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FEATURE: Richard Smith Should medical journals carry drug advertising? Yes BMJ 2007; 335: 74 [Full text]

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Drug and poison

Vasiliy Vlassov   (13 July 2007)

Consistency

Piero Baglioni   (14 July 2007)

Medical schools need to take the lead

David Biles, Patrick Howlett and Robert Hughes   (18 July 2007)

The power of drug advertising

Andrew P Jewell   (19 July 2007)

Medical Journals and Drug Advertising: Some Reflections!

Nitin Gupta   (20 July 2007)

Time for medical journals to disentangle from drug companies

Gavin M Yamey, Virginia Barbour, Paul Chinnock, Barbara Cohen, Larry Peiperl, Emma Veitch   (24 July 2007)

Faux-papers and Trojan horses: buying your way into peer-reviewed journals

Geraint H Lewis, Peter M Hockey, Harvard Medical School   (25 May 2008)

Re: Faux-papers and Trojan horses: buying your way into peer-reviewed journals

Tony Delamothe   (27 June 2008)

Re: Re: Faux-papers and Trojan horses

Geraint H Lewis, Peter M Hockey, Harvard Medical School   (3 July 2008)

Re: Re: Re: Faux-papers and Trojan horses

Tony Delamothe   (7 July 2008)

Re: Re: Re: Re: Faux-papers and Trojan horses

Geraint H. Lewis   (9 February 2009)

