Commentary: Advertising adversities

BMJ 1997;315:460 (23 August)

Papers

Commentary: Advertising adversities

GG Christo, executive editor,^a R Balasubramaniam, consulting editor ^a

^a BMJ Indian Edition, Academy House, Manipal 576 119, India

Misleading drug advertising in medical journals has been a thornyissue for over 100 years¹ in many countries.² ³ ⁴ In India,dealing with the pharmaceutical industry and its promotional activitiespresents some distinctive challenges. Firstly, there is no legislationor statutory organisation such as the Food and Drug Administrationin the United States that regulates the accuracy of advertisementsfor prescription drugs. Secondly, there are no effective watchdog groups suchas the Pharmaceutical Advertising Advisory Board in Canada³or the Medical Lobby for Appropriate Marketing in Australia.⁴Thirdly, ayurvedic and other non-allopathic medications arewidely used and there are few scientific data on these drugs,though they are ubiquitously advertised.

Most medical journals run on lean budgets, and advertising revenuein the early years of the Indian edition of the BMJ providedfinancial stability. It soon became apparent, however, thatsome advertisements lacked information and scientific accuracy. Severalcontained excessive or vague claims—"first choice empiric therapy," "assurescontrol," "superior to other parenteral therapies"—and didnot provide substantiating references. Others omitted to mentionside effects. The need for an editorial policy and evaluatorymechanisms was apparent.

In 1994 all existing advertisers were sent copies of the editorialpolicy of the Indian edition as well as that of the parent editionof the BMJ, the World Health Organisation's monograph Ethicalcriteria for medicinal drug promotion, and a checklist againstwhich all future advertisements would be screened (see box).The covering letter asked the drug company to ensure that futureadvertisements complied with the policy. An editorial committee consistingof four professors was set up to screen each month the 20-30advertisements submitted. Advertisements were either rejected,sent back for modification, or accepted. In a typical monthabout three quarters of the advertisements are accepted; theremainder are returned for modification with specific requests.Fortunately most of our advertisers complied, though some grumbledthat other journals were not as strict and some sought to defendtheir data. Six advertisers (out of 45) stopped sending advertisements.We estimate that overall about 5% of advertising revenue hasbeen lost. The system is not perfect; the editorial committeemembers sometimes disagree and the degree of strictness varies.Advertisements for ayurvedic products continue to be publishedprovided the claims are not outlandish.

Checklist for assessing advertisements

Name of product
Name and address of company
Name and address of advertising agency
Are the following included in the advertisement?

Generic name/constituents/active ingredients

Content of active ingredients per dosage form or regimen

Dosage or regimen

Precautions

Contraindications

Adverse effects

References

Name and address of manufacturer

Are the claims appropriate?

Several medical journals have published articles on this topicand formulated editorial policies.⁵ ⁶ ⁷ ⁸ The Annals of InternalMedicine found that 92% of their advertisements suggested lackof compliance with FDA regulations, 62% needed major revisions,and 28% would not be recommended for publication.⁵

In a country such as India, where there are no legal constraintsto medical advertising, the scope of misuse extends beyond journalsto package inserts, pamphlets handed out by medical representatives,"scientific" newsletters published by drug companies, promotional videos,exhibits at medical conferences, and preprinted prescriptionpads and other complimentary items. The largesse of drug companiesextends to sponsoring conferences, travel grants, and research awardsand the recipients are inclined to be accommodating. A glancethrough scientific journals published in India reveals thatall of them run more or less the same advertisements as theIndian edition of the BMJ.

One leading Indian editor said privately that the pharmaceuticalindustry was too powerful and he was not willing to join a futilecampaign against them. This attitude may be widespread amongeditors. One author believes, on the basis of an unpublishedstudy, "that few medical journals, including leading peer reviewedjournals make any attempt to formally screen pharmaceuticalsadvertisements."⁵ Some investigators argue that too much attentionhas been focused on advertisements that are never read.⁹ ¹⁰Others cite the expense of evaluating advertisements and thedisincentive to a truly rigorous review because of the financial dependenceon advertising revenue.⁵

Our experience has led us to conclude that, when not monitored,companies, even respected multinationals, will stretch the limitsof scientific credibility when making claims about the efficacy oftheir drugs; but when we raise the issue and institute supervisorymechanisms most can be persuaded to bring their advertisementswithin the confines of scientific propriety.

The roles of editors and the drug companies are perhaps lesscritical than that of the reader. Doctors and medical studentsneed to be educated to increase their ability to recognise misleading promotionalactivities, especially those disguised as research or medicaleducation.

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