Changes in Retail Tobacco Product Availability Following a Chicago City Ordinance Restricting Sales of Menthol and Other Flavored Tobacco Products Near Schools.

BACKGROUND: In April 2016, the City of Chicago implemented an ordinance restricting the sale of all flavored (including menthol) tobacco products (FTPs), including electronic cigarettes, at retailers located within 500 feet of any public, private, or alternative elementary, middle ("primary"), or high ("secondary") school. We examined changes in retail availability of FTPs from before to after policy implementation among policy-affected retailers compared with retailers not subject to the policy. METHOD: Observational data were collected in June to September 2015 (Wave 1; pre-policy) and November to December 2016 (Wave 2; post-policy) from a panel of 194 randomly selected policy-area stores (located within 500 feet of a school), and a panel of 199 randomly selected comparison-area stores (located more than 500 feet from a school). Using generalized estimation equation regression, we assessed differences in FTP availability changes across study areas. RESULTS: We observed a statistically significant policy effect on FTP availability (Area × Wave interaction, p < .05); however, more than half of policy-area retailers continued to display at least one FTP after policy implementation (87.11% at Wave 1, 57.73% at Wave 2, p < .05). Similar reductions were seen for the availability of flavored cigarillos/little cigars and menthol cigarettes, while policy effects varied across store types. DISCUSSION: FTP availability reductions appear to be associated with policy implementation, but FTPs remained readily available at retailers subject to the policy. This study contributes to the evidence base indicating that policies with exclusions or exemptions for certain flavors, products, store types, or retailer locations have a limited effect on retail availability of FTPs.

Association of Playground "Playability" With Physical Activity and Energy Expenditure.

INTRODUCTION: Children's physical activity, especially play, is important for healthy physical, social, and psychological development. Playgrounds are public spaces for children, but not all playgrounds are conducive to play and physical activity. We examined "playability," the ability of a space to promote active play, and associations with moderate-to-vigorous physical activity (MVPA) and energy expenditure. METHODS: This cross-sectional study assessed playground features with the Play Space Audit Tool; we calculated playability scores from audit data, overall and by domain (general amenities, surface, path, and play structure), from playgrounds in 70 parks in Chicago, Illinois, in 2017. We observed 2,712 individuals during the audits and used the System for Observing Play and Recreation in Communities tool to assess MVPA and energy expenditure. We used generalized estimating equation negative binomial regression to calculate incidence rate ratios for MVPA and mixed effects models to calculate energy expenditure (in kcal/kg/min) associated with playability scores. RESULTS: General amenities and play structure scores were associated with 1.28 (95% CI, 1.08-1.52) and 1.15 (95% CI, 1.00-1.31) times as many individuals (any age) engaged in MVPA, respectively. The general amenities score was significantly associated with 0.51 (95% CI, 0.24-0.79) and 0.42 (95% CI, 0.15-0.68) higher energy expenditure in renovated playgrounds and in all playgrounds, respectively. CONCLUSION: Overall, general amenities and play structure scores were associated with MVPA and were robust to adjustment for weather, neighborhood socioeconomic characteristics, and crime. These playground playability indices may strengthen future evaluations of community infrastructure for children's physical activity.

Active living-oriented zoning codes and cardiometabolic conditions across the lifespan.

Environments that make it easier for people to incorporate physical activity into their daily life may help to reduce high rates of cardiometabolic conditions. Local zoning codes are a policy and planning tool to create more walkable and bikeable environments. This study evaluated relationships between active living-oriented zoning code environments and cardiometabolic conditions (body mass index, hyperlipidemia, hypertension). The study used county identifiers to link electronic health record and other administrative data for a sample of patients utilizing primary care services between 2012 and 2016 with county-aggregated zoning code data and built environment data. The analytic sample included 7,441,991 patients living in 292 counties in 44 states. Latent class analysis was used to summarize municipal- and unincorporated county-level data on seven zoning provisions (e.g., sidewalks, trails, street connectivity, mixed land use), resulting in classes that differed in strength of the zoning provisions. Based on the probability of class membership, counties were categorized as one of four classes. Linear and logistic regression models estimated cross-sectional associations with each cardiometabolic condition. Models were fit separately for youth (aged 5-19), adults (aged 20-59), and older adults (aged 60+). Little evidence was found that body mass index in youth, adults, or older adults or the odds of hyperlipidemia or hypertension in adults or older adults differed according to the strength of active living-oriented zoning. More research is needed to identify the health impacts of zoning codes and whether alterations to these codes would improve population health over the long term.