Drug and poison 13 July 2007
Vasiliy Vlassov, Professor Moscow Medical Academy 101000 Send response to journal: Re: Drug and poison	What is a drug for one is a poison for another. What R. Smith describes as a source of independence may be the worst dependence. Why not look at what is going in the real world? In the real world some first class journals wear on every issue the ad from the one and the same company. Many second class journals do the same. They do this despite this practice being specifically known as damaging, and they do this specifically for getting more money, to enjoy a kind of dependence. In the real world journals strongly depend on advertisement income. Not 20% of them, but, as I know, for example, in the post Soviet space, almost all journals depend mostly on advertisements. More, the most prosperous journals bring profits to the owner, and the owner presses the journal to raise more money through advertisements. In this case the owner does not reduce its pressure on the content of the journal, but introduces another line of pressure – the demand for more profits. In the real world all advertisers enjoy some influence on the content of the journals to support their advertisements. And if one advertiser succeeds in that, this will not lead to complaints from competitor. Opposite: competitor advertiser will demand that the journal provides a similar service for them. E.g. in Russia these days the publication of advertisements with the supporting “scientific” paper is a usual advertiser’s package. Why do journals do that? “Because they are funded mostly by drug advertising” – this is the explanation for newspapers by R. Smith, but this explanation is applicable to medical journals. Only a small proportion of medical journals is supported mostly by subscription, as I know in the field. R. Smith says, “advertising is there for all to see and easy to police”. It is not so simple. Journals practise insertions, which makes policing almost impossible. “We are conditioned to (advertisements) and discount it,” says R. Smith, and it is again not quite right, because as I mentioned earlier advertisements are these days “evidence based” and supported by accompanying “scientific papers”. Fortunately, I agree with the final recommendation: readers, skip the ads! But I would add another recommendation: readers, condemn editors of journals for manipulating the content in the interest of advertisers. Competing interests: None declared
Consistency 14 July 2007
Piero Baglioni, Consultant Physician Prince Charles Hospital , Merthyr Tydfil, MidGlamorgan CF47 9DT Send response to journal: Re: Consistency	I welcome the current debate because I have been puzzled for some time by the BMJ increasingly playing host to paid advertising from pharmaceutical companies. If -as usually stated- this is consequence of the fact that journals have to survive in a competitive enviroment, then there is no doubt that when it comes to advertising the BMJ is well ahead of the pack, both in terms of volume [over 30% of the total number of pages in some issues] and prominence [neither the NEJM nor the Lancet -for instance- allow advertising to be interspersed with the scientific material, or attached to their front cover]. This is even more puzzling because it was not so long ago that the journal claimed on its front cover that it was "time to disentangle doctors from pharmaceutical companies" [BMJ 31 May 2003]. As a matter of consistency, I submit that if this high moral standard applies to the jobbing doctor, it should apply to the journal which them represents as well. The fact that ads bring millions of pounds in revenues to the BMJ [1] should not lead to dismiss the fact that, as inaccurate and misleading their content may be[2,] it is still a powerful instrument in promoting prescription of targeted drugs in a dose related manner [3]. This is not only at odds with the journal professed mission of "helping doctors make better choices" : it is also socially irresponsible because while most of the drugs advertised are rarely innovative [4] they are major contributors to the escalating cost of providing fair and equitable health care for all[5]. Finally, while proper respect is due to Smith's opinion that " ... greater trust should be placed in a journal that carries advertising than one that does not ... " , as a clinician I cannot help feeling that Drugs & Ther Bulletin is still a better guide to rational and cost-effective prescribing. 1) Leichin J, Light DW - Commercial influence and the content of medical journals - BMJ 2006 vol. 332 : 1444-1447 2) New drugs from old - Drugs & Ther Bull, Oct 2006 : 73-77 3) Villanueva P et al - Accuracy of pharmaceutical advertisement in medical journals - Lancet 2003 vol. 361 : 27-32 4) Fugh-Berman A, Alladin K et al - Advertising in medical journals : should current practice change ? - PLoS Medicine 2006 vol. 3 [e130] : 0762 -0768 5) Morgan SG, Bassett KL et al - "Breackthrough" drugs and growth in expenditure on prescription drugs in Canada - BMJ 2005 vol. 331 : 815-816 Competing interests: None declared
Medical schools need to take the lead 18 July 2007
David Biles, medical student Bristol Medical School BS2 8DZ, Patrick Howlett and Robert Hughes Send response to journal: Re: Medical schools need to take the lead	Williams and Smith present powerful arguments over the ethics of drug advertisements in medical journals. Whilst they take different views on journal marketing, there is much on which they seem to agree. Central to this is acceptance that doctors are at the heart of the problem. Williams clearly states that “the culture that helps make medical advertising both acceptable and profitable” is outdated, and that respected journals should take a lead in changing this. Arguably, Smith agrees; his “killer point” suggests that the limiting factor to doctors paying for marketing free journals is the culture amongst doctors that pharmaceutical advertising is acceptable. It is not only journal editors who need to take leadership in changing this culture; medical schools need to recognise their responsibility. Research reveals that professional conduct acquired or learnt during medical school persists into future practice [1]. Medical schools