Commentary: Advertising adversitiesBMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7106.460 (Published 23 August 1997) Cite this as: BMJ 1997;315:460
Misleading drug advertising in medical journals has been a thorny issue for over 100 years1 in many countries.2 3 4 In India, dealing with the pharmaceutical industry and its promotional activities presents some distinctive challenges. Firstly, there is no legislation or statutory organisation such as the Food and Drug Administration in the United States that regulates the accuracy of advertisements for prescription drugs. Secondly, there are no effective watchdog groups such as the Pharmaceutical Advertising Advisory Board in Canada3 or the Medical Lobby for Appropriate Marketing in Australia.4 Thirdly, ayurvedic and other non-allopathic medications are widely used and there are few scientific data on these drugs, though they are ubiquitously advertised.
Most medical journals run on lean budgets, and advertising revenue in the early years of the Indian edition of the BMJ provided financial stability. It soon became apparent, however, that some advertisements lacked information and scientific accuracy. Several contained excessive or vague claims—“first choice empiric therapy,” “assures control,” “superior to other parenteral therapies”—and did not provide substantiating references. Others omitted to mention side effects. The need for an editorial policy and evaluatory mechanisms was apparent.
In 1994 all existing advertisers were sent copies of the editorial policy of the Indian edition as well as that of the parent edition of the BMJ, the World Health Organisation's monograph Ethical criteria for medicinal drug promotion, and a checklist against which all future advertisements would be screened (see box). The covering letter asked the drug company to ensure that future advertisements complied with the policy. An editorial committee consisting of four professors was set up to screen each month the 20-30 advertisements submitted. Advertisements were either rejected, sent back for modification, or accepted. In a typical month about three quarters of the advertisements are accepted; the remainder are returned for modification with specific requests. Fortunately most of our advertisers complied, though some grumbled that other journals were not as strict and some sought to defend their data. Six advertisers (out of 45) stopped sending advertisements. We estimate that overall about 5% of advertising revenue has been lost. The system is not perfect; the editorial committee members sometimes disagree and the degree of strictness varies. Advertisements for ayurvedic products continue to be published provided 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
Name and address of manufacturer
Are the claims appropriate?
Several medical journals have published articles on this topic and formulated editorial policies.5 6 7 8 The Annals of Internal Medicine found that 92% of their advertisements suggested lack of 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 constraints to medical advertising, the scope of misuse extends beyond journals to package inserts, pamphlets handed out by medical representatives, “scientific” newsletters published by drug companies, promotional videos, exhibits at medical conferences, and preprinted prescription pads and other complimentary items. The largesse of drug companies extends to sponsoring conferences, travel grants, and research awards and the recipients are inclined to be accommodating. A glance through scientific journals published in India reveals that all of them run more or less the same advertisements as the Indian edition of the BMJ.
One leading Indian editor said privately that the pharmaceutical industry was too powerful and he was not willing to join a futile campaign against them. This attitude may be widespread among editors. One author believes, on the basis of an unpublished study, “that few medical journals, including leading peer reviewed journals make any attempt to formally screen pharmaceuticals advertisements.”5 Some investigators argue that too much attention has been focused on advertisements that are never read.9 10 Others cite the expense of evaluating advertisements and the disincentive to a truly rigorous review because of the financial dependence on advertising revenue.5
Our experience has led us to conclude that, when not monitored, companies, even respected multinationals, will stretch the limits of scientific credibility when making claims about the efficacy of their drugs; but when we raise the issue and institute supervisory mechanisms most can be persuaded to bring their advertisements within the confines of scientific propriety.
The roles of editors and the drug companies are perhaps less critical than that of the reader. Doctors and medical students need to be educated to increase their ability to recognise misleading promotional activities, especially those disguised as research or medical education.