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.

Neighbourhood deprivation across eight decades and late-life cognitive function in the Lothian Birth Cohort 1936: a life-course study.

INTRODUCTION: although neighbourhood may predict late-life cognitive function, studies mostly rely on measurements at a single time point, with few investigations applying a life-course approach. Furthermore, it is unclear whether the associations between neighbourhood and cognitive test scores relate to specific cognitive domains or general ability. This study explored how neighbourhood deprivation across eight decades contributed to late-life cognitive function. METHODS: data were drawn from the Lothian Birth Cohort 1936 (n = 1,091) with cognitive function measured through 10 tests at ages 70, 73, 76, 79 and 82. Participants' residential history was gathered with 'lifegrid' questionnaires and linked to neighbourhood deprivation in childhood, young adulthood and mid-to-late adulthood. Associations were tested with latent growth curve models for levels and slopes of general (g) and domain-specific abilities (visuospatial ability, memory and processing speed), and life-course associations were explored with path analysis. RESULTS: higher mid-to-late adulthood neighbourhood deprivation was associated with lower age 70 levels (ß = -0.113, 95% confidence intervals [CI]: -0.205, -0.021) and faster decline of g over 12 years (ß = -0.160, 95%CI: -0.290, -0.031). Initially apparent findings with domain-specific cognitive functions (e.g. processing speed) were due to their shared variance with g. Path analyses suggested that childhood neighbourhood disadvantage is indirectly linked to late-life cognitive function through lower education and selective residential mobility. CONCLUSIONS: to our knowledge, we provide the most comprehensive assessment of the life-course neighbourhood deprivation and cognitive ageing relationship. Living in advantaged areas in mid-to-late adulthood may directly contribute to better cognitive function and slower decline, whereas an advantaged childhood neighbourhood likely affects functioning through cognitive reserves.

Association of Life-Course Neighborhood Deprivation With Frailty and Frailty Progression From Ages 70 to 82 Years in the Lothian Birth Cohort 1936.

Neighborhood features have been postulated to be key predictors of frailty. However, evidence is mainly limited to cross-sectional studies without indication of long-term impact. We explored how neighborhood social deprivation (NSD) across the life course is associated with frailty and frailty progression among older Scottish adults. Participants (n = 323) were persons selected from the Lothian Birth Cohort 1936 with historical measures of NSD in childhood (1936-1955), young adulthood (1956-1975), and mid- to late adulthood (1976-2014). Frailty was measured 5 times between the ages of 70 and 82 years using the Frailty Index. Confounder-adjusted life-course models were assessed using a structured modeling approach; associations were estimated for frailty at baseline using linear regression and for frailty progression using linear mixed-effects models. Accumulation was the most appropriate life-course model for males; greater accumulated NSD was associated with higher frailty at baseline (b = 0.017, 95% confidence interval: 0.005, 0.029). Among females, the mid- to late adulthood sensitive period was the best-fitting life-course model, and higher NSD in this period was associated with widening frailty trajectories (b = 0.005, 95% confidence interval: 0.0004, 0.009). To our knowledge, this is the first investigation of the life-course impact of NSD on frailty in a cohort of older adults. Policies designed to address deprivation and inequalities across the full life course may support healthy aging.

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.

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.

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.

Availability and promotion of alcohol across different outlet typologies and under different area-level socioeconomic status. / Disponibilidad y promoción de alcohol según la tipología de los locales y las condiciones socioeconómicas del área.

We aimed to characterize the availability and promotion of alcohol at alcohol outlets in Madrid and to compare them according to type of outlet and area-level socioeconomic status. We used the OHCITIES instrument to characterise the alcohol outlets in 42 census tracts of Madrid in 2016. We specified alcohol availability as the density of alcohol outlets and the number of alcohol outlets with extended opening hours (12 or more). We registered any type of promotion associated to alcohol outlets that could be perceived from outside the outlet. We calculated and compared proportions of availability and promotion by alcohol outlet (on- and off-premise) using chi-squared and Fisher Exact tests. We estimated the availability and promotion of alcohol densities per census tract according to area-level socioeconomic status. To assess statistical significance, we used Kruskal-Wallis tests. We recorded 324 alcohol outlets, 241 on-premise and 83 off-premise. Most of the outlets had extended opening hours (73.77%) and at least one sign promoting alcohol (89.51%). More on-premise outlets had extended opening hours and higher presence of alcohol promotion than off-premise (p < 0.001). Higher density of alcohol outlets, extended opening hours and presence of alcohol promotion were found in higher socioeconomic areas (all p < 0.001). These results were also observed for on-premise alcohol outlets. Alcohol availability and promotion were associated with alcohol outlets in Madrid. Future alcohol policies regulating the availability and promotion of alcohol should consider outlet types and area-level socioeconomic status.

