Geographical differences in the financial impacts of different forms of tobacco licence fees on small retailers in Scotland.

OBJECTIVE: Retailer licencing fees are a promising avenue to regulate tobacco availability. However, they face strong opposition from retailers and the tobacco industry, who argue significant financial impacts. This study compares the impacts of different forms of tobacco licence schemes on retailers' profits in Scotland. METHODS: We calculated gross profits from tobacco sales in 179 convenience stores across Scotland using 1 099 697 electronic point-of-sale records from 16 weeks between 2019 and 2022. We estimated different fees using universal, volumetric and separate urban/rural schemes. We identified the point at which 50% of retailers would no longer make a gross profit on tobacco sales for each scheme and modelled the financial impact of 10 incremental fee levels. The financial impact was assessed based on changes in retailers' tobacco gross profits. Differences by neighbourhood deprivation and urban/rural status were examined. RESULTS: The gross profit from tobacco per convenience store averaged £15 859/year. Profits were 2.29 times higher in urban (vs rural) areas and 1.59 times higher in high-deprivation (vs low-deprivation) areas, attributable to higher sales volumes. Tobacco gross profit decreased proportionally with increasing fee levels. Universal and urban/rural fees had greater gross profit reductions in rural and/or less deprived areas, where profits were lower, compared with volumetric fees. CONCLUSION: The introduction of tobacco licence fees offers a potential opportunity for reducing the availability of tobacco retailers. The likely impact of a tobacco licence fee is sensitive to the type of licence scheme implemented, the level at which fees are set and the retailers' location in relation to neighbourhood deprivation and rurality.

Exploring the influence of local alcohol availability on drinking norms and practices: A qualitative scoping review.

INTRODUCTION: High alcohol availability is related to increased alcohol consumption and harms. Existing quantitative research provides potential explanations for this relationship but there is little understanding of how people experience local alcohol availability. This is the first review to synthesise qualitative research exploring the relationship between alcohol availability and other factors in local alcohol environments. METHODS: The scoping review includes qualitative studies exploring community-level alcohol availability and other factors, facilitating the purchase and consumption of alcohol. We included studies focusing on children and adolescents as well as adults. Study findings were brought together using thematic analysis and the socio-environmental context model, which explains how certain environments may facilitate drinking. RESULTS: The review includes 34 articles. The majority of studies were conducted since 2012. Most studies were conducted in the United Kingdom, Australia and South Africa. The physical availability of alcohol and proximity to local amenities and temporal aspects, like late night opening hours, may be linked to social factors, such as normalisation of drinking and permissive drinking environments. The review highlights the importance of social and cultural factors in shaping interactions with local alcohol environments. DISCUSSION AND CONCLUSION: This qualitative scoping review advances understanding of the pathways linking alcohol availability and alcohol harms by showing that availability, accessibility and visibility of alcohol may contribute towards permissive drinking environments. Further research is needed to better understand how people experience alcohol availability in their local environment and how this can inform alcohol control policies.

Inequalities in children's exposure to alcohol outlets in Scotland: a GPS study.

BACKGROUND: Alcohol use is a leading cause of harm in young people and increases the risk of alcohol dependence in adulthood. Alcohol use is also a key driver of rising health inequalities. Quantifying inequalities in exposure to alcohol outlets within the activity spaces of pre-adolescent children-a vulnerable, formative development stage-may help understand alcohol use in later life. METHODS: GPS data were collected from a nationally representative sample of 10-and-11-year-old children (n = 688, 55% female). The proportion of children, and the proportion of each child's GPS, exposed to alcohol outlets was compared across area-level income-deprivation quintiles, along with the relative proportion of exposure occurring within 500 m of each child's home and school. RESULTS: Off-sales alcohol outlets accounted for 47% of children's exposure, which was higher than expected given their availability (31% of alcohol outlets). The proportion of children exposed to alcohol outlets did not differ by area deprivation. However, the proportion of time children were exposed showed stark inequalities. Children living in the most deprived areas were almost five times more likely to be exposed to off-sales alcohol outlets than children in the least deprived areas (OR 4.83, 3.04-7.66; P < 0.001), and almost three times more likely to be exposed to on-sales alcohol outlets (OR 2.86, 1.11-7.43; P = 0.03). Children in deprived areas experienced 31% of their exposure to off-sales outlets within 500 m of their homes compared to 7% for children from less deprived areas. Children from all areas received 22-32% of their exposure within 500 m of schools, but the proportion of this from off-sales outlets increased with area deprivation. CONCLUSIONS: Children have little control over what they are exposed to, so policies that reduce inequities in alcohol availability should be prioritised to ensure that all children have the opportunity to lead healthy lives.

Assessing the profile of support for potential tobacco control policies targeting availability in Great Britain: a cross-sectional population survey.

AIM: To examine the level of support for tobacco availability policies across Great Britain (GB) and associations between support for policy and sociodemographic, smoking and quitting characteristics. METHODS: A cross-sectional representative survey (the Smoking Toolkit Study) of adults in GB (n=2197) during September 2021. Logistic regressions estimated the associations between support for each policy and sociodemographic and smoking characteristics. FINDINGS: There was majority support for requiring retailers to have a license which can be removed if they sell to those under-age (89.6%) and for restrictions on the sale of cigarettes and tobacco near schools (69.9%). More supported than opposed raising the legal age of sale of cigarettes and tobacco to 21 (49.2% supported; 30.7% opposed; 20.1% unsure) and reducing the number of retailers selling tobacco in neighbourhoods with a high density of tobacco retailers (46.5% supported; 23.3% opposed; 30.2% unsure). More opposed than supported a ban on the sale of cigarettes and tobacco to everyone born after a certain year from 2030 onward (a 'tobacco-free generation') (41.3% opposed; 34.5% supported; 24.2% unsure). Age was positively associated with support for raising the age of sale and inversely associated with requiring tobacco retailer licenses. Women were more likely to support raising the age of sale and reducing the number of retailers. CONCLUSIONS: Requiring tobacco retailer licensing and restrictions on sales near schools received majority support. Other tobacco availability policies received substantial support despite considerable opposition.

Is tobacco a driver of footfall among small retailers? A geographical analysis of tobacco purchasing using electronic point of sale data.

OBJECTIVE: Opponents of policies designed to reduce tobacco retail availability argue that tobacco products are a vital driver of 'footfall' in small retailers. This study considers the changing contribution of tobacco to footfall and revenue among convenience stores across Britain, compares tobacco to other 'footfall driver' products and assesses whether tobacco's importance varies by neighbourhood deprivation and urban/rural status. METHODS: We conducted an analysis of electronic point of sale systems data from 1253 convenience stores in Britain in 4 weeks in 2016 and 2019. We calculated the number and value of purchased basket types (Tobacco Only, Non-Tobacco, Mixed) in each year and by neighbourhood characteristics. RESULTS: The mean numbers of baskets per store containing tobacco fell by 47% during 2016-2019, a greater decline than any other footfall driver product. The sales value of tobacco products rose sharply over this time period due to increasing unit price. However, the proportion of store turnover accounted for by tobacco transactions declined. There were marked falls in the turnover from non-tobacco products in Mixed tobacco baskets. The proportion of baskets containing tobacco and the value of turnover from these baskets was greater in more deprived and urban areas but these places also experienced larger reductions over time, narrowing differences between areas. CONCLUSION: Tobacco's importance as a driver of footfall and related turnover among convenience retailers has reduced significantly in Britain in recent years, particularly in deprived and urban areas, undermining industry claims that tobacco is essential to the viability of these businesses.

Children's perceptions of environment and health in two Scottish neighbourhoods.

This article explores children's understanding of the role that neighbourhood plays in their health and well-being. Whilst evidence exists on the relationship between the environment and children's health, we have little knowledge of this from the perspective of children themselves. Children's experiences are all too frequently researched through the eyes of adults. Following a Rights of the Child framework, respecting children's views and giving them due weight, this paper reports from a project that worked with children from two relatively deprived urban neighbourhoods in Scotland. Using this framework, the children themselves were the researchers who designed the themes, decided upon the methods, conducted the research and analysed the resulting data. Using focus groups, visual mapping and community walks the children explored their local neighbourhoods and the findings reveal features of the environment that the children perceive as important for their health and well-being. The children selected three themes to explore in the research: safety, littering, and family and friends, through which they elicit their experiences, feelings and attitudes towards the environment and their well-being. The paper reveals that not only do the children have a deep understanding of the link between environment and health, but that they also understand how aspects of disadvantage, including place-based stigma, can limit their social participation and inclusion in society. We conclude with recommendations made by the children themselves, ranging from access to affordable activities, improved open spaces, 'support not stigma' and the need to be heard in local decision making.

