Advertising in medical journals: should current practices change?

Mapping conflict of interests: scoping review

OBJECTIVE

To identify all known ties between the medical product industry and the healthcare ecosystem.

DESIGN

Scoping review.

METHODS

From initial literature searches and expert input, a map was created to show the network of medical product industry ties across parties and activities in the healthcare ecosystem. Through a scoping review, the ties were then verified, cataloged, and characterized, with data abstracted on types of industry ties (financial, non-financial), applicable policies for conflict of interests, and publicly available data sources.

MAIN OUTCOME MEASURES

Presence and types of medical product industry ties to activities and parties, presence of policies for conflict of interests, and publicly available data.

RESULTS

A map derived through synthesis of 538 articles from 37 countries shows an extensive network of medical product industry ties to activities and parties in the healthcare ecosystem. Key activities include research, healthcare education, guideline development, formulary selection, and clinical care. Parties include non-profit entities, the healthcare profession, the market supply chain, and government. The medical product industry has direct ties to all parties and some activities through multiple pathways; direct ties extend through interrelationships among parties and activities. The most frequently identified parties were within the healthcare profession, with individual professionals described in 422 (78%) of the included studies. More than half (303, 56%) of the publications documented medical product industry ties to research, with clinical care (156, 29%), health professional education (145, 27%), guideline development (33, 6%), and formulary selection (8, 1%) appearing less often. Policies for conflict of interests exist for some financial and a few non-financial ties; publicly available data sources seldom describe or quantify these ties.

CONCLUSIONS

An extensive network of medical product industry ties to activities and parties exists in the healthcare ecosystem. Policies for conflict of interests and publicly available data are lacking, suggesting that enhanced oversight and transparency are needed to protect patient care from commercial influence and to ensure public trust.

Cross-sectional study of medical advertisements in a national general medical journal: evidence, cost, and safe use of advertised versus comparative drugs

Background

Healthcare professionals are exposed to advertisements for prescription drugs in medical journals. Such advertisements may increase prescriptions of new drugs at the expense of older treatments even when they have no added benefits, are more harmful, and are more expensive. The publication of medical advertisements therefore raises ethical questions related to editorial integrity.

Methods

We conducted a descriptive cross-sectional study of all medical advertisements published in the Journal of the Danish Medical Association in 2015. Drugs advertised 6 times or more were compared with older comparators: (1) comparative evidence of added benefit; (2) Defined Daily Dose cost; (3) regulatory safety announcements; and (4) completed and ongoing post-marketing studies 3 years after advertising.

Results

We found 158 medical advertisements for 35 prescription drugs published in 24 issues during 2015, with a median of 7 advertisements per issue (range 0 to 11). Four drug groups and 5 single drugs were advertised 6 times or more, for a total of 10 indications, and we made 14 comparisons with older treatments. We found: (1) ‘no added benefit’ in 4 (29%) of 14 comparisons, ‘uncertain benefits’ in 7 (50%), and ‘no evidence’ in 3 (21%) comparisons. In no comparison did we find evidence of ‘substantial added benefit’ for the new drug; (2) advertised drugs were 2 to 196 times (median 6) more expensive per Defined Daily Dose; (3) 11 safety announcements for five advertised drugs were issued compared to one announcement for one comparator drug; (4) 20 post-marketing studies (7 completed, 13 ongoing) were requested for the advertised drugs versus 10 studies (4 completed, 6 ongoing) for the comparator drugs, and 7 studies (2 completed, 5 ongoing) assessed both an advertised and a comparator drug at 3 year follow-up.

Conclusions and relevance

In this cross-sectional study of medical advertisements published in the Journal of the Danish Medical Association during 2015, the most advertised drugs did not have documented substantial added benefits over older treatments, whereas they were substantially more expensive. From January 2021, the Journal of the Danish Medical Association no longer publishes medical advertisements.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41073-021-00111-9.

Product advertisements in orthodontic journals: Are they evidence-based?

INTRODUCTION

Previous research has suggested orthodontic advertisements are poorly supported by evidence. The primary aim of this study was to identify the type and quality of evidence supporting advertisement claims in leading orthodontic journals.

METHODS

A cross-sectional study was undertaken to assess all advertisements published between January 2015 and December 2017 in 6 major orthodontic journals. Only advertisements implying superior product performance in clinical practice or patient care were selected for further evaluation. Study variables were collected using a prespecified data collection form. In the presence of a supporting citation, the reference article was obtained, and the quality was assessed in duplicate. Associations between advertisement variables and quality of evidence were explored using contingency tables (Fisher exact test).

