Should medical journals carry drug advertising? Yes
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39259.472998.AD (Published 12 July 2007) Cite this as: BMJ 2007;335:74
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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_....
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests