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Context: Patients with non-malignant, advanced lung diseases (NMALD), such as chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD), experience a high symptom burden over a prolonged period. Involvement of palliative care has been shown to improve symptom management, reduce hospital visits and enhance psychosocial support; however, optimal timing of referral is unknown. Objective: The aim of this study was to identify the stage in the illness trajectory that patients with NMALD are referred to an ambulatory palliative care clinic. Methods: A retrospective chart review was conducted on all patients with NMALD who attended a Supportive Care Clinic (SCC) between March 1, 2017 and March 31, 2019. Results: Thirty patients attended the SCC during the study period. The most common diagnoses included COPD (36.7%), ILD (36.7%), and bronchiectasis (3.3%). At the time of initial consultation, the majority (89.4%) had Medical Research Council (MRC) class 4-5 dyspnea, however, only 1 patient had been prescribed opioids for management of breathlessness. Twenty-six patients had advance care planning discussions in the SCC. Phone appointments were a highly utilized feature of the program as patients had difficulty attending in-person appointments due to frailty and dyspnea. One-half of patients had at least 1 disease-related hospital admission in the previous year. Six patients were referred directly to home palliative care at their initial consultation. Conclusions: Referral to palliative care often occurs at late stages in non-malignant lung disease. Further, opioids for the management of dyspnea are significantly underutilized by non-palliative providers.

Meaningful inclusion of young people’s perceptions and experiences of inequalities is argued to be critical in the development of pro-equity policies. Our study explored young people’s perceptions of what influences their opportunities to be healthy within their local area and their understandings of health inequalities. Three interlinked qualitative focus group discussions, each lasting 90 to 100 min, with the same six groups of young people (n = 42) aged 13–21, were conducted between February and June 2021. Participants were recruited from six youth groups in areas of high deprivation across three geographical locations in England (South Yorkshire, the North East and London). Our study demonstrates that young people understand that health inequalities are generated by social determinants of health, which in turn influence behaviours. They highlight a complex interweaving of pathways between social determinants and health outcomes. However, they do not tend to think in terms of the social determinants and their distribution as resulting from the power and influence of those who create and benefit from health and social inequalities. An informed understanding of the causes of health inequalities, influenced by their own unique generational experiences, is important to help young people contribute to the development of pro-equity policies of the future.

Background Reducing inequalities in health is an enduring global public health challenge. Worryingly in England, inequalities across some groups and places are worsening, highlighted and exacerbated by the Covid-19 pandemic. While there has been growing interest in exploring public understandings of health inequalities, few studies have explored the views of young people. Our study seeks to redress this by exploring young people's perspectives of inequalities in health. Methods Working with existing youth organisations, we recruited young people (aged 13-21) from six youth groups in areas of high deprivation across three geographical locations in England. Each group took part in three interlinked focus groups (n = 18), the majority of which were run online using video conferencing platforms. Focus groups were co-delivered with partnering youth organisations during 2021. They involved participatory concept mapping activities, and the discussion of health related news articles. Results Key themes emerged around young people's perspectives of: i) factors influencing health within their local area; ii) understandings of inequalities in health; and iii) key messages to convey to those with a role in addressing health inequalities at a place level. Conclusions Our study highlights the importance of exploring and understanding young people's perspectives of inequalities in order to better shape policies which are supported by the communities and people they impact. Key messages Young people have a nuanced, experiential understanding of key factors influencing their health and inequalities in health within their local areas. Building upon young people’s understandings of inequalities in health provides opportunities to mobilise support for policies seeking to change the distribution of key social determinants.

Background: Advance care planning (ACP) is a process of reflection and discussion wherein a patient, in consultation with a health-care provider, family, and/or loved ones, clarifies values and treatment preferences and establishes goals, including a plan for end-of-life (EOL) care. Advance care planning encompasses appreciating and understanding illness and treatment options, elucidating patient values and beliefs, and identifying a substitute decision maker (SDM) or designating a power of attorney (POA) for personal care. These discussions have proven to be effective in improving patient–family satisfaction, reducing anxiety regarding EOL care in patients and family members, and improving patient-centered care by empowering patients to direct their care at EOL. However, ACP conversations are often difficult to have due to the sensitive nature of such discussions. Objective: The aim of this study was to determine whether group facilitation for teaching and discussing ACP enhances participants’ understanding of ACP and allows them to feel comfortable and supported when discussing these sensitive issues. Methods: Patients who were registered in North York General Hospital’s (NYGH) pulmonary rehabilitation program from June 2016 until August 2017 were given the opportunity to attend two 1-hour sessions related to ACP. The first session was dedicated to educating patients on ACP, explaining the hierarchy of the SDM and the role of the POA for personal care. The second session, provided a short time later, was devoted to discussions of values, wishes, fears, and trade-offs for future medical and EOL care. These discussions led by the supportive care nurse practitioner and a physician who are members of the NYGH Freeman Palliative Care Team were held in a group-facilitated format. Anonymous feedback forms, including both qualitative and quantitative feedback, were completed by the participants and analyzed. Participants: Analysis of a sample of 30 participants who attended 1 or 2 of the ACP sessions revealed that 21 identified as female and 9 identified as male. The average age of the participants was 76 years. Findings: Participants felt the content was relevant to their needs and were comfortable asking questions with all feedback averages ranging from good to very good. Participants appreciated the opportunity to share their thoughts in an open and interactive format. Conclusion: Discussing issues relevant to ACP, including providing information about ACP, sharing fears, wishes, and tradeoffs, were well-received in a group-support environment. Future studies should assess the impact of ACP group discussion on the individual, such as identifying a POA, having discussions regarding wishes and values with the SDM/POA, and examining the clinical impact of such sessions.

