Smart prevention: A new approach to primary and secondary cancer prevention in smart and connected communities

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Cities journal homepage: www.elsevier.com/locate/cities

Smart prevention: A new approach to primary and secondary cancer prevention in smart and connected communities Alexander Wraya, Dana Lee Olstadb, Leia Michelle Minakera, a b

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University of Waterloo School of Planning, 200 University Avenue W, Waterloo, Ontario N2L 3G5, Canada Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada

A R T I C L E I N F O

A B S T R A C T

Keywords: Smart cities Urban planning Urban health Cancer prevention Public policy Scoping review

Smart and connected communities (SCC) describe the shift in urbanism towards technological solutions and the production of knowledge-based industries. Local governments are recognizing the opportunity of this paradigm shift to improve services, create more efficient policies, and increase the wellbeing of their citizens. These new tools create the possibility for local governments to respond differently to “wicked problems” facing cities, including increasing chronic disease prevalence. Using lung and skin cancers as case studies, we present smart prevention as a novel approach that uses smart city-enabled built environment monitoring to trigger local cancerprevention policies. First, we present results of a scoping review we conducted to describe mechanisms by which features in urban built and social environments are hypothesized to contribute to lung cancer and skin cancer. We systematically searched fourteen electronic databases, yielding 47 articles that examined associations between built and social environment features and lung cancer (n = 34), and/or built and social environment features and skin cancer (n = 13). Second, we present a narrative review of smart city theory and governance. Third, we use findings from both reviews to draw conceptual links between cancer prevention and SCC – presenting a hypothetical suite of built environment and policy interventions to prevent lung and skin cancer.

1. Background The concept of smart and connected communities (SCC) encompasses varying definitions of smart cities, digital cities, and connected cities discussed in the literature. The SCC vision has become reality in some cities, which are beginning to implement examples of these complex systems-level innovations (Dameri & Rosenthal-Sabroux, 2014). Smart and connected approaches to urban spaces present an opportunity to address ‘wicked problems’ – complex, multifactorial problems that are difficult to solve (Rittel & Webber, 1973) - facing the globe's communities. The growing burden of chronic illness and disease in industrialized nations has been characterized as a ‘wicked problem’ (Wheeler, 2013). Across the globe, non-communicable diseases (NCDs) are becoming increasingly prevalent, burdening healthcare systems and lowering economic productivity (Global Burden of Disease Study 2013 Collaborators, 2015). Cancer comprises a substantial proportion of this disease burden, with an estimated 17.5 million cancer cases and 8.7 million cancer deaths in 2015, and this number expected to increase in the future given current epidemiological and demographic trajectories (Fitzmaurice et al., 2017). Importantly, half of cancers are preventable through behavioural or environmental modifications (Vineis & Wild,

⁎

2014). These environmental modifications have potential to change community structures in a way that promotes cancer prevention behaviours. The link between environmental factors and health has been well documented (Frumkin, Wendel, Abrams, & Malizia, 2011; Yen & Kaplan, 1998; Yen & Syme, 1999). The social ecological theory seeks to explain inter-connections between human health and determinants at various levels (Golden & Earp, 2012; Mcleroy & Bibeau, 1988). Briefly, humans are understood to be embedded within contexts that influence their behaviours and health outcomes, including the intrapersonal level (e.g., health knowledge and skills), the interpersonal level (e.g., health behaviour within social networks), the institutional level (e.g., institutional health policies), the community level (e.g., health-related attributes of a community's physical environment), and the policy level (e.g., broad-scale policies that impact health). Importantly, factors that influence behaviours (determinants of health, which can be social, biological, physical or political in nature (World Health Organization, 2017)) are seen as interacting with other behavioural determinants within and between levels of the social ecological model. Within this theoretical backdrop, built and social environments are important health promotion contexts given their role in spatially

Corresponding author. E-mail addresses: [email protected] (D.L. Olstad), [email protected] (L.M. Minaker).

https://doi.org/10.1016/j.cities.2018.02.022 Received 25 September 2017; Received in revised form 23 January 2018; Accepted 24 February 2018 0264-2751/ © 2018 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

Please cite this article as: Wray, A., Cities (2018), https://doi.org/10.1016/j.cities.2018.02.022

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secondary cancer prevention. Third, we use these findings to propose several SCC-enabled built environment interventions to reduce the population-level risks of lung and skin cancer, which we term as smart prevention based interventions.

patterning (in)equitable access to resources, their ability to affect the distribution of disease risk, and the structuring of human behaviour (Diez Roux, 2001; Schneider, 2011; Wheeler, 2013). For cancer in particular, the Multilevel Biologic and Social Integrative Construct framework has been proposed as an extension of the general socioecological model that identifies environmental and psychosocial contexts as a significant determinants of cancer at the macro-environmental, individual, and microbiologic levels of human physiology (Lynch & Rebbeck, 2013). A recent systematic review confirmed this relationship, suggesting the built environment can indeed affect cancer risk, incidence, treatment results, survivorship experiences, and survival outcomes (Gomez et al., 2015). The planning profession's ability to influence the built environment (Collison, 1954) presents a unique opportunity to deploy SCC enabled interventions to prevent cancer using real-time data. Given the substantial and growing global burden of cancer, that half of all cancers can be prevented, that over half the world's population lives in cities (United Nations, 2014), and that SCCs are advancing closer to the dominant reality, the objective of this paper is to examine how technological advances can be used in urban cancer prevention. We use lung and skin cancer as case studies to present a novel approach to cancer prevention in cities – smart prevention. There are three forms of cancer prevention: (1) primary prevention, which aims to prevent the onset of disease by altering cancer risk behaviours (e.g., tobacco smoking) and contexts (e.g., high levels of air pollution) (2) secondary prevention, which encompasses screening and early diagnosis to slow or stop cancer progression; and, (3) tertiary prevention, which aims to prevent recurrence or progression of established cancers (Gordon, 1983; Roberts, 1954). The built environment can contribute to primary prevention through reducing exposures to risk factors for cancer (Gomez et al., 2015). Major risk factors for cancer include poor air quality, alcohol use, tobacco use, physical activity, diet, and ultraviolet radiation (UVR) exposure (Institute of Medicine and National Research Council, 2003). Secondary prevention can also be influenced by the built environment, specifically through the spatial distribution of healthcare and cancer screening resources in a community (Neutens, 2015; Zenk, Tarlov, & Sun, 2006). Given that typical approaches to tertiary cancer prevention include medical interventions (i.e., chemotherapy, radiation treatment, and surgery), we focus on primary and secondary prevention of cancer, and consider tertiary prevention out of scope for the current review. This paper proceeds in three parts. First, we summarize the results from a scoping review that examines how researchers from diverse disciplinary backgrounds conceptualize associations between built and social environment features and lung and skin cancer prevalence or incidence, as well as hypothesized mechanisms underlying these associations. Second, we conduct a narrative review of the literature that seeks to define SCC, advancing the literature to encompass primary and

2. Scoping review A scoping review is a form of literature synthesis that follows a systematic protocol to investigate potential relationships between two concepts (Arksey & O'Malley, 2005; Colquhoun et al., 2014) without seeking to comprehensively identify or quantify all potential literature on the subject (Daudt, van Mossel, & Scott, 2013). Our scoping review encompasses four distinct fields of research: (1) cancer epidemiology and control, (2) urban planning and other built environment professions, (3) human geography, and (4) public administration and policy. We conducted a scoping (rather than systematic) review given our interest in how environmental exposures, outcomes, and covariates have been operationalized by these various disciplines, and disciplinary perspectives on the underlying conceptual mechanisms by which features of the built and social environment are associated with lung and skin cancer. Therefore, our review did not seek to explicitly quantify associations between built environment features and cancer risk, but rather to demonstrate how this multidisciplinary research question has been discussed to date. 2.1. Methods This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines in the description of the methods (Samaan et al., 2013). We adopt a scoping review methodology to the methods, following established guidance on the conduct of these reviews (Colquhoun et al., 2014; Levac, Colquhoun, & O'Brien, 2010). This section details the methods of the larger scoping review (which sought to examine environmental determinants of all cancers). The results section describes a subset of the total included records that focus exclusively on lung and skin cancer sites. 2.2. Search strategy We searched fourteen databases: ABI/INFORM, CINAHL, Cochrane Library, EMBASE, ERIC, ESPM, Google Scholar, HeinOnline, JSTOR, LexisNexus, Medline, Scopus, and Web of Science for peer-reviewed journal articles published in English from January 1990 to April 2017. The search strategy consisted of combining terms that represented the built environment, the urban planning profession, and cancer using AND and OR Boolean operators to search titles, abstracts and keywords. Thus, built environment themed terms are combined with an OR operator

