Correspondence

We were surprised to read in The Lancet (Nov 1, p 1576), 1 Lorien Jollye’s criticisms of the public health community for, as she alleges, insulting and ignoring the supporters of electronic cigarettes (e-cigarettes). A recent Lancet–London School of Hygiene & Tropical Medicine Global Health Lab (held in London, on Nov 4, 2014) debating the tobacco endgame, that was widely advertised, was an opportunity to engage on this issue. Yet rather than put forward their arguments, advocates of e-cigarettes instead chose to remain silent in the lecture theatre while insulting the participants on twitter. Two things are now clear. First, the advocates of e-cigarettes seem only willing to engage on their own terms. Second, anyone with the temerity to suggest that e-cigarettes are anything other than the game changing solution to the problem of tobacco will be subject to grossly offensive attacks,2 with growing evidence that these are being orchestrated.3 One recent example, a tweet directed at two of us, contained a picture of a noose with the caption “your days are numbered”. The public health community has listened, but it has also systematically reviewed the evidence. 4 Numerous national and international organisations have reached the conclusion that it is possible that these products might help some people who are heavily addicted to nicotine but there are many very serious concerns about their effectiveness, safety, and potential to renormalise smoking. 5 Moreover, there are real concerns that they are introducing non-smoking adolescents to nicotine addiction,6 so it is certainly premature to encourage their use. However, the very effective campaign waged by their supporters has ensured that other measures of www.thelancet.com Vol 384 December 13, 2014

known effectiveness have almost disappeared from the debate on tobacco control. We declare no competing interests.

*Martin McKee, Simon Chapman, Mike Daube, Stanton Glantz [email protected] European Centre on Health of Societies in Transition, London School of Hygiene & Tropical Medicine, WCIE 7HT London, UK (MM); Sydney School of Public Health, University of Sydney, Sydney, Australia (SC); Curtin University, Perth, Australia (MD); and Center for Tobacco Control Research and Education, University of California, San Francisco, CA, USA (SG) 1 2

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Jollye L. E-cigarettes in the UK: a more inclusive debate is needed. Lancet 2014; 384: 1576. Mills D. Opponents of e-cigarettes bombarded with abusive ‘four-letter emails starting with C and F’ in bitter row with online cult groups. http://www.dailymail.co. uk/news/article-2656160/Healthcampaigners-receiving-incredibly-abusiveemails-bitter-row-alternative-smoking.html (accessed Nov 27, 2014). Harris JK, Moreland-Russell S, Choucair B, et al.Tweeting for and against public health policy: response to the Chicago Department of Public Health’s electronic cigarette twitter campaign. J Med Internet Res 2014; 16: e238. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation 2014; 129: 1972–86. de Andrade M, Hastings G, Angus K. Promotion of electronic cigarettes: tobacco marketing reinvented? BMJ 2013; 347: f7473. Dutra LM, Glantz SA. High international electronic cigarette use among never smoker adolescents. J Adolesc Health 2014; 55: 595–97.

Prevalence of overweight and obesity in children and adults The global burden of overweight and obesity study by Marie Ng and colleagues (Aug 30, p 766)1 will be crucial to drive political change. We emphasise two important additional steps in global obesity surveillance to inform action. First, obesity trends should be reported stratified by socioeconomic position. A socioeconomic gradient in obesity has been reported in most developed countries; greater prevalence of overweight and obesity is seen in more disadvantaged groups.2 Although levelling off of the obesity epidemic has been reported in some countries,

preliminary evidence suggests that this has not been shared across all socioeconomic levels. 3 Obesity is one of the few preventable risk factors with increasing prevalence worldwide. Reduction of socioeconomic inequalities in obesity is an opportunity to reduce future social disparities in health. Routine monitoring of obesity trends by socioeconomic position should be introduced to make inequalities central to policy making. Second, the composition of the obese population should be described with respect to the degree of severity. During the past three decades, increases have been reported in overall obesity prevalence, with the largest increases in the most severe obesity subgroups. 4,5 Consequently, cases of severe obesity (body mass index [BMI] more than 35 kg/m²) account for an increasingly large proportion of the obese population over time. One in seven Americans are now severely obese, and the total obesity prevalence is 35% in the USA.6 Severe obesity is associated with greater adverse consequences than mild obesity (BMI between 30·0 and 34·9 kg/m²). Monitoring trends in the severity composition of the obese population is essential to predict the associated disease burden and inform options for intervention.

B Boissonnet BSIP/Science Photo Library

The debate on electronic cigarettes

We declare no competing interests.