Children and young people (CYP) have suffered challenges to their mental health as a result of the COVID-19 pandemic; effects have been most pronounced on those already disadvantaged. Adopting a whole-school approach embracing changes to school environments, cultures and curricula is key to recovery, combining social and emotional skill building, mental health support and interventions to promote commitment and belonging. An evidence-based response must be put in place to support schools, which acknowledges that the mental health and well-being of CYP should not be forfeited in the drive to address the attainment gap. Schools provide an ideal setting for universal screening of mental well-being to help monitor and respond to the challenges facing CYP in the wake of the pandemic. Research is needed to support identification and implementation of suitable screening methods.

ObjectivesTo explore sociodemographic differences in exposure to advertising for foods and drinks high in fat, salt and sugar (HFSS) and whether exposure is associated with body mass index (BMI).DesignCross-sectional survey.SettingUK.Participants1552 adults recruited to the Kantar Fast Moving Consumer Goods panel for London and the North of England.Outcome measuresSelf-reported advertising exposure stratified by product/service advertised (processed HFSS foods; sugary drinks; sugary cereals; sweet snacks; fast food or digital food delivery services) and advertising setting (traditional; digital; recreational; functional or transport); BMI and sociodemographic characteristics.ResultsOverall, 84.7% of participants reported exposure to HFSS advertising in the past 7 days. Participants in the middle (vs high) socioeconomic group had higher odds of overall self-reported exposure (OR 1.48; 95% CI 1.06 to 2.07). Participants in the low (vs high) socioeconomic group had higher odds of reporting exposure to advertising for three of five product categories (ORs ranging from 1.41 to 1.67), advertising for digital food delivery services (OR 1.47; 95% CI 1.05 to 2.05), traditional advertising (OR 1.44; 95% CI 1.00 to 2.08) and digital advertising (OR 1.50; 95% CI 1.06 to 2.14). Younger adults (18–34 years vs ≥65 years) had higher odds of reporting exposure to advertising for digital food delivery services (OR 2.08; 95% CI 1.20 to 3.59), digital advertising (OR 3.93; 95% CI 2.18 to 7.08) and advertising across transport networks (OR 1.96; 95% CI 1.11 to 3.48). Exposure to advertising for digital food delivery services (OR 1.40; 95% CI 1.05 to 1.88), digital advertising (OR 1.80; 95% CI 1.33 to 2.44) and advertising in recreational environments (OR 1.46; 95% CI 1.02 to 2.09) was associated with increased odds of obesity.ConclusionsExposure to less healthy product advertising was prevalent, with adults in lower socioeconomic groups and younger adults more likely to report exposure. Broader restrictions may be needed to reduce sociodemographic differences in exposure to less healthy product advertising.

Introduction:\ud Applying a complex systems perspective to public health evaluation may increase the relevance and strength of evidence to improve health and reduce health inequalities. In this review of methods, we aimed to: (i) classify and describe different complex systems methods in evaluation applied to public health; and (ii) examine the kinds of evaluative evidence generated by these different methods.\ud \ud Methods:\ud We adapted critical review methods to identify evaluations of public health interventions that used systems methods. We conducted expert consultation, searched electronic databases (Scopus, MEDLINE, Web of Science), and followed citations of relevant systematic reviews. Evaluations were included if they self-identified as using systems- or complexity-informed methods and if they evaluated existing or hypothetical public health interventions. Case studies were selected to illustrate different types of complex systems evaluation.\ud \ud Findings:\ud Seventy-four unique studies met our inclusion criteria. A framework was developed to map the included studies onto different stages of the evaluation process, which parallels the planning, delivery, assessment, and further delivery phases of the interventions they seek to inform; these stages include: 1) theorising; 2) prediction (simulation); 3) process evaluation; 4) impact evaluation; and 5) further prediction (simulation). Within this framework, we broadly categorised methodological approaches as mapping, modelling, network analysis and ‘system framing’ (the application of a complex systems perspective to a range of study designs). Studies frequently applied more than one type of systems method.\ud \ud Conclusions:\ud A range of complex systems methods can be utilised, adapted, or combined to produce different types of evaluative evidence. Further methodological innovation in systems evaluation may generate stronger evidence to improve health and reduce health inequalities in our complex world.