El objetivo fue caracterizar la disponibilidad y promoción de alcohol asociados a los locales de venta y consumo de alcohol en Madrid, así como explorar las diferencias en su distribución en función de la tipología del local y las características socioeconómicas del área. Se utilizó el instrumento OHCITIES para caracterizar locales situados en 42 secciones censales de Madrid durante 2016. Se registró la densidad de locales y el número de locales con amplios horarios de apertura (12 o más horas). Se registró cualquier tipo de promoción asociada al local visible desde el exterior. Se compararon los porcentajes de características de disponibilidad y promoción asociada a los locales de consumo y venta de alcohol utilizando el test de chi cuadrado y la prueba exacta de Fisher. Se estimó la densidad de disponibilidad y promoción por sección censal y se exploró su distribución en función de las características socioeconómicas del área mediante el test de Kruskal-Wallis. Se registraron 324 locales, 241 de consumo y 83 de venta. La mayoría tenía un horario amplio de apertura (73,77%) y algún elemento promocional (89,51%). Los locales de consumo tenían horarios más amplios de apertura y más elementos promocionales que los de venta (p < 0,001). Se encontraron mayor densidad de locales, amplitud de horarios y elementos promocionales en áreas de nivel socioeconómico alto (todos p < 0,001). La disponibilidad y promoción estuvieron asociadas con los locales de venta y consumo de alcohol en Madrid. Futuras políticas cuyo objetivo sea la prevención del consumo de alcohol deben tener en cuenta la influencia de los tipos de locales y las características socioeconómicas del área en la distribución de la disponibilidad y promoción de alcohol.

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.

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.

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.

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.

Exploring the impact of public health teams on alcohol premises licensing in England and Scotland (ExILEnS): procotol for a mixed methods natural experiment evaluation.

BACKGROUND: Recent regulatory changes in the system by which premises are licensed to sell alcohol, have given health representatives a formal role in the process in England and Scotland. The degree to which local public health teams engage with this process varies by locality in both nations, which have different licensing regimes. This study aims to critically assess the impact on alcohol-related harms - and mechanisms - of public health stakeholders' engagement in alcohol premises licensing from 2012 to 2018, comparing local areas with differing types and intensities of engagement, and examining practice in Scotland and England. METHODS: The study will recruit 20 local authority areas where public health stakeholders have actively engaged with the alcohol premises licensing system (the 'intervention') and match them to a group of 20 lower activity areas using genetic matching. Four work packages are included: (1) Structured interviews and documentary analysis will examine the type and level of intervention activity from 2012 to 2018, creating a novel composite measure of the intensity of such activity and will assess the local licensing system and potential confounding activities over the same period. In-depth interviews with public health, licensing, police and others will explore perceived mechanisms of change, acceptability, and impact. (2) Using longitudinal growth models and time series analyses, the study will evaluate the impact of high and low levels of activity on alcohol-related harms using routine data from baseline 2009 to 2018. (3) Intervention costs, estimated National Health Service cost savings and health gains will be evaluated using the Sheffield Alcohol Policy Model to estimate impact on alcohol consumption and health inequalities. (4) The study will engage public health teams to create a new theory of change for public health involvement in the licensing process using our data. We will share findings with local, national and international stakeholders. DISCUSSION: This interdisciplinary study examines, for the first time, whether and how public health stakeholders' involvement in alcohol licensing impacts on alcohol harms. Using mixed methods and drawing on complex systems thinking, it will make an important contribution to an expanding literature evaluating interventions not suited to traditional epidemiological research.

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.

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.

The relationship between wealth and loneliness among older people across Europe: Is social participation protective?