Table 1 List of search terms by theme. Theme

Search terms

Built environment

“Built environment” OR “obesogenic environment” OR “urban form” OR neighbourhood OR “neighbourhood development” OR neighbourhood OR “neighbourhood development” OR “built form” OR “food environment” OR “food access” OR “urban design” OR architecture OR “traditional neighbourhood design” OR “traditional neighbourhood design” OR “healthy built environment” OR “healthy communities” OR “healthy places” OR “public space” OR sidewalk* OR park OR “green space” OR greenspace OR “green corridor” OR greenway OR “rail-trail” OR “open space” OR “community garden” OR albedo OR “LEED-ND” OR street* OR road* OR highway OR freeway OR walkability OR “transportation infrastructure” OR “transportation network” OR “public transit” OR “light rail” OR bus OR streetcar OR tram OR subway OR metro OR pedestrian OR ((bicycle OR cycle OR bike) AND (infrastructure OR lane*)) Cancer OR neoplasm* Vegetable* OR fruit* OR nutrition OR diet* OR “food consumption” OR smoking OR cigarette* OR tobacco OR “thermal stress” OR airshed OR “particulate matter” OR “PM 2.5” OR “air pollution” OR “air quality” OR “air pollutants” OR drinking OR alcohol OR walking OR “active transportation” OR “physical activity” OR exercise OR sedentary OR biking OR “active living” OR “ultraviolet radiation” OR UV OR tanning OR “sun exposure” OR UVR OR “light exposure” ((Local OR municipal OR regional OR urban OR rural OR town OR community) AND (bylaw* OR law* OR legislation OR policy)) (Zoning OR bylaw OR “urban policy” OR “municipal policy” OR “local policy” OR “official plan” OR “community plan” OR “secondary plan” OR “district plan” OR “urban planning” OR “rural planning” OR “town planning” OR “regional planning” OR “city planning” OR “community planning” OR “land use planning” OR “development charge” OR “population-based planning” OR “new urbanism” OR “smart growth” OR “transit oriented development”)

Cancer Risk factors

Policy Planning

2

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Fig. 1. Scoping review flowchart, adapted from Effective Public Health Practice Project (2009).

Journal articles were included in the review if they: (1) focused on primary and/or secondary cancer prevention strategies, that correspond to the risk factors of cancer and screening; (2) described a planningrelevant built or social environment exposure or intervention of any study design and population of interest; and (3) took place in Australia, Canada, Ireland, New Zealand, the United Kingdom, or the United States of America. This geographical limitation was applied given the similarity of these countries' political and urban planning systems compared to other nations (Hall, 2014). Of note, given that the built environment can influence neighbourhood socioeconomic status (SES) through land use, transportation, public service, and urban design decisions (Campleman, 1951; Collison, 1954; Rohe & Gates, 1981; Zwiers, Kleinhans, & Ham, 2017), we included articles that addressed neighbourhood SES as an exposure variable. Articles were excluded if they were book reviews, commentaries, or news items on current research projects. The primary reasons for exclusion of articles were not being related to primary or secondary forms of cancer prevention.

the titles were scanned for relevance, followed by an abstract review of articles with potentially relevant titles. Full-text articles of potentially relevant abstracts were retrieved and read to check relevancy before inclusion in the final scoping review dataset. One reviewer (AW, expertise in planning) processed articles through each stage to determine whether an article should be included. The other reviewer (LM, expertise in public health and tobacco control) assessed a random subset of titles, abstracts, and full-text articles for inclusion at each stage of the process. Disagreements were resolved by consensus. Another researcher (DO, expertise in public health and nutrition policy) provided guidance on review methods, and assisted in the development of this manuscript. Included articles were then subjected to a systematic data extraction process using a piloted data extraction tool developed by LM and AW. Data extracted from each article included: bibliographic information; subject classifications; methodological details; Population, Intervention, Comparators, Outcomes, Timing, Setting (PICOTS) information; evidence quality given study design type; results; and, new studies for further analysis from hand searches of reference lists. Each article took approximately 30 min to process using a combination of Google Forms (Google, 2017) and Zotero (Roy Rosenzweig Center for History and New Media, 2017). The ability to automate this process was limited given the a priori requirements of classifying and synthesizing material in a common format that meets the analytic objectives of the review. There is certainly potential for the use of text-mining to investigate broad trends in the literature (see Grubert, 2017), however significant limitations exist when examining the methodological and epistemological details of individual articles.

2.4. Analytic methods

3. Results

to policy and planning themed terms. Cancer themed terms are combined with an OR operator to risk factor themed terms. These two themed statements were then combined using an AND operator. Table 1 describes these search terms in depth. Search terms were adapted to fit within the limitations of the database. For example, searching in some databases required searching a controlled set of indexed keywords or MeSH headings instead of titles and/or abstracts. 2.3. Inclusion/exclusion criteria

The search of all fourteen databases resulted in 9958 potentially

Using Arksey and O'Malley's (2005) framework for scoping reviews, 3

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Fig. 2. Distribution of results across built environment factors, risks and cancer types.

Thirty-four articles focused on the relationship between built environment or area-level social factors and lung cancer. Of the six previously noted risk factors typically addressed through primary cancer prevention approaches, 28 articles assessed air quality, one article assessed alcohol use, one article assessed diet, six articles assessed physical activity, and five articles assessed tobacco use. No articles assessed UVR exposure. Three articles were related to secondary prevention by assessing some element of the built and/or social environment and lung cancer screening. Table 2 provides a summary of all 34 articles.

majority of articles were observational in nature (n = 23). We also identified five reviews: four narrative (Bailey & Solomon, 2004; Bartrip, 2013; Boffetta, Jourenkova, & Gustavsson, 1997; Stöber, Abel, & McClellan, 1998) and one systematic (Hamra et al., 2015); two simulation studies (Annenberg et al., 2011; Kam, Delfino, Schauer, & Sioutas, 2013), and one qualitative study (Jacobs, Kelly, & Sobolewski, 2007). Among the observational studies, exposure to poor air quality was either assessed through geographic proximity to major roadways or industry (n = 23 studies) and/or through automotive-based transportation systems (n = 22 studies). In all studies, closer proximity to industry or major roadways, or increased dependency on automotive transportation was considered to represent higher exposure to poor air quality, and therefore hypothesized to be associated with increased cancer risk. Two studies (Hystad, Carpiano, Demers, Johnson, & Brauer, 2013; Knox, 2008) examined area-level sociodemographic variables and associations with lung cancer. Socio-demographic factors were hypothesized to explain the relationship between air quality and lung cancer through both contextual (i.e., disadvantaged neighbourhoods are more likely to be located near roadways and industry, thereby increasing residents' air pollution exposure) and compositional (i.e., people in disadvantaged neighbourhoods are more likely to smoke, which is a primary risk factor for cancer) mechanisms. Finally, we assessed one qualitative study, which examined housing policy interventions, and found that poor organization of governance structures at the local, state, and federal levels are barriers to improving internal and external air quality through housing policy, which may increase lung cancer incidence (Jacobs et al., 2007). This study was the only one to draw links between governance structures (as features of the social environment), air quality, and lung cancer.