Background:\ud Engaging the community in decisions-making is recognised as important for improving public health, and is\ud recommended in global alcohol strategies, and in national policies on controlling alcohol availability. Yet\ud there is little understanding of how to engage communities to influence decision-making to help reduce\ud alcohol-related harms. We sought to identify and understand mechanisms of community engagement in\ud decision-making concerning the local alcohol environment in England.\ud Methods:\ud We conducted case studies in three local government areas in England in 2018, purposively selected for\ud examples of community engagement in decisions affecting the local alcohol environment. We conducted 20\ud semi-structured interviews with residents, workers, local politicians and local government practitioners, and\ud analysed documents linked to engagement and alcohol decision-making.\ud Results:\ud Four rationales for engaging the community in decision-making affecting the alcohol environment were\ud identified: i) as part of statutory decision-making processes; ii) to develop new policies; iii) as representation\ud on committees; and iv) occurring through relationship building. Many of the examples related to alcohol\ud licensing processes, but also local economy and community safety decision-making. The impact of\ud community inputs on decisions was often not clear, but there were a few instances of engagement\ud influencing the process and outcome of decision-making relating to the alcohol environment.\ud Conclusions:\ud While influencing statutory licensing decision-making is challenging, community experiences of alcoholrelated harms can be valuable ‘evidence’ to support new licensing policies. Informal relationship-building\ud between communities and local government is also beneficial for sharing information about alcohol-related \ud Authors’ accepted manuscript. Accepted for publication by International Journal of Drug Policy in 2020.\ud 3\ud harms and to facilitate future engagement. However, care must be taken to balance the different interests\ud among diverse community actors relating to the local alcohol environment, and extra support is needed for\ud those with least capacity to engage but who face more burden of alcohol-related harms, to avoid\ud compounding existing inequalities.

In January 2014, Mexico introduced a soda tax of 1 Mexican Peso (MXP) per litre. The aim of this paper is to examine the political context out of which this policy emerged, the main drivers for the policy change, and the role of stakeholders in setting the policy agenda and shaping the policy design and outcomes. Thirty-one semi-structured interviews were conducted with key stakeholders, and 145 documents, including peer-reviewed papers, policy briefs, press releases, industry, government, and CSO reports, were analysed. An iterative thematic analysis was conducted based on relevant theories of the policy process using a complementary approach, including Stages Heuristic Model, Policy Triangle Framework, and Multiple Streams Model. Results showed that a major motivation was the new administration seeking funds as they entered government. The soda tax was supported by a key group of legislators, civil society actors and by academics promoting evidence on health effects. However, the policy measure was challenged by the food and beverage industries (F&BI). Non-state actors were both formally and informally involved in setting the agenda, regardless of some of them having opposing interests on the soda tax policy. Approaches used by non-state actors to influence the agenda included: calls for action, marketing strategies, coalition building, challenging evidence, and engaging in public–private partnerships (PPPs). The effectiveness of the soda tax was highly debated and resulted in public polarization, although the framing of the outcomes was instrumental in influencing fiscal policies elsewhere. This study contributes to the debate around implementing fiscal policies for health and how power is exercised and framed in the agenda-setting phase of policy development. The article examines how the F&BI sought to influence the national strategy for obesity prevention. It argues that the experience of the soda tax campaign empowered policy advocates, strengthening national and international civil society networks.

INTRODUCTION: There are increased opportunities for public health practitioners (PHPs) in England to shape alcohol availability and reduce harms through a statutory role in licensing processes in local government. However, how public health can effectively influence alcohol licence decision-making is little understood. METHODS: A mixed methods study was conducted to identify challenges faced by PHPs and mechanisms to strengthen their role. This involved a survey of practitioners across London local authorities (n = 18) and four focus group discussions with a range of licensing stakeholders (n = 36). RESULTS: Survey results indicated a varied picture of workload, capacity to respond to licence applications and levels of influence over decision-making among PHPs in London. Practitioners described a felt lack of status within the licence process, and difficulties using and communicating public health evidence effectively, without a health licensing objective. Strategies considered supportive included engaging with other responsible authorities and developing understanding and relationships over time. CONCLUSIONS: Against political and resource constraints at local and national government levels, pragmatic approaches for strengthening public health influence over alcohol licensing are required, including promoting relationships between stakeholders and offering opportunities for PHPs to share best practice about making effective contributions to licensing.