Examining the Implementation of Activity-Friendly Zoning and Land Use Policies Through the Use of Google Street View Measures: A Pilot Study.

INTRODUCTION: Pedestrian-oriented zoning and land use policies are being used by local jurisdictions as tools to implement population-level built environmental changes to create more walkable communities. There is a paucity of evidence examining whether these policies lead to actual changes in the built environment. We used Google Street View (GSV), an established, less expensive, alternative built environment data collection method, to conduct an exploratory pilot study of 19 jurisdictions to examine associations between variations in the presence of these adopted zoning policies and their corresponding specific street-level built environment features. METHODS: Samples of 10 large and 9 small jurisdictions (18 municipalities and 1 county) were purposively selected on the basis of the presence of activity-friendly zoning policy provisions (sidewalks, crosswalks, bike-pedestrian connectivity, street connectivity, trails/paths, bike lanes, bike parking, and other items). Corresponding activity-friendly street-level built environment measures were constructed using GSV. Street segments in these jurisdictions were sampled using ArcGIS and stratified by type (residential and arterial) and income (high, medium, and low). RESULTS: A total of 4363 street segments were audited across the 19 sampled jurisdictions. Results show significant differences in the presence of activity-friendly street features when the corresponding zoning policy element was addressed in New Urbanist zones/districts in the site's zoning code (eg, crosswalks, 24.48% vs 16.18%; and bike lanes, 12.60% vs 7.14%). Street segments in the middle- and high-income block groups were less likely to have activity-friendly features than low-income segments, except bike lanes. CONCLUSIONS: Results show that having activity-friendly policy provisions embedded in a jurisdiction's (municipality/county) zoning codes was associated with a greater presence of the corresponding built environmental street feature on the ground. Results suggest that the methods tested in this article may be a useful policy tool for local governments to identify high need areas that should be prioritized for built environment improvements.

Racial/ethnic and educational differences in perceptions and use of a new urban trail.

ABSTRACTObjectives: Obesity and its associated health risks are on the rise throughout the US due, in part, to an overall decline in physical activity. Although public green spaces, and in particular trails, show promise as population-level interventions to promote physical activity among adults, these amenities may have disparate impacts across racial/ethnic and socioeconomic groups within a community.Design: This cross-sectional study employed an intercept survey of users of a newly opened $95 million rail-to-trail development in Chicago, IL, immediately after its opening and one year later to examine differences by race/ethnicity and educational attainment in trail use behaviors, motivations for trail use, safety concerns, and change in physical activity attributed to the trail.Results: Although the overall impact of the trail was positive, Latino users were more likely to report frequent use (4+ times/week), health motivations for using the trail, and increased physical activity attributed to the trail. However, Latino users were also more likely to indicate safety concerns and less likely to use areas of the trail in predominately white communities, even after controlling for community of residence. The least educated trail users frequented fewer trail areas and were less likely to indicate health motivations for trail use.Conclusions: Although urban trails represent an opportunity for cost-effective community-wide health promotion, they may not benefit all groups equally. Urban trails may have particularly promising benefits for Latino users, but safety concerns and the possibility of community racial segregation being replicated on trails should be addressed to maximize and sustain these benefits. Less educated residents in particular may not benefit from such projects as intended.

Did Playground Renovations Equitably Benefit Neighborhoods in Chicago?