OBJECTIVE: 1. Examine the relationship between household wealth, social participation and loneliness among older people across Europe. 2. Investigate whether relationships vary by type of social participation (charity/volunteer work, sports/social clubs, educational/training course, and political/community organisations) and gender. 3. Examine whether social participation moderates the association between wealth and loneliness. METHODS: Data (N=29,795) were taken from the fifth wave of the Survey of Health, Ageing and Retirement in Europe (SHARE), which was collected during 2013 from 14 European countries. Loneliness was measured using the short version of the Revised-University of California, Los Angeles (R-UCLA) Loneliness Scale. We used multilevel logistic models stratified by gender to examine the relationships between variables, with individuals nested within countries. RESULTS: The risk of loneliness was highest in the least wealthy groups and lowest in the wealthiest groups. Frequent social participation was associated with a lower risk of loneliness and moderated the association between household wealth and loneliness, particularly among men. Compared to the wealthiest men who often took part in formal social activities, the least wealthy men who did not participate had greater risk of loneliness (OR=1.91, 95% CI: 1.44 to 2.51). This increased risk was not observed among the least wealthy men who reported frequent participation in formal social activities (OR=1.12, 95% CI: 0.76 to 1.67). CONCLUSION: Participation in external social activities may help to reduce loneliness among older adults and potentially acts as a buffer against the adverse effects of socioeconomic disadvantage.

Tobacco Retail Environments and Social Inequalities in Individual-Level Smoking and Cessation Among Scottish Adults.

INTRODUCTION: Many neighborhood characteristics may constrain or enable smoking. This study investigated whether the neighborhood tobacco retail environment was associated with individual-level smoking and cessation in Scottish adults, and whether inequalities in smoking status were related to tobacco retailing. METHODS: Tobacco outlet density measures were developed for neighborhoods across Scotland using the September 2012 Scottish Tobacco Retailers Register. The outlet data were cleaned and geocoded (n = 10,161) using a Geographic Information System. Kernel density estimation was used to calculate an outlet density measure for each postcode. The kernel density estimation measures were then appended to data on individuals included in the 2008-2011 Scottish Health Surveys (n = 28,751 adults aged ≥16), via their postcode. Two-level logistic regression models examined whether neighborhood density of tobacco retailing was associated with current smoking status and smoking cessation and whether there were differences in the relationship between household income and smoking status, by tobacco outlet density. RESULTS: After adjustment for individual- and area-level confounders, compared to residents of areas with the lowest outlet densities, those living in areas with the highest outlet densities had a 6% higher chance of being a current smoker, and a 5% lower chance of being an ex-smoker. There was little evidence to suggest that inequalities in either current smoking or cessation were narrower in areas with lower availability of tobacco retailing. CONCLUSIONS: The findings suggest that residents of environments with a greater availability of tobacco outlets are more likely to start and/or sustain smoking, and less likely to quit.

Are migration patterns and mortality related among European regions?

Geographical inequalities in mortality across Europe may be influenced by migration between regions. The relationship between age- and sex-standardised death rates, 2008-2010, and population change resulting from migration 2000-2010, was analysed in 250 'Nomenclature of Statistical Territorial Units' (NUTS) level 2 regions in 26 European countries. Across Europe death rates were significantly higher in regions experiencing population loss. This association continued after adjustment for 2005 household income among all regions and Western regions but not among Eastern areas. This analysis suggests migration could contribute to Europe's persistent inequalities in mortality, and highlights the problems of Eastern regions with the highest death rates, lowest incomes and declining populations.

Social protection spending and inequalities in depressive symptoms across Europe.