This study is funded by the NIHR School for Public Health Research (SPHR) (Grant Reference NumberPD-SPH-2015). The National Institute for Health Research (NIHR) School for Public Health Research is a partnership between the Universities of Sheffield; Bristol; Cambridge; Imperial; and University College London; The London School for Hygiene and Tropical Medicine (LSHTM); LiLaC –a collaboration between the Universities of Liverpool and Lancaster; and Fuse -The Centre for Translational Research in Public Health, a collaboration between Newcastle, Durham, Northumbria, Sunderland and Teesside Universities. CT is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration East of England. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. JA, MW and TB are supported by the MRC Epidemiology Unit, University of Cambridge [grant number MC/UU/12015/6] and Centre for Diet and Activity Research (CEDAR), a UK Clinical Research Collaboration (UKCRC) Public Health Research Centre of Excellence. Funding for CEDAR from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research [grant numbers ES/G007462/1 and MR/K023187/1], and the Wellcome Trust [grant number 087636/Z/08/Z], under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. FdV is partly funded by National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol NHS Foundation Trust. AAL is a member of Fuse, the Centre for Translational Research in Public Health (www.fuse.ac.uk). Fuse is a Public Health Research Centre of Excellence funded by the five North East Universities of Durham, Newcastle, Northumbria, Sunderland and Teesside. SC is funded by Health Data Research UK (HDR-UK). HDR-UK is an initiative funded by the UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities. The views expressed are those of the authors and do not necessarily represent those of any of the above named funders. The funders had no role in the design of the study, or collection, analysis and interpretation of the data, or in the decision to publish, or in writing the manuscript.

Background 'Reducing the Strength' (RtS) is a public health initiative encouraging retailers to voluntarily stop selling cheap, strong beers/ciders (≥6.5% alcohol by volume). This study evaluates the impact of RtS initiatives on alcohol availability and purchasing in three English counties with a combined population of 3.62 million people. Methods We used a multiple baseline time-series design to examine retail data over 29 months from a supermarket chain that experienced a two-wave, area-based role out of RtS: initially 54 stores (W1), then another 77 stores (W2). We measured impacts on units of alcohol sold (primary outcome: beers/ciders; secondary outcome: all alcoholic products), economic impacts on alcohol sales and substitution effects. Results We observed a non-significant W1 increase (+3.7%, 95% CI: -11.2, 21.0) and W2 decrease (-6.8%, 95% CI: -20.5, 9.4) in the primary outcome. We observed a significant W2 decrease in units sold across all alcohol products (-10.5%, 95% CI: -19.2, -0.9). The direction of effect between waves was inconsistent for all outcomes, including alcohol sales, with no evidence of substitution effects. Conclusions In the UK, voluntary RtS initiatives appear to have little or no impact on reducing alcohol availability and purchase from the broader population of supermarket customers.

Background Across England, inequalities in health are worsening. They have been exacerbated by the COVID-19 pandemic and are particularly acute for some ethnic and socioeconomic groups, and some regions. Exploration of the public's understanding of health inequalities has increased, but few studies have looked at the views of young people. Our study seeks to redress this gap by exploring young people's perspectives of inequalities in health. Methods We did a qualitative study consisting of three interlinked focus groups (online and face-to-face) with young people from six youth organisations. Focus groups took place from Feb 10 to June 28, 2021. They were co-delivered with partnering youth organisations and involved participatory concept mapping activities and the discussion of health-related news articles. Working with youth organisations, we recruited young people (aged 13–21 years) from six youth groups in areas of high and mixed deprivation across three geographical locations in England (the North East, South Yorkshire, and London). Data were analysed using thematic analysis. The data management software NVivo 12 was used to facilitate coding. All participants provided written informed consent, following acquisition of verbal informed consent from parents or guardians. Ethical approval for the study was granted by the University of Sheffield, Durham University, and London School of Hygiene & Tropical Medicine ethics committees. Findings We ran 15 focus groups online and three face-to-face with 42 young people (19 male, 18 female, two non-binary, and three trans-male). Numbers ranged from two to ten participants in each group. Young people described a variety of different factors that shaped their health, including individual behaviours, personal or household resources, relationships and community, local services, the physical environment (particularly reputation and safety), psychosocial factors (including sense of belonging), and the socioeconomic context of the area (eg, quality and quantity of local jobs). However, throughout their discussions they foregrounded the importance of interrelationships between factors. Young people's understanding of inequalities in health were often rooted in their own experience and focused on an awareness of advantage and disadvantage. Young people articulated several different pathways through which they perceived health inequalities to be created, and consistently emphasised the importance of poverty as a root cause of inequality. Priorities for change included improving mental health support, access to safe and healthy local spaces, affordability of activities, healthy food availability, and youth group funding. Interpretation Our study highlights that young people have nuanced, experiential understandings of factors influencing their and other people's health within their local areas. Exploring young people's perspectives of inequalities is crucial in designing policies that are relevant to, and informed by, the people and places they affect. Funding UK National Institute for Health Research (NIHR) School for Public Health Research (SPHR).