3.1.1. Air quality and lung cancer Twenty-eight articles assessed at least one built and/or social environment feature and air quality as they relate to lung cancer. The vast

3.1.2. Alcohol use and lung cancer One large ecological study conducted in 352 English local authority areas examined geographical distribution of standardized mortality

relevant titles. After scanning the titles for relevance, 2166 articles were identified for abstract review. These 2166 titles were first scanned for duplicates, leaving 1620 unique titles. After reviewing the abstracts of those 1620 titles, there were 874 papers left to review for relevance. The full text review left 558 articles included in the final scoping review dataset. This paper reviews the 47 articles related to lung (n = 34) and skin cancer (n = 13) sites. Fig. 1 provides a breakdown of the scoping process. The search rendered the following results by database: CINAHL (n = 11), Cochrane Library (n = 7), EMBASE (n = 24), ESPM (n = 12), Google Scholar (n = 4), JSTOR (n = 2), Medline (n = 13), Scopus (n = 12), Web of Science (n = 1). Searches of ABI/INFORM, ERIC, HeinOnline, and LexisNexis did not retrieve any relevant results for the purposes of this review. A number of articles were duplicated across databases, with 24 being found in more than one search string. An alluvial diagram (see Rosvall & Bergstrom, 2010) for the distribution and correlation of results across built environment, risk factor, and cancer themes of interest is presented in Fig. 2. 3.1. Lung cancer

4

5

United States

United States

Guajardo and Oyana (2009)

Canada

Brown et al. (2016)

Garshick et al. (2008)

Canada, United Kingdom & United States

Boffetta et al. (1997)

United States

United Kingdom

Bixby et al. (2015)

Fryzek, Mumma, McLaughlin, Henderson, and Blot (2001)

United States

Bailey and Solomon (2004)

New Zealand

Australia, Canada, United Kingdom, United States

Annenberg et al. (2011)

Corbin et al. (2011)

Region

Authors

Table 2 Summary table of articles related to lung cancer.

Ecological study (n = 417,423 residents in 38 zip code areas)

Retrospective cohort study (n = 31,135)

Ecological study (n = 107,277 cases, 103,578 controls)

Case-control study (n = 457 cases, 792 controls)

Individual cross-sectional study (n = 2412)

Narrative review (n = 201)

Ecological study (n = 50)

Narrative review (n = 220)

Simulation model (n = 12)

Methods

Air quality

Air quality

Air quality

Air quality

Screening

Air quality

Air quality Physical activity

Air quality

Air quality

Risk factor

This paper describes a simulation model of a hypothetical 50% reduction in black carbon emissions in 12 different global regions. PM2.5 is assumed to be representative of black carbon, both pollutants associated with relative risk of lung cancer. In developed nations, transportation and land use emissions form the dominant contributions. The simulation model estimates 15,700 lung cancer deaths could be avoided annually by reducing black carbon emissions by 50% through policy and built environment interventions. This narrative review of marine freight impacts to human health, consisted of 220 articles published between 1997 and 2004, of which 16 assessed port facility emissions and lung cancer, finding: + port facility emissions and lung cancer (n = 16) An ecological study of the 50 largest cities' greenspace coverage in England and diseasespecific and all-cause mortality. Greenspace coverage was classified into quintiles. The analysis controlled for air quality, SES, and demographics. There was a weak correlation between PM10 concentrations and greenspace coverage. Lung cancer mortality was included as a way to establish discriminant validity given there was no hypothesized relationship with green space availability. Ø greenspace coverage and lung cancer This narrative review of exposure to common aerosol pollutants and cancer sites, consisted of 201 articles published between 1956 and 1995, finding: + risk of lung cancer and exposure to diesel exhaust (n = 30) + risk of lung cancer and exposure to polycyclic aromatic hydrocarbons (n = 25) This study analyzed 2412 lung cancer cases occurring from 2004 to 2008 in Toronto, Ontario, Canada. The spatial analysis compared incidence patterns with demographic and SES variables. Overall, higher lung cancer incidence and risk occurred in southeastern Toronto. No further individual-level analysis was conducted. + recent immigration and lung cancer risk Ø household SES and lung cancer risk Ø African ethnicity and lung cancer risk − Asian ethnicity and lung cancer risk This paper reports on a case-control study of New Zealand registered lung cancer cases, with 457 patients interviewed, along with 792 control individuals. These cases and controls were matched to create a comparative sample of different professions. The analysis controlled for tobacco use, demographics, workplace behaviour, and use of personal protective equipment. Occupations related to driving were found to have an excess risk of lung cancer. The built environment's creation of an automotive reliant society encourages large numbers of driving based occupations. + driving as an occupation and lung cancer risk from harmful pollutants This study reviews the 107,277 deaths in Kettleman City, Hinkley, and Topock, California, United States from 1989 to 1996. These deaths are compared to a control group of 103,578 from Kings and San Bernardino County. The analysis focused on whether the presence of two chromium emitting gas compressor plants in the case counties would result in higher observed lung cancer mortality. Chromium is documented as a carcinogenic environmental emission. Ø proximity to industrial facilities and lung cancer mortality This study examines lung cancer mortality among 31,135 drivers in the United States from 1960 to 2000. The analysis controlled for changes in employment position, tobacco use, race, age, and years of service. The monitoring period occurred from 1960 to 1985, with the follow up period from 1986 to 2000. It is hypothesized that the reliance of US on driving occupations, and exposure to harmful pollutants increases lung cancer risk. + years worked in driving related occupation and lung cancer mortality risk This study analyzed lung cancer incidence among 417,423 residents grouped by 38 zip code areas near the Tittabawassee and Saginaw rivers of Michigan, United States from 1989 to 2002. The spatial analysis revealed geographic clusters of lung cancer in certain neighbourhoods. The authors hypothesize environmental emissions and proximity to (continued on next page)

Study summary and results

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Region

Canada, United Kingdom, United States

Canada

Canada

Canada

United States

United States

United States

Authors

Hamra et al. (2015)

Hystad et al. (2012)

Hystad et al. (2013)

Hystad et al. (2013)

Jacobs et al. (2007)

Jia, James, and Kedia (2014)

Kam et al. (2013)

Table 2 (continued)

6 Simulation model (n = 5)

Ecological study (n = 650,000 residents in 212 census tracts)

Content analysis; Case study

Cohort analytic study (n = 3340 cases, 5039 controls)

Cohort analytic study (n = 2390 cases, 3507 controls)

Methods paper

Systematic review (n = 20)