Between 2013 and 2016, the Chicago Park District renovated 327 playgrounds in need of repair across Chicago through a $44 million investment. This study evaluated whether short-term and longer-term impacts of renovations on park use and park-based moderate-to-vigorous physical activity (MVPA) differed by neighborhood income level and neighborhood concentration of Black residents. A total of 39 parks with renovated playgrounds and 39 matched comparison parks with playgrounds that needed repair but not selected for renovation in year 1 were studied. Three waves of observational data were collected at each park: baseline, 12 months post-renovation, and 24 months post-renovation. Difference-in-differences mixed-effects Poisson regression models estimated renovation effects. The effects of renovations differed by the income level and concentration of Black residents in the neighborhoods where parks were located. In low-income neighborhoods, renovations were associated with reductions in park use and park-based MVPA over the longer term. In contrast, renovations were associated with short- and longer-term increases in park use and park-based MVPA in medium-income neighborhoods and with longer-term increases in MVPA in high-income neighborhoods. Renovations were generally not associated with any changes in park use or park-based MVPA in high-percent Black neighborhoods, but they were associated with increased park use and park-based MVPA in low-percent Black neighborhoods. This study suggests playground renovations in Chicago may have had unintended consequences, increasing neighborhood income and racial disparities in park use and park-based MVPA. Future playground renovation efforts may need to allocate more resources for renovating the broader park where in disrepair, more intensely involve neighborhood residents, and employ complementary strategies such as additional park programming to ensure renovations benefit all neighborhoods.

Alcohol excise taxes as a percentage of retail alcohol prices in 26 OECD countries.

BACKGROUND: Many countries have implemented alcohol excise taxes. However, measures of excise taxes as a percentage of alcohol prices have not been systematically studied. METHODS: Data on the retail prices of alcoholic beverages sold in stores and excise taxes in 26 countries during 2003-2018 was from the Economist Intelligence Unit price city data and the Organization for Economic Co-operation and Development (OECD) tax database. The percentages of excise taxes in off-premise retail prices were derived as the ratio of taxes to prices at different price levels. Changes of excise taxes over time were assessed using negative binominal regressions. RESULTS: The percentage of excise taxes in average off-premise alcohol prices was from 5 % in Luxembourg to 59 % in Iceland for beer, and from 0 % in France to 26 % in Iceland for wine. Excise taxes accounted for 5% of discount liquor prices in Czech Republic to 41 % in Sweden for Cognac, for 19 % in the United States (US) to 67 % in Sweden for Gin, for 13 % in the US to 63 % in Australia for Scotch Whisky six years old, and for 6 % in Iceland to 76 % in Sweden for Liqueur Cointreau. There were no significant changes in the percentage of excise taxes in alcohol prices over time in most countries except for Nordic countries. While wine had the lowest excise taxes, liquors had the highest tax burden. CONCLUSION: Tax burden on alcoholic beverages is low in OECD countries, indicating ample room for increasing alcohol excise taxes, particularly for beer and wine in those countries.

Encouraging "Active Learning": Assessing Implementation of Head Start's Physical Activity Requirements Within the Teaching and Learning Environment.

BACKGROUND: Head Start serves over 1 million diverse low-income preschool children and is an ideal setting for developing and implementing obesity prevention efforts, which is expected to have positive impacts on behavior as youth age. This study examined how regional- and state-level Head Start offices have supported implementation of the recently updated physical activity (PA) requirement within the teaching and learning environment Head Start Program Performance Standard (1302.31). METHODS: Key informant telephone interviews were conducted with 8 regional- and 36 state-level Head Start representatives. Interviews were recorded and professionally transcribed. Data were coded and analyzed using constant comparative methods in ATLAS.ti (version 8). Audit trails were maintained, and disagreements in codes were discussed and resolved among coders. RESULTS: The following 3 overarching themes emerged: communication, resources and technical assistance, and challenges. Results showed variation in respondent knowledge regarding the Standards. Although regional contacts provide technical assistance, state-level contacts have many information sharing strategies for programs. Implementation challenges included the need for frequent professional development opportunities given staff turnover and low PA competency, and additional PA curricula. CONCLUSION: Findings can help identify existing or potential strategies that could be adopted more widely or developed to assist Head Start programs incorporate PA into daily activities.

Recommendations for Keeping Parks and Green Space Accessible for Mental and Physical Health During COVID-19 and Other Pandemics.

