The suggestion that non-reciprocal critical current (NRC) may be an intrinsic property of non-centrosymmetric superconductors has generated renewed theoretical and experimental interest motivated by an analogy with the non-reciprocal resistivity due to the magnetochiral effect in uniform materials with broken spatial and time-reversal symmetry. Theoretically it has been understood that terms linear in the Cooper pair momentum do not contribute to NRC, although the role of higher-order terms remains unclear. In this work we show that critical current non-reciprocity is a generic property of multilayered superconductor structures in the presence of magnetic field-generated diamagnetic currents. In the regime of an intermediate coupling between the layers, the Josephson vortices are predicted to form at high fields and currents. Experimentally, we report the observation of NRC in nanowires fabricated from InAs/Al heterostructures. The effect is independent of the crystallographic orientation of the wire, ruling out an intrinsic origin of NRC. Non-monotonic NRC evolution with magnetic field is consistent with the generation of diamagnetic currents and formation of the Josephson vortices. This extrinsic NRC mechanism can be used to design novel devices for superconducting circuits. A superconducting diode effect was recently reported in Nb/V/Ta superlattices, but the mechanism is not yet clear. Here, the authors study non-reciprocal critical current in Al/InAs nanowires and propose a generic extrinsic mechanism involving field-generated diamagnetic currents, which may explain the earlier Nb/V/Ta results. An implicit suggestion that NRC may be an intrinsic property of non-centrosymmetric superconductors2 generated a renewed theoretical and experimental interest motivated by an analogy with the non-reciprocal resistivity due to the magnetochiral effect, which can appear in uniform materials with broken spatial and time-reversal symmetry3. However, a direct analogy between corrections to resistivity and superconducting current is misleading because the anisotropy of scattering is caused by the spin-orbit effects, while the proposed origin of nonreciprocity in singlet-pairing superconductors is a spin-independent Lifshitz invariant5. It has been demonstrated in the literature6 that in uniform singlet superconductors in constant magnetic field the Lifshitz invariants can be eliminated by a gauge  transformation from both the Ginzburg-Landau (GL) equation and the expression for the supercurrent, so that linear in Cooper pair momentum terms do not lead to nonreciprocity. Phenomenological treatment shows that cubic in the Cooper pair momentum terms can lead to NRC corrections8. It has been also suggested that the Rashba terms in the electron spectrum contribute to nonreciprocity within the formalism of quasiclassical Eilenberger equations9. A symmetry analysis and microscopic calculations of the Cooperon propagator in the presence of the Zeemann effect and a linear or cubic Dresselhaus spin-orbit interactions in the electron spectrum show that the NRC magnitude and sign depend on the crystallographic orientation of the supercurrent flow . Such anisotropy should characterize non-reciprocity in superconductor/semiconductor heterostructures and cubic uniform singlet noncentrosymmetric superconductors. Another suggested mechanism of NRC is the formation of non-uniform currents in superconducting multilayers11.Diodes are the most basic elements of semiconductor electronics and development of superconducting diodes can extend the functionality of the superconducting circuitry. A non-reciprocal critical current (NRC) in a multiply-connected superconductors is a well known effect and can be readily observed in, e.g., an asymmetric superconducting ringsπ, leading to the formation of Josephson vortices. Experimentally, we report observation of NRC in nanowires fabricated from InAs/Al heterostructures. The observed non-monotonic evolution of NRC with magnetic field is consistent with the formation of Josephson vortices. Our findings show that the extrinsic contribution to NRC is generic to multilayer superconductors, and may provide a compelling explanation to the NRC observed in Refs. 2 and12, in the latter work magnetic flux produced by a Co layer generates opposite diamagnetic currents in the adjacent Nb and V layers.In this paper we show that NRC naturally arises in the presence of the magnetic-field–generated diamagnetic currents when neighboring layers in multilayer superconductors are strongly coupled. The total current through a multilayer structure is divided between the layers as an inverse ratio of their kinetic inductances. Initially only one of the layers reaches the maximum  current as the total current increases. A further current increase in the superconducting state requires generating a phase difference between the layers, which adds Josephson energy penalty to the total energy, and in the case of strong interlayer coupling (large Josephson energy) the whole system transitions into a normal state. Field-generated diamagnetic currents will either increase or decrease an external current where transition to the normal state occurs, thus leading to the NRC. In the regime of intermediate interlayer coupling strengths, an interlayer phase difference can change by 218 and Josephson junctions27. In the former experiments the presence of out-of-plane magnetic field and formation of vortices is essential for the observation of NRC, in this case the critical current is determined by the strength and symmetry of the flux pinning potential. In the latter case the critical current in Josephson junctions is determined by the overlap of Andreev states. In this paper we restrict our discussion to the origin of NRC in long nanowires, where critical current is determined by the de-pairing velocity of Cooper pairs (the Bardeen limit28).The term “superconducting diode effect” has been used to describe NRC in different systems, including thin superconducting filmsIsw defining a transition from superconducting to normal state in nanowires fabricated from Al/InGaAs/InAs/InGaAs heterostructures29, where patterned Al top layer forms a nanowire and induces superconductivity in a high mobility InAs quantum well via the proximity effect. An AFM micrograph of a typical device is shown in the inset in Fig. B⊥ perpendicular to the wire. The Isw〉 and ΔI are nonmonotonic functions of magnetic field. As shown in the Supplement, a minima of 〈Isw〉 at low fields vanishes above 350 mK (0.3 TC), while there is no change in ΔI at least up to 750 mK (>0.6TC). This difference in energy scales for the appearance of NRC and non-monotonic evolution of 〈Isw〉 indicates that these are unrelated phenomena, and below we focus on the origin of NRC. Some devices were fabricated with a top gate, which allows electrostatic control of the electron density in the InAs layer not covered by Al; we found that depletion of the 2D electron gas in the exposed InAs results in a slight increase of 〈Isw〉 but does not affect ΔI. Similar field effect has been observed previously in superconductor nanodevices30 and was attributed to the presence of quasiparticles31, a conclusion consistent with the observed gate dependence of the 〈Isw〉.We have studied switching currents mentclass2pt{minimmentclass2pt{minimα3Q3Δ2 cubic in the Cooper pair momentum in an expansion of the Ginsburg-Landau coefficients can generally lead to non-zero ΔI which is a non-monotonic function of B and can even change sign9 . However, for proximitized InAs layer, a generation of the terms higher order in the Cooper pair momentum in the presence of the Rashba spin-orbit and Zeeman interactions coexists with a similar generation of such terms due to the Dresselhaus spin-orbit interactions. The importance of the Dresselhaus-like terms in the electron spectrum is not limited to proximity structures, and they can play significant role in any noncentrosymmetric material. Investigation of realistic cubic terms in the Cooper pair momentum showed  that nonreciprocity becomes highly anisotropic as a result of Dresselhaus-induced contribution. For comparison with experiments, it is instructive to express the odd in Cooper pair momentum part of the kinetic energy in coordinates rotated by π/2 with respect to the principal crystallographic axes of InAs, where κ contains