Intended for healthcare professionals

BMJ: 322 (7294)

BMJ 2015; 322 doi: (Published 19 January 2015) Cite this as: BMJ 2015;322:1073

Tobacco companies are a source of evil, whereas pharmaceutical companies are a source of good

John Dowden's rapid response that seems to see similarities between
the tobacco and pharmaceutical industries makes no sense to me. They are
world's apart, not least in that tobacco companies are a source of evil
and pharmaceutical companies a source for good.

The companies may be similar in that they tend to be large
multinational companies, but so what? Hitler and John Dowden are (or were
in one case) both human beings. I'm not against private industry and
profit, and pharmaceutical companies are perhaps the best example of why
profit matters. Well over 90% of effective drugs have been developed by
the pharmaceutical industry, and even the few not discovered by the
industry tend to be manufactured in a pure form by it.

Yes, the industry has behaved unethically at times, but so have the
Australian and British governments, the BMJ, most (probably all) medical
institutions, and most human beings. John Dowden may be an exception, but
I doubt it. I certainly am not.

The point about the tobacco industry is that it has behaved
unethically systematically and consistently. This is not true of the
pharmaceutical industry, and--I think I could make the case--many examples
of unethical interactions between the industry and doctors are more the
fault of doctors than the industry.

Those who read both the BMJ and the Student BMJ were amused that in
the same week that I was on my high horse and resigning from Nottingham
because it took money from the tobacco industry I was defending
pharmaceutical advertising in the Student BMJ. (Rhona MacDonald argued
against.) I can't unfortunately give you the URL of the article because it
isn't yet posted, but I'm appending an unedited version of the
article to this rapid response.

Finally, it was coincidence that my resignation letter was
accompanied by an advertisement for a smoking cessation product. But I'd
like to see many more advertisements on bmj.com so that we can keep it
free to those who access the site.

Richard Smith
Editor, BMJ

A retired hippie (now editor of the BMJ) makes the case for drug
advertising

This is the piece I've dreaded writing. I grew old the day John
Lennon died. Today I grow very old. I'm 49, as ancient in your minds as
Winston Churchill, Spitfire planes, and spitting in the street. But if I'm
old enough to preach to you about the need to include drug advertising in
the BMJ I must be as old as them. I want to make my case--in part--by
telling you my story. I started from where you may be now. It is the fate
of revolutionaries to turn into the people they despise, and I'm the
living proof--but I still think I'm right.

While at school in South London I was a communist. I sometimes
imagine myself explaining what that means to my grandchildren (which, as
far as I know, I don't yet have). It will seem as strange as having
believed in the phlogiston theory. I do have the excuse that one reason I
joined the communists was to meet girls and even kiss them (that's all we
did before sexual intercourse was famously invented in 1963, even later in
South London). But I did care passionately about world poverty and
injustice, racism, and colonialism. Like everybody else I knew, I read
Regis Debray's notes on guerilla warfare, learning how to keep my gun dry
in the jungle. (For the geographically challenged I should explain that
South London has urban but no green jungle.) I believed that big business--as symbolised par excellence by pharmaceutical companies--were the root of
most, if not all, evil.

At medical school I swept into political power on a slogan that would
have made Peter Mandelson envious: "Don't be thick, vote for Dick." I sat
on committees with other rebellious youths like Gordon Brown, illustrating
that this "growing old thing" affects the best and the brightest. I edited
Synapse the medical school magazine--boldy renaming it Prolapse--and earned
a tiny place in its history be being the first editor to print the word
"fuck."

Later at the BMJ I wrote articles on alcohol policy and asked a
leader of the advertising industry to "give me one reason why all
advertising shouldn't be banned." I also wrote on unemployment and health
and tried my hand at some economics, assuming that the government could if
it wanted fix unemployment.

The point I'm making is that I understand something of the position
of those who think that the Student BMJ should not carry advertising from
the pharmaceutical industry. The adverts come from business monsters who
are corrupt and the source of much of the injustice in the world. The
advertisements cannot be believed and distort knowledge and prescribing
patters--and they simply aren't necessary. So ban them.

The most dramatic moment in my transition to a different way of
thinking about business and economics came in November 1989. I was doing
the Sloan programme ("an MBA for the middle-aged") at the Stanford
Graduate School of Business in California. I was upstairs in our student
house doing my homework on microeconomics when my wife called me. I went
downstairs to see television pictures of the Berlin Wall being pulled down.

I learnt in economics that there are two broad options for economies--planned and market. The collapse of the planned economies of eastern
Europe ended any serious belief in planned economies. Markets must be
regulated and create their own problems, but they are essentially the only
option for running economies. The "third way" is nothing qualitatively
different: it's simply a form of a regulated market economy.

Pharmaceutical companies illustrate the power of market economies.
It's virtually impossible to think of an important drug that wasn't
developed by the industry, and even those that go back a long way--such as
digitalis---are manufactured by the industry in a pure form so that they can
be used therapeutically. The profit motive has given doctors an array of
effective interventions that hardly existed before the 1950s.

And advertising is an important part of a market economy. It is
needed to promote competition and is essential for allowing new and
superior products to come through. It must be regulated, and it is--by
British and European legislation, by a code of practice committee, and by
the Advertising Standards Authority.

It's true that advertising tells only part of the story, but so do
most articles in newspapers and--it must be said--the BMJ. We might aspire
to complete objectivity but we never reach it. The beauty of advertising
is that everybody knows it's biased. My 10 year old daughter knows that,
and so do medical students. They have been bombarded by advertising all
their lives and will continue to be. They need to learn to interpret it,
and where better to learn than the Student BMJ? The websites of the BMJ
and Student BMJ contain many pieces on problems with advertising and
advice on how to deal with promotions from pharmaceutical companies.

So there could be a case for including advertising in the Student BMJ
even if we weren't paid for it--but of course we are. We can use that money
to underwrite some of the high costs of the journal and importantly buy
our editorial independence. Making a profit is the biggest single
guaranteee of editorial independence.

Perhaps the clinching argument for advertising comes courtesy of the
web. It has allowed publications to give readers the choice of receiving
material free with advertising or paying for it without advertising.

Surprise, surprise almost nobody pays.

Competing interests: No competing interests

28 May 2001
Richard Smith
Editor
BMJ