Background Restricting advertising of products with high fat, salt, and sugar (HFSS) content has been recommended as a tool to tackle obesity, but the impact on purchases is unknown. This study evaluates the impact of outdoor HFSS advertising restrictions, implemented across the London transport network in February, 2019, on HFSS purchases. Methods Take-home food and drink purchase data (n=5 089 988) from 1970 households (London [intervention] n=977; North of England [control] n=993) from the Kantar Fast Moving Consumer Goods panel were analysed with a controlled interrupted time series design. We estimated average weekly household purchases of energy and nutrients from HFSS products in the postintervention period (Feb 25 to Dec 29, 2019) compared with a counterfactual constructed from the control and preintervention (June 18, 2018, to Feb 24, 2019) series. The London School of Hygiene & Tropical Medicine ethics committee approved the study (16297/RR/11721), and written informed consent was obtained from participants. Findings After adjustment for confounders, average weekly household purchase of energy was reduced by 6·8% (1015·4 kcal, 95% CI 473·6–1557·2) compared with the counterfactual. Reductions in purchases of fat (57·4 g, 95% CI 21·7–93·0), saturated fat (26·4 g, 12·5–40·4) and sugar (85·5 g, 46·7–124·3) from HFSS products were also observed. When stratified by product category, we found a 19·4% reduction in energy purchased from chocolate and confectionery (317·9 kcal, 95% CI 200·0–435·8), along with reductions in fat (13·1 g, 95% CI 7·5–18·8), saturated fat (8·7 g, 5·7–11·7), sugar (41·4 g, 27·4–55·4), and salt (0·2 g, 0·1–0·2) purchased. Interpretation To our knowledge, this was the first UK study to examine the impact of outdoor HFSS advertising restrictions on food and drink purchases. Our findings provide support for policies that restrict HFSS advertising as a tool to reduce purchases of HFSS products. However, the sustainability of the observed effects is unclear. Confounding due to other events occurring at the same time as the intervention in either the intervention or control group cannot be ruled out. However, observed intervention effects were greater among frequent public transport users, and were specific to the week the advertising restrictions were introduced. Funding National Institute for Health Research School for Public Health Research (grant number PD-SPH-2015).

Introduction: Engaging communities in actions to reduce alcohol harms has been identified as an international\ud priority. While there exist recommendations for community engagement within alcohol licensing legislation,\ud there is limited understanding of how to involve communities in local decision-making to reduce harms from the\ud alcohol environment.\ud Methods: A scoping literature review was conducted on community engagement in local government decisionmaking\ud with relevance to the alcohol environment. Academic and grey literature databases were searched between\ud April and June 2018 to identify examples of community engagement in local government in the UK,\ud published since 2000. Texts were excluded if they did not describe in detail the mechanisms or rationale for\ud community engagement. Information was extracted and synthesised through a narrative approach.\ud Results: 3030 texts were identified through the searches, and 30 texts were included in the final review. Only one\ud text described community engagement in alcohol decision-making (licensing); other local government sectors\ud included planning, regeneration and community safety. Four rationales for community engagement emerged:\ud statutory consultation processes; non-statutory engagement; as part of broader participatory initiatives; and\ud community-led activism. While not all texts reported outcomes, a few described direct community influence on\ud decisions. Broader outcomes included improved relationships between community groups and local government.\ud However, lack of influence over decisions was also common, with multiple barriers to effective engagement\ud identified.\ud Conclusion: The lack of published examples of community engagement in local alcohol decision-making relevant\ud to the UK suggests little priority has been placed on sharing learning about supporting engagement in this area.\ud Taking a place-shaping perspective, useful lessons can be drawn from other areas of local government with\ud relevance for the alcohol environment. Barriers to engagement must be considered carefully, particularly around\ud how communities are defined, and how different interests toward the local alcohol environment are represented,\ud or not.

The multiple burdens of persistent undernutrition and micronutrient deficiencies, along with the rapidly growing rates of overweight, obesity, and associated chronic diseases, are major challenges globally. The role of agriculture and the food system in meeting these challenges is very poorly understood. Achieving food security and addressing malnutrition in all its forms, a Sustainable Development Goal, requires an understanding of how changing food systems affect health outcomes and the development of new tools to design and evaluate interventions. An interinstitutional programme to address this interdisciplinary research challenge is described. Over the past seven years, the Leverhulme Centre for Integrative Research on Agriculture and Health has built a portfolio of successful and innovative research, trained a new cadre of interdisciplinary researchers in “Agri‐Health,” and built an international research community with a particular focus on strengthening research capacity in low‐ and middle‐income countries. The evolution of this programme is described, and key factors contributing to its success are discussed that may be of general value in designing interdisciplinary research programmes directed at supporting global development goals.

The role of the neighbourhood environment in influencing health behaviours continues to be an important topic in public health research and policy. Foot-based street audits, virtual street audits and secondary data sources are widespread data collection methods used to objectively measure the built environment in environment-health association studies. We compared these three methods using data collected in a nationally representative epidemiological study in 17 British towns to inform future development of research tools. There was good agreement between foot-based and virtual audit tools. Foot based audits were superior for fine detail features. Secondary data sources measured very different aspects of the local environment that could be used to derive a range of environmental measures if validated properly. Future built environment research should design studies a priori using multiple approaches and varied data sources in order to best capture features that operate on different health behaviours at varying spatial scales., Highlights • This study compares multiple data collection methods for measuring built environment features. • Virtual street audits are reliable for more objective built environment measures. • Street-based audits are superior for collecting fine detail environmental features. • Routine secondary data sources need less resources but must be properly validated. • Appropriate methods for health studies vary depending on the research question and resources.