Life Course Air Pollution Exposure and Cognitive Decline: Modelled Historical Air Pollution Data and the Lothian Birth Cohort 1936.

BACKGROUND: Air pollution has been consistently linked with dementia and cognitive decline. However, it is unclear whether risk is accumulated through long-term exposure or whether there are sensitive/critical periods. A key barrier to clarifying this relationship is the dearth of historical air pollution data. OBJECTIVE: To demonstrate the feasibility of modelling historical air pollution data and using them in epidemiologicalmodels. METHODS: Using the EMEP4UK atmospheric chemistry transport model, we modelled historical fine particulate matter (PM2.5) concentrations for the years 1935, 1950, 1970, 1980, and 1990 and combined these with contemporary modelled data from 2001 to estimate life course exposure in 572 participants in the Lothian Birth Cohort 1936 with lifetime residential history recorded. Linear regression and latent growth models were constructed using cognitive ability (IQ) measured by the Moray House Test at the ages of 11, 70, 76, and 79 years to explore the effects of historical air pollution exposure. Covariates included sex, IQ at age 11 years, social class, and smoking. RESULTS: Higher air pollution modelled for 1935 (when participants would have been in utero) was associated with worse change in IQ from age 11-70 years (ß = -0.006, SE = 0.002, p = 0.03) but not cognitive trajectories from age 70-79 years (p > 0.05). There was no support for other critical/sensitive periods of exposure or an accumulation of risk (all p > 0.05). CONCLUSION: The life course paradigm is essential in understanding cognitive decline and this is the first study to examine life course air pollution exposure in relation to cognitive health.

Using point-of-sale data to examine tobacco pricing across neighbourhoods in Scotland.

OBJECTIVES: To assess the geographical variation in tobacco price (cigarettes and roll-your-own (RYO) tobacco) in convenience stores across Scotland and how this relates to neighbourhood income deprivation, tobacco retail outlet density and urban/rural status. METHODS: Tobacco price data from 124 566 shopping baskets purchased in 274 convenience stores during 1 week in April 2018 were obtained through an electronic point-of-sale system. These data were combined with neighbourhood-level measures of income deprivation, tobacco retail outlet density and urban/rural status. We examined brand price for 12 of the most popular cigarette brands and 3 RYO brands and variations in purchases by price segment; multivariable regression analysis assessed associations between area variables and tobacco price. RESULTS: Most stores sold tobacco in all price segments. The lowest priced subvalue brands were the most popular in all neighbourhoods but were most dominant in shops in more deprived neighbourhoods. When total sales were assessed, overall purchase price varied significantly by neighbourhood income deprivation; packets of 20 cigarettes were 50 pence (5.6%) lower and RYO 34 pence (2.7%) lower among shops in the two highest income deprivation quintiles relative to the lowest. Analysis of individual brands showed that for 3 of the 12 cigarette brands considered, average prices were 12-17 pence lower in more deprived neighbourhoods with the most popular RYO brand 15 pence lower. There was limited evidence of a relationship with tobacco retail outlet density. CONCLUSION: Across Scottish convenience stores, the purchase price of cigarettes and RYO was lower in more income-deprived neighbourhoods. The lower prices primarily reflect greater sales of cheap brands in these areas, rather than retailers reducing the prices of individual brands.

Simulating the density reduction and equity impact of potential tobacco retail control policies.