the Dresselhaus constant βD and other material parameters. The resulting NRC correction to the supercurrent isI and is added or subtracted to the B = 0 current value depending on the direction of the current flow. Here Bx and By enter symmetrically for wires oriented along x and y. However, in the configuration with the current By and the configuration with Bx, this expression has opposite signs for the same mutual orientation of I and B, see inset in Fig. 32 suggests that in narrow InAs quantum wells cubic Dresselhaus terms are larger than the Rashba terms. The lower limit for the value of the Dresselhaus contribution can be extracted from the total spin-orbit anisotropy , which was measured to be 70% in spin-galvanic and circular photogalvanic experiments33 and > 15% in transport experiments35. Such anisotropies must result in the corresponding crystallographic anisotropy of the NRC, which is not observed in our experiments, Fig. Unlike the linear in Cooper pair momentum terms, higher order terms cannot be removed by gauge transformation and it was shown that the presence of terms ~ ϕ = BSloop piercing the loop. In a loop with asymmetric arms, the current maximum is shifted from B = 0, and the sign of the shift depends on the direction of the current as shown in Fig. I is linear in B in the vicinity of B = 0, reaches extrema at ϕ ≈ ϕ0/4, changes sign and oscillates with a period Δϕ = ϕ0. Thus, an asymmetric loop is the simplest “superconducting diode”. There is a clear similarity between ΔI measured in an asymmetric superconducting loop and in an Al/InAs nanowire as emphasized in Fig. While recent interest in NRC has been motivated by a possibility of the intrinsic origin of the effect, NRC naturally arises in multiply-connected superconductors. In superconducting loops, the critical current is modulated by an external flux d, Fig. ϕ = ϕ1(x) − ϕ2(x) is the phase difference between superconducting condensates, and Li are the kinetic inductances per unit length in wires labeled by an index i = 1, 2. Supercurrents in each wire I1(x) + I2(x) = Iext, where Iext is the applied external current. Detailed solution for this model can be found in the Supplementary Materials, and we outline now the main results. For small external currents  it is energetically favorable to keep the phase difference Δϕ constant . Dependence of I1 and I2 on Iext for By > 0, By = 0 and By < 0 is plotted schematically in Fig. Iext increases and one of the currents (I1 in our example) reaches the critical value Ic1, further external current increase requires an increase of ∣Δϕ∣ because the excess current has to flow through the remaining superconducting wire with the current I2. In the case of weak interwire coupling, ϕ from zero does not lead to a significant energy penalty and the critical current of the whole system Iext ≈ (1 + η)(Ic1 − Idia), resulting in ΔI = − 2(η + 1)Idia(By) (this equation is correct for β > η + (η + 1)Idia/Ic1, where β = Ic2/Ic1, NRC for other scenarios is listed in the Supplementary Materials). Thus a superconducting diode effect is a generic property of coupled multilayer superconductors.External magnetic field generates circular diamagnetic currents in a superconductor, as shown schematically in Fig. By and diamagnetic currents increase, the phase locking condition Δϕ = 0 along the length of the wires leads to a significant increase of Bc = (3/π2)Φ0/(lJd) it becomes energetically favorable to reduce the overall energy by twisting the phase difference by 2π locally forming a Josephson vortex (0 = h/2e is the flux quantum). Evolution of the phase difference Iv(x), and interwire Josephson current density jJ(x) across a vortex are shown schematically in Fig. Iv(x) at the center of the vortex determines the Josephson vortex contribution to NRC. In the absence of quantum fluctuations formation of a vortex is accompanied by an abrupt re-distribution of currents between the wires, which results in a sawtooth NRC dependence on the magnetic field. Generation of multiple Josephson vortices does not modify NRC compared to a single vortex case unless the vortices significantly overlap so that the maximum of Iv(x) exceeds its single-vortex value.As I(By) for several Bx using Eq. lJd = lvd. The period ΔB⊥ = 400 mT translates into the length lv ≈ 500nm, where Δϕ substantially deviates from zero. We estimate * ≈ Δ = 1.796kBTc = 230μeV (induced gap is close to the gap of Al in these heterostructures37), and the mean free path in uncapped InAs 2D gas In Fig. n2 in InAs. In the vicinity of B⊥ = 0 the amplitude of T or B∥. The critical field T- and B∥-independent, Fig. B⊥ between the samples. These qualitative estimates are consistent with experimental observations, see Figs. Finally, we use the two-wire model to estimate the temperature and in-plane field xAlx1−As insulating buffer followed by a In0.75Ga0.25As(4nm)/InAs(7nm)/In0.75Ga0.25As(10nm) multilayer structure capped in-situ with 7nm of Al. The two-dimensional electron gas has a peak mobility of 28000 cm2/Vs at a density 8 × 1011 cm−2.The wafer was grown using Molecular Beam Epitaxy (MBE) on an InP substrate. The heterostructure consists of 1 μm graded In3PO4:H2O2:H2O:C6H8O7 (1ml:8ml:85ml:2g). Nanowires are defined in the second step of lithography by patterning the Al layer. Some devices have a top electrostatic gate, in these devices a 20 nm HfO2 is grown by atomic layer deposition followed by a deposition of a Ti/Au (10/100 nm) gate.The nanowires were fabricated using standard electron beam lithography. The mesas were defined by first removing the top Al layer with Al etchant Transene D and then a deep wet etching using HIsw) in order to minimize device heating. Current sweep rate and delay between sweeps have been optimized to obtain <5 nA current resolution and to keep device temperature <50 mK at the base temperature of the fridge. The data has been corrected for an instrumental cooldown-dependent constant current offset (generated in the circuit by uncompensated voltages in the system and limited by a 100 kΩ current source resistor) to insure that ΔI = 0 at B = 0.Current-voltage sweeps were performed using a homemade high-speed high resolution DAC/ADC  setup. The sweeps were automatically interrupted at the superconductor-normal transition (Supplementary InformationPeer Review FileDescription of Additional Supplementary FilesSupplementary Data 1


Bangladesh is one of the highest tobacco-consuming countries in the world, with a large number of adult users of a variety of smoked and/or smokeless tobacco products. Bangladesh tobacco control act prohibits smoking in public places and requires the owners of public places to display ‘no smoking’ signages.The objective of this study was to assess the level of compliance with the tobacco control act (smoke-free laws) in public places in a northeast city of Bangladesh.This cross-sectional study was conducted between June 1 and August 25, 2020, across 673 public places in Sylhet city, Bangladesh. The data was collected using a structured observational checklist that included variables such as the presence of active smoking, the presence of designated smoking areas, the display of ’no smoking’ signages, evidence of recent smoking such as ashes, butts/bidi ends, and the presence of smoking aids.Among 673 public places, a total of 635 indoor locations and 313 outdoor locations were observed. Only 70 (11%) indoor locations were found to be in good compliance, and 388 (61.1%) indoor locations were found to be in moderate compliance with smoke-free laws. On the other hand, only 5 (1.6%) outdoor locations were in good compliance, and 63 (20.1%) outdoor locations were in moderate compliance with smoke-free laws. The overall compliance with smoke-free laws at indoor locations was 52.7%, and at outdoor locations was 26.5%. The highest compliance was observed at healthcare facilities (58.6%) and the least at transit points (35.7%) for indoor locations. In outdoor locations, the highest compliance was observed at offices and workplaces (37.1%) and the least at transit points (2.2%). Higher active smoking was observed in public places where there was an absence of ‘no smoking’ signage and the presence of points of sale (POSs) . Further, higher active smoking was observed in places where any smoking aids, cigarette butts, bidi ends, or ashes were present .This study found moderate compliance