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No one can fail to notice the adverts in medical journals but are they really necessary? Richard Smith maintains they are essential to editorial independence, whereas Gareth Williams argues that they undermine a journal's integrity
The central argument for carrying advertising in medical journals is independence. Ironically, the main argument against may also be independence, but you can place greater trust in a journal that carries advertising than one that does not.
Independence is a journal's most precious asset, and independence means financial independence. “He who pays the piper calls the tune.” So to be able to play multiple tunes a journal needs multiple sources of income—and drug advertising is one of the most important and profitable. The beauty of drug advertising is that there are many companies who want to advertise in a journal that has a wide circulation. This means that none of them alone has the power to influence the journal.
Advertisers may huff and puff in response to articles that upset them, and they may for a while take away their advertising. But the journal doesn't depend on any one advertiser—and so can ignore the protests. Furthermore, the multiple advertisers keep a close eye on each other. If an advertiser breaks any of the many codes that regulate them, the first protest is often from a competitor.
But what about the joint power of the drug companies? Can't they together influence the journal? Again, it's back to money. If the sole source of income for a publication is advertising, then it may lose its independence. The dozens of glossy publications that drop through my door at home promote only local housing, restaurants, and amenities—because they are paid for entirely by estate agents.
Medical newspapers rather than journals are vulnerable in this way because they are funded mostly by drug advertising. The job of the editor is to keep the adverts apart, and any nonsense will suffice. Furthermore, these editors must be careful not to upset their readers. They tend to play to the lowest common denominator to keep eyeballs flicking across their pages.
In contrast, major journals like the BMJ have multiple sources of income—subscriptions, classified advertising, non-pharmaceutical advertising, reprints, and sales of articles to other publications. These multiple sources bring independence from each, but at least one is, I believe, much more pernicious than advertising—and that is reprints (sales of large numbers of copies of individual articles).
Drug companies may spend upwards of a million dollars to purchase reprints to give to doctors—as was the case with the much criticised VIGOR trial in the New England Journal of Medicine1 2 3—and the profit margin is likely to be around 70%. So by publishing such a trial a journal may add $700000 (£350000; €520000) straight to its bottom line. Editors know the trials that will attract such profits, and the conflict of interest is huge. And for some journals reprints are the largest source of income or profit. As I've argued elsewhere, the threat to independence from reprint sales is far more worrying than the threat from advertising.4 Furthermore, the major journals operate a “Chinese wall” between editors and the staff who sell advertising space—so that the sales staff have no idea what articles will be in a particular issue of the journal. Reprint sales, however, occur after publication.
Advertising is there for all to see and easy to police. Its influence isn't hidden. We are all used to being bombarded with advertising, and we are conditioned to discount it. I'm not arguing that it has no influence, but advertising in a journal will have only a small influence on the average doctor. He or she is bombarded with messages from drug companies—through drug representatives, advertising in free newspapers, studies in medical journals, direct mail, and “education” funded by the industry.
If advertisements in medical journals were the only way that drug companies could influence doctors, then the question of banning drug advertising would be much more serious. As it is, the downside would be much worse than the upside.
If advertising were banned, publishers of journals would have to find other sources of income. Publishing more drug company sponsored studies in order to boost reprint sales would be deeply damaging. If subscriptions were raised, many doctors would simply switch to what is free—and, as I argued above, much more likely to be influenced by drug companies. (All the evidence shows that given a choice between having a publication funded by advertising or paying for it themselves almost all doctors will accept the advertising—which is perhaps a killer argument.) Or, for open access journals like the BMJ, it might mean putting the research articles on journal websites behind access controls—something far worse in my mind than carrying advertising.
A ban on advertising might also mean financial dependence on the owners of journals—and this is by far the greatest threat to independence. Journal owners have got rid of the editors of JAMA, the New England Journal of Medicine, the Canadian Medical Association Journal, the Annals of Internal Medicine, the Irish Medical Journal, and others because they didn't like what they published or how they behaved.5
The BMJ has not yet had this experience, and one of the most important reasons is that money flows from the BMJ to the BMA. Not one penny of the subscription that members pay to the BMA reaches the BMJ. The journal funds itself, and drug advertising is an important source of revenue. If the BMA had to support the BMJ financially, my bet is that it would be much more bothered about anything that upset members (and there are—and should be—many such pieces).
My advice to readers is to flip over the adverts in the journal, which you probably do anyway, and enjoy the independence that they bring.
Competing interests: RS was editor of the BMJ and chief executive of the BMJ Publishing Group. His pension from the BMA (if he lives that long) will be funded in part by income from drug advertising. He is on the board of the Public Library of Science, a position for which he is not paid.