are to be commended for integrating many of the principles of evidence based medicine into their curricula. However, when it comes to teaching about the ethics of marketing there is much to be done; to our knowledge no British medical school has a policy on pharmaceutical interaction. At medical school we have all experienced therapeutics teaching sessions directly preceded by ‘education’ from reps that raises a similar “two fingers to evidence based medicine” as the drug adverts Williams correctly challenges. Our American counterparts are setting the standard; Yale, Stanford and many other American medical schools have policies restricting pharmaceutical interaction during medical school [2]. Their policies reflect the value of marketing representatives as a source of evidence. The BMA’s recent ARM signalled the beginnings of a cultural shift in the UK. The ARM voted almost unanimously in favour of supporting medical schools in not only forming policies, but dedicating time in the curriculum for teaching on professional conflicts of interest. Tomorrow’s prescribers need to be making decisions based on the best available evidence, not the most persuasive marketing. Medical schools need to take the lead. Email: db2065@bris.ac.uk (1) McCormick BB, Tomlinson G, Brill-Edwards P, Detsky AS. Effect of restricting contact between pharmaceutical company representatives and internal medicine residents on post-training attitudes and behavior. JAMA. 2001;286:1994-1999. (2) McCarthy M. US campaign tackles drug company influence over doctors. Lancet. 2007;369(9563):730 Competing interests: None declared
The power of drug advertising 19 July 2007
Andrew P Jewell, Professor SW17 0RE Send response to journal: Re: The power of drug advertising	On page 75 of the 14th July issue of the British Medical Journal in the debate about whether medical journals should carry drug advertising, Gareth Williams states that "Fifty years ago, the American Journal of Medicine regularly ran advertisments for Camel cigarettes..". On the previous pages (72-73) I was interested to note how many doctors were smoking in the photograph of the special representative meeting of the BMA to discuss the creation of the NHS. Even in this small photograph there are at least four who appear to have cigarettes in their mouth, and at least four with pipes, and I can only clearly see the first five rows of the meeting. The power of advertising perhaps? Competing interests: None declared
Medical Journals and Drug Advertising: Some Reflections! 20 July 2007
Nitin Gupta, Consultant Psychiatrist-South Staffordshire and Shropshire Healthcare NHS Foundation Trust Margaret Stanhope Centre, Belvedere Road, Burton upon Trent, DE13 0RB. Send response to journal: Re: Medical Journals and Drug Advertising: Some Reflections!	The argument presented by Smith [1] is more compelling than that by Williams [2]. I would not like to go into a detailed dissection of the ‘head to head’ debate by both, but would like to place on record that both authors have discussed issues that are not only interesting but quite powerful and thought-provoking. Williams [2] mentions about two key features which I would like to raise for possible further discussion. Firstly, is the issue of ‘hype’ and ‘big headline claims…’. The argument presented for drug advertisements is easily generalizable to any other advertisement which we encounter in day- to-day life. Do we not find everyday- advertisements with similar (if not identical) hype, big headlines, and most of the relevant information in small print? It can be argued that the drug companies are commercial organizations, and in similar vein, tend to adopt similar methods. Hence, in the current scenario of commercial advertising and consumerism, it is not a new thing we are being exposed to, even if we are to look at it from the viewpoint of ‘ethical physicians’. Secondly, is the issue of ‘….project the positive, while the negative gets little coverage’ and ‘editors set high standards….. two fingers to evidence based medicine’. These statements need to be interpreted in the light of compelling evidence regarding ‘positive publication bias’ in various scientific journals on clinical drug trials [3]. One may, therefore, argue that drug advertisements are not solely and/or contributing significantly to the hype surrounding evidence for use of a new drug. Both Smith [1] and Williams [2] have alluded to ‘ethical responsibility’. It may be helpful to remember here that doctors are (though not mandatory) expected to follow the Hippocratic Oath, which sets grounds for one’s professional ethical standards. Also, it may be emphasized here that if one has to achieve an appropriate balance between such commercial interests and ethical principles, then all the key partners i.e. the medical journal, the drug company, and the doctor(s) need to be fully and practically cognizant of these relevant issues. In this scenario, probably at the heart of both the problem and solution is the medical profession (i.e. the doctors). Overall, I would be more inclined to agree with the approach suggested by Smith [1], but to keep in active consideration the issues raised by Williams [2]. REFERENCES: [1] Smith R. Should medical journals carry drug advertising? YES. BMJ 2007; 335 (14): 74. [2] Williams G. Should medical journals carry drug advertising? NO. BMJ 2007; 335 (14): 75. [3] Eysenbach G. Tackling publication bias and selective reporting in health informatics research: register your eHealth trials in the International eHealth Studies Registry. J Med Internet Res 2004; 6 (3): e35. Competing interests: NG has received honorarium as speaker fees and also has accepted educational grants/invitations for attending conferences from various pharmaceutical companies in Psychiatry.
Time for medical journals to disentangle from drug companies 24 July 2007