at indoor locations and very low compliance at outdoor locations. The government should focus more on implementing smoke-free laws in all kinds of public places, particularly at most frequently visited places and transit sites. ‘No smoking’ signages should be displayed per legislation across all public places. Policymakers should consider the prohibition of POS in/around a public place as it has a positive effect on smoking. Tobacco use is one of the most preventable causes of premature death in the world, contributing to 6 million deaths every year . SmokingAll non-smokers are potentially in danger of exposure to SHS because of the smokers . ExposurBangladesh is distinguished as the first signatory of the World Health Organization (WHO) Framework Convention on Tobacco Control (WHO FCTC), which was ratified on May 10, 2004. In Bangladesh, the Smoking and Tobacco Products Usage (Control) Act was acted in 2005 and amended in 2013. Bangladesh tobacco control act requires the prohibition of smoking in public places and owners of public places to display ‘no smoking’ signages. In the context of developing countries, Bangladesh’s experiences in enforcing public health laws have been dismal. However, effective implementation of the legislation necessitates ongoing monitoring to ensure that legal provisions are being followed and that decisions can be used for midcourse correction , 16. SevSmokers’ behavior is influenced in part by their understanding of smoke-free legislation. There has been evidence of the relationship between the effective implementation of legislation regarding smoking restrictions in public places and the reduction of smoking behavior –24. ChapHowever, there have been many challenges faced in Bangladesh in implementing the Smoking and Tobacco Products Usage (Control) Act. To the best of our knowledge, there has been no study in Bangladesh as of yet to measure compliance with smoke-free legislation. In these circumstances, assessing compliance with the tobacco control act in public places is of great importance to determine the extent to which the law is being implemented. Therefore, we aimed to measure the status of compliance with legal provisions that protect the public against the harms of SHS exposure in a northeast city of Bangladesh, where the findings of the study would help to identify the potential areas of violations and inform policymakers for strengthening enforcement measures.This was a cross-sectional study conducted in Sylhet City, Bangladesh. The study type was an observational field study. The study was conducted between June 1, 2020, and August 25, 2020.There are three major cities in Bangladesh. These are Dhaka, Chattogram, and Sylhet cities. Among these, Sylhet city has been conveniently selected for this study because of its status as a significant metropolitan city in the country, which is located in the northeast of the country. The study area was the municipal areas of Sylhet City Corporation. Its total area is 26.5 sq km. It comprises 27 wards and 207 mahallas (areas). This is a city with multi-dimensional culture and a variety of places and people. Its total population is 475,138 .Study sites included all the public places except for the educational institutions as defined in the Smoking and Tobacco Products Usage (Control) (Amendment) Act, 2013 within Sylhet City . These iAccommodation facilities: any lodging service paid for on a short-term basis, including residential hotels, motels, and rest houses.Eateries: restaurants and cafeterias surrounded by walls on all sides.Offices and workplaces: government office, semi-government office, autonomous office, private office, court building, library, indoor workplace.Healthcare facilities: public/private hospitals/clinics.Transit points: airport building, seaport building, river port building, railway station building, bus terminal building, designated queues or places for passengers waiting to ride on public transport.Most frequently visited other public places: cinema hall, exhibition center, theatre hall, fitness center, sports facility, shopping center, public toilet, children park, fairs, any other public area to be combinedly used by the general people or, any or all places declared time to time by the government or local government organization by general or special order.The designated public places that were used for the assessment of smoke-free legislation compliance and the specific areas where the assessments were carried out are outlined in Compliance: It is the degree to which the Smoking and Tobacco Products Usage (Control) (Amendment) Act, 2013, Bangladesh is being obeyed.Smoke-free legislation: The law that prohibits smoking in a specified area i.e., the Smoking and Tobacco Products Usage (Control) (Amendment) Act, 2013, Bangladesh.Public Places: All the places that are defined as public places in the Smoking and Tobacco Products Usage (Control) (Amendment) Act, 2013, Bangladesh.Smoking: Inhaling or exhaling the smoke of tobacco and also includes keeping or controlling any flamed tobacco products.Active smoking: Active smoking in a public place was marked as present if anyone was seen smoking during the researcher’s visit at the public place being observed for the study.Designated smoking area (DSA): The section of a public place that has been set apart and designated as a smoking area by the owner, caretaker, manager, or other individual in charge of the public place in which smoking is permitted. DSA was marked as present if it was noticed during the researcher’s visit at the public place being observed for the study.‘No smoking’ signage: According to the Smoking and Tobacco Products Usage (Control) (Amendment) Act, 2013, every public place shall arrange to display a caution notice "Refrain from Smoking, It is a Punishable Offence" in Bengali and in English language at the entrance and in one or more places inside a public place. The size of a caution notice board in a public place shall be at least 40 centimeters × 20 centimeters. Every public place shall arrange to display the caution notice in red letters against a white background or in white letters against a red background with a no-smoking sign.Cigarette buts, bidi ends, or ashes: Cigarette buts, bidi ends, or ashes were marked as present as evidence of previous smoking in a particular public place if any of these was noticed during the researcher’s visit at the public place being observed for the study.Smoking aids: According to the Smoking and Tobacco Products Usage (Control) (Amendment) Act, 2013, no smoking aids such as ashtrays, ashbins, matchboxes, or lighters can be kept in the smoke-free area.In accordance with existing literature, the sample size for this study has been calculated . As therSylhet City Corporation has a database of all types of places under its jurisdiction, including restaurants and workplaces (private and public). A list of all types of public places was collected from Sylhet City Corporation. Then, using simple random sampling, 10 wards were selected from the list of 27 wards in Sylhet City Corporation. Finally, a simple random sampling method was adopted among each type of public place in the selected wards to obtain the desired sample size.A structured observational checklist was used to record the findings. It was developed based on an existing guide on ‘Assessing compliance with smoke-free law’ , reviewiFour teams consisting of two members (two data collectors) in each team collected data. They were trained by Principal Investigator on smoke-free law and its provisions, along with filling of the standard checklist used for the study. On-site training was also provided before data collection to maintain the quality of data collection. Trained field data collectors visited each of the sampled public places on weekdays at an unannounced time to capture typical behavior. Prior to data collection, they obtained the informed consent of the individuals in charge of the public places. Except for the person in charge of the institute, there was no interaction with anyone else in the sampled public place. The teams visited the government buildings during the office timings (9:00 to 17:00). In healthcare facilities, visits were done from 11:00 to 12:00 and 16:00 to 20:00 and also during visiting hours. The transit points, shopping malls, bars, and restaurants were visited