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Introduction: Non-compliance with smoke-free law is one of the determinants of untimely mortality and morbidity globally. Various studies have been conducted on non-compliance with smoke-free law in public places in different parts of the world; however, the findings are inconclusive and significantly dispersed. Moreover, there is a lack of internationally representative data, which hinders the evaluation of ongoing international activities towards smoke-free law. Therefore, this meta-analysis aimed to assess the pooled prevalence of non-compliance with smoke-free law in public places., Methods: International electronic databases, such as PubMed/MEDLINE, Science Direct, Cochrane Library, CINAHL, African Journals Online, HINARI, Semantic Scholar, google and Google Scholar were used to retrieve the relevant articles. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA) guidelines. The Higgs I 2 statistics were used to determine the heterogeneity of the reviewed articles. The random-effects model with a 95% confidence interval was carried out to estimate the pooled prevalence of non-compliance., Results: A total of 23 articles with 25,573,329 study participants were included in this meta-analysis. The overall pooled prevalence of non-compliance with smoke-free law was 48.02% (95% CI: 33.87-62.17). Extreme heterogeneity was observed among the included studies (I 2 = 100%; p  < 0.000). The highest non-compliance with smoke-free law was noted in hotels (59.4%; 95% CI: 10.5-108.3) followed by homes (56.8%; 95% CI: 33.2-80.4), with statistically significant heterogeneity., Conclusion: As the prevalence of non-compliance with smoke-free law is high in public places, it calls for urgent intervention. High non-compliance was found in food and drinking establishments and healthcare facilities. In light of these findings, follow-up of tobacco-free legislation and creating awareness that focused on active smokers particularly in food and drinking establishments is recommended., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Daba, Atamo, Gasheya, Geto and Gebrehiwot.)

Introduction: There is no known safe level of secondhand smoke exposure; yet, less than 30% of the global population is covered by comprehensive smoke-free policies as of 2016 and there are few smoke-free policies in sub-Saharan Africa (SSA). This study examines the support for smoke-free public places in SSA and delineates their correlates., Methods: Data collected through the Global Adult Tobacco Survey (2012-2017) were analyzed using SAS for descriptive and multivariable analyses, with a significance level set at p < .05., Results: No SSA country had comprehensive smoke-free policies, defined as a prohibition of smoking in eight public places. In the four countries whose Global Adult Tobacco Survey data were analyzed (Nigeria, Cameroon, Kenya, and Uganda), support for the prohibition of smoking in public places was over 90% in all eight public places except bars. Support for smoking prohibition in bars was 65.8%, 81.1%, 81.4%, and 91.0% in Nigeria, Cameroon, Kenya, and Uganda, respectively. Factors associated with support for smoke-free bars differed across the four countries, but in all countries, current smokers had decreased odds of support for smoke-free bars. Knowledge of secondhand smoke harm and living in smoke-free homes were associated with increased odds of support for smoke-free bars in all countries except Kenya., Conclusion: The high support for smoke-free public places should inform the efforts of the public health community and policymakers in these four SSA countries toward meeting their obligations of Article 8 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC)., Implications: Much of the population in SSA is not protected by comprehensive smoke-free policies. It was found that the overwhelming majority of adults in four large countries in SSA support the prohibition of smoking in public places and that knowledge of the health dangers of smoking and exposure to secondhand smoke and home smoking rules increased support for the prohibition. High support for the prohibition of smoking in these four SSA countries suggests tobacco control proponents should advocate for comprehensive smoke-free policies., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Background: Several studies have demonstrated that smoke-free legislation is associated with a reduced risk of mortality from acute myocardial infarction (AMI). This study aimed to examine and quantify the potential effect of smoke-free legislation on AMI mortality rate in different countries., Methods: Studies were identified using a systematic search of the scientific literature from electronic databases, including PubMed, Web of Science, ScienceDirect, Embase, Google Scholar, and China National Knowledge Infrastructure (CNKI), from their inception through September 30, 2017. A random effects model was employed to estimate the overall effects of smoke-free legislation on the AMI mortality rate. Subgroup analysis was performed to explore the possible causes of heterogeneity in risk estimates based on sex and age. The results of meta-analysis after excluding the studies with a high risk of bias were reported in this study., Results: A total of 10 eligible studies with 16 estimates of effect size were included in this meta-analysis. Significant heterogeneity in the risk estimates was identified (overall I 2  = 94.6%, p < 0.001). Therefore, a random effects model was utilized to estimate the overall effect of smoke-free legislation. There was an 8% decline in AMI mortality after introducing smoke-free legislation (RR = 0.92, 95% confidence interval (CI): 0.90-0.94). The results of subgroup analyses showed that smoke-free legislation was significantly associated with lower rates of mortality for the following 5 diagnostic subgroups: smoke-free in workplaces, restaurants and bars (RR = 0.92, 95% CI: 0.90-0.95), smaller sample size (RR = 0.92, 95% CI: 0.89-0.95), study location in Europe (RR = 0.90, 95% CI: 0.85-0.94), regional study area (RR = 0.92, 95% CI: 0.89-0.94), and no previous local smoke-free legislation (RR = 0.91, 95% CI: 0.90-0.93). However, there was not much difference in AMI mortality rates after the legislation between the longer (RR = 0.92, 95% CI: 0.86-0.98) and shorter follow-up duration subgroups (RR = 0.92, 95% CI: 0.89-0.94)., Conclusion: Smoke-free legislation could significantly reduce the AMI mortality rate by 8%. The reduction in the AMI mortality rate was more significant in studies with more comprehensive laws, without prior smoke-free bans, with a smaller sample size, at the regional level, and with a location in Europe.