Gavin M Yamey, Senior Editor, PLoS Medicine Public Library of Science, 185 Berry Street, Suite 3100, San Francisco, CA 94107, Virginia Barbour, Paul Chinnock, Barbara Cohen, Larry Peiperl, Emma Veitch Send response to journal: Re: Time for medical journals to disentangle from drug companies	We do not share Richard Smith's belief that "advertising in a journal will have only a small influence on the average doctor" or that "you can place greater trust in a journal that carries advertising than one that does not."[1] In 2003, drug companies spent US$448 million on advertising in medical journals,[2] and the return on investment (the average increase in revenues per incremental dollar spent in any given month) was US$5.00.[3] Companies spent such enormous sums pitching their products at doctors because they get the results they want: advertising increases prescriptions for targeted drugs.[4] The BMJ has repeatedly called for doctors and drug companies to disentangle,[5] and yet it continues to seek revenue from drug companies for its financial sustainability. As for all businesses, medical journals are wise to seek multiple revenue streams. But the risk of overdependence on the vagaries of advertising revenue is illustrated by BMJ-USA, which folded because "it has fallen victim to the widespread downturn in US pharmaceutical advertising and has become financially unsustainable for the BMJ Publishing Group."[6] Richard argues that if the BMJ abandoned drug advertising, it would be forced to start charging readers to access the original research papers. But he forgets to mention one increasingly important avenue of funding—publication charges paid by research funders to cover the costs of publication. Funders wish to make the final reports of the research they fund universally accessible and are increasingly supportive of covering such costs. The Wellcome Trust, one of the world’s largest biomedical research charities, now makes it a condition of receiving a grant that the final report is made freely available—and the trust will cover publication costs.[7] References 1. Smith R. Should medical journals carry drug advertising? BMJ 2007;335:74 (14 July), doi:10.1136/bmj.39259.472998.AD 2. IMS Health, Integrated Promotional Services, CMR. (2004) Top-line industry data. Fairfield (Connecticut): IMS Health. Available: http://www.imshealth.com/ims/portal/front/articleC/0,2777,6599_44304752_44889690,00.html. 3. http://www.rxpromoroi.org/rapp/index.html 4. Wang TJ, Ausiello JC, Stafford RS (1999) Trends in antihypertensive drug advertising, 1985–1996. Circulation 99:2055–2057. 5. Abbasi K, Smith R. No more free lunches. BMJ. 2003 May 31;326(7400):1155-6. 6. Kamerow D, Godlee F (2005) BMJ USA is ending. BMJ 331:e394 DOI: 10.1136/bmj.331.7530.E394. 7. http://www.wellcome.ac.uk/doc_WTD002766.html Competing interests: PLoS Medicine bans adverts for drugs and devices. The journal is funded through multiple revenue streams, including publication charges, foundation support, institutional membership, and non-pharmaceutical advertising. Richard Smith is on PLoS’ Board of Directors. Before joining PLoS Medicine, GY was an assistant editor at the BMJ.
Faux-papers and Trojan horses: buying your way into peer-reviewed journals 25 May 2008
Geraint H Lewis, Harkness Fellow New York University, NY 10012, Peter M Hockey, Harvard Medical School Send response to journal: Re: Faux-papers and Trojan horses: buying your way into peer-reviewed journals	Two research papers [1],[2] were published recently in the BMJ, neither of which stated its funding, competing interests, ethical approval, provenance or peer review status. Both papers extrapolated in- vitro data to clinical situations and made other potentially misleading claims. However readers of the journal were unable to post Rapid Responses to point out these shortcomings. The explanation becomes apparent on closer inspection: these ‘research papers’ were in fact advertisements. We and several of our colleagues began reading them as legitimate BMJ scientific papers and only later noticed the light blue header stating ‘Advertisement Feature’. We all feel misled. The company paying for these adverts has effectively purchased ‘academic copy’ in a high-impact journal, bypassing the peer-review process and using the reputation of the journal as a Trojan horse to catch our attention [3]. In doing so it has made it impossible for us to follow Richard Smith’s advice to “flip over the adverts in the journal” [4]. Of more concern is the fact that we, like many readers, sometimes skim-read articles without poring over the details. We do this because we trust the BMJ to scrutinize articles on our behalf. These adverts pose a danger because skim-readers may turn to the next page of the journal without realizing that they had just read an advert rather than peer-reviewed research. In retrospect we can see that these adverts do use a different layout and font from that of the BMJ (although there are remarkable similarities to the style of the New England Journal of Medicine). Nevertheless they set a hazardous precedent since it is only a small step to publishing adverts that follow the journal’s own house style exactly. Would the BMJ have allowed them in these circumstances? What if the advertisements had involved animal or human subjects rather than in vitro experiments: would it then have insisted on imposing ethics requirements? Surely every page of the journal should be subject to all of the same rigorous standards that editors rightly set for scientific research. We are not claiming that the pharmaceutical company that paid for these adverts, nor the BMJ, contravened any regulations. This means that changes to the regulatory framework are needed if readers are to be protected from such adverts that masquerade as research. We can see three potential courses of action. First there could be tighter regulation, for example by amending Clause 6 of the ABPI Code of Practice for the Pharmaceutical Industry, which relates to journal advertising [5]. In theory, this clause could be changed to prohibit faux-papers from being published in journals. However we cannot see how this could be codified in a way that dealt with every eventuality, and so we feel that this solution is unworkable. Secondly, pharmaceutical advertising could be completely deregulated. Readers would then have to become more discerning when looking at adverts and stop skim-reading [6]. However, as these recent BMJ faux-papers demonstrate, advertisers might then emulate the house style of the journal ever more closely, making the distinction between advertisements