Methods

Air quality

Air quality

Air quality

Air quality Tobacco use

Air quality

Air quality

Air quality

Risk factor

noxious land uses are the source of the higher observed incidence. + proximity to highways/industrial facilities and lung cancer incidence This systematic review and meta-analysis of articles about air pollution and lung cancer (n = 20) from 1999 to 2014 found: + traffic-related air pollution, represented by nitrogen oxides, and lung cancer risk + proximity to major roadways and lung cancer risk This paper describes an exposure assessment of a previous lung cancer incidence casecontrol study of 8353 individuals, with self-reported residential histories, conducted from 1975 to 1994 in Canada. Exposure was defined as NO2, O3, and PM2.5/10 compounds. All these compounds have been identified to correlate with risk of lung cancer. By spatial analysis of the proximity of major highways, industrial facilities, and air quality monitoring stations to individual postal codes, the authors generated an air exposure value. No correlations were reported in this paper, however, the authors demonstrate the importance of residential histories in exposure modelling, and the estimated exposures of study participants to air pollution. Examining data from a Canadian case-control study of lung cancer, this paper reports on a retrospective examination of the exposure to air pollution of the case (n = 2390) and control (n = 3507) cohorts using residential histories. Observation periods include 1975 to 1980, 1981 to 1985, and 1986 to 1990. The study deploys the methods described in the previous paper to generate the exposure estimates. + PM2.5 and lung cancer incidence + NO2 and lung cancer incidence + Proximity to highways (100 m) and lung cancer risk Ø O3 and lung cancer incidence Ø Proximity to major roads (100 m) and lung cancer risk Examining data from a previous lung cancer case-control study conducted in Canada from 1975 to 1994, this paper reports on a retrospective examination of associations between neighbourhood SES and incidence among case and control cohorts. Using census SES data at the census tract level for 1971, 1981, 1986, 1991 and 1996; and the residential history data from the case-control study, the authors constructed an analysis of spatial correlations. The study also examined the mediation by tobacco use, health behaviour, and occupational factors + Neighbourhood SES status and lung cancer incidence + Tobacco use mediated the correlation between SES and lung cancer incidence Ø No observed mediation by health behaviour, occupational factors, and environmental conditions This case study examines housing and land use policies enacted by Cuyahoga County, Ohio, United States, to improve public housing air quality. These improvements are expected to reduce the lung cancer risks of exposure to harmful indoor and outdoor pollutants. The authors note the disarrayed governance structure of housing at the local, state, and federal levels as a major impediment to public health interventions. This study examines the association between racial composition and lung cancer risk from air pollution exposure in 212 census tracts of the Memphis, Tennessee, United States area. Air toxics data was generated from the 2005 National Scale Air Toxics Assessment. All other data is from the 2000 US Census. The spatial weighted regression analysis examined the density of African Americans to air toxics lung cancer risk controlling for population density, and SES. African American dominant census tracts face a 6% higher risk of lung cancer compared to other tracts. This elevation is due to proximity to major roads and industrial facilities. + African Americans and lung cancer risk from airborne toxics + proximity to major roads/industrial facilities and lung cancer risk from airborne toxics This study measures the PM2.5 exposure level along five transportation corridors in Los Angeles, California, United States. Data collection was conducted at an individual user level, with researchers carrying personal monitoring equipment to simulate the journey of a typical traveller. Exposure to pollutants by transportation use may pose a lifetime lung (continued on next page)

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7

United Kingdom

Papathomas et al. (2011)

United Kingdom

Knox (2008)

United Kingdom

United Kingdom

Knox (2006)

Mitchell and Popham (2008)

United Kingdom

Knox (2005)

United States

United States

Keller and Howe (1993)

McEntee and Ogneva-Himmelberger (2008)

Region

Authors

Table 2 (continued)

Case-control study nested within a prospective cohort study (n = 271 cases, 2977 controls)

Ecological study (n = 32,482)

Ecological study (n = 1361)

Ecological study (n = 352)

Retrospective cohort study (n = 12,017)

Retrospective cohort study (n = 12,018)

Case-control study (n = 20,334 cases, 14,902 controls)

Methods

Air quality Physical activity

Physical activity (unmeasured)

Air quality

Air quality Alcohol use Tobacco use

Air quality

Air quality

Air quality

Risk factor

cancer risk. + freeway use and lifetime lung cancer risk − light rail use and lifetime lung cancer risk This study compares lung cancer cases (n = 20,334) to colon cancer cases (n = 14,902) as the controls from 1985 to 1987 in Illinois, United States. The analysis focused on spatial clustering, occupational exposures, urbanity, and environmental exposure, with a control for tobacco use. + driving as an occupation and lung cancer Ø environmental exposure and lung cancer Ø residence in urban area and lung cancer This study examines the correlation between children dying from leukaemia and lung cancers before their 16th birthday, and home address proximity to noxious land uses in the United Kingdom from 1955 to 1980. These noxious land uses include industrial facilities, transportation infrastructure, and power generation plants – emissions of PM2.5, benzene, dioxins and VOCs. The analysis developed a measure of excess relative risk of cancer for proximity to each of the hazards. + proximity (300 m) to emissions intensive land uses and excess relative risk + proximity (500 m) to transportation facilities and excess relative risk This study examines the correlation between birth locations and childhood lung cancer in the United Kingdom from 1955 to 1980. Proximity of birth address to noxious land uses was estimated similarly to the previously described study. + proximity (100 m) to transportation infrastructure and excess cancer risk This study documents the correlations between a standardized mortality ratio (SMRs) of lung cancer and atmospheric emissions in 352 English cities from 1996 to 2004. The analysis compared spatially the SMRs and emissions by 1x1km blocks, controlling for SES, tobacco use, alcohol use, and being located in a northern location. Large variations were noted in the SMRs for lung cancer among cities. + air pollution and lung cancer SMR + SES, tobacco use, alcohol use and lung cancer SMR This observational study examined the air pollution exposure and proximity to major highway corridors by census tract in Massachusetts, United States for 2005. This exposure variable was then compared with lung cancer incidence to determine the presence of spatial clustering along major highway corridors. The authors identify missing incidence and retrospective longitudinal data as key limiting factors. Ø proximity to major highway corridor and lung cancer incidence This study of the English population under the retirement age examined the associations of lung cancer mortality with quantile SES and exposure to greenspace, from 2001 to 2005. The authors hypothesize that SES-related inequities in lung cancer rates will be reduced among those living near green space, although they hypothesize little to no moderation of the relationship between SES inequity in lung cancer mortality by greenspace given unestablished plausible biological pathways. The population was divided into four SES classes, and five greenspace exposure typologies. Besides lung cancer mortality, all cause, circulatory, and self-harm mortality were examined for correlations. Ø exposure to greenspace and lung cancer mortality Ø Greenspace exposure did not moderate the (non)association between SES and lung cancer mortality This article describes a case-control study of data collected from the 1992 to 1999 European Prospective Investigation into Cancer and Nutrition prospective cohort study. The analysis consisted of correlating lung cancer incidence among non-smokers with exposure profiles from various risk factors. These risk factors include exposure to heavy traffic, exposure to PM10, exposure to NO2, and physical activity. + PM10/NO2 exposure and lung cancer incidence + proximity to major roads and lung cancer incidence Ø Physical activity and lung cancer incidence (continued on next page)

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8

United States

United States

United States

Richardson et al. (2012)

Stöber et al. (1998)

Tousey et al. (1999)

United Kingdom

Raaschou-Nielsen et al. (2013)

New Zealand

United States

Puett et al. (2014)

Richardson et al. (2010)

United States

Polidor, Hu, Biswas, Delfino, and Sioutas (2008)

United Kingdom

United States

Patel et al. (2017)

Richardson and Mitchell (2010)

Region

Authors

Table 2 (continued)

Narrative review (n = 11) Case-control study (n = 507 cases, 1007 controls)

Ecological study (n = 43,000,000 individuals in 49 cities)

Ecological study (n = 1,546,405 residents in 1009 census area units)

Ecological study (n = 28,600,000 adults in 6432 wards)

Meta-analytic prospective cohort study (n = 312,944)

Individual cross-sectional study (n = 103,650)

Ecological study (n = 8640)

Repeating cross-sectional study (n = 231,205 cases over three observation periods)