The importance of engaging in any type of physical activity regularly, for both physical and mental health, is well established, and may be particularly beneficial in protecting the body and limiting the damage caused by the coronavirus disease 2019 (COVID-19). Exposure to nature or green space also has positive physical and mental health benefits. Closures of parks and green spaces during the COVID-19 pandemic has limited the options for physical activity and may affect vulnerable populations more than others. We provide both short-term and long-term recommendations to encourage access to green space for people while allowing for physical distancing.

Neighborhood Walkability and BMI Change: A National Study of Veterans in Large Urban Areas.

OBJECTIVE: Improving neighborhood walkability has been proposed as a policy intervention to reduce obesity. The objective of this study was to evaluate longitudinal relationships between neighborhood walkability and body weight among adults living in large urban areas. METHODS: In this retrospective longitudinal study of United States military veterans using Department of Veterans Affairs health care, Veterans Affairs clinical and administrative data (2007-2014) were linked to environmental measures constructed from public (2006-2014) and proprietary (2008-2014) sources, and linear regression models with person fixed effects were used to estimate associations between walkability and BMI among 758,434 men and 70,319 women aged 20 to 80 years in 2009 to 2014. RESULTS: Neighborhood walkability was associated with small reductions in BMI. Effects were most pronounced among men aged 30 to 49 and 50 to 64. For women, differences were largest in the two youngest age groups, 20 to 29 and 30 to 49, though only estimates for all women combined were statistically significant. For women aged 30 to 49, effect sizes grew when the sample was limited to those who remained in the same neighborhood during the entire follow-up period. CONCLUSIONS: Investments in the built environment to improve walkability may be a useful strategy for weight control in some segments of the adult population.

Development and Testing of a Brief Play Space Audit Tool.

BACKGROUND: Spaces that promote play are important for the physical, social, and psychological growth of children. Public spaces, including playgrounds, provide an important venue for children to engage in play. A simple tool is needed to evaluate playground features and conditions. METHODS: A simple play space audit instrument to assess the presence and condition of playground features was tested on a sample of 70 playgrounds during the summer of 2017, in Chicago, IL. Duplicate observations were collected on 17 playgrounds. Frequencies of features were tabulated, and reliability of variables was assessed using percent agreement and kappa statistic. Scores were created to summarize playground "playability," overall and within domains of general overview, surface, path, and play equipment/structure features. RESULTS: The tool demonstrated acceptable reliability with high kappa values between .79 and .90 for all items in domains. The overall score, general overview score, and play equipment/structure scores were correlated with mean playground usage. CONCLUSIONS: This brief instrument allows reliable assessment of playground features and their conditions. The scoring method generates a summary of playground conditions and features, which facilitates comparison of playgrounds. This tool has the potential to assist communities in evaluating their play spaces and identifying where to focus resources for improvements.

Does the built environment influence the effectiveness of behavioral weight management interventions?

Outcomes of behavioral lifestyle interventions for promoting weight loss vary widely across participants. The effectiveness of a weight management intervention may depend on a person's environmental context. This study compared short- and longer-term effects of a structured nationwide weight management program for people living in neighborhoods with different levels of walkability and different access to recreational places (parks, fitness facilities). Drawing on the health production model, we tested competing hypotheses for whether treatment effects of the program complement environmental supports or substitute for environmental constraints. We studied the US Department of Veterans Affairs (VA) MOVE! weight management program using VA electronic heath record data (2009-2014) and a difference-in-differences design with an inverse propensity score matched comparison group. A total of 114,256 program participants and 498,494 non-participants comprised the sample. Built environment features were measured within one-mile of each person's home. We estimated program effects on body mass index (BMI) for subgroups with different built environments at 6-, 12-, 18-, and 24-month follow-up using linear regressions with person and year fixed effects. At 6 months, the program reduced BMI by 0.4-0.6 kg/m2 among men and 0.3-0.5 kg/m2 among women. The effect diminished at 12, 18, and 24 months. The program effect did not vary significantly across subgroups with different walkability, park access, or fitness facility access. The MOVE! program was not sensitive to environmental context. Results did not lend support to either hypothesis that the MOVE! program complements or substitutes for a person's built environment to affect weight management outcomes.