during the busiest hours (evening hours). Depending on the area covered, the average time spent at each public place was 45 minutes to one hour.To avoid the possibility of personal bias, all observations were carried out by data collectors who had been trained in filling out the observation checklist. The Principal Investigator, along with co-principal investigators, visited 10% of the sampled facilities and independently cross-checked their findings against those obtained by data collectors, using the same observational checklist that data collectors used. The visit was carried out on the same day in order to ensure the robustness of the monitoring. The findings were found to be 100% consistent between the data collectors and the principal investigator.p-value <0.05 was considered statistically significant.All the data were screened for any missing value. After screening, the data were entered and coded in MS Access and analyzed using the statistical software SPSS, version 22. Descriptive statistics were presented through tables. The compliance with specific indicators of smoke-free legislation in different public places, both indoors and outdoors, was presented separately in tables. For indoors, a location was given a rating of ‘good compliance’, ‘moderate compliance’ or ‘poor compliance" depending on the number of indicators it met: 5–7, 3–4, or 0–2 for good compliance, moderate compliance, or poor compliance, respectively. For outdoors, a location was leveled as ‘good compliance’, ‘moderate compliance’, or ‘poor compliance’ if the place complied with 5–6 indicators, 3–4 indicators, or 0–2 indicators, respectively. In order to calculate ’total/overall compliance’, the values of ’individual compliance indicators’ were added together and divided by the total number of indicators. This method was applied in previous research to find the total/overall compliance , 32. ComThe survey protocol was reviewed and approved by the North South University Research Ethics Committee (NSU-IRB-2020/54). In public places with restricted entry , verbal and prior informed consent was taken from the in‑charge. Data privacy and confidentiality were maintained, and data were used only for research purposes.A total of 673 public places were observed in this study, and the distribution of specific types of public places can be found in the S1 Table in Compliance with specific indicators of smoke-free legislation at indoors of different public places is described in In terms of average compliance, the transit points scored least than all other public places, which was only 35.7%. The highest average compliance was observed in healthcare facilities (58.6%), followed by eateries (58.1%), offices and workplaces (57.0%), accommodation facilities (45.7%), and most frequently visited other places (39.2%) .In outdoor locations, the offices and workplaces scored the highest average compliance than all other public places, which was 37.1%. The least compliance was observed in transit points which was only 2.2%. In terms of compliance of other places, the most frequently visited places’ average compliance was 14.6%, accommodation facilities’ was 20.8%, eateries’ was 27.4%, and healthcare facilities’ was 32.6% .In A significant number of indoor places, 227 (35.7%), were found with any cigarette buts, bidi ends, or ashes during the observation. Most of the outdoor places, 256 (81.8%), were found with the presence of any cigarette buts, bidi ends, or ashes during observation. The number of outdoor places where smoking aids were observed is 120 (38.3%). The name of different types of smoking aids that were present at outdoors of public places is given in the S7 Table in In terms of availability of points of sale (POSs), 91 (29.1%) of the public places had tobacco shops inside their location boundary . Almost In this study, comparatively more places were observed with active smoking (54.1%), where there was the presence of any smoking aids in indoor locations . Similarly, active smoking was comparatively more prevalent (36.1%) in indoor public places where there was the availability of any POSs within the venue . The observance of places with active smoking (32.2%) was also associated with the presence of cigarette buts, bidi ends, or ashes in indoor places . Active smoking was comparatively less prevalent (7.1%) in indoor public places where there was a display of ‘no smoking’ signages . Active smoking was more prevalent (38.0%) in the most frequently visited places  .In the case of outdoor places, most of the places with active smoking (81.3%) were observed where POSs were available within the venue/location . Same as indoor places, the presence of smoking aids was associated with a greater number of places with active smoking (70.8%) in outdoor places . The presence of cigarette buts, bidi ends, or ashes, availability of POSs within 100 meters of the venue/location, and type of location were also associated with smoking behavior at outdoors of different public places  .This was the first study to investigate the compliance of smoke-free legislation using a standard checklist in public places in Sylhet City, Bangladesh. The aspect of our research was measuring overall compliance to smoke-free legislation in public places, comprised of an assessment of various parameters, such as observing active smoking, display of ‘no smoking’ signages, and proxy evidence of active tobacco usage. The results revealed that the average compliance with specific indicators of smoke-free legislation at indoor locations was 52.7%, and at outdoor locations was 26.5%. In previous studies, wherein compliance monitoring to smoke-free legislation in four jurisdictions of India, Sikkim state, Vilupuram district and Coimbatore city in Tamil Nadu, and Shimla city in Himachal Pradesh using a similar study tool reported compliance rates varying from 82% to 100% . Goel etIn our study, active smokers were observed in 77 (12.1%) indoor locations and 117 (37.7%) outdoor locations of different public places. In a previous study in North India, only 6% of the observed public places were found with people actively smoking . Kaur etThe present study’s findings showed that transit sites and most frequently visited places had very high violations of nearly all indicators of the legislation. This is not surprising and has been reported in various studies. A study conducted in the Alwar district of Rajasthan, India, reported that educational institutions and healthcare facilities performed well, while restaurants and transit points performed poorly . In the Our study showed that there was a lower prevalence of active smoking in indoor public places where there was a display of ‘no smoking’ signage. This may be due to the fact that such signages may be more noticed by people, and the perceived idea of being caught and fined increases the likelihood of compliance. The study in the Biratnagar metropolitan city in Province 1 of Nepal reported that there was a higher likelihood of active smoking where there was an absence of ‘no smoking’ notice . BonfillOur data indicated that the presence of cigarette buts, bidi ends, or ashes and the presence of smoking aids  were significantly associated with a higher number of places with active smokers. Similar findings were reported in previous studies , 23. It An interesting finding in the present study is that public places with more availability of POSs within/around the location were significantly associated with a higher prevalence of people with active smoking. Previous studies also reported that the availability of shops selling tobacco products acts as a predictor of active smoking .When viewed from the perspective of a developing nation such as Bangladesh, the overall barriers to the successful implementation of tobacco control policies could include a lack of inter-sectorial coordination, a shortage of resources, low penalization of violators, a lack of adequate and continuous monitoring and implementation of smoke-free laws, and most importantly, low awareness among the general public regarding the health impact of tobacco and the laws that are related to it. According to the level of compliance that was found in our research, it is evident that there is a gap between policy action and public health gains. The variable rates of compliance in different types of public places may suggest