Methods

This study examines three observational periods of lung cancer cases in California, United States. The time periods are: 1988 to 1992, 1998 to 2002, and 2008 to 2012. The analysis focuses on neighbourhood SES by quintile, ethnicity, sex and histology. Spatial and SES patterns observed were theorized to be the result of environmental exposures and access to health care resources. + low SES and increased lung cancer incidence − high SES and decreased lung cancer incidence This article describes an observational study of PAH emissions along major highway corridors in Wilmington, California, United States. The data collection consisted of an intensive monitoring period in May 2007, resulting in 8460 unique observations of particle attached PAHs. The analysis examined the correlations of PAH levels with traffic volume and time of day along the observed freeway corridors. Researchers documented time and volume points that PAH levels exceeded lifetime lung cancer risk levels. + traffic volume and lung cancer risk + morning/afternoon rush hours and lung cancer risk This article reports on the Nurses' Health Study, an individual cross-sectional study conducted from 1976 to 2010 across the United States. This version extends the study to estimate average exposures to particulate matter, and residential proximity to roads. The analysis then examines correlations between long term exposure and lung cancer outcomes. Researchers controlled for history of tobacco use, with only non-smoking cases included. + particulate matter exposure and lung cancer Ø distance to road and lung cancer This study examines the role of long-term air pollution in the incidence of lung cancer. The data is retrieved from the European Study of Cohorts for Air Pollution Effects, which consists of 12 sub-cohorts. One cohort is located in Oxford, United Kingdom. The analysis controlled for tobacco use, demographics, and SES. + PM10 exposure and lung cancer incidence + vehicle kilometres travelled and lung cancer incidence Ø Nitrogen oxides exposure and lung cancer incidence Ø Traffic density and lung cancer incidence This 2001 ecological study examines the gendered differences in relationship between health (cardiovascular disease mortality, respiratory disease mortality, long-term illness, and lung cancer mortality) and urban green space among 6432 urban wards in the United Kingdom. Greenspace availability is defined as the % area. Physical activity is assumed to be the primary risk factor of focus with the measure of greenspace availability. Lung cancer mortality was included as a way to establish discriminant validity given there was no hypothesized relationship with green space availability. Ø green space availability and lung cancer mortality This study reviews the potential correlation between greenspace and 1) cardiovascular mortality and 2) lung cancer mortality in New Zealand from 1996 to 2005. Availability is defined as % area coverage. The analysis controlled for tobacco use, demographic and SES factors. Again, lung cancer was included in the analyses as a way to establish discriminant validity. Ø greenspace availability and lung cancer mortality This study examines the potential link between greenspace and lung cancer mortality at the city level in the United States for 2004. Greenspace was defined as “greenness” of city land cover across all public and private property types. The analysis controlled for SES and automotive reliance. As above, lung cancer was included in the analyses as a way to establish discriminant validity. Ø greenness and lung cancer mortality This narrative review of 11 articles published between 1976 and 1991 found: Ø driving related occupational exposure to diesel exhaust and lung cancer This study examined the potential causal factors of lung cancer, from 507 documented cases in northeast Florida for 1993 to 1996. The analysis examined localized air quality, (continued on next page)

Screening

Air quality

Physical activity

Physical activity

Physical activity

Air quality

Air quality

Air quality

Study summary and results

Risk factor

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Individual cross-sectional study (n = 74,179) United States Wong et al. (2013)

ratios of 14 types of cancer (including lung cancer) and 13 other chronic diseases (Knox, 2008). The study found that area-level binge drinking was significantly correlated with lung cancer. However, binge drinking was considered to be a confounder of the association between air quality and lung cancer, and was used (along with other area-level social variables) to standardize local authority areas and isolate the effects of poor air quality on lung cancer risk. 3.1.3. Diet and lung cancer One case-control study explored the high prevalence of lung cancer in Northeast Florida, examining a variety of individual-level behavioural and social factors as well as environmental factors (e.g., residential location). However, while dietary fat intake was positively associated with odds of having lung cancer, it was (like alcohol in the above example), considered to be a potentially confounding variable in the hypothesized relationship between built environment and lung cancer (Tousey et al., 1999).

NOTES: (n=) denotes population of the study | (+) denotes positive correlation or association | (Ø) denotes null correlation or association | (−) denotes protective correlation or association.

diet, occupation, residential patterns, and tobacco use; while controlling for ethnicity and SES. Overall, lifestyle factors had greater influence than environmental factors for lung cancer. + tobacco use and lung cancer + dietary fat and lung cancer Ø air quality, occupation, residential patterns and lung cancer This study examines the influence of neighbourhood SES on lung cancer incidence among Hispanics in California, United States from 1998 to 2002. In addition, the analysis examined language skills, age, acculturation, and immigration status. Tobacco use is a leading cause of lung cancer, and therefore, individual SES factors may drive riskier behaviours associated with lung cancer. + acculturation and tobacco use Ø associations between neighbourhood SES and LC incidence vary in magnitude and direction by sex and ethnicity. Air quality Diet Tobacco use

Tobacco use

Study summary and results Risk factor Methods Region Authors

Table 2 (continued)

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3.1.4. Physical activity and lung cancer Five studies examined the relationship between greenspace and lung cancer (Bixby, Hodgson, Fortunato, Hansell, & Fecht, 2015; Mitchell & Popham, 2008; Richardson et al., 2012; Richardson & Mitchell, 2010; Richardson, Pearce, Mitchell, Day, & Kingham, 2010). All five of these studies examined associations between greenspace and both all-cause and disease-specific mortality. Each study included lung cancer mortality as an outcome to demonstrate discriminant validity within their studies. In other words, while lung cancer was treated as an outcome variable in statistical models, authors in all studies expected to find no association between greenspace and lung cancer because of a lack of hypothesized mechanism. Only one study (Papathomas, Molitor, Richardson, Riboli, & Vineis, 2011) sought to examine hypothesized links between genetic, environmental, and behavioural factors and lung cancer among non-smokers. Their hypothesis was physical activity would result in exposure to harmful air pollutants, as part of a larger exposure risk profile for lung cancer. None of the six studies found significant associations between greenspace and lung cancer. 3.1.5. Tobacco use and lung cancer Four articles assessed whether and how tobacco use can affect associations between features of the built or social environment and lung cancer using an observational study design (Hystad et al., 2013; Knox, 2008; Tousey et al., 1999; Wong et al., 2013). All four observational studies treated tobacco use or second-hand-smoke exposure as a relevant compositional confounder between either area-level SES characteristics or geographic clustering and lung cancer. Therefore, in this body of research, tobacco use and second-hand smoke are typically viewed as compositional confounders rather than as stand-alone characteristics that can be modified by built-environment interventions or policies that affect population behaviours. 3.1.6. Screening and lung cancer Three studies assessed built or social environment factors and screening for lung cancer. Two of these (Brown, Jiang, Ezzat, & Sawka, 2016; Patel et al., 2017) conducted geospatial analysis of lung cancer cases, with the purpose of guiding the provision of both primary and secondary prevention efforts. Of note, all studies included socio-demographic variables, and hypothesized that access to screening services is inequitably geographically distributed. Taken together, these studies point to the ability of the built environment to shape access to screening services through land use, transportation and public service decisions. 3.2. Skin cancer Thirteen articles focused on the relationship between the built environment and skin cancer (Table 3). Two articles related to air quality, two articles related to physical activity, and nine articles related to UVR 9

10

United States

Australia

Dobbinson et al. (2017)

Glanz et al. (2001)

Australia

Dobbinson et al. (2014)

United States

Australia & United States

Buller et al. (2017)

Glanz et al. (2000)

Canada & United States

Buller et al. (2016)

United States

New South Wales, Australia

Astell-Burt et al. (2014)

Escobedo et al. (2017)

Region

Authors

Table 3 Summary table of articles focusing on skin cancer.

