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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
There is no escape from them and their quaint little catchphrases: the woman with a toilet for a head (“It's always on my mind”), the blurred bloke on a beach (“A feeling says a thousand words”), the kayak in the waterfall (“The big drop”). Like it or not, drug advertisements have embedded themselves deep in the fabric of medical journals. You can almost understand why: they help drug companies to recoup the huge costs of developing new drugs while providing medical journals with a useful income stream. And why not? Adverts may be an irritating distraction, but surely they are harmless—after all, no doctor could be gullible enough to prescribe a drug because of a picture of a toilet-headed woman and a puerile lavatorial pun.
I believe, however, that drug advertising is no more acceptable than a drug representative's foot around the doctor's door, and that it has no place in medical journals.
Drug advertisements exist only to sell a product and inevitably, like all marketing copy, are biased. For many new drugs, an honest appraisal is that they seem no better than existing alternatives, are grossly overpriced, and may turn out to have dodgy side effects. A clear statement of those facts is unlikely to send sales into the stratosphere. Hence the hype, which in many cases far outstrips the hard evidence. All too often, reading the fine print will show that the wonder drug's credentials are worryingly threadbare. The big headline claims may rest only on a poster presentation, an article in a journal supplement paid for by the company, the company's summary of product characteristics, or the enigmatic “data on file.” The poverty of evidence makes a striking contrast with the obvious wealth of the advertising campaign and raises some important questions. Do they have something to hide—or perhaps nothing to show? If this is the best evidence they can roll out, is the drug really ready to go into patients?
Predictably, drug advertisements project the positive, while the negative gets little coverage. You never see a full-page colour spread announcing the demise of a wonder drug that didn't turn out to be so wonderful after all; instead, bad news tends to creep out in a “Dear prescriber” letter that follows the discreet withdrawal of the discredited product. The story of the ill-fated troglitazone, which was withdrawn after it was found to cause liver failure, is illuminating in this regard.1
Doctors, as the targets of the advertising, are a key part of the problem, because they help to perpetuate the culture that makes drug advertising both acceptable and profitable. Doctors should prescribe a drug only because they have a sound understanding of its indication, benefits, shortcomings, and value for money; all that information is readily available in authoritative, balanced, and up to date publications such as the British National Formulary. Patients should not have to take a drug because their doctor's eye has been caught by an advertisement while leafing through a journal. Sadly, the fact that the toilet-headed woman and her associates still ply their trade can only mean that there are enough impressionable doctors out there to justify the companies' vast advertising budgets.
Medical journals, being the Trojan horse that brings drug advertisements into the doctor's home and workplace, also need to examine their collective conscience. They have to survive in a competitive market but exist for a higher purpose that requires them to be totally objective and untainted by conflicts of financial interest; unfortunately, some have found it difficult to live up to those noble ideals.2 Editors set high standards for their publications, and contributors who fall short on evidence, honesty, clarity of writing, and professionalism can expect to face the full wrath of peer review. How peculiar that the journals feel able to relax their principles and print, alongside the research papers, material that would not look out of place in a glossy tabloid and that often raises two fingers to evidence based medicine.
So what should be done? As a minimum, drug advertisements should be vetted independently and much more stringently than at present and barred from publication if they make inflated or substantiated claims. Ideally, though, drug advertising should be banned completely from medical journals. This would be a big financial hit on some journals—some of which raise 20-30% of their income from advertising2—but comes at a time when doctors, institutions, and patients are under increasing pressure to re-examine the morality of their links with the drug industry.3 4 5 6 7 It would be fitting for the journals, especially those that hold the respect of the profession, to lead the march to the moral high ground.
Fifty years ago, the American Journal of Medicine regularly ran advertisements for Camel cigarettes, improbably peddled by Pasteur and other big names from medical history. It took many years for the ethical arguments to outweigh the lucrative, but eventually they won and tobacco advertising in medical journals—which would be unthinkable today—became nothing more than an embarrassing memory. It's high time that drug advertising went the same way.
Competing interests: GW has received numerous research grants and honorariums for advisory work with several drug companies active in diabetes and obesity.