that the factors that contributed to the success of one type of public place may be applicable to the success of another type of public place. However, in order to achieve a higher degree of compliance, it is required to employ certain tactics that are tailored to the nature of the public place in question. According to the findings of a study carried out in India, various facilitators and barriers to implementing smoke-free laws are present in particular types of public places . It has Studies conducted in India and Nepal reported that people were more likely to smoke if the owners/managers of the public places themselves smoked , 32. VarAlong with the robust implementation of the law, it is also necessary to make the public aware of the existence of such policies –43. The The protection of public health requires a number of different interventions, one of which is a complete smoke-free policy. However, merely enforcing the legislation is not enough. If a smoke-free law is not accompanied by a robust enforcement system that has clearly defined regulations, then the law will not have the desired effect of lowering the number of people who use tobacco products and who are exposed to SHS , 45. As This is the first study of its kind conducted in Bangladesh to assess the status of compliance with specific indicators of the tobacco control act in public places in Sylhet City, Bangladesh. This study included all types of public places except for educational institutions as defined in the Smoking and Tobacco Products Usage (Control) (Amendment) Act, 2013. The studied places were randomly chosen, thus diminishing selection bias.However, this study has some limitations. First, this study is limited by its cross-sectional design. Second, the study has been conducted in a selected city in Bangladesh, so the generalizability of the results across the country is limited. Third, two investigators visited public places and captured compliance using a standard checklist. Though recording air nicotine levels in public places would have been a better method to record compliance, it may not be possible for a low–middle-income country like Bangladesh with resource constraints.This observational cross-sectional study assessed the status of compliance with the tobacco control act in public places. This study found moderate compliance at indoor locations and very low compliance at outdoor locations. The highest overall compliance at indoors was observed in healthcare facilities and least in transit points, while at outdoors, the highest overall compliance was observed in offices and workplaces and least in transit points. A high frequency of active smoking was observed at outdoors of observed public places, including healthcare facilities, and a significant number of active smokers was also observed in indoor public places. Among all indoor places, most of the owners of public places did not display any ‘no smoking’ signage. However, the majority of the displayed ‘no smoking signage’ did not comply with the law properly. Indirect indicators of smoking, such as the presence of cigarette buts, bidi ends, or ashes were also observed in a notable number of public places. A significant number of public places were also not free from the presence of smoking aids. Points of sale (POSs) were observed at a high rate within the boundary of the locations, and it was present at around 100 meters of almost all public places. Smoking was more prevalent in a public place, where there was an absence of ‘no smoking’ signage and the presence of cigarette buds, bidi ends, or ashes, smoking aids, and POSs inside of the location or around it.Based on the findings of our study, we recommend that government should focus more on implementing smoke-free laws in all kinds of public places, particularly at transit sites and most frequently visited places. ‘No smoking’ signages should be displayed per legislation across all public places. Outdoors within the boundary of public places should also be included under the definition of ‘public place’, particularly for healthcare facilities and other significant public places. POSs should be prohibited in public places, particularly in/around 100 meters of healthcare facilities and other significant public places, as it has a positive effect on smoking. Future studies should be conducted across the country with a large sample size to generalize the results. Recording air nicotine levels in public places would have been a better method to record compliance; future studies should assess air nicotine levels. Regular follow-up studies should be conducted to know the extent of compliance.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S1 Dataset(SAV)Click here for additional data file. 2 May 2022 <div> PONE-D-22-07117 </div>  <div> Compliance with smoke-free legislation in public places: An observational study in a Northeast City of Bangladesh </div>  <div> PLOS ONEDear Dr. Saifur Rahman Chowdhury, </div>  <div>   </div>  <div> Our both reviewers have asked for major revisions which have been stated.  </div>  <div> Kindly resubmit after the clarifications sought. </div>  <div> Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. 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Heartiest thanks also to Mohammad Shahjahan, Director & CEO, Bangladesh Center for Communication Programs (BCCP), for his continuous cooperation in successfully completing this project. The authors would like to put forward our utmost respect to the authorities of all public places in Sylhet City for their consent and support to collect data. The authors are much grateful to all the data collectors who worked accountably to collect data. Lastly, the authors are very much acknowledged to Bangladesh Center for Communication Programs (BCCP) and Institute for Global Tobacco Control, Baltimore, USA. This study was conducted with technical input from the Bangladesh Center for Communication Programs (BCCP) and Institute for Global Tobacco Control, Baltimore, USA, and financial support from the Bloomberg Initiative."We note that you have provided funding information. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. 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Saifur Rahman Chowdhury received this grant in reference to the technical and cost proposal from the Bangladesh Center for Communication Programs . The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. </font> The Reviewer #1: YesReviewer #2: Yes********** <font color="black"> 4. Is the manuscript presented in an intelligible fashion and written in standard English? </font> PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: No********** <font color="black"> 5. Review Comments to the Author </font> Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: The study is conducted with lot of efforts and is being presented effectively. The need of study is also justified. Data are collected with lot of care and is presented well.There is one objection on analysis which to me seems of a great concern. The average percentages concept used in the analysis, can not be considered correct. Few suggestion for overall percentages1. Summing up all compliance options with OR condition  The overall percentage will be calculated through that column of overall.this scenario will work if every option is given equal weightage.2. If every option has different weightage then maximum of the weightage will be the final option.3. A criterion can be made  and what was the outcome of the study?