Airbnb helps hosts rent all or part of their home to guests as an alternative to traditional hospitality settings. Airbnb venues are not uniformly regulated across the USA. This study quantified the reported prevalence of fire safety and first-aid amenities in Airbnb venues in the USA. The sample includes 120 691 venues in 16 US cities. Proportions of host-reported smoke and carbon monoxide (CO) detectors, fire extinguishers and first-aid kits were calculated. The proportion of venues that reportedly contained amenities are as follows: smoke detectors 80% (n=96 087), CO detectors 57.5% (n=69 346), fire extinguishers 42% (n=50 884) and first-aid kits 36% (n=43 497). Among this sample of Airbnb venues, safety deficiencies were noted. While most venues had smoke alarms, approximately 1/2 had CO alarms and less than 1/2 reported having a fire extinguishers or first-aid kits. Local and state governments or Airbnb must implement regulations compliant with current National Fire Protection Association fire safety standards., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Abstract: We compared Spanish autonomous communities' regulations affecting the use of semiautomatic external defibrillators (semi-AEDs), including requirements for training and providing devices outside health care settings. We analyzed differences in the development of regulations across the different geographic areas. Regulations published in the official bulletins of Spain's 17 autonomous communities and 2 autonomous cities in effect in May 2019 were reviewed to extract directives affecting training, authorized use, and the provision of semi-AEDs outside health care centers. We found that both doctors and nurses are authorized to use the devices in most communities, with the exception of Murcia, where only doctors may use them. Fourteen communities also authorize emergency responders to operate semi-AEDs. Other individuals must call for emergency help before using one, and specific rules vary by community. In the Basque Country anyone may use them, but in other communities, only individuals who have taken a training course on how to use a semi-AED may. The duration of training programs varies from 4 to 9 hours in different parts of Spain, and retraining is required at intervals that vary from 1 to 3 years. However, in 11 communities any citizen may use a semi-AED in an emergency in which authorized persons are not present (after first calling for emergency responders). Eleven autonomous communities regulate the required provision of semi-AEDs outside health care centers. We conclude that although Spain's autonomous communities have regulations in place for the use of these devices, the regulatory map is highly diverse. Therefore, we think that harmonization is desirable in the interest of unifying criteria and encouraging the use of semi-AEDs when they are needed.

Public accommodation laws (PALs) are used to address discrimination against minorities. There is broad discussion about using such laws to either protect or prohibit access to sex-segregated spaces for transgender people. Health care facilities are subject to PALs, which affect rooming assignments and access to sex-segregated environments. Around the time that a Massachusetts transgender PAL went into effect in October 2016, the first author (EB) facilitated 18 professional trainings at 5 health care facilities in greater Boston. During these trainings, staff repeatedly brought up 2 areas of moral concern reflecting public conversations about transgender rights: risk posed by the presence of transwomen in sex-segregated spaces and feelings of unpreparedness for dealing with anti-trans bias. This article discusses the role of education in responding to gender panic in inpatient settings., (© 2018 American Medical Association. All Rights Reserved.)

Objective: Tobacco-free policies in hospital campus reduce exposure to tobacco smoke; change the demeanour of the professionals, patients and people visiting hospitals towards tobacco use. Section-4, 5 and 6 of COTPA (Cigarettes and Other Tobacco Products Act) necessitates the need for implementation of the prohibition on smoking in public places. Against this background, the present work was designed to evaluate the status of compliance Section 4, 5 and 6 of COTPA in Delhi Government hospitals Methods: A cross-sectional observational study was conducted within Government hospitals. Multistage random sampling was used to select 18 hospitals out of 39 hospitals from 5 zones. Standard assessment Proforma developed by John Hopkins School of Public Health for assessing compliance to Tobacco-Free Law was used and modified to address certain aspects of Section-4, 5 and 6 of COTPA. Hospital campuses were assessed by dividing them into zones like hospital buildings, office buildings, public places outside the hospital and residential areas. Result: Signs of active tobacco use observed in 40.6% of hospital buildings, 35.3% in office buildings, and 75.4% in public places outside the buildings. ‘No smoking signage was not as per the COTPA guidelines in 21.4% of the hospitals and 72% were not tobacco free outdoors in these positions. Conclusion: The study highlighted a lower compliance rate than expected which raises questions on law enforcement concerning tobacco. Hence necessary measures have to be used up for sustained awareness campaigns, backed by enforcement drives. Periodic compliance surveys will strengthen the implementation of tobacco free legislation in health care institutions., (Creative Commons Attribution License)

Introduction and Aims: Those involved in organised sport have a high risk of excessive alcohol consumption and alcohol-related harm, the implementation of alcohol management practices have been proven to reduce these risks. Measuring alcohol management practice implementation by sporting clubs is impeded by a lack of valid tools. The aim of this study was to determine the validity of online self-report of alcohol-management practices by community football clubs via comparison with observational methods., Design and Methods: A cross-sectional study was undertaken with a sample of community football clubs within Australia. The implementation of 12 alcohol management practices was collected via: (i) an online survey; and (ii) observational audit at a clubs home ground. The prevalence of implementation of alcohol management practices for both data collection methods was calculated as was percent agreement and Kappa/Prevalence Adjusted and Bias Adjusted Kappa (PABAK) statistics., Results: Data were collected from 58 football clubs. For both assessment methods, implementation prevalence was greater than 80% for 6 of the 12 alcohol management practices. A total of 75% (n = 9) of practices had at least 70% agreement between the online and observation methods of assessment. Kappa/PABAK scores ranged from -0.08 (poor agreement) to 0.97 (almost perfect agreement)., Discussion and Conclusion: The online survey provided valid measure of assessing some but not all alcohol management practices in community sporting clubs. The validity of the measure may be improved by enhancements to the manner in which the self-report data are collected., (© 2018 Australasian Professional Society on Alcohol and other Drugs.)

