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Editor's Choice Editor's choice

Tooth and nail

BMJ 2007; 335 doi: (Published 04 October 2007) Cite this as: BMJ 2007;335:0
  1. Fiona Godlee, editor
  1. fgodlee{at}

If you're interested in what BMJ editors do when they are out and about, there's a new blog on ( It gives a flavour of some of the conferences we've been at and some of the people we've met: the eponymous Dr Kawasaki for one, UK public health grandee Rod Griffiths for another. I met Rod at a conference in Athens and we got talking about fluoride. No one in their right mind would get involved in the debate about water fluoridation, he said. It's a minefield. But this week we do get involved, and against his better judgment, so does Rod.

In the Analysis section (doi: 10.1136/bmj.39318.562951.BE), KK Cheng, Iain Chalmers, and Trevor Sheldon summarise the problems that bedevil reasoned discussion on whether fluoride should be added to water supplies. Highly polarised disputes are fuelled by misuse of what little evidence there is, and the Department of Health is not innocent of this, they say. It commissioned a systematic review, to which two of the authors contributed but then, in Cheng and colleagues' view, misrepresented the findings in fluoride's favour.

Objective though they strive to be, my reading is that Cheng and colleagues come down against fluoridation because of uncertainty about its safety, questions of autonomy, and because there are other ways of preventing caries. Meanwhile, at my invitation Rod Griffiths tells us how, as regional director for public health, he took on an already fluoridated water supply and consistently defended it because he saw no evidence of harm and some of benefit (doi: 10.1136/bmj.39356.470694.59). Cheng and colleagues want more and better research on fluoride's effects. Griffiths wants research into why people get so worked up about it all.

Evidence on fluoride may be lacking, but there's a growing body of evidence and experience on the effects (largely adverse) of direct to consumer advertising. Some of this was outlined in the BMJ two years ago (BMJ 2005;330:5-6, doi: 10.1136/bmj.330.7481.5); more comes in a stark warning this week from New Zealand. Les Toop and Dee Mangin explain that, in the absence of legislation to prevent it, direct to consumer advertising has taken hold. Having opened Pandora's box, New Zealand's government now seems unable to close it (doi: 10.1136/bmj.39346.525764.AD).

It's obvious why industry wants direct to consumer advertising: it's particularly effective at driving up prescription of expensive new drugs. What is not obvious is why the European Commission has allowed this question back on the table after its plans to relax the rules were voted out in 2002. The commission has now set up a new body, the Pharmaceutical Forum (, which is dominated by industry groups. Its proposal is to require objective rather than independent information for patients—but who will judge objectivity?

Drug information for patients may be woefully inadequate across Europe. But as Nicola Magrini and Maria Font said a few weeks ago (BMJ 2007;335:526, doi: 10.1136/bmj.39310.506308.AD), this should be a spur for improving access to unbiased information. We must not allow industry to fill the information gap with advertising by another name.

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