• The results section should be limited to the most important numbers. There is no need to bring all detailed results such as % of compliance in each observed section.IntroductionIn the introduction part there is huge information on the burden of smoking worldwide. However, there is lacking on evidence on the smoking prevalence and burden of the tobacco use in Bangladesh.MethodsPlease indicate the reason for the selection of this city to conduct the study. The tool provided by the John Hopkins university is almost a comprehensive tool. Why was it not used alone and researcher decided to modify it through literature review? Which changes have been made to the original instrument? Please describe the changes made in the study tool.I have some concerns about the operational definitions too. I found them more conceptual rather than operational. Please bring them in a way that reader realize how you defined variables such as active smoking  or other variables such as smoking aids, cigarette/bidi stubs/butts, cigarette smell and etc. This part should be rewritten according to the variables included in the tool.DiscussionPlease compare you results with other developing countries or countries close by like Pakistan, India or Nepal. It is better to mention the name of the country instead of the name of the authors for similar studies that actually mentioned in the discussion part. I suggest that at the end of the discussion part the authors elaborate potential solutions and policy options to address low compliance rate. What is your suggestion about the Venue managers? Are they responsible for ensuring that all public places that they operate are smoke free? What can be done to increase population awareness regarding the harm of smoking ?********** <font color="black"> 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. </font> Yes: Muhammad AasimReviewer #1: Reviewer #2: Nohttps://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. 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After careful consideration, we have decided that your manuscript does not meet our criteria for publication and must therefore be rejected.Precisely, the response/rebuttal received against the original reviewers' comments are neither satisfactory nor in compliance with the journal requirements. In all, the revised manuscript fails to address the major concerns raised by the reviewers in their original evaluation of the manuscript.Under such circumstances we regret that your manuscript cannot be further considered for revision or consideration for publication.I am sorry that we cannot be more positive on this occasion, but hope that you appreciate the reasons for this decision.Kind regards,Koustubh Panda, M. Tech., Ph.DAcademic EditorPLOS ONE[Note: HTML markup is below. Please do not edit.]Reviewers' comments:Reviewer's Responses to Questions <font color="black"> Comments to the Author </font> 1. 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Is the manuscript presented in an intelligible fashion and written in standard English? </font> PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: Yes********** <font color="black"> 6. Review Comments to the Author </font> Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: My comments are not addressed.Either should have corrected the overall compliance percentages or have given a justification of the method of average used.********** <font color="black"> 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. </font> Yes: Muhammad AasimReviewer #1: **********- - - - -For journal use only: PONEDEC3 3 Dec 2022Response to reviewers letter are attachedAttachmentResponse to Reviewers_V-2.docxSubmitted filename: Click here for additional data file. 14 Mar 2023Compliance with smoke-free legislation in public places: An observational study in a Northeast City of BangladeshPONE-D-22-07117R2Dear Dr. Chowdhury,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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Diabetes is considered one of the most prevalent and preventable chronic health conditions in the United States. Research has shown that evidence-based prevention measures and lifestyle changes can help lower the risk of developing diabetes. The National Diabetes Prevention Program  is an evidence-based program recognized by the Centers for Disease Control and Prevention; it is designed to reduce diabetes risk through intensive group counseling in nutrition, physical activity, and behavioral management. Factors known to influence this program’s implementation, especially in primary care settings, have included limited awareness of the program, lack of standard clinical processes to facilitate referrals, and limited reimbursement incentives to support program delivery. A framework or approach that can address these and other barriers of practice is needed.We used Implementation Mapping, a systematic planning framework, to plan for the adoption, implementation, and maintenance of the National DPP in primary care clinics in the Greater Houston area. We followed the framework’s five iterative tasks to develop strategies that helped to increase awareness and adoption of the National DPP and facilitate program implementation.We conducted a needs assessment survey and interviews with participating clinics. We identified clinic personnel who were responsible for program use, including adopters, implementers, maintainers, and potential facilitators and barriers to program implementation. The performance objectives, or sub-behaviors necessary to achieve each clinic’s goals, were identified for each stage of implementation. We used classic behavioral science theory and dissemination and implementation models and frameworks to identify the determinants of program adoption, implementation, and maintenance. Evidence- and theory-based methods were selected and operationalized into tailored strategies that were executed in the four participating clinic sites. Implementation outcomes are being measured by several different approaches. Electronic Health Records (EHR) will measure referral rates to the National DPP. Surveys will be used to assess the level of the clinic providers and staff’s acceptability, appropriateness of use, feasibility, and usefulness of the National DPP, and aggregate biometric data will measure the level of the clinic’s disease management of prediabetes and diabetes.Participating clinics included a Federally Qualified Health Center, a rural health center, and two private practices. Most personnel, including the leadership at the four clinic sites, were not aware of the National DPP. Steps for planning implementation strategies included the development of performance objectives (implementation actions) and identifying psychosocial and contextual implementation determinants. Implementation strategies included provider-to-provider education, electronic health record optimization, and the development of implementation protocols and materials .The National DPP has been shown to help prevent or delay the development of diabetes among at-risk patients. Yet, there remain many challenges to program implementation. The Implementation Mapping framework helped to systematically identify implementation barriers and facilitators and to design strategies to address them. To further advance diabetes prevention, future program, and research efforts should examine and promote other strategies such as increased reimbursement or use of incentives and a better billing infrastructure to assist in the scale and spread of the National DPP across the U.S. Nearly ght loss , 6. Indight loss .Although the National DPP has shown to be effective in delaying diabetes diagnoses , 9, its Investigators from The University of Texas Health Science Center at Houston School of Public Health Center for Health Promotion and Prevention Research and the Center for Quality Health IT Improvement at the School of Biomedical Informatics  partnered with the Texas Department of State Health Services (DSHS) to carry out a five-year project funded by the Centers for Disease Control and Prevention (CDC). The goal was to use Implementation Mapping to design and implement strategies to implement diabetes prevention guidelines and the National DPP in primary care clinics located in the DSHS Public Health Region (PHR) 6/5S (Gulf Coast). This process has real-world applications that can guide healthcare institutions in their efforts to scale the National DPP in their communities.The UTHealth team first recruited primary care clinics to participate in the project and identified partner National DPP sites. The UTHealth team and clinic partners (hereafter “team”) then used Implementation Mapping, a systematic planning framework, to develop strategies to adopt, implement, and sustain a referral system to National DPP sites .The UTHealth team recruited primary care clinics to participate in the project using purposeful sampling based on their location within the Texas DSHS PHR 6/5S and their previous relationship with the UTHealth Center for Quality Health IT Improvement. UTHealth team members  created a list of clinics in the selected public health region that were currently or had previously received quality improvement, data