Background: Harmful gambling has been identified as an important public health issue that affects individuals, families and the broader community. One gambling product, electronic gambling machines (EGMs), has been associated with significant gambling harm in Australia. There has been limited research that has explored community perceptions of EGMs and attitudes towards reform. This study, conducted in NSW, Australia, aimed to explore community use of EGM venues (clubs and hotels containing EGMs), attitudes towards EGMs and whether the use of these venues influenced attitudes towards EGM reform., Methods: An online survey was conducted with 500 adults aged 16 years and over, representative of the population for age and gender. Discrete choice and open-ended questions were used to gather data on gambling behaviours, use of and attitudes towards EGMs and EGM venues and support for gambling harm reduction measures., Results: Three quarters of participants had visited an EGM venue in the previous year. Participants who had attended such venues were significantly more likely to use EGMs at least once per month. Participants attended EGM venues for a range of reasons including use of non-gambling facilities such as restaurants, the social aspects of the venue and ease of access to the venue. Some participants also attended EGM venues specifically for the gambling facilities. Most participants identified some negative impacts of EGMs for local communities and were supportive of measures to reduce the number of EGMs and prevent children's exposure to EGMs in such venues., Conclusions: This study shows a high level of support for EGM reform amongst both individuals who attend EGM venues and also those who do not. There is potential for government to further regulate EGMs and the environments where they are located.

Background The legal status of transgender (trans) people is in constant flux. Over the past 70 years, gradually increasing transgender visibility, national and global advocacy, and, more recently, widespread Internet access, communication, and broadening support from allies, have all contributed to successful campaigns that have improved transgender lives and legitimised transgender. Still, traumatic interactions with the legal system or policing agencies remain plentiful. This is a very general overview of the most common legal issues confronting trans people. It aims to inform medical and mental health providers about the trepidation with which their patients and clients must engage legal systems, and the scope of their concerns, which ultimately affect their health. This review relies upon reports generated by advocacy organisations based on population surveys in several countries, the projects undertaken by legal and human rights advocacy groups, the topics most frequently discussed in academic texts examining transgender legal issues, and draws upon the author's personal advocacy experience. The most complicated and persistent issues are identity recognition, family law and relationship issues, adverse discrimination and anti-transgender violence and its aftermath. Criminal law, almost universally, treats trans people according to the lowest common denominator, their genital status, which supposedly supports expediency and "safety". Global legal and human rights efforts remain desperately needed to lift transgender people from the margins of society and provide them with equal opportunities to lead healthy and fulfilling lives. Access to appropriate and meaningful health care is a crucial element necessary to affirm the humanity of any person.

Objective: To know how managers of public and private companies view lactation support rooms and their implantation., Method: This is study is based on qualitative, exploratory, and descriptive research. Twenty managers from Greater Florianópolis participated in the research, in 2015. Data were collected by means of semi-structured/projective interviews, and subjected to content analysis associated with Atlas.ti software., Results: Data analysis led to the following two categories: difficulties and facilities of establishing a lactation room, with a predominance of financial difficulties and the lack of physical space. Dialectically, the subjects also recognised the low cost involved, which facilitates establishment., Conclusion: Financial, cultural, and political aspects make it difficult to set up lactation rooms, but the importance of this measure was acknowledged. Although the success of breastfeeding partly depends on these support rooms, it also requires multiple actions, especially the effective participation of nurses and other health workers.

Background : Environmental tobacco smoke (ETS) exposure is associated with an increased risk of many diseases. Many countries have ratified a national smoking ban in public places, but studies on factors related to smoking issues in public places post-ban are lacking. Aim : To identify facilitators and barriers that influenced smokers' compliance with smoking bans in public places. Methods : Using PubMed, MEDLINE, and the Web of Science database, we conducted a systematic search of English articles published before June 2015 on factors of smokers' compliance with the smoking bans in public places. Results : A total of 390 references were identified, among which seventeen articles (twelve quantitative studies, two qualitative studies, three mixed-method studies) were included in this review. These studies focused on four types of public places including recreational venues ( n = 7), hospital ( n = 5), school ( n = 4), and workplace ( n = 1). Factors at the  individual-, interpersonal-, and organizational-level were identified: at the individual level, nicotine dependence, insufficiency of tobacco-related knowledge, and the negative attitudes towards smoking bans were the most commonly identified barriers; at the interpersonal level, the smoking behaviors of people around, close relatives, and friends' approval were the main barriers; and at the organizational level, the main barriers were inefficient implementation of the bans and the inconvenience of the designative smoking areas. Conclusions : This synthesis of the literature provided evidence of the identified barriers and facilitators of smokers' compliance with the smoking bans. It will be beneficial for the policy-maker to consider interventions on multiple levels of factors to overcome the barriers and enhance smokers' compliance with the smoking bans in public places., Competing Interests: The authors declare no conflict of interest.

