Editorial
Public smoking regulation in China: no more hot air
Ramin Talaie/Corbis
As part of ongoing tobacco control efforts in China, the Communist Party and the state council have recently issued a statement banning officials from smoking cigarettes in places such as schools, hospitals, and on public transport. Tobacco will also no longer be sold at government or Communist Party offices. This welcome rule is an encouraging step forward, but in a country where smoking is widespread and socially acceptable, and the tobacco industry provides a huge source of income for the government, how effective is it likely to be? China has the most smokers in any country (about 300 million) and accounts for 40% of global tobacco production and consumption. High tobacco use is linked to an average of 1·2 million deaths annually in China, 100 000 of which are caused by exposure to second-hand smoke. Previous efforts to ban smoking in public areas in China have had little success. In 2011, locally regulated guidelines were issued banning smoking in indoor public places, and signs prohibiting smoking are commonplace in restaurants and bars. However, poor enforcement and
few penalties for non-compliance mean that the rule is widely ignored. Consequently, smoking in public remains widespread, and up to 70% of adults are regularly exposed to second-hand smoke. The new rule suggests government commitment to the issue, but it needs to be a step towards a national ban on smoking in public places. Moreover, it might be difficult to implement. According to the Chinese Association on Tobacco Control, 61% of male Chinese civil servants smoke, more than half of who say they have never tried to quit, and up to 60% of doctors in China are smokers. Awareness programmes highlighting the health benefits of smoking cessation are clearly key to the success of an effective tobacco control strategy. Once a strict national law banning smoking in public has been framed as the next stage of a proactive tobacco control strategy, the next bold step for China’s Government to consider would be to tackle the tobacco epidemic as done in Hong Kong by raising taxes on cigarettes and gearing up anti-tobacco leadership by the medical community. The Lancet
Amelie-Bensoist/Science Photo Library
Treatment of anorexia nervosa
See Comment page 105 See Articles page 127
100
In 1888 in The Lancet, Sir William Gull published a case report of a girl with anorexia nervosa stating that “The cure consists of three things—rest, warmth, and the regular and frequent introduction of food…” More than 120 years later, knowledge about treating this debilitating illness has progressed considerably but questions remain. Anorexia nervosa has the highest mortality of any mental illness. Psychotherapy is the treatment of choice for patients, however, evidence to support any specific form of psychotherapy is lacking. A Cochrane review on outpatient treatment for anorexia nervosa suggested that a specialised approach might be more successful than therapeutic support from a non-specialist clinician but identified an urgent need for large multicentre, randomised trials of commonly used psychotherapies. Stephan Zipfel and colleagues should therefore be commended for their trial in today’s Lancet, which assesses the efficacy of two manual-based outpatient treatments for anorexia nervosa—focal psychodynamic therapy and enhanced cognitive behaviour therapy—versus optimised treatment as usual in 242 female adult patients.
The study showed that body-mass index at the end of treatment increased in all groups but there were no significant differences between them, including at 12-month follow-up. However, at 12 months, focal dynamic therapy had higher rates of recovery (based on a combination of weight gain and eating-disorder specific psychopathology) and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology than optimised care. Although the search for an effective type of psychotherapy continues, the study shows that optimised care as usual constitutes good management and that specialist focal dynamic therapy and enhanced cognitive behaviour therapy are possible treatment options. Anorexia nervosa is a difficult-to-treat disorder with devastating effect on patients’ health, quality of life, and families. Whether a specialised or a non-specialised approach is used in treatment, care for people with this often misunderstood disorder should be supportive, empathetic, and collaborative. The Lancet www.thelancet.com Vol 383 January 11, 2014
Public smoking regulation in China: no more hot air
Ramin Talaie/Corbis
As part of ongoing tobacco control efforts in China, the Communist Party and the state council have recently issued a statement banning officials from smoking cigarettes in places such as schools, hospitals, and on public transport. Tobacco will also no longer be sold at government or Communist Party offices. This welcome rule is an encouraging step forward, but in a country where smoking is widespread and socially acceptable, and the tobacco industry provides a huge source of income for the government, how effective is it likely to be? China has the most smokers in any country (about 300 million) and accounts for 40% of global tobacco production and consumption. High tobacco use is linked to an average of 1·2 million deaths annually in China, 100 000 of which are caused by exposure to second-hand smoke. Previous efforts to ban smoking in public areas in China have had little success. In 2011, locally regulated guidelines were issued banning smoking in indoor public places, and signs prohibiting smoking are commonplace in restaurants and bars. However, poor enforcement and
few penalties for non-compliance mean that the rule is widely ignored. Consequently, smoking in public remains widespread, and up to 70% of adults are regularly exposed to second-hand smoke. The new rule suggests government commitment to the issue, but it needs to be a step towards a national ban on smoking in public places. Moreover, it might be difficult to implement. According to the Chinese Association on Tobacco Control, 61% of male Chinese civil servants smoke, more than half of who say they have never tried to quit, and up to 60% of doctors in China are smokers. Awareness programmes highlighting the health benefits of smoking cessation are clearly key to the success of an effective tobacco control strategy. Once a strict national law banning smoking in public has been framed as the next stage of a proactive tobacco control strategy, the next bold step for China’s Government to consider would be to tackle the tobacco epidemic as done in Hong Kong by raising taxes on cigarettes and gearing up anti-tobacco leadership by the medical community. The Lancet
Amelie-Bensoist/Science Photo Library
Treatment of anorexia nervosa
See Comment page 105 See Articles page 127
100
In 1888 in The Lancet, Sir William Gull published a case report of a girl with anorexia nervosa stating that “The cure consists of three things—rest, warmth, and the regular and frequent introduction of food…” More than 120 years later, knowledge about treating this debilitating illness has progressed considerably but questions remain. Anorexia nervosa has the highest mortality of any mental illness. Psychotherapy is the treatment of choice for patients, however, evidence to support any specific form of psychotherapy is lacking. A Cochrane review on outpatient treatment for anorexia nervosa suggested that a specialised approach might be more successful than therapeutic support from a non-specialist clinician but identified an urgent need for large multicentre, randomised trials of commonly used psychotherapies. Stephan Zipfel and colleagues should therefore be commended for their trial in today’s Lancet, which assesses the efficacy of two manual-based outpatient treatments for anorexia nervosa—focal psychodynamic therapy and enhanced cognitive behaviour therapy—versus optimised treatment as usual in 242 female adult patients.
The study showed that body-mass index at the end of treatment increased in all groups but there were no significant differences between them, including at 12-month follow-up. However, at 12 months, focal dynamic therapy had higher rates of recovery (based on a combination of weight gain and eating-disorder specific psychopathology) and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology than optimised care. Although the search for an effective type of psychotherapy continues, the study shows that optimised care as usual constitutes good management and that specialist focal dynamic therapy and enhanced cognitive behaviour therapy are possible treatment options. Anorexia nervosa is a difficult-to-treat disorder with devastating effect on patients’ health, quality of life, and families. Whether a specialised or a non-specialised approach is used in treatment, care for people with this often misunderstood disorder should be supportive, empathetic, and collaborative. The Lancet www.thelancet.com Vol 383 January 11, 2014