Clustered randomized control trial (n = 176 staff at 14 outdoor recreation sites)

Clustered randomized control trial (n = 285 children at 14 outdoor recreation sites)

Individual cross-sectional study (n = 10,068)

Protocol paper (n = 6 public parks)

Cluster randomized control trial (n = 51 secondary schools)

Cluster randomized control trial (n = 580 observations in 145 public parks)

Cluster randomized control trial (n = 3531 vacationers at 41 hotels and resorts)

Ecological study (n = 267,072 adults within 11,722 neighbourhoods)

Methods

Using a large sample of Australian adults 45 years old and over, this study examined associations between objectively measured greenspace (parkland within neighbourhoods defined as 1 km around participants' homes) and self-reported medically diagnosed melanoma and non-melanoma skin cancer. The study also examined whether physical activity mediated the association between greenspace and skin cancer. + neighbourhood green space and non-melanoma skin cancer Ø neighbourhood green space and melanoma skin cancer Ø very little mediation of green space and skin cancer risk by physical activity This study describes baseline characteristics and process evaluation of an advanced educational program (Go Sun Smart) to reduce UVR exposure among adult vacationers at hotels and resorts in Canada and the US. Though results were not reported, authors include an overview of the training program's components for built environment interventions. Hotel and resort staff were educated to make available shaded areas throughout outdoor areas, and encourage guests to make use of shade regularly. This study describes the methods and baseline characteristics of an intervention to reduce UVR exposure by installing shade sails in public parks. Though no results of the intervention are reported, this study hypothesizes that users of public parks in which shade sails are constructed will have reduced UVR exposure relative to those who use public parks without shade sails. This study reported qualitative and quantitative findings from 2006 related to a school-based intervention that installed shade sails in secondary schools. Qualitative data suggested that secondary students had positive perceptions of shade sails, and suggested further environmental alterations to increase use, including tables and chairs, the presence of greenery, defined and private spaces, and large-enough shade sales to accommodate groups. Quantitative data confirmed the qualitative finding that tables increased shade sail use. + tables and chairs, and shaded area use This paper reports the protocol for a non-randomized case-control study of three intervention parks and three control parks in lower income neighbourhoods of southwestern Sydney, Australia. The study reports baseline characteristics of the intervention and control locations. The proposed ShadePlus intervention will refurbish pathways and add new shaded areas. The study hypothesizes the built environment changes will have a positive impact on behaviour and community wellbeing. The study will document changes to physical activity, park use and observed sun protection behaviours post-intervention. This individual cross-sectional study documents 10,068 cases of invasive melanoma between 2004 and 2013 in Los Angeles County, California, United States. The characteristics of these patients were compared with census tract level SES and spatial determinants of access to medical care and screening. The analysis resulted in a measure of relative risk for melanoma at the census tract level, differences between Hispanic and non-Hispanic whites, and socioeconomic status. + Hispanic and melanoma + poverty and melanoma Ø proximity to clinic and melanoma − clinic density and melanoma − higher education level and melanoma This clustered randomized control trial examined the behaviour of 285 children (6-8yo) children enrolled in programming at 14 outdoor recreation sites in Oahu, Hawaii, United States for the summer of 1996. The study consisted of three arms: a control, an education only, and an education and environmental intervention. The education only group received staff training, on-site activities, informational materials, and incentive materials. The education and environment group received in addition sunscreen and sun safe environment education and modifications. Children's sun protection behaviours were reported by parents before and after exposure to the intervention. + use of sunscreen and shade among intervention groups + sun protection policies among intervention groups Ø no difference between Education Only and Education plus Environment interventions This clustered randomized control trial examined the behaviour of 176 staff at 14 outdoor recreation sites in Oahu, Hawaii, United States for the summer of 1996. The interventions are the same as the previously described study. Behaviour was recorded through staff completion of baseline, post-test and follow-up surveys. The study hypothesized that staff exposure and further dissemination of the program to children would result in change of their own sun protection behaviour. + knowledge, attitudes and norms about sun protective behaviour and intervention (continued on next page)

Physical activity UVR exposure

Physical activity UVR exposure

Physical activity UVR exposure

Screening

Physical activity UVR exposure

UVR exposure

Physical activity UVR exposure

UVR exposure

Study summary and results

Risk factor

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Canada

United States

United States

United States

Glanz et al. (2015)

Hussain et al. (1998)

Ray et al. (2016)

Wilde et al. (2013)

Wong et al. (1992)

Ecological study (n = 55,525 residents in 4 counties)

Individual cross-sectional study (n = 62)

Retrospective cohort study (n = 28,408)

Simulation model

Randomized cohort analytical study (n = 435)

Methods

Air quality

UVR exposure Screening

UVR exposure Screening

Air quality

Physical activity UVR exposure

Risk factor + implementation of sun protection policies for outdoor programming and intervention Ø no difference between Education Only and Education plus Environment interventions This clustered randomized cohort analytical study of 435 outdoor pools in the United States, reports the maintenance and user effects of sun protective policies and environments. Interventions consisted of a basic and enhanced condition. The basic condition consisted of Pool Cool educational materials, sun safety signs, and sunscreen. The enhanced condition expanded upon this with access to detailed resource materials on sun safe environments, shade structures, and incentive items. Two cohorts were recruited, and then randomized between the two interventions. Results were measured by a survey of pool visitors and observations by researchers. Implementation, maintenance, and sustainability of entire Pool Cool program were also measured for three years after recruitment. + enhanced condition (shade structures) and maintenance of program + enhanced condition (shade structures), and sun safety policies and program sustainability This study simulated the lifetime risk of developing skin cancer from exposure to high levels of polycyclic aromatic hydrocarbons (PAH) found in popular swimming locations of Ontario, Canada. PAH levels were found to significantly exceed lifetime exposure limits, however the authors noted showering off within 24 h of exposure would negate the overall risk. + PAH levels and excess risk of skin cancer This retrospective cohort study examined cases of basal cell carcinoma (BCC) in Los Angeles County, California, United States from 2011 to 2012. The study identified five spatial clusters of cases when controlling for age, sex and neighbourhood SES. No further analysis of clusters was conducted beyond hypothetical explanation. The authors noted the importance of spatial analysis in cancer control and prevention. This individual cross-sectional study documented the results of a screening and health education intervention in two homeless shelters in Salt Lake City, Utah, United States from 2011 to 2012. Free screenings were provided to homeless patients, with follow up procedures scheduled if diagnosed. Patients were also educated on sun protective behaviours, such as the importance of shade. + homelessness and UVR exposure This ecological study reports on the incidence of skin cancer cases in two case counties, and two control counties from 1980 to 1986 in Montana, United States. The case counties had industrial facilities emitting airborne arsenic until 1980. The authors hypothesized that environmental arsenic exposure could result in skin cancer. The analysis controlled for tobacco use and demographics. The study did not control for emigration, UVR exposure or SES. Also, the funding of this study by local industry may be a source of bias. Ø proximity to industry and skin cancer

Study summary and results

NOTES: (n=) denotes population of the study | (+) denotes positive correlation or association | (Ø) denotes null correlation or association | (−) denotes protective correlation or association.

Region

Authors

Table 3 (continued)

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melanoma (Escobedo et al., 2017). The second found that among people using homeless shelters, geographically proximate and no-cost skin cancer screening services was positively perceived by homeless shelter users, which was hypothesized to improve skin cancer screening uptake (Wilde et al., 2013). Thus, features in both the built (i.e., density of screening services) and social (i.e., economically accessible services) environments may be important for skin cancer prevention.

exposure. There were no articles related to alcohol use, diet, or tobacco use. In addition, four articles were related to secondary prevention screening mechanisms for skin cancer. Table 3 provides a summary of all the articles related to skin cancer. 3.2.1. Air quality Two studies examined associations between skin cancer and exposure to environmental pollutants. One examined the lifetime risk of developing skin cancer from exposure to polycylic aromatic hydrocarbons emissions that were deposited into the soil of popular swimming areas. The study found many locations exceeded the maximum levels of lifetime exposure, but suggested it could be mitigated by showering off within 24 h of activity (Hussain, Rae, Gilman, & Kauss, 1998). The other study found no correlation between airborne arsenic exposure from local industry and skin cancer rates, with control counties demonstrating higher skin cancer rates than counties with high exposure to air pollution (Wong, Whorton, Foliart, & Lowengart, 1992). Of note, this study was funded by a mining company operating facilities in the area that emitted airborne arsenic, which potentially biased study findings.