Problem/condition: Aquatic facility-associated illness and injury in the United States include disease outbreaks of infectious or chemical etiology, drowning, and pool chemical-associated health events (e.g., respiratory distress or burns). These conditions affect persons of all ages, particularly young children, and can lead to disability or even death. A total of 650 aquatic facility-associated outbreaks have been reported to CDC for 1978-2012. During 1999-2010, drownings resulted in approximately 4,000 deaths each year in the United States. Drowning is the leading cause of injury deaths in children aged 1-4 years, and approximately half of fatal drownings in this age group occur in swimming pools. During 2003-2012, pool chemical-associated health events resulted in an estimated 3,000-5,000 visits to U.S. emergency departments each year, and approximately half of the patients were aged <18 years. In August 2014, CDC released the Model Aquatic Health Code (MAHC), national guidance that can be adopted voluntarily by state and local jurisdictions to minimize the risk for illness and injury at public aquatic facilities., Reporting Period Covered: 2013., Description of System: The Network for Aquatic Facility Inspection Surveillance (NAFIS) was established by CDC in 2013. NAFIS receives aquatic facility inspection data collected by environmental health practitioners when assessing the operation and maintenance of public aquatic facilities. This report presents inspection data that were reported by 16 public health agencies in five states (Arizona, California, Florida, New York, and Texas) and focuses on 15 MAHC elements deemed critical to minimizing the risk for illness and injury associated with aquatic facilities (e.g., disinfection to prevent transmission of infectious pathogens, safety equipment to rescue distressed bathers, and pool chemical safety). Although these data (the first and most recent that are available) are not nationally representative, 15.7% of the estimated 309,000 U.S. public aquatic venues are located in the 16 reporting jurisdictions., Results: During 2013, environmental health practitioners in the 16 reporting NAFIS jurisdictions conducted 84,187 routine inspections of 48,632 public aquatic venues. Of the 84,187 routine inspection records for individual aquatic venues, 78.5% (66,098) included data on immediate closure; 12.3% (8,118) of routine inspections resulted in immediate closure because of at least one identified violation that represented a serious threat to public health. Disinfectant concentration violations were identified during 11.9% (7,662/64,580) of routine inspections, representing risk for aquatic facility-associated outbreaks of infectious etiology. Safety equipment violations were identified during 12.7% (7,845/61,648) of routine inspections, representing risk for drowning. Pool chemical safety violations were identified during 4.6% (471/10,264) of routine inspections, representing risk for pool chemical-associated health events., Interpretation: Routine inspections frequently resulted in immediate closure and identified violations of inspection items corresponding to 15 MAHC elements critical to protecting public health, highlighting the need to improve operation and maintenance of U.S. public aquatic facilities. These findings also underscore the public health function that code enforcement, conducted by environmental health practitioners, has in preventing illness and injury at public aquatic facilities., Public Health Action: Findings from the routine analyses of aquatic facility inspection data can inform program planning, implementation, and evaluation. At the state and local level, these inspection data can be used to identify aquatic facilities and venues in need of more frequent inspections and to select topics to cover in training for aquatic facility operators. At the national level, these data can be used to evaluate whether the adoption of MAHC elements minimizes the risk for aquatic facility-associated illness and injury. These findings also can be used to prioritize revisions or updates to the MAHC. To optimize the collection and analysis of aquatic facility inspection data and thus application of findings, environmental health practitioners and epidemiologists need to collaborate extensively to identify public aquatic facility code elements deemed critical to protecting public health and determine the best way to assess and document compliance during inspections.

Objectives: We examined receptivity to public smoke-free policies and smoke-free home status among adults in the Republic of Georgia., Methods: In Spring 2014, we conducted a national household survey of 1163 adults., Results: Our sample was on average 42.4 years old, 51.1 % male, and 43.2 % urban. Current smoking prevalence was 54.2 % in men and 6.5 % in women. Notably, 42.2 % reported daily secondhand smoke exposure (SHSe). Past week SHSe was 29.9 % in indoor public places and 33.0 % in outdoor public places. The majority reported no opposition to public smoke-free policies. Correlates of greater receptivity to public policies included being older, female, and a nonsmoker. Past week SHSe in homes was 54.2 %; 38.8 % reported daily SHSe at home. Only 14.3 % reported complete smoke-free home policies; 39.0 % had partial policies. The only correlate of allowing smoking in the home was being a smoker. Among smokers, correlates of allowing smoking in the home were being male and lower confidence in quitting., Conclusions: SHSe is prevalent in various settings in Georgia, requiring efforts to promote support for public smoke-free policies and implementation of personal policies.

Background: Smoke-free legislation may have positive effects on birth outcomes. Given that smoking and secondhand smoke during pregnancy vary with socioeconomic position, legislation may have greater effects in some socioeconomic groups. For this study, we evaluated the impact of a 2006 ban on smoking in public places in the Canadian province of Quebec on preterm birth, small-for-gestational-age birth and birth weight, and on educational differences in these birth outcomes., Methods: We analysed data on singleton births in Quebec between 2003 and 2010. Logistic regression was used to model the association of smoke-free legislation with preterm birth (<37 weeks), very preterm birth (<34 weeks), small-for-gestational-age birth (<10th centile for gestational age and sex), low birth weight (<2500 g) and mean birth weight, adjusting for secular trends before and after legislation. Interaction terms were included to assess differential effects by level of maternal education., Results: Smoke-free legislation was associated with average reductions of 3.1 preterm births (95% CI 0.1 to 6.0), 2.3 very preterm births (95% CI 0.9 to 3.7), 5.9 small-for-gestational-age births (95% CI 2.6 to 9.3) and 1.0 low birthweight infants (95% CI 0.4 to 1.6) per 1000 live births, as well as a 17.1 g increase in mean birth weight (95% CI 10.7 to 23.6). Legislation was associated with improved birth outcomes in all categories of maternal education., Conclusions: Smoke-free legislation in Quebec was associated with reductions in preterm and small-for-gestational-age births, and an increase in birth weight. There was no compelling evidence that legislation impacted educational gradients in birth outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Intake of sugar-sweetened beverages (SSBs) is associated with negative health effects. Access to healthy beverages may be promoted by policies such as the Healthy Beverage Executive Order (HBEO) established by former Boston mayor Thomas M. Menino, which directed city departments to eliminate the sale of SSBs on city property. Implementation consisted of "traffic-light signage" and educational materials at point of purchase. This study evaluates the impact of the HBEO on changes in beverage availability., Methods: Researchers collected data on price, brand, and size of beverages for sale in spring 2011 (899 beverage slots) and for sale in spring 2013, two years after HBEO implementation (836 beverage slots) at access points (n = 31) at city agency locations in Boston. Nutrient data, including calories and sugar content, from manufacturer websites were used to determine HBEO beverage traffic-light classification category. We used paired t tests to examine change in average calories and sugar content of beverages and the proportion of beverages by traffic-light classification at access points before and after HBEO implementation., Results: Average beverage sugar grams and calories at access points decreased (sugar, -13.1 g; calories, -48.6 kcal; p<.001) following the implementation of the HBEO. The average proportion of high-sugar ("red") beverages available per access point declined (-27.8%, p<.001). Beverage prices did not change over time. City agencies were significantly more likely to sell only low-sugar beverages after the HBEO was implemented (OR = 4.88; 95% CI, 1.49-16.0)., Discussion: Policies such as the HBEO can promote community-wide changes that make healthier beverage options more accessible on city-owned properties.