*Catherine Keating, Kathryn Backholer, Anna Peeters [email protected] Obesity and Population Health, Baker IDI Heart and Diabetes Institute, Melbourne VIC 3004, Australia (CK, KB, AP); and Deakin Health Economics, Deakin University, Melbourne VIC, Australia (CK) 1

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Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766–81. Devaux M, Sassi F. Social inequalities in obesity and overweight in 11 OECD countries. Eur J Public Health 2013; 23: 464–69. Rokholm B, Baker JL, Sorensen TI. The levelling off of the obesity epidemic since the year 1999—a review of evidence and perspectives. Obes Rev 2010; 11: 835–46. Sturm R. Increases in morbid obesity in the USA: 2000–2005. Public Health 2007; 121: 492–96.

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Walls HL, Wolfe R, Haby MM, et al. Trends in BMI of urban Australian adults, 1980–2000. Public Health Nutr 2010; 13: 631–38. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA 2014; 311: 806–14.

Authors’ reply We welcome the Correspondence from Catherine Keating and colleagues commenting on our recent Article1 and thank them for their suggested steps to improve the quality of global obesity surveillance. We agree that stratification of trends by socioeconomic status is important and relevant to understanding the obesity epidemic. In our study, we have focused mainly on estimating the national trends and revealing the intercountry similarities and differences. Intracountry variation was not studied. To address this limitation, the Global Burden of Disease Study is gradually incorporating sub-national analysis in some countries to generate the most policy-relevant results. One challenge, however, is the scarcity of reliable data for subpopulations. Surveillance and surveys are often designed to be nationally representative. To capture subnational and subpopulation information, a comprehensive monitoring system should be developed to allow gathering of data at a more localised level. Regarding the authors’ second point, we agree that it is important to examine the composition of the obese population according to severity. Again, the scarcity of data is a substantial challenge in the estimation process. Obesity is a pressing health issue worldwide. Effective monitoring and surveillance are crucial to inform action and trace success. I declare no competing interests.

Emmanuela Gakidou [email protected] Institute for Health Metrics and Evaluation, Seattle, WA 98121, USA 1

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Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766–81.

Education of health professionals in China

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Hou J, Michaud C, Li Z, et al. Transformation of the education of health professionals in China: progress and challenges. Lancet 2014; 384: 819–27. Duvivier RJ, Boulet JR, Opalek A, van Zanten M, Norcini J. Overview of the world’s medical schools: an update. Med Educ 2014; 48: 860–69.

With great interest I read Jianlin Hou and colleagues’ Review (Aug 30, p 819).1 I applaud the initiative of China’s Ministry of Education to provide previously unreleased data on the number of health professional graduates and faculty by school. I respectfully request this information to be made publicly available: improved data can drive research on the quality of schools and their graduates, both in China and worldwide. We recently reported an overview of the world’s medical schools,2 and identified many challenges associated with counting schools and tracking information at school level. Nevertheless, to help meet the projected demand for health professionals in China, its government must pay attention, not only to the number and capacity of their training institutions, but also to their quality. Hou and colleagues provide observations on the quality of health professional education, but do not comment on the availability of outcome measures, such as government recognition and oversight, licensure and test scores, or process measures, such as qualifications of faculty staff. The absence of standard setting processes, accreditation, and licensing processes poses a real threat to the quality of the educational institutions of health professionals in China. Rigid and static educational methods are prevalent—incorporation of adult learning principles coupled with state-of-the-art assessment and evaluation are urgently needed to bring the education of China’s health professionals into the 21st century. What China needs are health professionals with the knowledge and skills to bring major educational reform and create meaningful and sustainable advances.

We read with interest the Review by Jianlin Hou and colleagues on the progress and challenges of transformation of the education of health professionals in China.1 We are concerned about the training of nurses. We are worried by the fact that most nurses did not receive standard nursing training. According to figure 1 in the Review,1 in 2012, only 30 000 out of 186 000 graduate nurses earned standard bachelor degrees or above. Most nurses received diplomas associated with brief training. Based on the supplementary materials,1 more than 80% of nurses working in the Chinese medical system received a diploma or lower and lack adequate training. With a 1:1 ratio between doctors and nurses1 and stressful working conditions, inadequately trained nurses could make mistakes during their medical service. The Review 1 on education transformation was accompanied by three pieces of Correspondence2–4 about violence against doctors in China. Although we agree that stronger punishments and other measures should be implemented to reduce violence against health professionals, we also believe that the education of nurses in China could also participate to some degree to the issue of violence against medical personnel.5 Nurses are intermediates between doctors and patients. In our practice, we have seen misunderstanding and mistrust between patients and doctors most probably due to of the inadequate training of nurses. A more comprehensive training system for nurses is needed.

I declare no competing interests.

We declare no competing interests.

Robbert J Duvivier

*Fengxia Liu, Ruili Zhang, Cuizhi Geng, Hong Chen, Yongjun Wang

[email protected] University of Newcastle, Callaghan, NSW 2308, Australia

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[email protected]

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Prevalence of overweight and obesity in children and adults.

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