4. Defining smart cities Smart and connected communities do not have a universally-accepted definition. There is tension between academic and private enterprise understandings of the terms – smart cities, digital cities, or connected communities – resulting in confusion of the bounding parameters for this innovation in urbanism. Academic interpretations tend to focus on the governance and soft capital aspects of smartness, while the business community typically deals in technological advances (Dameri & Rosenthal-Sabroux, 2014). Thus, smart and connected communities (SCC) will be used as the high-level descriptor of these terms. Cocchia (2014) provides an excellent systematic review of the evolution in terms, and highly cited definitions of SCC. However, the present review focuses on a recently published theoretical framework for smart cities, with a brief review of the three other dominant understandings. First, the Vienna Centre for Regional Science defines SCC along their relative smartness in the six thematic areas of economy, people, government, mobility, environment, and living (Giffinger et al., 2007). Smartness is defined as any technological improvement within any of these six themes, provided investments are predicted to result in sustainable growth that improves quality, efficiency and democratic participation in the community (Caragliu, Del Bo, & Nijkamp, 2011; Colldahl, Frey, & Kelemen, 2013). Second, smart cities as “embedded intelligences” are an approach that evolved from the intelligent cities epistemological tradition. Transforming from a community containing disjointed bits of information to a hypothetical future of connected rationalized structures, the city would iterate into a network of embedded intelligences (Mitchell, 1995, 1999, 2004, 2005). However, Deakin (2014) noted an important flaw to this approach: it fails to address the underlying sociopolitical structure that manifests as the current socioeconomic inequality in communities. Thus, the embedded intelligence of SCC does not represent a panacea to the problems of human communities; it is merely a tool of reinforcing existing power structures. Therefore, SCC needs to be governed appropriately to ensure implementation does not cause undue harm to the most vulnerable populations (Meijer & Rodríguez Bolívar, 2016). The third definition approaches SCC from the position of knowledge capital networks and examines the underlying social dynamics of smart city formation. Deakin and Leydesdorff (2014) describe the triple-helix model, treating SCC as a community network of three subgroups: knowledge-producing universities, wealth-creating private enterprise, and democratically-engaging civil societies. These subgroup networks comprise the soft capital of a community. This model attempts to counter the assumption that urban structural change is an organic innovation, but actually an outcome of carefully constructed public or private decisions through policy and funding allocations (Deakin & Allwinkle, 2007; Etzkowitz, 2008). Essentially, the formation of SCCs is not an accident, but a product of conscious decision-making by all members of the innovation ecosystem. The latest approach to defining SCC takes a set of theoretical urban understandings of the city as the foundation for contextualizing the competing narratives of SCC terms. Kummitha and Crutzen (2017) undertook a content analysis of the smart city literature, arriving at a categorization of scholarship into four schools of thought: restrictive, reflective, rationalistic, and critical. The restrictive school approaches SCC as the pure advancement of technological influence within urban

3.2.2. Physical activity Of the two studies that assessed physical activity in relation to skin cancer prevention, both assessed physical activity in addition to UVR exposure (Astell-Burt, Feng, & Kolt, 2014; Dobbinson et al., 2017). Neither study examined physical activity as a direct risk factor for skin cancer, but instead conceived of physical activity as either: a potential mediator of the relationship between greenspace exposure and skin cancer, recognizing that physical activity and UVR exposure are highly correlated (Astell-Burt et al., 2014); or as a separate but relevant outcome of a shade intervention in public parks (Dobbinson et al., 2017). 3.2.3. UVR exposure Of the nine articles that explored features of the built or social environment, UVR exposure, and skin cancer risk, seven were intervention studies (Buller et al., 2016; Buller, Dobbinson, English, Wakefield, & Buller, 2017; Dobbinson et al., 2014, 2017; Glanz, Escoffery, Elliot, & Nehl, 2015; Glanz, Lew, Song, & Murakami-Akatsuka, 2000; Glanz, Maddock, Lew, & Murakami-Akatsuka, 2001), and two were observational studies (Astell-Burt et al., 2014; Ray, Kulldorff, & Asgari, 2016). Of the seven intervention studies, all included environmental interventions (e.g., installing shade structures in different settings), and four additionally included educational components (Buller et al., 2016; Glanz et al., 2000; Glanz et al., 2001; Glanz et al., 2015). Interventions took place in hotels and resorts (Buller et al., 2016), public parks (Buller et al., 2017; Dobbinson et al., 2017), secondary schools (Dobbinson et al., 2014), recreational settings (Glanz et al., 2000, 2001), and public pools (Glanz et al., 2015). Of the six observational studies, one study demonstrated spatial clustering of skin cancer in counties in Northern California (Ray et al., 2016) that remained robust even after adjusting for age, sex and neighbourhood SES, leading authors to suggest that area-level contextual variables may be responsible for contributing to the geographic clustering observed. One study examined area-level sociodemographic variables as a risk factor for increased UVR exposure, demonstrating that residential neighbourhood greenspace was positively associated with non-melanoma skin cancer (Astell-Burt et al., 2014). In summary, both built environment features (e.g., shade interventions) and social environment features (e.g., high SES) have been associated with reduced UVR exposure and skin cancer risk. 3.2.4. Screening Two studies examined built-environment and/or area-level sociodemographic factors related to skin cancer screening and skin cancer (Escobedo et al., 2017; Wilde, Jones, Lewis, & Hull, 2013). The first found that while screening clinic density was negatively associated with melanoma rates, screening clinic proximity was not associated with 12

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life. The reflective school seeks to temper the restrictive approach by placing human quality of life as the primary objective of technological intervention. The rationalistic approach places human development at the forefront of SCC innovation, with technological progress as a byproduct of investment in soft capital. The critical school rejects all of these traditions, critiquing SCC as another iteration of new public management and neoliberal governance. Thus, the definition of SCC is a spectrum of competing contextualized thought, not a singular set of defined conditions. This spectrum provides an excellent foundation to explore the potential of SCC enabled cancer prevention – the smart prevention theory.

behavioural and environmental change as the driving force of health intervention. Considering cancer prevention strategies together with Kummitha and Crutzen's (2017) schools of thought around SCC creates new opportunities for a cross-disciplinary healthy urban environments theory. With the smart cities paradigm increasingly dominating scholarship in built environment and health research (Cocchia, 2014; Sampri, Mavragani, & Tsagarakis, 2016), extending the SCC theory into the prevention of cancer at a population level is a logical progression in the healthy communities sphere of research.

5. Discussion

We propose smart prevention as an extension of the rational school of smart cities, suggesting a potential approach to lung and skin cancer prevention. However, an important distinction between smart prevention and smart healthcare or preventative medicine is the level of intervention. Smart health aims to respond to or prevent disease and negative health outcomes at an individual level through diagnostics and behaviour change (Baig & Gholamhosseini, 2013; Lymberis, 2003; Solanas et al., 2014). The end goal of smart prevention, on the other hand, seeks to lower the population level risk of disease by collecting and using micro-environmental data to create population-level shifts. In other words, smart prevention aims to shift from an individual-level focus to an environmental focus: instead of focusing on changing individuals' behaviours per se, smart prevention aims to change individuals' contexts to support healthier behaviours, as per the socioecological model discussed previously. Therefore, primary and secondary cancer prevention methods used within SCCs will enable a reduction of population risk for lung and skin cancer. A variety of smart prevention techniques could be applied to the risk factors, and related built environment pathways identified through our scoping review, thus reducing future incidence of lung and skin cancer. These techniques can be grouped into three areas of potential opportunity for smart cancer prevention: (1) micro-level risk factor monitoring; (2) the smart governance of built environment interventions; and, (3) implementing tools for cancer research.