Policy Points: Since 2012, Massachusetts law has provided legal protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not protect against discrimination based on gender identity in public accommodations settings such as transportation, retail stores, restaurants, health care facilities, and bathrooms. A 2013 survey of Massachusetts transgender and other gender minority adults found that in the past 12 months, 65% had experienced public accommodations discrimination since the law was passed. This discrimination was associated with a greater risk of adverse emotional and physical symptoms in the past 30 days. Nondiscrimination laws inclusive of gender identity should protect against discrimination in public accommodations settings to support transgender people's health and their ability to access health care., Context: Gender minority people who are transgender or gender nonconforming experience widespread discrimination and health inequities. Since 2012, Massachusetts law has provided protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not, however, protect against discrimination in public accommodations (eg, hospitals, health centers, transportation, nursing homes, supermarkets, retail establishments). For this article, we examined the frequency and health correlates of public accommodations discrimination among gender minority adults in Massachusetts, with attention to discrimination in health care settings., Methods: In 2013, we recruited a community-based sample (n = 452) both online and in person. The respondents completed a 1-time, electronic survey assessing demographics, health, health care utilization, and discrimination in public accommodations venues in the past 12 months. Using adjusted multivariable logistic regression models, we examined whether experiencing public accommodations discrimination in health care was independently associated with adverse self-reported health, adjusting for discrimination in other public accommodations settings., Findings: Overall, 65% of respondents reported public accommodations discrimination in the past 12 months. The 5 most prevalent discrimination settings were transportation (36%), retail (28%), restaurants (26%), public gatherings (25%), and health care (24%). Public accommodations discrimination in the past 12 months in health care settings was independently associated with a 31% to 81% increased risk of adverse emotional and physical symptoms and a 2-fold to 3-fold increased risk of postponement of needed care when sick or injured and of preventive or routine health care, adjusting for discrimination in other public accommodations settings (which also conferred an additional 20% to 77% risk per discrimination setting endorsed)., Conclusions: Discrimination in public accommodations is common and is associated with adverse health outcomes among transgender and gender-nonconforming adults in Massachusetts. Discrimination in health care settings creates a unique health risk for gender minority people. The passage and enforcement of transgender rights laws that include protections against discrimination in public accommodations-inclusive of health care-are a public health policy approach critically needed to address transgender health inequities., (© 2015 Milbank Memorial Fund.)

Community Transformation Grant awardees in North Carolina, Illinois, and Wisconsin promoted joint use agreements (formal agreements between 2 parties for the shared use of land or facilities) as a strategy to increase access to physical activity in their states. However, awardees experienced significant barriers to establishing joint use agreements, including 1) confusion about terminology and an aversion to complex legal contracts, 2) lack of applicability to single organizations with open use policies, and 3) questionable value in nonurban areas where open lands for physical activity are often available and where the need is instead for physical activity programs and infrastructure. Furthermore, promotion of formal agreements may unintentionally reduce access by raising concerns regarding legal risks and costs associated with existing shared use of land. Thus, joint use agreements have practical limitations that should be considered when selecting among strategies to promote physical activity participation.

Introduction: Joint use or shared use of public school facilities provides community access to facilities for varied purposes. We examined a nationally representative sample of school districts in the United States to identify characteristics associated with having a formal joint use agreement (JUA) and with the kinds of uses to which JUAs apply., Methods: We analyzed data from the 2012 School Health Policies and Practices Study. The response rate for the module containing questions about formal JUAs was 60.1% (N = 630). We used multivariate logistic regression models to examine the adjusted odds of having a formal JUA and χ(2) analyses to examine differences in district characteristics associated with the uses of the JUA., Results: Among the 61.6% of school districts with a formal JUA, more than 80% had an agreement for the use of indoor and outdoor recreation facilities; other uses also were identified. JUAs were more common in urban than rural areas, in large than small school districts, and in the West compared with the Midwest, South, and Northeast., Conclusion: In many districts, school facilities appear to be an untapped resource for community members. Formal JUAs provide an opportunity for shared use while addressing issues of liability, cost, and logistics.

The non-communicable disease burden in China is enormous, with tobacco use a leading risk factor for the major non-communicable diseases. The prevalence of tobacco use in men is one of the highest in the world, with more than 300 million smokers and 740 million non-smokers exposed to second-hand smoke. In the past decade public awareness of the health hazards of tobacco use and exposure to second-hand smoke has grown, social customs and habits have changed, aggressive tactics used by the tobacco industry have been revealed, and serious tobacco control policies have been actively promoted. In 2014, national legislators in China began actively considering national bans on smoking in public and work places and tobacco advertising. However, tobacco control in China has remained particularly difficult because of interference by the tobacco industry. Changes to the interministerial coordinating mechanism for implementation of the WHO Framework Convention on Tobacco Control are now crucial. Progress towards a tobacco-free world will be dependent on more rapid action in China., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Despite being a signatory since 2004, Japan has not yet fully implemented Article 8 of the World Health Organization's Framework Convention on Tobacco Control regarding 100% protection against exposure to second-hand smoke (SHS). The Japanese government still recognizes designated smoking rooms (DSRs) in public space as a valid control measure. Furthermore, subnational initiatives for tobacco control in Japan are of limited effectiveness. Through an analysis of the Hyogo initiative in 2012, we identified key barriers to the achievement of a smoke-free environment., Methods: Using a descriptive case-study approach, we analyzed the smoke-free policy development process. The information was obtained from meeting minutes and other gray literature, such as public records, well as key informant interviews., Results: Hyogo Prefecture established a committee to propose measures against SHS, and most committee members agreed with establishing completely smoke-free environments. However, the hospitality sector representatives opposed regulation, and tobacco companies were allowed to make a presentation to the committee. Further, political power shifted against completely smoke-free environments in the context of upcoming local elections, which was an obvious barrier to effective regulation. Throughout the approving process, advocacy by civil society for stronger regulation was weak. Eventually, the ordinance approved by the Prefectural Assembly was even weaker than the committee proposal and included wide exemptions., Conclusions: The analysis of Hyogo's SHS control initiative shed light on three factors that present challenges to implementing tobacco control regulations in Japan, from which other countries can also draw lessons: incomplete national legislation, the weakness of advocacy by the civil society, and the interference of the tobacco industry.

