Emergency Medicine Australasia (EMA) has taken a stand against drug company advertising in medical journals by making a decision to no longer publish such advertisements in the EMA journal. At the Editorial Meeting in Canberra last November 2010, and with the support of the Councils of the respective owners of the journal, the ACEM and the Australasian Society for Emergency Medicine, the Editors and Editorial Board of EMA unanimously upheld a motion to no longer accept drug advertisements.
This followed extensive debate on the growing evidence about the detrimental effects of the drug industry in medicine.1 Among the issues discussed were that the industry, one of the most profitable in the world, distorts research findings, such that drug company sponsored research is approximately four times as likely to be favourable to its product than independently funded research;2,3 authors of company-sponsored research are far more likely to recommend a company's drug than independent researchers,4 and researchers with industry connections are more likely to publish data favourable to a company's product than those without;5 selective reporting of results by industry is likely to inflate our views of the efficacy of company products;6 the drug industry has been shown to engage in dubious and unethical publishing practices, including guest and ghost authorship, and to apply pressure to academics to withhold negative findings;7 and the industry spends enormous amounts of money on advertising,8 which has been shown to change the prescribing practices of doctors,9 increasing sales in a dose-related manner to the volume of advertising.10
Meanwhile doctors (and indeed journal editors) generally deny that they are influenced,11 yet clearly they are. The editor of the Australian and New Zealand Journal of Psychiatry reportedly said on an ABC Radio interview in 2002, when questioned about all the drug company advertisements in that journal, and in particular the glossy advertisement encasing the journal: ‘Our doctors are not stupid, and they will simply rip the wrap-around and dispose of it. . . . Nobody is gullible’.12 The authors who pointed this out were critical of the journal's policy, and suggested that it might compromise the editorial independence of the journal, a point unfortunately disputed by the editor in reply.
Drug companies value drug advertising in medical journals because it works. It is regarded as highly effective by pharmaceutical marketers, generating at least US$2-5 in revenue per dollar spent, with returns growing in the long term.13 But this works both ways. Medical journals have equally played a big a part in the problem. Large medical journals keenly solicit drug advertisements as evidenced by adverts they themselves place in publications such as Medical Marketing and Media (MMR), a publication aimed at drug companies. The New England Journal of Medicine (NEJM) for example, in the November 2003 edition of MMR highlighted its value to the drug industry in these terms: ‘Place your ad in the NEJM and make our relationship with the medical community yours’. Some large journals even tout their ability to reach particular target groups of high-prescribing physicians such as cardiologists and oncologists through flyers and inserts placed in subsets of their journal mail-outs. The NEJM has, for example, stated that ‘You can run your Cancer or HIV/AIDS related product to a special list of high-prescribing physicians, including key oncology and infectious disease doctors’.13
Marketing of drugs by the pharmaceutical industry, whose prime aim is to bias readers towards prescribing a particular product, is fundamentally at odds with the mission of medical journals. This mission is to provide evidence-based, objective data and to eliminate bias where possible, so that doctors and other health professionals can make sound judgements based on the best available evidence, when prescribing for their patients. The duty of drug companies is to make profits for their shareholders, which is in conflict with the ethical duty of doctors to provide sound, unbiased advice for their patients. Doctors have a fiduciary relationship with their patients, and have an obligation to protect them from those who would use that relationship for profit. As former editor of the NEJM, Dr Jerome Kassirer said ‘It shouldn't have to be patients' responsibilities to protect themselves against the medical profession’.14
We in the specialty of Emergency Medicine are ideally placed to take a lead on this issue, as unlike many other specialty groups such as cardiologists and oncologists, we are not particularly targeted by the drug companies, as we prescribe in the short- rather than the long-term. Being in this fortunate position and remaining somewhat free of drug company influence affords us a privileged and objective view of the problem. Accordingly, at EMA, we have decided to take a stand. EMA will now no longer accept any pharmaceutical drug advertising. However, other organizations and medical journals also need to use this as an opportunity to more clearly articulate a viewpoint.
The journal Academic Emergency Medicine recently debated the same issue. Chisolm and colleagues argued that there is no need to include drug company advertising in medical journals.15 They contended that their mission is ‘To improve patient care by advancing research and education in emergency medicine’ and that accepting pharmaceutical advertising would directly conflict with that mission. Similarly, at EMA our mission is ‘To fairly publish valid emergency medicine related scientific information . . .’. It is clear that publishing drug company advertisements directly violates this mission, as these advertisements are not valid emergency medicine-related scientific information.
Claims made about particular pharmaceuticals in advertisements placed in medical journals are often not supported by evidence that is of either reasonable quality or independent.16,17 Also drug companies publish information about the economic benefits of prescribing their products, again with poor quality supporting evidence.18 Moreover, there is evidence that drug company advertising can threaten the editorial independence of journals. Fugh-Bergman et al. cite several instances of conflict between journal editorial decisions and drug company advertising, which on one occasion in 1993 ultimately led to the resignation of the co-editors of Annals of Internal Medicine.13
Prominent past and present journal editors have raised serious concerns about the influence of the drug industry in medicine.1 These include Richard Horton (Lancet) who says: ‘Journals have devolved into information laundering operations for the pharmaceutical industry’; Richard Smith (British Medical Journal) who describes medical journals as ‘an extension of the marketing arm of pharmaceutical companies’; and Marcia Angell (NEJM) who describes the pharmaceutical industry as: ‘Primarily a marketing machine to sell drugs of dubious benefit . . .’. Unfortunately, these views have not been translated into action; all three journals not only accept drug company advertising, but keenly solicit it.
Only a few journals, such as PLoS Medicine, have actively taken a stand against drug advertising by pharmaceutical companies. This is a difficult decision as drug company advertising makes good money not only for the drug companies, but also for the journal, and any sponsoring physician organization that publishes the journal, that might make up 10% or more of their total annual revenue.13 This represents a significant income stream for a journal, upon which it might come to rely.
Doctors need to stop being used as agents of the drug industry in the complex financial arrangement between drug companies and consumers. It is time to show leadership and make a stand, and medical journals have a critical role to play in this. At EMA we have therefore drawn a line in the sand, and have stopped all drug advertising forthwith. We invite other journals to show their support and follow suit, by declaring their hand and doing the same.