Excessive alcohol consumption leads to negative health and social impacts at individual and population levels. Interventions that aim to limit the density of alcohol retail premises (including cumulative impact policies (CIPs)) have been associated with decreases in alcohol-related crime and alcohol-related hospital admissions. We evaluated the quantitative impact of introducing a new alcohol licensing policy that included a comprehensive Cumulative Impact Policy (CIP) enforced in seven Cumulative Impact Zones (CIZs) in one English Local Authority in 2013. We used time series analysis to assess immediate and longer term impacts on licensing decisions and intermediate outcomes, including spatial and temporal alcohol availability, crime, alcohol-related ambulance call-outs and on-licence alcohol retail sales across the Local Authority and in CIZs and non-CIZs during the period 2008 to 2016. We found no impact on licence application rates but post-intervention applications involved fewer trading hours. Application approvals declined initially but not over the longer term. Longer term, small reductions in units of alcohol sold in bars (-2060, 95% confidence interval (CI) = -3033, -1087) were observed in areas with more intensive licensing policies ('Cumulative Impact Zones' (CIZs)). Significant initial declines in overall crime rates (CIZs = -12.2%, 95% CI = -18.0%, -6.1%; non-CIZs = -8.0%, 95% CI = -14.0%, -1.6%) were only partially reversed by small, longer term increases. Ambulance callout rates did not change significantly. The intervention was partially successful but a more intensive and sustained implementation may be necessary for longer term benefits.

ObjectiveFood packages were objectively assessed to explore differences in nutrition labelling, selected promotional marketing techniques and health and nutrition claims between countries, in comparison to national regulations.DesignCross-sectional.SettingChip and sweet biscuit packages were collected from sixteen countries at different levels of economic development in the EPOCH (Environmental Profile of a Community’s Health) study between 2008 and 2010.SubjectsSeven hundred and thirty-seven food packages were systematically evaluated for nutrition labelling, selected promotional marketing techniques relevant to nutrition and health, and health and nutrition claims. We compared pack labelling in countries with labelling regulations, with voluntary regulations and no regulations.ResultsOverall 86 % of the packages had nutrition labels, 30 % had health or nutrition claims and 87 % displayed selected marketing techniques. On average, each package displayed two marketing techniques and one health or nutrition claim. In countries with mandatory nutrition labelling a greater proportion of packages displayed nutrition labels, had more of the seven required nutrients present, more total nutrients listed and higher readability compared with those with voluntary or no regulations. Countries with no health or nutrition claim regulations had fewer claims per package compared with countries with regulations.ConclusionsNutrition label regulations were associated with increased prevalence and quality of nutrition labels. Health and nutrition claim regulations were unexpectedly associated with increased use of claims, suggesting that current regulations may not have the desired effect of protecting consumers. Of concern, lack of regulation was associated with increased promotional marketing techniques directed at children and misleadingly promoting broad concepts of health.

First proposed in 2010, the use of ‘value chain analysis’ to identify opportunities for targeted nutrition interventions in food systems is still an emerging method. This review explores and summarizes the application of value chain analysis to nutrition and from this provides five insights into how to more effectively conduct value chain analysis for nutrition: 1) use a consumer perspective to inform selection of foods and chains; 2) consider the research question, available resources, and the type of chain; 3) situate consumer research at the center of the analysis; 4) assess economic trade-offs; and 5) pay attention to governance and stakeholders’ capacity for and incentives to change.

Background Recognising the lack of research on daytime drinking practices in areas with managed night-time economies (NTEs), this qualitative study explores the phenomena in the London Borough of Islington; a rapidly gentrifying area with a highly regulated night-time economy (NTE). The objectives were to (i) Characterise the daytime drinking spaces of the local alcohol environment and (ii) Theorise the ways in which these spaces, and the practices and performativities within them, are situated within broader social and economic trends. Methods Adopting a legitimate peripheral participation approach to data collection, 39 licensed premises were visited in Islington and on-site observations carried out between the hours of 12 pm and 6 pm using a semi-structured observation guide. Observations were written-up into detailed fieldnotes, uploaded to NVivo and subject to a thematic analysis. Findings The daytime on-premises alcohol environment was characterised by two main trends: the decline of traditional pubs and a proliferation of hybrid establishments in which alcohol was framed as part of a suite of attractions. The consumption trends that the latter exemplify are implicated in processes of micro-cultural production and ‘hipster capitalism'; and it is via this framing that we explore the way the diverse local drinking spaces were gendered and classed. Hybrid establishments have been regarded as positive in terms of public health, crime and safety. However, they could also help introduce drinking within times and contexts where it was not previously present. Conclusion The intersection of an expanding hipster habitus with Local Authority efforts to tackle ‘determined drunkenness' create very particular challenges. The operating practices of hybrid venues may feed into current alcohol industry strategies of promoting ‘new moments' in which consumers can drink. They blur the divisions between work and play and produce temporal and classed divisions of drinking.

