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• Awareness of legal driving restrictions for PWE is poor in China. • PWE drive illegally frequently such that a large number of PWE have obtained their license and continue driving after a diagnosis of epilepsy. • Male and young/middle-aged PWE on fewer medications are more likely to be driving. • Driving restrictions for PWE require greater standardization, coordination, and enforcement. Patients with epilepsy (PWE) remain completely and permanently banned from driving under the latest changes to China's laws. The two aims of this study were, firstly, to evaluate the driving status of PWE with a driving license and the determinants of them continuing to drive; secondly, to investigate awareness and perceptions of epilepsy driving restrictions among PWE and the general population. Patients with epilepsy with a driver's license who attended the Fourth Affiliated Hospital and the Second Affiliated Hospital of Zhejiang University for treatment of their condition were invited to participate in a questionnaire survey between June 2021 and June 2022. During the same period, age-matched people with driver's licenses without epilepsy living in the cities of Hangzhou and Yiwu, Zhejiang province were invited to participate in the questionnaire study. A total of 291 PWE with a driver's license and 289 age-matched drivers among the general public participated in the survey. Of the sample, 41.6% of PWE and 26.0% of general drivers stated that they were aware of legal driving restrictions for PWE in China. In the past year, 54% of PWE had driven and 42.5% drove a vehicle daily. Logistic regression revealed that male sex (95% confidence interval [CI]: 1.36–3.61, P = 0.001), age (95% CI: 1.12–3.27, P ≤ 0.036), and the number of antiseizure medications taken (95% CI: 0.24–0.25, P ≤ 0.001) were independently associated with illegally driving with epilepsy. In terms of legal issues, 71.1% of PWE did not support a lifetime ban on driving and 50.2% disagreed with physician reporting of PWE to the traffic authorities. Illegal driving is highly prevalent among PWE who hold a driving license, and male gender, age, and number of ASMs had an independent association with illegal driving in patients with epilepsy. There are highly varying opinions on the current driving laws with respect to PWE. Detailed national standards for medical fitness for driving that are easy to implement and enforce are urgently required for China. [ABSTRACT FROM AUTHOR]