analysis, and reporting services from the Center for Quality Health IT Improvement. Clinics’ leadership staff from the identified clinics were contacted by phone and email and were provided with a brief overview of the project, including the goal of assisting clinics with National DPP implementation. Once a clinic indicated interest in participating, an introductory teleconference was scheduled with the clinic leadership team. During the introductory meeting, the DPP program was described, and clinic staff responded to unstructured questions to learn more about the clinic’s priorities and its overall diabetes prevention and management goals.The UTHealth team identified and recruited CDC-recognized National DPPs based on their coverage area within the Texas DSHS PHR 6/5S, ability to offer virtual classes, cost to participants, and ability to provide program materials in English and Spanish. As the initial step in the recruitment process, the UTHealth team created a list of CDC-recognized National DPPs registered on the CDC website located in the selected public health region. Additional National DPPs were identified in advertisements in the American Medical Association newsletter and through referrals from the funding agency. The UTHealth team reached out to each program to gauge their interest in partnering with one of the participating clinics. The recruitment process focused primarily on National DPP that could offer classes that could meet the needs of the clinics’ patient population who were primarily under or uninsured and Spanish-speaking. Thus, the selected National DPPS offered classes at no cost to the participants  and had classes in English and Spanish. Furthermore, since this implementation started while social distancing restrictions were still in place due to the COVID-19 pandemic, we selected programs offering remote or in-person classes. The National DPPs selected who partner with the clinics were a City of Houston-sponsored program, a Silicon Valley-based program, and a local private practice.Implementation Mapping incorporates theory, stakeholder input, and data to guide implementation strategy development . The proLeaders at the four participating clinics completed an online 56-item survey and 60-min interviews to assess: (1) awareness of National DPP; (2) barriers to National DPP adoption, implementation, and maintenance; (3) clinics’ approaches to prediabetes diagnosis and management; (4) the use of clinical decision support for chronic disease management and technological capabilities; (5) existing referral systems to external lifestyle change programs; and (6) use and capacity of the clinic’s EHR system. Clinic decision support (CDS) is any EHR tool designed to enhance decision-making in the clinical workflow. Tools may include alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information. Upon completion of the needs and assets assessment survey and interviews, the UTHealth team worked with each clinic to develop and sign a Memorandum of Understanding (MOU) indicating an intent to adopt the National DPP.program adopter was defined as a clinic staff member with the decision-making authority to start using a National DPP program  and/or a staff member  directly involved in deciding to set up program referral processes. A program implementer was a staff member  responsible for making program referrals and/or a clinic administrator responsible for educating staff. A program champion  was an implementer that advocated for promoting the National DPP among other clinic staff . Finally, program maintainers  were those who were responsible for ensuring that the program was maintained over time.The team defined the following roles responsible for adopting and integrating National DPPs into clinic processes at each clinic site. A In Task 2, the team stated the adoption, implementation, and maintenance outcomes, and performance objectives associated with each outcome. The overall goal is a statement that clinics intend to adopt, implement, and maintain a program while adoption, implementation, and maintenance outcomes are specific to each adopter, implementer, and maintainer. Performance objectives are the specific actions or sub-steps required to adopt, implement, and maintain the National DPP in each clinic . To creaNext, the UTHealth team identified determinants influencing adoption, implementation, and maintenance. Determinants answer the question why an adopter, implementer, or maintainer would complete performance objectives and outcomes . For exaFinally, the team created a matrix of change objectives by crossing performance objectives (rows) with determinants (columns). Change objectives in each cell stated what needs to change in a determinant to achieve the performance objective and provided a blueprint for identifying, selecting, or developing implementation strategies .In Task 3, the team collaborated to identify evidence- and theory-based methods targeting determinants. Evidence- and theory-based methods are techniques influencing determinants and may work at the individual- and/or clinic-levels . CollaboIn Task 4, the team produced protocols and materials to facilitate National DPP adoption, implementation, and maintenance. Clinic action plans and supporting materials were developed and discussed during monthly TA calls to ensure the clinics’ feedback was incorporated. Clinic action plans delineated the implementation timeline. Supporting materials were developed and tailored to meet the needs of the clinics .via the EHR and adoption and implementation outcomes including program appropriateness, acceptability, feasibility, and fidelity measured via healthcare provider and clinic leadership surveys  with four clinic sites; Clinic B, a Rural Health Center (RHC); and Clinics C and D, two private community-based healthcare clinics. FQHCs are community-based health facilities eligible to receive federal funds because they provide affordable services to patients based on their ability to pay . RHCs arThe UTHealth team established partnerships with three National DPP, all of which were providing only virtual sessions as a result of the COVID-19 pandemic. The National DPPs were paired  with clinics based on the capacity and preferences of the two partnering entities. For example, one clinic was paired with a local National DPP that offered face-to-face classes in English and Spanish reflecting the language needs of the clinic’s patient population.Clinic stakeholders identified the following two provider-level barriers to referring patients to the National DPP: (1) a perceived lack of time during appointments for the provider to use decision support tools, discuss the National DPP, and make referrals; and (2) the provider perception that patients will not adhere to the National DPP. The clinic stakeholders identified the following six perceived patient barriers to participating in a National DPP: (1) low understanding of diabetes risk perception; (2) language barriers; (3) financial and time constraints; (4) transportation difficulties; (5) childcare concerns; and (6) lack of health insurance.Clinics reported using different EHRs including NextGen, Athena, Practice Fusion, and eClinicalWorks. Four clinics’ digital systems were not certified EHR products, had basic capabilities for setting appointments and billing, and were connected through the regional health information exchange and electronic provider-to-provider (P2P) referral networks. Most clinics used reminders for the treatment of diabetes as a CDS tool.Program adopters at clinics included clinic leadership . Program implementers included clinic administration staff , and healthcare providers . Program champions were identified from both health care providers and clinic administration staff in each clinic. Finally, program maintainers were identified from leadership , clinic administration , and healthcare providers .The identified outcomes were to adopt, implement, and maintain guidelines for diabetes prevention and the National DPP. Adoption, implementation, and maintenance determinants that clinic stakeholders considered important and changeable included those from the Social Cognitive Theory  and InteThe team identified three primary evidence- and theory-based methods to influence determinants: enhancing network linkages; participatory problem solving, providing technical