while driving is a comparatively frequent habit. Thus, the observed point prevalence of smoking in vehicles was highest in northern Italy (6.9%)15 as compared with Spain (5.5%)16 and New Zealand (3.2%).17 Moreover, in Italy there have been no recent mass media campaigns about the harmful effects of SHS, particularly in passenger compartments of private cars. The objective of this study is therefore to analyse the prevalence and correlates of smoking in private vehicles among Italian smokers and the attitudes of the general Italian population towards a smoking ban in vehicles in general and when children are present.

    Methods

    Two face-to-face surveys on smoking were conducted in Italy in 2011 and 2012, using methods similar to previous ones.3 ,18–20 Data were collected during February–April 2011 and February–May 2012 by DOXA, the Italian branch of the Gallup International Association. The overall sample consisted of 6167 individuals (2963 men and 3204 women), representative of the general Italian population aged ≥15 years in terms of sex, age, geographical area and socioeconomic characteristics.

    Participants were selected through representative multistage sampling from 147 municipalities in 2011 and 117 in 2012 (the smallest Italian administrative division) in all of the 20 Italian regions (the largest Italian administrative division). In the municipalities selected, adults were randomly sampled from electoral rolls, within strata defined by sex and age group, in order to be representative of the demographic structure of the population. Whenever a selected participant was unavailable, they were replaced by a neighbour (living in the same floor/building/street) of the same sex and age group. Statistical weights were applied to both the surveys to achieve the representativeness of the data. These weights were used in the analyses.

    Interviews were conducted by ad hoc trained interviewers, using structured questionnaires in the context of a computer-assisted personal inhouse interview. The 2011 and the 2012 questionnaires included information on sociodemographic characteristics and smoking status. Smokers were defined as participants who had smoked 100 or more cigarettes in their lifetimes, ex-smokers as the participants who had quit smoking for at least 1 year. Level of education was categorised into low (no qualification up to middle school diploma), intermediate (high school) and high (university).

    The questionnaires included specific questions on smoking in cars. Adult current smokers were asked whether they smoked while driving a car. Moreover, smokers who reported they smoked while driving were asked if they also smoked when children were in the car. All participants (smokers and non-smokers) were asked about their attitude towards the extension of smoke-free legislation to cars, in general and in cars carrying children, as well as to selected outdoor areas including parks and public gardens, stadiums, school courtyards, open areas of hospitals, bus stops and beaches. Each question had a structured four-item score (strongly in favour, moderately in favour, moderately against and strongly against). An additional question was added to the 2012 questionnaire only, and was asked of all participants as follows: ‘In your opinion, does smoking while driving a vehicle increase the risk of accidents?’ Answers were categorised as low (‘not at all’ or ‘a little’), intermediate (‘moderately’) and high (‘a lot’).

    The relationship between selected individual level characteristics, the habit and the attitudes towards smoking in cars, was investigated by fitting logistic regression models21 to derive odds ratios (OR) and the corresponding 95% confidence intervals (CI). All models were adjusted for sex, age, level of education, geographical area and survey year (survey year was excluded for the analysis of the perception of risk of accidents, since data for this issue were available only for the 2012 survey). The models for attitudes towards a smoking ban in cars were also adjusted for smoking status. Multivariate analyses were performed using the LOGISTIC procedure with SAS V.9.2 statistical package (SAS Institute).

    Results

    Overall, 1339 (21.7%) respondents were identified as current smokers. Among adult smokers who drive (1173), 768 (65.5%) reported they smoked while driving (table 1). This proportion was significantly lower among women (53.2%) than men (73.5%; OR=0.37 for women vs men) and among older people (≥65 years; 55.0%), with a negative trend with age (p=0.003). A positive trend with education was observed (p=0.034). No significant difference was observed according to geographical area. With reference to perceived risk of accidents, the highest prevalence of smoking while driving was observed among those who believe that smoking while driving caused little or no increased risk of accidents (83.9%, data for 2012 only). A high proportion of heavy smokers smoked while driving (90.4% for smokers of 30 or more cigarettes per day; OR=14.06, as compared with <10 cigarettes per day), with a positive trend with the number of cigarettes (p<0.001). Fewer smokers smoked while driving in 2012 (62.7%) than in 2011 (68.1%; OR=0.76 for 2012 vs 2011).

