This study evaluated the relationship between the receipt by authors of payment from industry for speaking or consulting and authorship of articles considered to be scientifically in error or promotional in tone. We identified an association of review articles promoting the use of hormone therapy with authors with declared financial conflicts of interest. Scientific accuracy did not appear to be affected by author conflicts of interest.
The effect of industry funding on results in clinical trials 
, meta-analyses 
, clinical practice guidelines 
, and pay-for-performance quality measures 
has been well documented. Two publications have documented scientifically unsupportable statements on the risks and benefits of menopausal hormone therapy in the medical literature 
; many of these statements appeared in reviews, commentaries, editorials, and letters.
We assessed scientific accuracy based on whether or not two findings of the WHI were accurately reported: (1) There is no proven cardioprotective effect of estrogen-progestin therapy in menopausal women or in ten-year age subgroups of menopausal women, and (2) breast cancer is diagnosed more frequently in menopausal women receiving estrogen-progestin therapy 
. Promotional tone was evaluated without formal criteria, but the readers were asked to identify elements of the articles that conveyed a promotional tone. Readers evaluated articles masked as to the identity or affiliations of the authors. Prior to discussion, there was substantial agreement among the individual readers for promotional tone, and moderate agreement on scientific accuracy. After discussion, but prior to unmasking of author identities, there was consensus on both measures for all but two of the 50 papers evaluated.
We found that articles with a promotional tone were more likely to have been written by authors who had disclosed financial conflicts of interest than by authors without such disclosures. These conflicts were determined through publicly available declarations of conflicts of interest and may not be accurate or complete. It is possible, for example, that authors whom we identified as having no potential conflicts had undeclared conflicts or developed conflicts after the period we examined. One author, Nanette Wenger, for whom we identified no potential conflicts with hormone manufacturers during our study, later declared potential conflicts 
Our sample size of ten authors was small, although the authors assessed had written one out of five of the articles identified in our search. The prevalence of financial conflicts among authors in general is unknown, and our findings may not reflect the universe of authors. It is possible that an assessment that included less prolific authors would come to a different conclusion.
Almost all articles were evaluated as scientifically accurate regarding the effect of hormones on breast cancer diagnosis and cardiovascular risk, but readers found phrasing that minimized the risk of breast cancer or seemed to encourage reliance upon animal studies, observational studies, or expert recommendations rather than on randomized controlled trials. Our results support an in-depth interview study that found that physicians at two health plans commonly believed that WHI “was not applicable to the full range of patients seen in clinical practice” and “created uncertainty about the risks and benefits of HT” 
Our results suggest that authors who have received payments from industry convey more enthusiasm about the industry's products than do authors who have not declared that they received such payments. These results support the findings of a study that examined conflicts of interest in reviews (among other publications) and found that articles by authors with potential financial conflicts of interest were more likely to support the use of a specific class of drug therapy 
. The question of whether positive feelings about hormone therapy preceded payments from industry and were perhaps a basis for selection of these physicians as speakers and consultants or whether selection as a speaker or consultant led to more positive feelings about hormone therapy is an issue that should be explored in further research.
Our findings also support an analysis by Tatsioni and colleagues of “partisan editorializing articles on HRT” in the Thomson ISI database by five editorialists who had written at least 12 commentaries in medical journals between 2002 and 2008 
. All five had financial relationships with hormone manufacturers; these relationships were reported in only six of the 110 articles analyzed. Although there is no overlap in the author list between the Tatsioni analysis and ours, Tatsioni and colleagues identified similar themes, noting that common arguments included “HRT is effective for menopausal and related symptoms”; “Discussion of preclinical data that showed favorable effects for HRT”; “Statements challenging/criticizing unfavorable studies” (especially against the WHI and the Million Women Study); and “Statements that HRT may decrease life-threatening and other serious outcomes.” Additionally, Tatsioni et al. note that text was sometimes repeated verbatim in several articles; examples are provided in their online supplemental materials 
A scientist who consults for the pharmaceutical industry has described the process by which companies formulate key marketing messages into a product narrative to affect the discourse of medicine and ultimately medical knowledge 
. Although promotional linguistic and rhetorical strategies have been identified in television commercials for prescription drugs 
, there is a dearth of academic articles on the use of rhetoric and persuasion in medical journal articles. To our knowledge, the study by Tatsioni et al. and our study are the first to attempt to assess tone in review articles published in medical journals.
The extent of text reuse we identified was surprising. Tatsioni et al. documented different examples of text repeated verbatim in articles on menopausal hormone therapy, raising the question of how many more articles in the medical literature contain previously published passages. An editorial in The Lancet
noted that text recycling in review material could be viewed as “less of a crime” than “self-plagiarism” of original research, but that the practice “constitutes intellectual laziness at best” and is unacceptable 
The methodology used to evaluate promotional tone for this study has not been previously validated. Our evaluators were not physicians and it is possible that the use of physician evaluators would have yielded different results.
It is possible that the authors for whom no conflicts of interest were found actually did have conflicts of interest, either because we failed to identify a conflict or because a conflict was not disclosed. Misclassification of conflicted authors would be expected to bias the study results toward the null and is unlikely to be responsible for the difference in tone that we identified.
We cannot be certain that the ten authors we evaluated were representative of the universe of authors writing review articles on hormone therapy during the study period. We selected these authors because they were responsible for 20% of the relevant literature during the time period, but a study of authors with fewer publications during the period may have revealed different results. We also did not assess possible conflicts of interest of coauthors or the contribution these coauthors may have made to the accuracy or tone of the articles we assessed.
The assessment of multiple articles by each author may introduce an overcounting problem in the statistical analysis inasmuch as each author's perspective might be expected to stay the same. However, as can be seen in , about a quarter of articles by authors with potential financial conflicts of interest were deemed nonpromotional, and about a quarter of articles by those without potential financial conflicts of interest were deemed promotional.
Documents recently disclosed in litigation against manufacturers of hormone therapy revealed that dozens of articles ghostwritten by industry were published in the medical literature 
. The names of two of the authors whose work we assessed, Rogerio Lobo and Leon Speroff, were on the bylines of some of the reportedly ghostwritten articles 
. We could not determine whether or not any of the articles assessed in our study were ghostwritten.
Our study found that narrative review articles on hormone therapy may provide accurate statements about the risks of a therapy while simultaneously providing positive impressions of that therapy for uses unsupported by evidence. There may be a connection between industry funding for research, speaking, or consulting and the publication of promotional pieces on menopausal hormone therapy. Health care providers should exercise caution if they choose to read such articles. We believe that medical journals should follow the International Committee of Medical Journal Editors Uniform Requirements for Manuscripts (http://www.icmje.org/urm_main.html
), which require that all authors submit signed statements of their participation in authorship and full disclosure of any conflicts of interest. In order to prevent the bloating of journals with pages of “recycled” text, medical journals should consider using antiplagiarism software.