BACKGROUND: Reducing the provision of tobacco is important for decreasing inequalities in smoking and smoking-related harm. Various policies have been proposed to achieve this, but their impacts-particularly on equity-are often unknown. Here, using national-level data, we simulate the impacts of potential policies designed to reduce tobacco outlet density (TOD). METHODS: Tobacco retailer locations (n=9030) were geocoded from Scotland's national register, forming a baseline. Twelve policies were developed in three types: (1) regulating type of retailer selling tobacco, (2) regulating location of tobacco sales, and (3) area-based TOD caps. Density reduction was measured as mean percentage reduction in TOD across data zones and number of retailers nationally. Equity impact was measured using regression-based Relative Index of Inequality (RII) across income deprivation quintiles. RESULTS: Policies restricting tobacco sales to a single outlet type ('Supermarket'; 'Liquor store'; 'Pharmacy') caused >80% TOD reduction and >90% reduction in the number of tobacco outlets nationally. However, RIIs indicated that two of these policies ('Liquor store', 'Pharmacy') increased socioeconomic inequalities in TOD. Equity-promoting policies included 'Minimum spacing' and exclusion zones around 'Child spaces'. The only policy to remove statistically significant TOD inequalities was the one deliberately targeted to do so ('Reduce clusters'). CONCLUSIONS: Using spatial simulations, we show that all selected policies reduced provision of tobacco retailing to varying degrees. However, the most 'successful' at doing so also increased inequalities. Consequently, policy-makers should consider how the methods by which tobacco retail density is reduced, and success measured, align with policy aims.

Tobacco Retail Environment and Smoking: A Systematic Review of Geographic Exposure Measures and Implications for Future Studies.

INTRODUCTION: To review the geographic exposure measures used to characterize the tobacco environment in terms of density of tobacco outlets and proximity to tobacco outlets, and its association with smoking-related outcomes. METHODS: We used PubMed and Google Scholar to find articles published until December 2019. The search was restricted to studies that (1) measured the density of and/or proximity to tobacco outlets and (2) included associations with smoking outcomes. The extraction was coordinated by several observers. We gathered data on the place of exposure, methodological approaches, and smoking outcomes. RESULTS: Forty articles were eligible out of 3002 screened papers. Different density and proximity measures were described. 47.4% density calculations were based on simple counts (number of outlets within an area). Kernel density estimations and other measures weighted by the size of the area (outlets per square kilometer), population, and road length were identified. 81.3% of the articles which assessed proximity to tobacco outlets used length distances estimated through the street network. Higher density values were mostly associated with higher smoking prevalence (76.2%), greater tobacco use and smoking initiation (64.3%), and lower cessation outcomes (84.6%). Proximity measures were not associated with any smoking outcome except with cessation (62.5%). CONCLUSION: Associations between the density of tobacco outlets and smoking outcomes were found regardless of the exposure measure applied. Further research is warranted to better understand how proximity to tobacco outlets may influence the smoking outcomes. This systematic review discusses methodological gaps in the literature and provides insights for future studies exploring the tobacco environment. IMPLICATIONS: Our findings pose some methodological lessons to improve the exposure measures on the tobacco outlet environment. Solving these methodological gaps is crucial to understand the influence of the tobacco environment on the smoking outcomes. Activity spaces should be considered in further analyses because individuals are exposed to tobacco beyond their residence or school neighborhood. Further studies in this research area demand density estimations weighted by the size of the area, population, or road length, or measured using Kernel density estimations. Proximity calculations should be measured through the street network and should consider travel times apart from the length distance.

Socioeconomic inequalities in children's exposure to tobacco retailing based on individual-level GPS data in Scotland.

BACKGROUND: Identifying factors shaping knowledge of and attitudes towards tobacco products in preadolescence is a key component supporting tobacco control policies aimed at preventing smoking initiation. This study quantified exposure to tobacco retailing environments within the individual-level activity spaces of children across a socioeconomic gradient. METHODS: One week of global positioning system (GPS) tracking data were collected at 10 s intervals from a nationally representative sample of 10-11-year olds (n=692). Proximity of GPS locations (n=~16 M) to the nearest tobacco retailer (n=9030) was measured and exposure defined when a child came within 10 m of a retailer. Duration, frequency, timing and source of exposure were compared across income deprivation quintiles, along with retail density within children's home neighbourhoods. RESULTS: On average, children were exposed to tobacco retailing for 22.7 min (95% CI 16.8 to 28.6) per week in 42.7 (35.2-50.1) independent encounters. However, children from the most deprived areas accumulated six times the duration and seven times the frequency of exposure as children from the least deprived areas. Home neighbourhood retail densities were 2.6 times higher in deprived areas, yet the average number of businesses encountered did not differ. Most exposure came from convenience stores (35%) and newsagents (15%), with temporal peaks before and after school hours. CONCLUSIONS: By accounting for individual mobility, we showed that children in socially disadvantaged areas accumulate higher levels of exposure to tobacco retailing than expected from disparities in home neighbourhood densities. Reducing tobacco outlet availability, particularly in areas frequently used by children, might be crucial to policies aimed at creating 'tobacco-free' generations.