PURPOSE: Common mental disorders are an increasing global public health concern. The least advantaged in society experience a greater burden of mental illness, but inequalities in mental health vary by social, political, and economic contexts. This study investigates whether spending on different types of social protection alters the extent of social inequality in depressive symptoms. METHODS: Data were obtained from the 2006 and 2012 cross-sectional waves of the European Social Survey, which included 48,397 individuals from 18 European countries. Depressive symptoms were measured using the Centre for Epidemiologic Studies-Depression Scale (CES-D 8). Statistical interactions between country-level social protection spending and individuals' education level, employment and family status were explored using multilevel regression models. RESULTS: Higher spending on active labour market programmes was related to narrower inequality in depressive symptoms by education level. Compared to men with high education, the marginal effect of having low education was 1.67 (95 % CI, 1.46-1.87) among men in countries with lower spending and 0.85 (95 % CI, 0.66-1.03) in higher spending countries. Single parents exhibited fewer depressive symptoms, as spending on family policies increased. Little evidence was found for an overall association between spending on unemployment benefits and employment-related inequalities in depressive symptoms, but in 2012, unemployment spending appeared beneficial to mental health among the unemployed. CONCLUSIONS: Greater investment in social protection may act to reduce inequalities in depressive symptoms. Reductions in spending levels or increased conditionality may adversely affect the mental health of disadvantaged social groups.

Are income-related differences in active travel associated with physical environmental characteristics? A multi-level ecological approach.

BACKGROUND: Rates of active travel vary by socio-economic position, with higher rates generally observed among less affluent populations. Aspects of both social and built environments have been shown to affect active travel, but little research has explored the influence of physical environmental characteristics, and less has examined whether physical environment affects socio-economic inequality in active travel. This study explored income-related differences in active travel in relation to multiple physical environmental characteristics including air pollution, climate and levels of green space, in urban areas across England. We hypothesised that any gradient in the relationship between income and active travel would be least pronounced in the least physically environmentally-deprived areas where higher income populations may be more likely to choose active transport as a means of travel. METHODS: Adults aged 16+ living in urban areas (n = 20,146) were selected from the 2002 and 2003 waves of the UK National Travel Survey. The mode of all short non-recreational trips undertaken by the sample was identified (n = 205,673). Three-level binary logistic regression models were used to explore how associations between the trip being active (by bike/walking) and three income groups, varied by level of multiple physical environmental deprivation. RESULTS: Likelihood of making an active trip among the lowest income group appeared unaffected by physical environmental deprivation; 15.4% of their non-recreational trips were active in both the least and most environmentally-deprived areas. The income-related gradient in making active trips remained steep in the least environmentally-deprived areas because those in the highest income groups were markedly less likely to choose active travel when physical environment was 'good', compared to those on the lowest incomes (OR = 0.44, 95% CI = 0.22 to 0.89). CONCLUSIONS: The socio-economic gradient in active travel seems independent of physical environmental characteristics. Whilst more affluent populations enjoy advantages on some health outcomes, they will still benefit from increasing their levels of physical activity through active travel. Benefits of active travel to the whole community would include reduced vehicle emissions, reduced carbon consumption, the preservation or enhancement of infrastructure and the presentation of a 'normalised' behaviour.

A cross-sectional analysis of the relationship between tobacco and alcohol outlet density and neighbourhood deprivation.

BACKGROUND: There is a strong socio-economic gradient in both tobacco-and alcohol-related harm. One possible factor contributing to this social gradient may be greater availability of tobacco and alcohol in more socially-deprived areas. A higher density of tobacco and alcohol outlets is not only likely to increase supply but also to raise awareness of tobacco/alcohol brands, create a competitive local market that reduces product costs, and influence local social norms relating to tobacco and alcohol consumption. This paper examines the association between the density of alcohol and tobacco outlets and neighbourhood-level income deprivation. METHODS: Using a national tobacco retailer register and alcohol licensing data this paper calculates the density of alcohol and tobacco retail outlets per 10,000 population for small neighbourhoods across the whole of Scotland. Average outlet density was calculated for neighbourhoods grouped by their level of income deprivation. Associations between outlet density and deprivation were analysed using one way analysis of variance. RESULTS: There was a positive linear relationship between neighbourhood deprivation and outlets for both tobacco (p <0.001) and off-sales alcohol (p <0.001); the most deprived quintile of neighbourhoods had the highest densities of both. In contrast, the least deprived quintile had the lowest density of tobacco and both off-sales and on-sales alcohol outlets. CONCLUSIONS: The social gradient evident in alcohol and tobacco supply may be a contributing factor to the social gradient in alcohol- and tobacco-related disease. Policymakers should consider such gradients when creating tobacco and alcohol control policies. The potential contribution to public health, and health inequalities, of reducing the physical availability of both alcohol and tobacco products should be examined in developing broader supply-side interventions.