by Adriane Fugh-Berman, Karen Alladin, Jarva Chow

This is a condensed version of a longer article. The full article can be accessed at medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371/journal.pmed.0030130

Peer-reviewed medical journals are generally considered to be a source of unbiased and reliable information about drugs. But most medical journals contain advertisements that are intended to increase or maintain market share for targeted products. Pharmaceutical companies value print advertisements because they increase sales and, while ads in consumer magazines reach potential purchasers individually, an ad viewed by one physician could result in dozens or hundreds of drug purchases.

The authors examined the advertising policies of nine medical journals that receive the most advertising revenue: the New England Journal of Medicine (NEJM), the Journal of the American Medical Association (JAMA), the Annals of Internal Medicine (Annals), PLoS Medicine (the Public Library of Science online journal), American Family Physician, the Lancet, the BMJ (British Medical Journal), the Canadian Medical Association Journal, and the Medical Journal of Australia.

More than 95% of advertisements in these journals were for pharmaceutical products. The advertisements that were not for drugs were for health-related products, including medical books, medical web sites, and compu-ter products. Medical journals offer a variety of ways of targeting particular prescribers with different ads often sent to different physicians. This is made possible by "insert" advertisements, which are attached to the journal after production. This enables advertisers to target readers grouped by specialty, region, or most importantly, by prescribing proclivities. Physicians who write the most prescriptions receive the most advertisements.

Many medical journals rely on revenue from prescription drug advertisements. The argument has been made that advertisements provide doctors with valuable information about drugs and diseases. But are drug advertisements really educational? The primary purpose of pharmaceutical advertisements is to increase the sales of new products or maintain sales of established products. There are more than 10,000 drugs in the US market, but more than half of advertising dollars are spent on the 50 best-selling drugs — with an emphasis on new drugs.

New drugs are not always superior to old drugs, and best sellers are not always better than their competitors. If medical journals accepted only advertisements for drugs proven superior in comparative trials, the argument that drug advertisements are educational could be rationalized. No journal, however, requires demonstration of product superiority as a condition for advertising. The "advertising-as-education" argument actually reached the US Supreme Court where it was decided that "... the advertising [ ] does not contribute importantly to the journal's educational purposes."

Drug advertisements are not public service announcements. A review of 109 full-page pharmaceutical advertisements concluded that 44% would lead to improper prescribing if a physician relied only on the information presented in the advertisement. Another study found that 126 of 438 advertisements with medical claims contained no medical references. Even when references are cited, the studies are more likely to be company-sponsored.

Nor are advertisements the only source of revenue for most medical journals. Pharmaceutical companies are the primary purchaser of reprints and may buy thousands of reprints if they are advantageous to the drugs that they manufacture. Additionally, drug companies "sponsor" subscriptions provided free to targeted populations.

Journal advertisements generate profits not only for pharmaceutical companies and medical journals, but also for the physician organizations that publish the journals. In 1996, five of six physician organizations raised 10% or more of their total annual revenue from pharmaceutical company advertising in affiliated medical journals.

In consumer magazines, article content often caters to, or is ordered by, advertisers, and publishing articles that displease advertisers can financially jeopardize the publication. Medical journals are similarly prone to leash-yanking by advertisers. A 1995 survey of journal editors found that 12% noted conflicts between advertisers' wishes and editorial decisions, and 21% reported that they had no control over advertisements. In 1992, a study in Annals criticized the accuracy of advertisements in journals. Several large pharmaceutical companies subsequently withdrew advertising in that journal.

Dependence on single-industry drug advertising endangers the independence of medical journals. It can be financially disastrous for a journal that displeases its corporate funders and it may even risk closure if it can't attract sufficient revenue.

Accepting advertising for consumer goods removes the conflict of interest inherent in pharmaceutical advertising, but more importantly may free editors from the threat of lost revenue. It is disturbing that medical journals appear to have exclusive, largely undeclared arrangements with pharmaceutical companies.

Another option is to eschew journal advertising altogether. Some journals refuse to advertise drugs or devices, depending instead on other sources of income. The non-profit journal PLoS Medicine, for example, uses a business model that includes support from foundations, from institutional memberships, and from research funders who are asked to pay a publication charge for accepted research papers.

In conclusion, clinicians rely on medical journals for scholarly articles and the latest information on drugs and devices. Advertisements in these journals are unreliable sources of information, since they "educate" physicians to prescribe the newest, most expensive drugs (which may not be superior to existing, less expensive alternatives). The scholarly nature of journals confers credibility on both articles and advertisements within their pages. By exclusively featuring advertisements for drugs and devices, medical journals implicitly endorse corporate promotion of the most profitable products. Medical journals should not accept advertisements from pharmaceutical companies, medical device companies, or other industries "relevant to medicine."
(PLoS Medicine 6(3) June 2006)