Association Between the Activity Space Exposure to Parks in Childhood and Adolescence and Cognitive Aging in Later Life.

The exposure to green space in early life may support better cognitive aging in later life. However, this exposure is usually measured using the residential location alone. This disregards the exposure to green spaces in places frequented during daily activities (i.e., the 'activity space'). Overlooking the multiple locations visited by an individual over the course of a day is likely to result in poor estimation of the environmental exposure and therefore exacerbates the contextual uncertainty. A child's activity space is influenced by factors including age, sex, and the parental perception of the neighborhood. This paper develops indices of park availability based on individuals' activity spaces (home, school, and the optimal route to school). These measures are used to examine whether park availability in childhood is related to cognitive change much later in life. Multi-level linear models, including random effects for schools, were used to test the association between park availability during childhood and adolescence and cognitive aging (age 70 to 76) in the Lothian Birth Cohort 1936 participants (N = 281). To test for the effect modification, these models were stratified by sex and road traffic accident (RTA) density. Park availability during adolescence was associated with better cognitive aging at a concurrently low RTA density (ß = 0.98, 95% CI: 0.36 to 1.60), but not when the RTA density was higher (ß = 0.22, 95% CI: -0.07 to 0.51). Green space exposure during early life may be important for optimal cognitive aging; this should be evidenced using activity space-based measures within a life-course perspective.

Neighbourhood tobacco supply and individual maternal smoking during pregnancy: a fixed-effects longitudinal analysis using routine data.

BACKGROUND: Tobacco policy is increasingly focusing on the 'tobacco endgame' which commits to eradicating tobacco use (prevalence below 5%) within the next two decades. Strategies for achieving the endgame are likely to include addressing the supply of tobacco products, yet current evidence to support this approach is primarily cross-sectional. METHODS: We use longitudinal smoking information from routine maternity records of all women who gave birth in Scotland between 2000 and 2015. We linked this data to the residential density of retailers selling tobacco products and the neighbourhood prevalence of smoking during pregnancy. In the analysis, individual mothers act as their own controls because we compare changes in their smoking behaviour between pregnancies to changes in exposure to tobacco retailing that arises from residential movement between pregnancies. RESULTS: Adjusted ORs showed an increased risk of being a smoker associated with increases in exposure to retailer density (OR 1.67, 95% CI 1.27 to 2.20). CONCLUSIONS: The results provide the strongest evidence to date of an association between the neighbourhood availability of tobacco and smoking, and the first to do so among pregnant women. These findings provide supportive evidence for interventions targeting the supply of tobacco products in achieving the endgame.

Do 'environmental bads' such as alcohol, fast food, tobacco, and gambling outlets cluster and co-locate in more deprived areas in Glasgow City, Scotland?

This study utilised an innovative application of spatial cluster analysis to examine the socio-spatial patterning of outlets selling potentially health-damaging goods/services, such as alcohol, fast food, tobacco and gambling, within Glasgow City, Scotland. For all categories of outlets combined, numbers of clusters increased linearly from the least to the most income deprived areas (i.e. one cluster within the least deprived quintile to ten within the most deprived quintile). Co-location of individual types of outlets (alcohol, fast food, tobacco and gambling) within similar geographical areas was also evident. This type of research could influence interventions to tackle the co-occurrence of unhealthy behaviours and contribute to policies tackling higher numbers of 'environmental bads' within deprived areas.

Tobacco outlet density and tobacco knowledge, beliefs, purchasing behaviours and price among adolescents in Scotland.