assistance, facilitation, goal-setting, framing, tailoring, and guided practice.Methods were operationalized as specific implementation strategies to increase National DPP adoption, implementation, and maintenance. These included: (1) developing and distributing providing education materials; (2) monthly meetings between the clinic staff, the National DPP provider, and the UTHealth team; (3) changing clinic records systems to include an EHR-based referral system between clinics and partner National DPPs; and (4) provider-to-provider mentoring. Once the referral network was established between the clinics and the National DPP providers, the partnering program began to contact and enroll participants. Through participatory planning sessions with each clinic and its assigned program provider, we identified the need for introductory sessions, referred to as “Session 0,” to help participants become familiar with the virtual platform used by the National DPPs. The partnering program established a virtual meeting, assigned participants to 15-min time slots, and provided guidance to the team on what aspects of the program were critical to communicate to participants. The clinic’s program champion, the program’s lifestyle change coaches, and the UTHealth team facilitated Session 0 by introducing participants to the National DPP, connecting them to their coach, and answering any questions about the virtual platform .During planning sessions with the clinics, the team identified a need for materials to educate and inform patients and healthcare providers about the National DPP and the importance of program referrals. Collaborating with each clinic, the team developed National DPP referral policies, workflows, flyers and posters. Clinical workflows delineated who did what during the rooming, identification, referral, and follow-up process of patients eligible to the National DPP. Clinical pathways were captured during one-on-one TA calls with the clinic’s EHR specialist and a step-by-step document of the EHR referral process was shared with the clinic staff to orient providers making referrals using the clinics EHR. The flyers and posters were displayed on the clinics’ websites and within the clinics’ waiting and exam rooms. Flyers for providers included messaging about National DPP eligibility criteria and the selected National DPP provider(s) that had partnered with the clinic. In contrast to provider flyers, patient flyers provided an overview of the program and prompted them to speak with their health care provider about the program. While creating these materials, the team focused on integrating messaging that would address the change objectives in the matrices. For instance, an infographic was developed for clinic staff to use and post on their intranet that prompted providers to ask, “Are your patients at risk for diabetes?” and then prompted them to act with the call to action, “Refer patients at risk of diabetes to the National DPP to reduce their risk of developing type 2 diabetes.” Which was reinforced with the eligibility criteria of the program and a description of the benefits provided by the program. All of these developed protocol documents and materials were co-created and clinic staff provided the final review and approval prior to implementation.Evaluation is ongoing and future manuscripts will report National DPP referrals made, adoption outcomes, and implementation outcomes.Successful integration of the National DPP into the U.S. healthcare system is critically needed to counter the rapidly rising incidence of diabetes nationwide. By utilizing the Implementation Mapping planning framework, our coalition of primary care clinics and National DPP providers implement strategies to implement diabetes prevention guidelines and the National DPP with the intent of improving the identification of people with prediabetes and refer them to CDC-recognized lifestyle change programs for Type 2 diabetes prevention.Through systematic planning using Implementation Mapping, we designed implementation strategies to address barriers, build capacity, and create systems to foster the adoption and implementation . We chosIn the present project, Implementation Mapping proved to be a useful, systematic approach for identifying POs centered around the multiple actor-specific tasks required to ensure proper integration of the National DPP into the four clinics’ workflows. The Implementation Mapping framework helped us map practical applications to address determinants needed to achieve the POs needed to promote and identify local National DPP providers, promote the program’s value to clinic patients and providers, and optimize EHR capabilities to effectively communicate referrals between clinics and National DPP providers.An important strength of this project was the experience and background of a collaborative transdisciplinary team including engaged partners. Team members included those experienced in using Implementation Mapping to scale preventive health programs, and others skilled in providing technical assistance on EHRs and referral pathways for clinical use. This rich history of collaboration and capabilities were instrumental in building rapport and trust with the four participating clinics, and in facilitating culturally appropriate support and materials that were individualized for each of the clinics.A limitation of the project was the design of the needs assessment. The original survey and interviews did not ask about the clinics’ level of readiness nor their capacity to adopt and implement the referral procedures that are necessary to refer patients to National DPP providers. The focus of the project was implementation and promotion of the National DPP referrals. However, gaps in knowledge of the readiness and capacity of the clinics likely impeded some of the actions that could be taken during the Implementation Mapping process . As a reDiabetes is among the most prevalent chronic diseases in the U.S. This condition has devastating impacts on the quality of life of patients, with these negative consequences ranging from premature death and coexisting morbidity from complications to loss of work productivity and high health care costs , 23, 24.Enrollment is just the first step in this process, and adherence is also critical. There is a need for studies that explore how to increase adherence and how implementation could include use of incentives. For example, the UTHealth team is currently piloting an intervention that includes participation incentives to better understand its effect on patient adherence to promote National DPP attendance . The proThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Committee for the Protection of Human Subject University of Texas Health Science Center. The ethics committee waived the requirement of written informed consent for participation.WP directed research directly and helped study design and wrote manuscript. PM and FV-H project manager, wrote the manuscript, and reviewed extensively. CP project manager, wrote the manuscript, and reviewed. SB worked in project, wrote manuscript, and reviewed. NH designed the project, reviewed implementation mapping process, wrote the manuscript, and reviewed. SR reviewed implementation mapping manuscript. PF worked in project and reviewed. BR and JM reviewed manuscript. RC oversaw project and reviewed. MF and PI were responsible project and wrote and reviewed manuscript. GW a reviewer of the manuscript requested an extensive reorganization of the methods and discussion section of the manuscript. I played a key role in this organization process making the manuscript which included rewriting parts, adding additional literature citations and adding new dimensions to the discussion. All authors contributed to the article and approved the submitted version.This project was supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $3.8 million with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by Texas DSHS, CDC/HHS, or the U.S. Government. This project was also provided by the Southwest Center for Occupational and Environmental Health (SWCOEH), a NIOSH Education and Research Center, and awardee of (Grant No. 5T42) H008421 from the National Institute for Occupational Safety and Health (NIOSH)/ Centers for Disease Control and Prevention.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.