    View this table:
    Table 1

    Percent distribution of Italian adult current smokers according to smoking while driving a car in general and in the presence of children, overall and according to selected characteristics. Corresponding odds ratios (OR)* and 95% confidence intervals (CI). Italy, 2011-2012

    Among smokers who smoke while driving, 20.9% also smoke when children are present in the car, with no substantial difference between men (20.5%) and women (21.7%; table 1). The percentage was higher among young people (18–24 years, but no significant trend with age was found) and in those subjects with lower education (25.6%; OR=0.49 for high vs low education). The percentages were lower in northern Italy (12.2%) and substantially higher in heavy smokers (53.7%; OR=21.75; as compared with <10 cigarettes per day). There was no significant relationship between smoking while driving in cars carrying children and either perception of risk of accident or year of survey.

    Table 2 shows the percentage of the Italian population who moderately or strongly support a smoking ban in cars. Overall, 79.6% of Italians supported the ban of smoking in cars, and 92.5% supported it when children are in the vehicle. The support was greater in women than in men (OR=1.23 and 1.12, respectively). We found a positive trend with age (p<0.001) for support for smoking bans in cars with and without children. Never smokers had the highest prevalence of support (89.2% in cars and 95.2% in cars carrying children). The proportion of current smokers in favour of the smoking ban in cars carrying children was 83.5% (81.9% among men and 85.6% among women), with a positive trend with age (p<0.001). We found that support was highest for banning smoking in cars in general, and in cars carrying children, among people who believed that smoking while driving appreciably increases the risk of having an accident (OR=13.70 and OR=6.07, respectively). Support was not associated with level of education or geographical area.

    View this table:
    Table 2

    Distribution of the Italian population (smokers and non-smokers), by moderate to strong support to ban smoking in cars in general and in the presence of children, overall and according to selected characteristics. Corresponding odds ratios (OR)* and 95% confidence intervals (CI). Italy, 2011-2012

    The proportion of Italians moderately to strongly in favour of a smoking ban in cars carrying children (92.5%) in 2011 and 2012 was higher than the support to extend smoking restrictions to selected outdoor areas such as in school courtyards (82.6%), open areas of hospitals (75.0%), stadiums (66.7%), parks and public gardens (60.5%), bus stops (59.8%) and beaches (59.4%). The same pattern was also observed when the analyses were limited only to current smokers (figure 1).

    Figure 1
    Figure 1

    Percentage of current and non-smokers (never and former) who support banning smoking in cars and selected outdoors areas in Italy, 2011–2012.

    Discussion

    The majority of the Italian population (smokers and non-smokers) support banning smoking in cars carrying children. However, we found that almost two thirds of smokers smoke while driving, and among these, more than one fifth smoke when children are in the car. The proportion of Italian smokers who smoke while driving has not decreased appreciably since 2007, when a similar study estimated that 69% smoked while driving.22 The percentage of Italian smokers who smoke while driving was higher than that reported for French (59%) and German smokers (52%).23 However, the prevalence of smokers who smoke while driving in cars with children was higher in the Netherlands (36%) than in Italy.23

    Our data show that young people and men are more likely to smoke while driving. Previous studies conducted in other European countries by questionnaire23 and direct observation16 report similar results. We also observed that smokers who smoked more than 30 cigarettes per day were more likely to smoke while driving in general and when driving a car carrying children. Heavier smokers (with highest nicotine dependence) are more likely to allow smoking in their cars, since it is more difficult for them to control their smoking.23 The lower percentage of lower educated smokers who smoke while driving compared with smokers with higher education may be partly explained by residual confounding by age (since smoking while driving is less frequent in older people, who have lower education levels). In part, the difference observed may also be explained in terms of different patterns of use of cars (weekly/daily time spent, car cleaning rules, etc) according to various education levels. The lower proportion of university educated smokers who smoke while driving a car carrying children compared with those with less than a high school diploma could be due to greater knowledge of the harmful effects of SHS exposure on children. The percentage of highly educated smokers in our study who smoked while driving a car carrying children with high education was lower than that observed in the Netherlands (15% in Italy vs 27% in the Netherlands).23 Differences in the prevalence of smoking and the perceived acceptability of smoking between northern and southern Italy may explain the regional differences in the proportion of smokers who smoke while driving a car carrying children.4 ,24