Would increasing access to recreational places promote healthier weights and a healthier nation?

Addressing gaps in evidence on causal associations, this study tested the hypothesis that better access to recreational places close to home helps people to maintain lower body mass index (BMI) using a retrospective longitudinal study design and up to 6 years of data for the same individuals (1,522,803 men and 183,618 women). Participants were military veterans aged 20-64 who received healthcare through the U.S. Department of Veterans Affairs in 2009-2014 and lived in a metropolitan area. Although there were cross-sectional associations, we found no longitudinal evidence that access to parks and fitness facilities was associated with BMI for either men or women in the full sample or in subgroups of residential movers and stayers. Our findings suggest that simply increasing the number of parks and fitness facilities may not be enough to achieve needed population-level reductions in weight.

Weight and Veterans' Environments Study (WAVES) I and II: Rationale, Methods, and Cohort Characteristics.

PURPOSE: To present the rationale, methods, and cohort characteristics for 2 complementary "big data" studies of residential environment contributions to body weight, metabolic risk, and weight management program participation and effectiveness. DESIGN: Retrospective cohort. SETTING: Continental United States. PARTICIPANTS: A total of 3 261 115 veterans who received Department of Veterans Affairs (VA) health care in 2009 to 2014, including 169 910 weight management program participants and a propensity score-derived comparison group. INTERVENTION: The VA MOVE! weight management program, an evidence-based lifestyle intervention. MEASURES: Body mass index, metabolic risk measures, and MOVE! participation; residential environmental attributes (eg, food outlet availability and walkability); and MOVE! program characteristics. ANALYSIS: Descriptive statistics presented on cohort characteristics and environments where they live. RESULTS: Forty-four percent of men and 42.8% of women were obese, whereas 4.9% of men and 9.9% of women engaged in MOVE!. About half of the cohort had at least 1 supermarket within 1 mile of their home, whereas they averaged close to 4 convenience stores (3.6 for men, 3.9 for women) and 8 fast-food restaurants (7.9 for men, 8.2 for women). Forty-one percent of men and 38.6% of women did not have a park, and 35.5% of men and 31.3% of women did not have a commercial fitness facility within 1 mile. CONCLUSION: Drawing on a large nationwide cohort residing in diverse environments, these studies are poised to significantly inform policy and weight management program design.

Neighborhood Resources to Support Healthy Diets and Physical Activity Among US Military Veterans.

INTRODUCTION: Among the nearly 21 million military veterans living in the United States, 64.0% of women and 76.1% of men are overweight or obese, higher rates than in the civilian population (56.9% of women and 69.9% of men). Attributes of the residential environment are linked to obesity. The objective of this study was to characterize the residential environments of the US veteran population with respect to availability of food and recreational venues. METHODS: We used American Community Survey data to determine the concentration of veterans (the percentage of veterans among the adult population) in all continental US census tracts in 2013, and we used proprietary data to construct measures of availability of food and recreational venues per census tract. Using descriptive statistics and ordinary least-squares regression, we examined associations between the concentration of veterans per census tract and those residential environmental features. RESULTS: In census tracts with high concentrations of veterans, residents had, on average, 0.5 (interquartile range, 0-0.8) supermarkets within a 1-mile radius, while residents in census tracts with low concentrations of veterans had 3.2 (interquartile range, 0.6-3.7) supermarkets. Patterns were similar for grocery and convenience stores, fast food restaurants, parks, and commercial fitness facilities. In adjusted analyses controlling for census-tract-level covariates, veteran concentration remained strongly negatively associated with availability of those food and recreational venues. In nonmetropolitan tracts, adjusted associations were greatly attenuated and even positive. CONCLUSION: Where veterans live is strongly associated with availability of food outlets providing healthy (and unhealthy) foods and with recreational venues, raising questions about the contributions of veterans' residential environments to their high obesity rates. Additional research is needed to address those questions.

Pedestrian-oriented zoning is associated with reduced income and poverty disparities in adult active travel to work, United States.