BackgroundPolicy initiatives such as WHO Age Friendly Cities recognise the importance of the urban environment for improving health of older people, who have both low physical activity (PA) levels and greater dependence on local neighbourhoods. Previous research in this age group is limited and rarely uses objective measures of either PA or the environment.MethodsWe investigated the association between objectively measured PA (Actigraph GT3x accelerometers) and multiple dimensions of the built environment, using a cross-sectional multilevel linear regression analysis. Exposures were captured by a novel foot-based audit tool that recorded fine-detail neighbourhood features relevant to PA in older adults, and routine data.Results795 men and 638 women aged 69–92 years from two national cohorts, covering 20 British towns, were included in the analysis. Median time in moderate to vigorous PA (MVPA) was 27.9 (lower quartile: 13.8, upper quartile: 50.4) minutes per day. There was little evidence of associations between any of the physical environmental domains (eg, road and path quality defined by latent class analysis; number of bus stops; area aesthetics; density of shops and services; amount of green space) and MVPA. However, analysis of area-level income deprivation suggests that the social environment may be associated with PA in this age group.ConclusionsAlthough small effect sizes cannot be discounted, this study suggests that older individuals are less affected by their local physical environment and more by social environmental factors, reflecting both the functional heterogeneity of this age group and the varying nature of their activity spaces.

Background and aims: Recent years have seen a rise in new and innovative policies to reduce alcohol consumption and related harm in England, which can be implemented by local, as opposed to national, policy-makers. The aim of this paper is to explore the processes that underpin the adoption of these alcohol policies within local authorities. In particular, it aims to assess whether the concept of policy transfer (i.e. a process through which knowledge about policies in one place is used in the development of policies in another time or place) provides a useful model for understanding local alcohol policy-making. Methods: Qualitative data generated through in-depth interviews and focus groups from five case study sites across England were used to explore stakeholder experiences of alcohol policy transfer between local authorities. The purposive sample of policy actors included representatives from the police, trading standards, public health, licensing, and commissioning. Thematic analysis was used inductively to identify key features in the data.Results: Themes from the policy transfer literature identified in the data were: policy copying, emulating, hybridization, and inspiration. Participants described a multitude of ways in which learning was shared between places, ranging from formal academic evaluation to opportunistic conversations in informal settings. Participants also described facilitators and constraints to policy transfer, such as the historical policy context and the local cultural, economic, and bureaucratic context, which influenced whether or not a policy that was perceived to work in one place might be transferred successfully to another context. Conclusions: Theories of policy transfer provide a promising framework for characterising processes of local alcohol policy-making in England, extending beyond debates regarding evidence-informed policy to account for a much wider range of considerations. Applying a policy transfer lens enables us to move beyond simple (but still important) questions of what is supported by ‘robust’ research evidence by paying greater attention to how policy making is carried out in practice and the multiple methods by which policies diffuse across jurisdictions.

In this paper, we describe the measures of intervention exposure used in the cluster randomised trial of the Well London programme, a public health intervention using community engagement and community-based projects to increase physical activity, healthy eating and mental health and well-being in 20 of the most deprived neighbourhoods in London.10 No earmarked resources to support the development of these measures and associated data collection were provided to either the research team or to those delivering the interventions on the ground. Instead, these were derived from contractually specified performance management information reported quarterly by partners and by inclusion of questions seeking information about participation in the follow-up questionnaires used to measure the main trial outcomes. The exposure measures are consequently considerably less sophisticated than those used in the US studies, where earmarked funding was available.

Objective To analyse available review-level evidence on the effectiveness of population-level interventions in non-clinical settings to reduce alcohol consumption or related health or social harm. Method Health, social policy and specialist review databases between 2002 and 2012 were searched for systematic reviews of the effectiveness of population-level alcohol interventions on consumption or alcohol-related health or social outcomes. Data were extracted on review research aim, inclusion criteria, outcome indicators, results, conclusions and limitations. Reviews were quality-assessed using AMSTAR criteria. A narrative synthesis was conducted overall and by policy area. Results Fifty-two reviews were included from ten policy areas. There is good evidence for policies and interventions to limit alcohol sale availability, to reduce drink-driving, to increase alcohol price or taxation. There is mixed evidence for family- and community-level interventions, school-based interventions, and interventions in the alcohol server setting and the mass media. There is weak evidence for workplace interventions and for interventions targeting illicit alcohol sales. There is evidence of the ineffectiveness of interventions in higher education settings. Conclusion There is a pattern of support from the evidence base for regulatory or statutory enforcement interventions over local non-regulatory approaches targeting specific population groups.