    We found very strong support towards smoking bans in cars, particularly when children are in the vehicle (92.5%), including among current smokers (83.5%). Support in Italy appears to be much higher than has been observed in other countries such as the USA (59%), Canada (74%) and the UK (75%), and similar to that observed in Australian states (83%), where some states have already banned smoking in cars in the presence of children.25 Furthermore, the support among the Italian population (smokers and non-smokers) for banning smoking in cars carrying children was higher than for extending smoke-free legislation to selected outdoor areas.19 There was greater support to ban smoking in cars among women compared with men, overall and among current smokers, confirming findings from the International Tobacco Control study conducted in the USA, Australia, Canada and the UK (75% among women and 71% among men).25 We found the highest support among smokers aged over 65 years, while in the International Tobacco Control study25 the highest support was among young adults (18–24 years).

    Smoking while driving increases the risk of accidents.26 ,27 As compared with non-smoking drivers, those who smoke are 1.5 times more likely to have an accident.26 In Italy about 7% of car crashes could involve a subject who smokes while driving.22 We found the lowest percentage of smoking while driving (around 50%) and the highest support to ban smoking in cars (93.1%) among people who perceive that smoking while driving increases the risk of accidents. Thus, our results emphasise the need to increase knowledge of the increased risk of car accidents when smoking while driving, particularly among current smokers. Thus, warning labels in cigarette packages should also include information on the increased risk of accidents and injuries when engaging in smoking while driving. Likewise, mass media campaigns should also consider targeting this topic.

    Possible limitations and biases of this study derive from sample selection and the use of self-report data. However, our samples were representative of the Italian population. We also trained the interviewers to collect data (face-to-face interview) to minimise the potential information bias. Also, national population surveys have been conducted by DOXA annually since 2001 and estimates on smoking prevalence and attitudes show consistent trends over time.3 ,20 Moreover, we only measured smoking while driving private vehicles. We did not have information on smoking among passengers in cars. This limitation of our study may well result in an underestimation of the real prevalence of smoking in cars.

    In conclusion, in Italy there is strong support for banning smoking in cars carrying children. This support is higher than that observed for extending smoke-free legislation to other selected outdoor areas. For this reason, public health policies in Italy should focus on banning tobacco consumption in cars, particularly when children are in the vehicle.

    What is already known on this subject

    • Even a single lit cigarette within a car can cause extremely high concentrations of pollutants.

    • Children are more vulnerable than adults to exposure to secondhand smoke.

    • Most countries do not regulate smoking in cars.

    What this paper adds

    • The majority of the Italian adult population (smokers and non-smokers) support banning smoking in cars carrying children. This support is higher than that observed for the extension of the smoke-free legislation in selected outdoor areas.

    • Public health policies in Italy should focus on banning smoking in cars, particularly when children are in the vehicle.

    • The increased risk of accidents when smoking while driving should be considered as a target for mass media campaigns and pack health warnings.

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    Footnotes

    • Contributors JMMS and SG had the original idea for the study and drafted the manuscript. AL conducted the data analysis; JMMS, SG, EF, GI and CLV gave substantial contributions to conception, design and interpretation of data; PC and RP gave contributions to conception and design of the study and provided data from the surveys; all authors critically revised the manuscript and approved its final version.

    • Funding This work was conducted with contributions from the Italian Ministry of Health, the Italian Association for Cancer Research (AIRC, No. 10068) and the Italian League Against Cancer (LILT), Milan. JMMS and EF are supported by Instituto de Salud Carlos III, Government of Spain (RTICC RD06/0020/0089 and RD12/0036/0053) and Ministry of Universities and Research, Government of Catalonia (grant 2009SGR192).

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement A presentation providing some aggregate data is available in Italian at: http://www.iss.it/binary/fumo/cont/Rapporto_annuale_sul_fumo_2012.pdf.