5.1. Smart prevention

Results of the scoping review demonstrated that the most commonly hypothesized mechanism by which built and social environments affect lung cancer prevalence is through air quality. Air quality can in turn be influenced by land use, spatial proximity of neighbourhoods and individuals to industry and transportation infrastructure. Neighbourhood SES is an important confounder of the relationship between the built environment and lung cancer, both as a compositional confounder (i.e., people living in lower SES neighbourhoods are more likely to smoke relative to those living in higher SES neighbourhoods, and smoking is a primary cause of lung cancer) and as a contextual confounder (i.e., low SES neighbourhoods tend to be situated in areas with poorer air quality). For skin cancer, the built environment is predominantly hypothesized to influence disease prevalence by altering individuals' UVR exposure. Built environment modifications such as shade interventions have been commonly studied, and happen frequently in conjunction with efforts to educate the population about sun safety behaviours. For both types of cancer, both geographic and economic access to secondary prevention (i.e., screening) services were viewed as important determinants of use. The four schools of SCC theory provide an excellent framing device for cancer prevention. In Fig. 3, we demonstrate how the four schools of thought align with the four SCC theories described in Section 4, and how each aligns with cancer prevention. Furthermore, we provide an example of smart prevention within each school of SCC theory. Briefly, the restrictionist school relies on technological advances to problems, which we argue corresponds to tertiary cancer prevention, which is increasingly technological in nature. The reflectivist school uses technological innovations to improve human wellbeing, and has been termed a smart health approach (Baig & Gholamhosseini, 2013; Cocchia, 2014; Solanas et al., 2014). We argue that this school corresponds to secondary prevention, as screening technology is improved with a view to avoiding or reducing the harm of cancer. The rationalist view corresponds to Deakin and Leydesdorff's (2014) approach, and matches the primary cancer prevention approach by treating human

5.1.1. Micro-level monitoring The results of the scoping review suggest that cities can play a significant role in preventing lung cancer through air quality improvements, and in preventing skin cancer through reducing UVR exposure. The first smart-prevention solution we propose is the creation of a micro-level monitoring network of static devices that can instantaneously measure harmful air pollutants and UVR exposure levels. There is already significant research about the crowdsensing of air quality using individuals' mobile devices (Feng, Wang, Tian, Que, & Gong, 2017; Ganti, Ye, & Lei, 2011; Ishigaki, Matsumoto, Ichimiya, & Tanaka, 2013; Leonardi, Cappellotto, Caraviello, Lepri, & Antonelli,

Fig. 3. Smart prevention theoretical matrix.

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unrelated to the scope of the study but able to influence the results) is fundamental to ensuring the integrity of interventions studied in randomized controlled trials (Bauman, Suchindran, & Murray, 1999). SCC technology could be deployed to monitor a variety of secular trends during community based trials (Lorenzi et al., 2014), and then used to assess relevant contexts to provide assessments of intervention impacts.

2014). While a cost-effective and democratic approach to the collection of data, there are inherent flaws in this method of collection. Firstly, the opportunistic nature of this type of data collection (Dutta, Chowdhury, Roy, Middya, & Gazi, 2017; Dutta, Gazi, Roy, & Chowdhury, 2016) introduces a variety of confounders – measurement error, selection bias, over/undersampling – that are difficult to control for in analysis (Schwarz, 1999). Therefore, we propose a complementary approach that addresses these issues of bias by using a network of fixed monitoring devices connected using existing telecommunications infrastructure. This type of static micro-technology has already been demonstrated as a cheap and reliable form of measurement (Balasubramaniyan & Manivannan, 2016; Briand, Oprea, Courbat, & Bârsan, 2011; Catarinucci, Colella, Esposito, Tarricone, & Zappatore, 2009; Nasir & Soong, 2009; Rajalakshmi, Karthick, & Valarmathy, 2015). This network of static devices could be used for personalized and group alerts to which individuals subscribe (Solanas et al., 2014), with GPS routing to reduce exposure risk. The network could also be used to drive public interventions to reduce poor air quality or UVR exposure in real time, such as rerouting of traffic, free public transit, or deployment of mobile shade sails and air purification units.

6. Conclusions This review of lung and skin cancer research found the majority of literature exploring associations between built environment features and cancer risk focus on air quality and UVR exposure, respectively. Adopting smart prevention solutions to modify these risk factors is a novel and promising approach to lower the prevalence of lung and skin cancer. The potential for smart and connected communities to reduce the risk of cancer is based on the adoption of techniques that align with the rationalist and reflective schools of thought proposed by Kummitha and Crutzen (2017). The impending market saturation of wearable personal devices, and development of new model smart communities (i.e. Sidewalk Labs Toronto) creates a unique opportunity to address the complexities of non-communicable disease. Techniques that draw from both individual-level data collection methods, and micro-level environmental monitoring sources would provide the most beneficial outcomes for research in this field. Our theory of smart prevention suggests new opportunities for cancer prevention research, improved governance of built environment interventions, and more discrete levels of health monitoring.

5.1.2. Smart governance Smart governance describes the SCC-enabled suite of policy interventions that can respond immediately, or long term, to observable trends in the city. The limiting factor to realizing smart governance networks is the competing interests of data immediacy with the methodological slowness of democratic decision-making (Meijer & Rodríguez Bolívar, 2016). One potential solution to this impasse would be for the governing administration to pass pre-emptive policy actions, triggered by specific thresholds in a data collection and performance reporting system; empowering operational managers to make real-time decisions (Merli & Bonollo, 2014). Another is the integration of existing crowd-based feedback systems (i.e. Twitter) into the broader remote sensing framework (Adeel, Yang, & McCann, 2014; Anastasi et al., 2013). These performance management systems are at the core of an SCC. Applying the monitoring network example described previously, a local government could pass a set of policy responses that would be triggered when certain air pollutant thresholds are reached in an area. For example, if there was high particulate matter, motorized traffic could be temporarily re-routed from local streets to allow pollutants to dissipate from the area. In the tradition of smart administration (Caragliu & Del Bo, 2012), the monitoring network data could also rationalize the most cost effective and socially equitable allocation of public resources to reduce localized risk. This allocation could be planting more trees along certain streets to improve air quality and lower UVR exposure, the construction of shade structures to reduce UVR exposure, or the electrification of public transit corridors to alter local air quality.

6.1. Limitations This scoping review of lung and skin cancer research related to the built environment may not fully capture the extent of the conceptual field, although the 14 research databases employed in the current review far exceed the number of research databases employed in other, similar studies (Gomez et al., 2015). This is the primary limitation of a scoping review when compared to a systematic review (Colquhoun et al., 2014). In addition, scoping reviews are normally conducted with two independent reviewers (Levac et al., 2010). In this case, one reviewer (AW) screened and analyzed all the literature, with the other reviewer (LM) assessing a random subsample of documents at each stage of the study process. Any disagreements were resolved by consensus. The authors are not aware of any funding or professional obligations that would bias the results of this review. 6.2. Future research Future research should focus on the potential of smart governance approaches to health problems. Case studies of implemented solutions would provide the most value to proving the conceptual links drawn by our work. Much of the evidence found in the scoping review was of an observational design, limiting the ability to draw generalizable conclusions about the relationships between the built environment and cancer prevention. In addition, the expansion of SCC theories into a formalized theory of smart health and prevention would be beneficial in the grounding of future work in this field.

5.1.3. Cancer research There are multiple opportunities for SCC methods to improve the quality and conduct of cancer prevention research. As a first step to realizing the potential of smart prevention, smart health technology would enable the collection of highly-individualized and context specific data that could be used in a range of study designs (Baig & Gholamhosseini, 2013; Solanas et al., 2014) to comprehensively demonstrate links between micro-environmental exposures and cancer risk. Many of the studies reviewed as part of the scoping review identified the lack of individualized data as a limiting factor. New wearable medical technology, and more discrete monitoring could satisfy this demand (Lymberis, 2003). In addition, more intensive monitoring and collection of data would improve the practice of health impact assessment of new development in the built environment (Mindell, Boaz, Joffe, Curtis, & Birley, 2004). Second, monitoring secular trends (events

Acknowledgments The authors would like to thank Marian Davies, the University of Waterloo School of Planning's subject librarian for her guidance in developing the search strategy and review methodology. Funding sources This work was supported by the Canadian Cancer Society (grant #704744), and a University of Waterloo Undergraduate Research 14

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Initiative award.

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