Over the past several years, an increasing number of military installations have installed splash pads that provide fun, recreational water entertainment for Soldiers and their families. The addition of splash pads brings added responsibilities for medical treatment facility preventive medicine oversight and installation facilities maintenance to ensure a safe and healthy environment. Currently, there are no consistent standards or detailed guidance for military installations to follow when installing and maintaining splash pads. The central issues associated with splash pads on military installations are water quality and risk for waterborne illnesses, responsibility for safety and health oversight, and federal energy and water sustainability mandates. This article examines the importance of implementing a standard for design and oversight to ensure the health and safety of Soldiers and their families.

We assessed the relationship between breastfeeding initiation and duration with laws supportive of breastfeeding enacted at the state level. We analyzed breastfeeding practices using the 2003-2010 National Health and Nutrition Examination Survey. We evaluated three measures of breastfeeding practices: Mother's reported breastfeeding initiation, a proxy report of infants ever being breastfeed, and a proxy report of infants being breastfeed for at least 6 months. Survey data were linked to eight laws supportive of breastfeeding enacted at the state level. The most robust laws associated with increased infant breastfeeding at 6 months were an enforcement provision for workplace pumping laws [OR (95 % CI) 2.0 (1.6, 2.6)] and a jury duty exemption for breastfeeding mothers [OR (95 % CI) 1.7 (1.3, 2.1)]. Having a private area in the workplace to express breast milk [OR (95 % CI) 1.3 (1.1, 1.7)] and having break time to breastfeed or pump [OR (95 % CI) 1.2 (1.0, 1.5)] were also important for infant breastfeeding at 6 months. This research responds to breastfeeding advocates' calls for evidence-based data to generate the necessary political action to enact legislation and laws to protect, promote, and support breastfeeding. We identify the laws with the greatest potential to reach the Healthy People 2020 targets for breastfeeding initiation and duration.

Background: India has been implementing smoke-free legislation since 2008 prohibiting smoking in public places. This study aimed to assess the level of compliance with smoke-free legislation (defined as the presence of no-smoking signage and the absence of active smoking, smoking aids, cigarette butts/bidi ends and smoking smell) and the role of enforcement systems in Indian jurisdictions., Methods: This was a cross-sectional, retrospective review of reports and primary data sheets of surveys conducted in 38 selected jurisdictions across India in 2012-2013., Results: Of 20 455 public places (in 38 jurisdictions), 10 377 (51%) demonstrated full compliance with smoke-free law. Educational institutions and healthcare facilities performed well at 65% and 62%, respectively, while eateries and frequently visited other public places (such as bus stands, railway stations, shopping malls, stadia, cinema halls etc.) performed poorly at 37% and 27%, respectively. Absence of no-smoking signage was the largest contributor to non-compliance across all types of public places. Enforcement systems were present in all jurisdictions, but no associations could be demonstrated between these and smoke-free compliance., Conclusion: Smoke-free compliance in public places in India was suboptimal and was mainly related to the absence of no-smoking signage. This warrants further pragmatic and innovative ways to improve the situation., (© The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Smokefree policies (SFPs) have diffused throughout the US and worldwide. However, the development of SFPs in the difficult policy environment of tobacco-producing states and economies worldwide has not been well-explored. In 2007, Tennessee, the third largest tobacco producer in the US, enacted the Non-Smoker Protection Act (NSPA). This study utilizes the multiple streams model to provide understanding of why and how this policy was developed by triangulating interviews with key stakeholders and legislative debates with archival documents. In June 2006, the Governor unexpectedly announced support for SFP, which created a window of opportunity for policy change. The Campaign for Healthy and Responsible Tennessee, a health coalition, seized this opportunity and worked with the administration and the Tennessee Restaurant Association to negotiate a comprehensive SFP, however, a weaker bill was used by the legislative leadership to develop the NSPA. Although the Governor and the Tennessee Restaurant Association's support generated an environment for 100% SFP, health groups did not fully capitalize on this environmental change and settled for a weak policy with several exemptions. This study suggests the importance for proponents of policy change to understand changes in their environment and be willing and able to capitalize on these changes.