Active travel to work can provide additional minutes of daily physical activity. While the literature points to the relationship between zoning, equity and socioeconomic status, and physical activity, no study has quantitatively explored these connections. This study examined whether zoning may help to moderate any income and poverty inequities in active travel and taking public transit to work. Research was conducted between May 2012 and June 2015. Zoning data were compiled for 3914 jurisdictions covering 45.45% of the U.S. population located in 471 of the most populous U.S. counties and 2 consolidated cities located in 48 states and the District of Columbia. (Sensitivity analyses also captured unincorporated areas which, with the municipalities, collectively covered ~72% of the U.S. POPULATION: ) Zoning codes were obtained and evaluated to assess the pedestrian-orientation of the zoning codes. Public transit use, active travel to work, median household income, and poverty data were obtained for all study jurisdictions from the 2010-2014 American Community Survey estimates. Associations were examined through multivariate regression models, controlling for community sociodemographics, clustered on county, with robust standard errors. We found that certain pedestrian-oriented zoning provisions (e.g., crosswalks, bike-pedestrian connectivity, street connectivity, bike lanes, bike parking, and more zoning provisions) were associated with reduced income and/or poverty disparities in rates of public transit use and active travel to work. Findings from this study can help to inform cross-sectoral collaborations between the public health, planning, and transportation fields regarding zoning for pedestrian-orientation and active travel.

More Active Living-oriented County and Municipal Zoning is Associated with Increased Adult Leisure Time Physical Activity-United States, 2011.

Although zoning is recognized for its role in facilitating healthy communities, no study has examined whether active living-oriented zoning codes are associated with adult leisure time physical activity (PA). This study sought to fill this gap and hypothesized that adult leisure time PA would be greater in communities with more progressive zoning code reforms and more active living-oriented zoning. Zoning codes for 1,617 county and municipal jurisdictions located in 30 states (covering ~40% of the U.S. population) were evaluated for code reform zoning and 11 active living markers. County-aggregated zoning measures were created for linking with five adult PA behaviors obtained from the 2011 Behavioral Risk Factor Surveillance System controlling for individual and county sociodemographics. Zoning elements most associated with adult PA included requirements for mixed use, active and passive recreation, bike parking/street furniture, and bike-pedestrian trails/paths. This study provides new insights as to the role that zoning can play in facilitating adult PA.

Does Pedestrian Danger Mediate the Relationship between Local Walkability and Active Travel to Work?

BACKGROUND: Environmental and policy factors play an important role in influencing people's lifestyles, physical activity (PA), and risks for developing obesity. Research suggests that more walkable communities are needed to sustain lifelong PA behavior, but there is a need to determine what local built environment features facilitate making being active the easy choice. PURPOSE: This county-level study examined the association between local walkability (walkability and traffic calming scales), pedestrian danger, and the percent of adults who used active transport to work. METHODS: Built environment and PA outcome measures were constructed for the 496 most populous counties representing 74% of the U.S. population. Geographic information system-based walkability scales were constructed and include a census of roads located within the counties using 2011 Navteq data. The pedestrian danger index (PDI) includes data collected from the Fatality Analysis Reporting System 2009-2011, and measures the likelihood of a pedestrian being hit and killed by a vehicle. Four continuous outcome measures were constructed using 2009-2013 American Community Survey county-level 5-year estimates. The measures represent the percentage of workers living in a county who worked away from home and (1) walked to work; (2) biked to work; (3) took public transit; and (4) used any form of active transport. Linear regression and mediation analyses were conducted to examine the association between walkability, PDI, and active transport. Models accounted for clustering within state with robust SEs, and controlled for median household income, families with children in poverty, race, ethnicity, urbanicity, and region. RESULTS: The walkability scale was significantly negatively associated with the PDI (ß = -0.06, 95% CI = -0.111, -0.002). In all models, the PDI was significantly negatively associated with all active travel-related outcomes at the p < 0.01 level. The walkability scale was positively associated with all four outcomes at the p < 0.01 level. Results showed that the significant positive relationship between local walkability and the four active transport outcome measures was partially mediated by the PDI. We found no association between traffic calming, the PDI, and the active transport outcomes. CONCLUSION: Results from this study show that, at the county-level, walkability is associated with active travel, and this association is partially mediated by an index of pedestrian safety.