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 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


4 5


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. 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




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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