Despite long-term falls in global adult smoking prevalence and over 50 years of tobacco control policies, adolescent smoking persists. Research suggests greater densities of tobacco retail outlets in residential neighbourhoods are associated with higher adolescent smoking rates. Policies to reduce retail outlets have therefore been identified by public health researchers as a potential 'new frontier' in tobacco control. Better understanding of the pathways linking density of tobacco retailers and smoking behaviour could support these policies. In this study we use path analysis to assess how outlet density in the home environment is related to adolescent tobacco knowledge, beliefs, retail purchases and price in Scotland. We assessed 22,049 13 and 15 year old respondents to the nationally representative cross-sectional 2010 Scottish School Adolescent Lifestyle and Substance Use Survey. Outlet density was based on Scottish Tobacco Retailers Register, 2012, data. A spatially-weighted Kernel Density Estimation measure of outlet density within 400 m of respondents' home postcode was grouped into tertiles. The analysis considered whether outlet density was associated with the number of cigarette brands adolescents could name, positive beliefs about smoking, whether smokers purchased cigarettes from shops themselves or through adult proxies and perceived cost of cigarettes. Models were stratified by adolescent smoking status. The path analyses indicated that outlet density was not associated with most outcomes, but small, significant direct effects on knowledge of cigarette brands among those who had never smoked were observed. With each increase in outlet density tertile the mean number of brands adolescents could name rose by 0.07 (mean = 1.60; SD = 1.18; range = 4). This suggests greater outlet densities may have affected adolescents' knowledge of cigarette brands but did not encourage positive attitudes to smoking, purchases from shops or lower cigarette prices. Exposure to tobacco outlets may influence adolescents' awareness of tobacco products, a potential pathway to smoking behaviour.

Alcohol risk environments, vulnerability and social inequalities in alcohol consumption.

Alcohol and alcohol related harm are key public health challenges. Research has shown that individual level factors, such as age and sex, are important predictors of alcohol consumption, but such factors provide only a partial account of the drivers of consumption. In this paper we argue that individual level factors interact with features of the 'risk environment' to increase the vulnerability of individuals to such environments. Features of the alcohol 'risk environment' include the density of alcohol premises in a neighbourhood. Previous research has shown that neighbourhoods with a higher density of alcohol outlets have higher levels of both alcohol consumption and alcohol related harm. There has however been a distinct lack of attention paid to the differential ways in which particular socio-demographic groups may be more vulnerable to such 'risk environments'. In this paper we address the risk environment through a primary focus on the local supply and availability of alcohol products (captured using a measure of outlet density) and the relationship with the harmful use of alcohol. Using responses to the Scottish Health Survey (2008-2011) we explore vulnerability through the interaction between individual level socio-economic position, measured using household income, and environmental risk to assess differential social vulnerability to such environments. We report findings showing that those in the lowest income groups may be disproportionately affected by outlet density. This evidence suggests that risk environments may not affect us all equally and that there may be socially differentiated vulnerability to such environments.

Green space and cognitive ageing: A retrospective life course analysis in the Lothian Birth Cohort 1936.

International evidence suggests that green space has beneficial effects on general and mental health but little is known about how lifetime exposure to green space influences cognitive ageing. Employing a novel longitudinal life course approach, we examined the association between lifetime availability of public parks and cognitive ageing. Lifetime residential information was gathered from the participants of the Lothian Birth Cohort 1936 using a "life-grid" questionnaire at age 78 years. Parks information from 1949, 1969 and 2009 was used to determine a percentage of parks within a 1500 m buffer zone surrounding residence for childhood, adulthood, and later adulthood periods. Linear regressions were undertaken to test for association with age-standardised, residualised change in cognitive function (Moray House Test score) from age 11 to 70 years, and from age 70 to 76 (n = 281). The most appropriate model was selected using the results of a partial F-test, and then stratified by demographic, genetic and socioeconomic factors. The local provision of park space in childhood and adulthood were both important in explaining the change in cognitive function in later life. The association between childhood and adulthood park availability and change in the Moray House Test Score from age 70 to 76 was strongest for women, those without an APOE e4 allele (a genetic risk factor), and those in the lowest socioeconomic groups. Greater neighbourhood provision of public parks from childhood through to adulthood may help to slow down the rate of cognitive decline in later life, recognising that such environmental associations are always sensitive to individual characteristics.