Background: Compliance survey of smoke-free law is an effective means of measuring progress towards a smoke-free society. They also help policy makers to take action where strengthening measures are required. India has a comprehensive tobacco control law known as Cigarettes and Other Tobacco Products Act (COTPA 2003) which prohibits smoking in public places and requires display of 'No smoking' signages with proper specifications at conspicuous points. However, its implementation and enforcement are still a matter of concern., Aims and Objectives: To ascertain the level of compliance with smoke-free law in public places of a district of North India., Methodology: A cross sectional study was conducted in the months of November-December 2011 in district SAS Nagar Mohali of North India. The public places including hotels/restaurants/bars/shopping malls, government offices, educational institutions, healthcare facilities and transit stations were surveyed. The study tool was adapted from the guide on 'Assessing compliance with smoke-free law' developed jointly by the Campaign for Tobacco Free Kids, Johns Hopkins Bloomberg School of Public Health and International Union against Tuberculosis and Lung Disease., Results: The overall compliance rate towards section 4 of COTPA was 92.3%. No active smoking was observed in 94.2% of the public places. In 90% of the public places 'No Smoking' signage were displayed as per COTPA. Health and educational institutions had maximum compliance with the smoke-free law while transit sites showed the least compliance., Conclusions: Compliance to the smoke-free law was high in the study., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Hyogo is the second prefecture, after Kanagawa, to enact a smoking ban in public places in Japan. The effect of this smoking ban on acute coronary syndrome (ACS) has not been evaluated., Purpose: Changes in the annual number of ACS hospital cases in Hyogo Prefecture, before and after the enactment of the prefectural legislative ban on smoking in public places, are to be compared with those in Gifu Prefecture, where there is no smoking-ban legislation., Methods: Consecutive Hyogo residents with ACS, admitted to 33 major hospitals in the Hanshin-Awaji-Kobe district, which covers 56% of the population, during the 12 months before implementation of the legislation (April 2012 through March 2013) and during the same 24 months thereafter (April 2013 through March 2015) will be enrolled. Consecutive patients with ACS, who are Gifu residents, treated at the 20 major hospitals in Gifu Prefecture will be enrolled as geographical controls. The primary endpoint is the change in number of ACS admissions from April 2012 through March 2015, considering the periods before and after the smoking-ban legislation in Hyogo prefecture., Conclusion: Our study has certain strengths: (1) This is the first large Japanese study of ACS registry with smoking-ban legislation. (2) Major hospitals in the Hanshin-Awaji-Kobe district are included. (3) The data will cover 3 years including 1 year before legislation enactment. (4) The data will be compared with those of Gifu Prefecture, where smoking-ban legislation will not be enacted. (5) The very large database makes possible analysis of subgroups based on age and gender., (Copyright © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

This contribution presents a survey of the obligatory measures to be taken according to German Law in the case of the outbreak of infectious diseases in public facilities. The analysis is based on a decision by the German Federal Administrative Court in the year 2012, BVerwGE 142, 205 ff. The author subjects the intepretation of the term suspicion of an infectious disease in the sense of § 2 Nr. 7 IfSG (law for protection against infection) to a critical appraisement. The article closes with a check-list on the legally appropriate measures to be taken in the case of an outbreak of infectious diseases in public facilities that is intended for practitioners in the health services., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: In the United States, more than 600 municipalities have smoke-free parks, and more than 100 have smoke-free beaches. Nevertheless, adoption of outdoor smoke-free policies has been slow in certain regions. Critical to widespread adoption is the sharing of knowledge about the policy development and implementation process. In this article, we describe our experience in making City of Philadelphia recreation centers and playgrounds smoke-free., Community Context: Of the 10 largest US cities, Philadelphia has among the highest rates of adult and youth smoking. Our objectives for an outdoor smoke-free policy included protecting against secondhand smoke, supporting a normative message that smoking is harmful, motivating smokers to quit, and mitigating tobacco-related sanitation costs., Methods: The Philadelphia Department of Public Health and the Department of Parks and Recreation engaged civic leaders, agency staff, and community stakeholders in the following steps: 1) making the policy case, 2) vetting policy options and engaging stakeholders, and 3) implementing policy. Near-term policy impacts were assessed through available data sources., Outcome: More than 220 recreation centers, playgrounds, and outdoor pools became smoke-free through a combined mayoral executive order and agency regulation. Support for the policy was high. Estimates suggest a policy reach of 3.6 million annual visitors and almost 850 acres of new smoke-free municipal property., Interpretation: Localities can successfully implement outdoor smoke-free policies with careful planning and execution. Such policies hold great potential for reducing exposure to secondhand smoke, promoting nonsmoking norms, and providing additional motivation for residents to quit smoking.

Campaigns to limit tobacco use started in the 1970s and have led to bans on public smoking, which have been extended to parks and beaches. A review of state and local statutes shows that during 1993-2011, smoking was banned in 843 parks and on 150 beaches across the United States. Three justifications for these restrictions have been invoked: the risk of passive smoke to nonsmokers, the pollution caused by cigarette butts, and the long-term risks to children from seeing smoking in public. Our analysis of the evidence for these claims found it far from definitive and in some cases weak. What, then, accounts for the efforts to impose such bans? We conclude that the impetus is the imperative to denormalize smoking as part of a broader public health campaign to reduce tobacco-related illness and death. Although invoking limited evidence may prove effective in the short run, it is hazardous for public health policy makers, for whom public trust is essential.

This article describes the evaluation of the law banning smoking in New York City's parks and beaches that went into effect in 2011. We discuss the practical and methodological challenges that emerged in evaluating this law, and describe how we applied the principles of critical multiplism to address these issues. The evaluation uses data from three complementary studies, each with a unique set of strengths and weaknesses that can provide converging evidence for the effectiveness of the law. Results from a litter audit and an observational study suggest the ban reduced smoking in parks and beaches. The purpose, methodology and baseline results from an ongoing survey that measures how frequently adults in NYC and across New York State notice people smoking in parks and on beaches are presented and discussed. Limitations are considered and suggestions are offered for future evaluations of similar policies.

Despite their wellness mandate, many publicly funded recreational facilities offer primarily unhealthy foods. Governments have developed programs and resources to assist facilities to improve their food offerings, however the challenge to incent preferential sale of healthier foods remains substantial. In the Canadian province of Alberta, uptake of government-issued voluntary nutrition guidelines for recreational facilities has been limited, and offers of free assistance to implement them as part of a research study were not embraced. Financial constraints appear to be the most important barrier to offering healthier items in Alberta's recreational facilities, as facility and food service managers perceive that selling healthier foods is unprofitable and might jeopardize sponsorship agreements. Mandatory government regulation may therefore be required to overcome the barriers to offering healthier foods in this setting. The advantages of a regulatory approach appear to outweigh any disadvantages, with benefits for population health, more effective use of public funds, and greater equity for the public and industry. Adverse effects on corporate profitability and freedom of choice are expected to be limited. Regulation may offer an efficient, effective and equitable means of ensuring that recreational facilities support child health and do not undermine it by exposing children to unhealthy food environments.