Cumulative impact policies (CIPs) are widely used in UK local government to help regulate\ud alcohol markets in localities characterised by high density of outlets and high rates of alcohol\ud related harms. CIPs have been advocated as a means of protecting health by controlling or\ud limiting alcohol availability. We use a comparative qualitative case study approach (n=5\ud English local government authorities, 48 participants) to assess how CIPs vary across\ud different localities, what they are intended to achieve, and the implications for local-level\ud alcohol availability. We found that the case study CIPs varied greatly in terms of aims, health\ud focus and scale of implementation. However, they shared some common functions around\ud influencing the types and managerial practices of alcohol outlets in specific neighbourhoods\ud without reducing outlet density. The assumption that this will lead to alcohol harm-reduction\ud needs to be quantitatively tested

9 p., Background Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and aff ordability. Methods We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random eff ects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost. Findings Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66–3·86) per day. Mean daily consumption was 2·14 servings (1·93–2·36) in low-income countries (LICs), 3·17 servings (2·99–3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09–4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13–5·71) in highincome countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06–57·88) of household income in LICs, 18·10% (14·53–21·68) in LMICs, 15·87% (11·51–20·23) in UMICs, and 1·85% (–3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p

Background Many key determinants of alcohol health harms lie outside the health sector and are affected by non-health sector policies. Public health practitioners tackling alcohol health harms need to work effectively with non-health sectors. Understanding how health can be addressed through non-health policies will improve the public health response to alcohol harms in England. We aimed to identify the barriers to and opportunities for implementation of population-level health interventions in English local government that effectively address alcohol health harms. Methods We used a three-stage research design. First, an overview of systematic reviews identified effective population-level interventions addressing alcohol-related health harms. 6775 articles were retrieved from Medline, Embase, Cochrane, Social Policy and Practice, DARE, Campbell, and NICE database searches, supplemented by screening of references of included reviews and contacting key experts to identify missed and unpublished reviews. 10% of articles were independently dual screened with the remainder screened individually after reconciling all classification disagreements. Systematic reviews were included if they were published since 2002, assessed the effectiveness of population-level interventions, and reported quantitative outcomes on alcohol use or related harm. Two reviewers independently assessed the included reviews' quality using the AMSTAR criteria. Second, a legal and policy analysis established the legislative framework governing English local authority alcohol control policies, identifying opportunities to enact effective policies to address alcohol health harms. Third, case studies were done in two local authorities to understand how local factors affected the choice and implementation of alcohol control policies. Data were obtained through non-audio recorded qualitative interviews with local government staff, work shadowing, documentary analysis of reports and external-facing communications, and quantitative analysis of administrative data. Findings 52 systematic reviews were identified. The evidence base showed a pattern of support for regulatory or statutory enforcement interventions over local non-regulatory approaches. Interventions with proven effectiveness that are especially relevant to English local authority intervention include limiting alcohol outlet density and opening hours and increasing alcohol prices. By contrast, the legal and policy analysis showed that licensing decisions in England that might control local alcohol availability and affordability should be framed around non-health arguments. Licensing committees need data that relate to a specific premises or local geography, limiting how much aggregate population health indices can be used to justify policy choices. Nevertheless, alcohol health harms can be addressed by developing sufficiently detailed local health evidence; designing special policy areas to address cumulative effect; aligning local planning policy with licensing; and cross-sector collaborations—in particular with licensing, planning, the police, and community safety—such as joint needs assessments and strategies to tackle alcohol harms. The legal framework and local government operating practices do, however, make interventions that address the immediate harms associated with alcohol intoxication more feasible to implement in non-health sectors than those that tackle chronic overconsumption. Case study findings suggest that local government practitioners perceive that policy decisions relate to the priorities of a range of constituencies that might not align with health concerns. Interpretation Opportunities exist to address local health consequences of alcohol consumption through English local government policies. Public health practitioners wishing to engage with non-health sectors will benefit from understanding how other sectors define evidence in terms of relevance and validity, how legislation constrains and enables their practice and policy, and whose priorities shape policy choices. Funding National Institute for Health Research (NIHR)'s School for Public Health Research (SPHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

BACKGROUND: The power to influence many social determinants of health lies within local government sectors that are outside public health's traditional remit. We analyse the challenges of achieving health gains through local government alcohol control policies, where legal and professional practice frameworks appear to conflict with public health action. METHODS: Current legislation governing local alcohol control in England and Wales is reviewed and analysed for barriers and opportunities to implement effective population-level health interventions. Case studies of local government alcohol control practices are described. RESULTS: Addressing alcohol-related health harms is constrained by the absence of a specific legal health licensing objective and differences between public health and legal assessments of the relevance of health evidence to a specific place. Local governments can, however, implement health-relevant policies by developing local evidence for alcohol-related health harms; addressing cumulative impact in licensing policy statements and through other non-legislative approaches such as health and non-health sector partnerships. Innovative local initiatives-for example, minimum unit pricing licensing conditions-can serve as test cases for wider national implementation. CONCLUSIONS: By combining the powers available to the many local government sectors involved in alcohol control, alcohol-related health and social harms can be tackled through existing local mechanisms.