A sibling study of whether maternal exposure to different types of natural space is related to birthweight.

Background: Birthweight is an important determinant of health across the life course. Maternal exposure to natural space has been linked to higher birthweight, but stronger evidence of a causal link is needed. We use a quasi-experimental sibling study design to investigate if change in the mother's exposure to natural space between births was related to birthweight, in urban Scotland. Methods: Amount (% area) of total natural space, total accessible (public) natural space, parks, woodlands and open water within 100 m of the mother's postcode was calculated for eligible births (n = 40 194; 1991-2010) in the Scottish Longitudinal Study (a semi-random 5.3% sample of the Scottish population). Associations between natural space and birthweight were estimated, using ordinary least squares and fixed effects models. Results: Birthweight was associated with the total amount of natural space around the mother's home (+8.2 g for interquartile range increase), but was unrelated to specific types of natural space. This whole-sample relationship disappeared in the sibling analysis, indicating residual confounding. The sibling models showed effects for total natural space with births to women who already had children (+20.1 g), and to those with an intermediate level of education (+14.1 g). Conclusions: The importance of total natural space for birthweight suggests that benefits can be experienced near to as well as within natural space. Ensuring expectant mothers have good access to high quality neighbourhood natural space has the potential to improve the infant's start in life, and consequently their health trajectory over the life course.

The role of public and private natural space in children's social, emotional and behavioural development in Scotland: A longitudinal study.

INTRODUCTION: Poor mental health in childhood has implications for health and wellbeing in later life. Natural space may benefit children's social, emotional and behavioural development. We investigated whether neighbourhood natural space and private garden access were related to children's developmental change over time. We asked whether relationships differed between boys and girls, or by household educational status. METHODS: We analysed longitudinal data for 2909 urban-dwelling children (aged 4 at 2008/9 baseline) from the Growing Up in Scotland (GUS) survey. The survey provided social, emotional and behavioural difficulty scores (Strengths and Difficulties Questionnaire (SDQ)), and private garden access. Area (%) of total natural space and parks within 500m of the child's home was quantified using Scotland's Greenspace Map. Interactions for park area, total natural space area, and private garden access with age and age2 were modelled to quantify their independent contributions to SDQ score change over time. RESULTS: Private garden access was strongly related to most SDQ domains, while neighbourhood natural space was related to better social outcomes. We found little evidence that neighbourhood natural space or garden access influenced the trajectory of developmental change between 4 and 6 years, suggesting that any beneficial influences had occurred at younger ages. Stratified models showed the importance of parks for boys, and private gardens for the early development of children from low-education households. CONCLUSION: We conclude that neighbourhood natural space may reduce social, emotional and behavioural difficulties for 4-6 year olds, although private garden access may be most beneficial.

Multi-scalar influences on mortality change over time in 274 European cities.

Understanding determinants of urban health is of growing importance. Factors at multiple scales intertwine to influence health in cities but, with the growing autonomy of some cities from their countries, city population health may be becoming more a matter for city-level rather than national-level policy and action. We assess the importance of city, country, and macroregional (Western and East-Central Europe) scales to mortality change over time for 274 cities (population 80 million) from 27 European countries. We then investigate whether mortality changes over time are related to changes in city-level affluence. Using Urban Audit data, all-age all-cause standardised mortality ratios (SMRs) for males and females were calculated at three time points (wave one 1999-2002, wave two 2003-2006, and wave three 2007-2009) for each city. Multilevel regression was used to model the SMRs as a function of survey wave and city region gross domestic product (GDP) per 1000 capita. SMRs declined over time and the substantial East-West gap narrowed slightly. Variation at macroregion and country scales characterised SMRs for women in Western and East-Central European cities, and SMRs for men in East-Central European cities. Between-city variation was evident for male SMRs in Western Europe. Changes in city-region GDP per capita were not associated with changes in mortality over the study period. Our results show how geographical scales differentially impact urban mortality. We conclude that changes in urban health should be seen in both city and wider national and macroregional contexts.