and research papers imperceptible. Readers would now be compelled to use other sources of information that carried no advertising, thereby threatening the future of medical journals. The third option, which to our mind is the only workable solution, is a complete ban on pharmaceutical adverts in peer-reviewed journals. The publication of these two adverts, despite being calculatedly inconspicuous, has once again reopened the debate about whether medical journals should carry drug advertising. ACKNOWLEDGEMENTS The Commonwealth Fund supports both authors as Harkness Fellows in the United States. The opinions expressed here are not necessarily those of the Fund. REFERENCES [1] Strugala V, Avis J, Jolliffe IG, Johnstone LM, Dettmar PW. The role for liquid alginate suspension (Gaviscon Advance®) in the protection of the oesophagus against damage by bile in the refluxate. BMJ 22 March 2008; Volume 336. [2] Strugala V, Avis J, Jolliffe IG, Johnstone LM, Dettmar PW. The role for liquid alginate suspension (Gaviscon Advance®) in the protection of the oesophagus against damage by pepsin in the refluxate. BMJ 12 April 2008; Volume 336 [3] Williams D. Should medical journals carry drug advertising? No. BMJ 2007;335:75 [4] Smith R. Should medical journals carry drug advertising? Yes. BMJ 2007;335:74 [5] Code of Practice for the Pharmaceutical Industry 2006. Prescription Medicines Code of Practice Authority. http://www.pmcpa.org.uk/files/sitecontent/code06use.pdf Accessed online 15/5/08. [6] Vaithianathan R. Better the devil you know than the doctor you don't: is advertising drugs to doctors more harmful than advertising to patients? J Health Serv Res Policy 2006;11:235-239 Competing interests: None declared
Re: Faux-papers and Trojan horses: buying your way into peer-reviewed journals 27 June 2008
Tony Delamothe, Deputy editor BMA House, London WC1H 9JR Send response to journal: Re: Re: Faux-papers and Trojan horses: buying your way into peer-reviewed journals	We're sorry that you were misled, particularly since one of the main principles of our advertising policy is that readers must immediately be able to tell what is advertising and what is editorial material. Another principle is that "readers understand that advertising is different from editorial material. They know that the claims made in advertising are not endorsed by the BMJG." The full list of principles is at: http://group.bmj.com/group/advertising/policy Specific guidelines for advertisement features (advertorials), include: * The whole advertisement should appear in a box, which should be centred on the page. A minimum of a 10 mm gap should separate the box and the edge of the page. * The words “Advertisement Feature” should be prominently displayed between the top of the box and the top of the page. * Advertisers should have no intention to imitate the editorial style of the BMJ or any of the BMJ Journals. * The typefaces Plantin, Baskerville, and any other typeface closely resembling these must not be used in body count, headlines, and crossheads. * Copy should not be presented on any grid pattern that matches part of the BMJ or the BMJ Journals. *Tints that commonly appear in the BMJ must not be used, thereby avoiding confusion with editorial matter. For the full document, see: http://group.bmj.com/group/advertising/policy/acceptance-of-adverts ** The advertisments in question fulfilled these criteria, and looked nothing like BMJ articles. (Although they used a serifed font, it was several point sizes larger than we use in the print BMJ.) We have a horror of advertisements becoming hard to distinguish from research papers, and will maintain our already high levels of vigilance. Competing interests: I pass all advertisements that appear in the BMJ Group's publications.
Re: Re: Faux-papers and Trojan horses 3 July 2008
Geraint H Lewis, Harkness Fellow New York University, 10012, Peter M Hockey, Harvard Medical School Send response to journal: Re: Re: Re: Faux-papers and Trojan horses	Thank you for clarifying the BMJ's guidelines for advertorials. However we would question whether the "advertorial" does actually fulfil these criteria: * The pale blue box is <10mm from the side and bottom edges of the page (5mm x 7mm x 6mm) * Being in pale blue, the words “Advertisement Feature” are not prominently displayed. * By using the structure and headings of a research paper, the advertiser has undoubtedly intended to imitate the editorial style of the BMJ. * The two-column grid pattern in the advert is used in BMJ research papers. * The light blue tint in the advertorial is used extensively in the BMJ, thereby causing confusion with editorial matter. Competing interests: None declared
Re: Re: Re: Faux-papers and Trojan horses 7 July 2008
Tony Delamothe, Deputy editor BMA House, London WC1H 9JR Send response to journal: Re: Re: Re: Re: Faux-papers and Trojan horses	We're due another review of our advertising guidelines, and we'll take your very useful comments into account. Thank you. Competing interests: I pass all the ads for the BMJ Group
Re: Re: Re: Re: Faux-papers and Trojan horses 9 February 2009
Geraint H. Lewis, Specialist Registrar London, N1 Send response to journal: Re: Re: Re: Re: Re: Faux-papers and Trojan horses	I was disappointed that the BMJ chose to allow another "advertorial" for Gaviscon Advance to be circulated [Insert to BMJ, 7 February 2009]. The insert is, for all intents and purposes, an advert for Gaviscon Advance, but it is written and formatted in such a way that a casual reader might mistake it for an article similar to a BMJ "Clinical Review". I do not believe that the words, "supported by an educational grant from Reckitt Benckiser" are sufficiently prominent in this advertorial. They appear only once on the front page and are written in a relatively small and light font. Furthermore, I do not believe that this statement accurately reflects the nature of the company’s involvement in this advert. Given the similarity of the layout, font and style of the insert to the BMJ, I believe that the journal should have insisted that the words "Advertising Feature" be printed prominently at the top of every page of the supplement in order to avoid misleading readers. Competing interests: None declared