Background: Secondhand smoke (SHS) exposure is higher among lower socioeconomic status (SES) children. Legislation restricting smoking in public places has been associated with reduced childhood SHS exposure and increased smoke-free homes. This paper examines socioeconomic patterning in these changes., Methods: Repeated cross-sectional survey of 10 867 schoolchildren in 304 primary schools in Scotland, Wales and Northern Ireland. Children provided saliva for cotinine assay, completing questionnaires before and 12 months after legislation., Results: SHS exposure was highest, and private smoking restrictions least frequently reported, among lower SES children. Proportions of saliva samples containing <0.1 ng/ml (i.e. undetectable) cotinine increased from 31.0 to 41.0%. Although across the whole SES spectrum, there was no evidence of displacement of smoking into the home or increased SHS exposure, socioeconomic inequality in the likelihood of samples containing detectable levels of cotinine increased. Among children from the poorest families, 96.9% of post-legislation samples contained detectable cotinine, compared with 38.2% among the most affluent. Socioeconomic gradients at higher exposure levels remained unchanged. Among children from the poorest families, one in three samples contained >3 ng/ml cotinine. Smoking restrictions in homes and cars increased, although socioeconomic patterning remained., Conclusions: Urgent action is needed to reduce inequalities in SHS exposure. Such action should include emphasis on reducing smoking in cars and homes.

Aims: To examine whether English legislation to make virtually all indoor public places and work-places smoke-free on 1 July 2007 displaced smoking into the home and hence increased the proportion of children exposed to levels of second-hand smoke known to be detrimental to health., Design: Repeated cross-sectional study with data from 10 annual surveys undertaken from 1996 to 2008., Setting: England., Participants: Nationally representative samples of non-smoking children aged 4-15 years old living in private households., Measurements: Salivary cotinine, parental smoking status, whether smoking is allowed within the house, socio-demographic variables., Findings: The proportion of children exposed to damaging levels of second-hand smoke (defined as those with cotinine levels >1.7 ng/ml) has fallen over time, from 23.5% in 1996 to 12.6% in 2008. The legislation was not associated with further changes in the proportion of children above this threshold-the odds of having cotinine >1.7 ng/ml did not change after adjustment for the pre-legislative trend and confounders (odds ratio: 1.0, 95% confidence interval: 0.78, 1.4). Non-significant associations were also found when examining children by parental or household smoking status., Conclusions: Legislation to prohibit smoking in indoor public places and work-places does not increase the proportion of children exposed to damaging levels of second-hand smoke. Even in a country with a strong tobacco control climate, a significant proportion of children remain highly exposed to second-hand smoke and future policies need to include interventions to reduce exposure among these children., (© 2012 University of Bath.)

Background: Secondhand smoke causes cardiovascular and respiratory disease. Smoke-free legislation is associated with a lower risk of hospitalization and death from these diseases., Methods and Results: Random-effects meta-analysis was conducted by law comprehensiveness to determine the relationship between smoke-free legislation and hospital admission or death from cardiac, cerebrovascular, and respiratory diseases. Studies were identified by using a systematic search for studies published before November 30, 2011 with the use of the Science Citation Index, Google Scholar, PubMed, and Embase and references in identified articles. Change in hospital admissions (or deaths) in the presence of a smoke-free law, duration of follow-up, and law comprehensiveness (workplaces only; workplaces and restaurants; or workplaces, restaurants, and bars) were recorded. Forty-five studies of 33 smoke-free laws with median follow-up of 24 months (range, 2-57 months) were included. Comprehensive smoke-free legislation was associated with significantly lower rates of hospital admissions (or deaths) for all 4 diagnostic groups: coronary events (relative risk, 0.848; 95% confidence interval 0.816-0.881), other heart disease (relative risk, 0.610; 95% confidence interval, 0.440-0.847), cerebrovascular accidents (relative risk, 0.840; 95% confidence interval, 0.753-0.936), and respiratory disease (relative risk, 0.760; 95% confidence interval, 0.682-0.846). The difference in risk following comprehensive smoke-free laws does not change with longer follow-up. More comprehensive laws were associated with larger changes in risk., Conclusions: Smoke-free legislation was associated with a lower risk of smoking-related cardiac, cerebrovascular, and respiratory diseases, with more comprehensive laws associated with greater changes in risk.

Background: Joint use or community use policies are state-, district-, or school-level policies that allow for shared use of space or facilities between a school and a city or private organization. For this study, we (1) created an inventory of community use policies within Missouri school districts; (2) analyzed the policies for content, and (3) identified district characteristics that predict the presence of a community use policy., Methods: A coding tool was developed to assess the content of collected policies. Descriptors of 515 districts was gathered from the Missouri Department of Elementary and Secondary Education website. The policies were collected via district website or phone/e-mail contact and coded. Frequency of variables and a logistic regression to predict district presence of policy were computed., Results: Of the 515 districts in Missouri, 375 had a community use policy. Most (216) came from a policy template from the Missouri School Boards' Association or Missouri Consultants for Education (115). Only 42 districts had unique community use policies. Large or medium-sized districts were more likely to have a policy than small districts. Districts with higher percentage of students qualifying for free/reduced lunch were less likely to have a policy., Conclusion: Making changes to the 2 main resource templates have the potential to improve many district community use policies. Future efforts should focus on increasing policies and implementation in low resource and small districts. More research is needed on implementation and evaluation of community use policies., (© 2012, American School Health Association.)