RESULTS

A total of 1753 advertisements were identified. After the application of eligibility criteria, 124 were included in the final analysis. Advertisements promoting bracket systems predominated. Of these, 34.7% were supported by evidence, of which 10.5% (n = 13) included accessible references. Only 6 out of 13 studies involved orthodontic patients. Primarily expert opinion and observational study types were referenced. Less than 2% of advertisements were supported by high-value evidence. There was an association between the quality of evidence in advertisements and the product category (P = 0.003).

CONCLUSIONS

There is a lack of both references and high-value evidence cited in orthodontic manufacturers' advertisements. Without critical appraisal of references cited in advertisements, clinicians need to be cautious before implementing manufacturers' recommendations in clinical practice. Efforts should be made to ensure appropriate high-value evidence is cited in advertisements to support manufacturers' claims.

Off the Market: The Percentage of Products Available After Ten Years

Background:

We observed that medical devices advertised in journals are often no longer available 5 to 10 years after first being advertised. In this study, we quantified the percentage of products advertised from 2003 to 2008 in the Journal of Bone and Joint Surgery, American, which were still available 5 to 10 years after first being advertised.

Methods:

We created a database of 427 unique orthopaedic products advertised in the Journal of Bone and Joint Surgery. In 2013, we classified products into categories: available in advertised form, available in modified form, available under a different manufacturer, and available but temporarily recalled, discontinued voluntarily, or discontinued by forced recall.

Results:

A total of 13.8% of products were discontinued 5 to 10 years after being advertised. Three percent were discontinued through forced recall, and 10.8% were discontinued voluntarily. Of the products still available, 60.2% were in current form, 12.9% were modified, 11.9% were available under a different company, and 1.2% were available but were temporarily recalled.

Conclusion:

Five to 10 years after the initial advertisement, nearly 40% of products were not available in their original advertised form.

Are claims made in orthodontic journal advertisements evidence-supported?

OBJECTIVE

To examine the supporting evidence of advertisements published in six leading orthodontic journals.

MATERIALS AND METHODS

The 2012-2013 printed issues of American Journal of Orthodontics and Dentofacial Orthopedics, Australian Orthodontic Journal, Journal of Orthodontics, European Journal of Orthodontics, Journal of Clinical Orthodontics, and Journal of Orofacial Orthopedics were screened for advertisements implying superior performance compared with competitor products. Advertisements were classified according to type of product, availability, and currency of supporting references.

RESULTS

A total of 99 unique advertisements claiming clinical benefit or superiority were identified. The overwhelming majority of the identified advertisements promoted appliance products (62.6%), orthodontic materials (14.1%), and dental operatory equipment, including imaging systems (12.1%). Advertisements were found to provide references or not regardless of the product type. Half of the advertisements referred to at least one peer-reviewed publication, whereas unpublished studies were cited by 25% of the advertisements. Most of the referenced articles were published within the past 5 years.

CONCLUSIONS

The scientific background of advertisements in the orthodontic literature appears limited. While surveillance of journal advertising needs to be regulated, clinicians are urged to critically appraise the claims being made in orthodontic print advertisements by consulting the associated existing evidence.

Are the claims made in orthopaedic print advertisements valid?

PURPOSE

Advertisements are commonplace in orthopaedic journals and may influence the readership with claims of clinical and scientific fact. Since the last assessment of the claims made in orthopaedic print advertisements ten years ago, there have been legislative changes and media scrutiny which have shaped this practice. The purpose of this study is to re-evaluate these claims.

METHODS

Fifty claims from 50 advertisements were chosen randomly from six highly respected peer-reviewed orthopaedic journals (published July-December 2011). The evidence supporting each claim was assessed and validated by three orthopaedic surgeons. The assessors, blinded to product and company, rated the evidence and answered the following questions: Does the evidence as presented support the claim made in the advertisement and what is the quality of that evidence? Is the claim supported by enough evidence to influence your own clinical practice?

RESULTS

Twenty-eight claims cited evidence from published literature, four from public presentations, 11 from manufacturer "data held on file" and seven had no supporting evidence. Only 12 claims were considered to have high-quality evidence and only 11 were considered well supported. A strong correlation was seen between the quality of evidence and strength of support (Spearman r = 0.945, p < 0.0001). The average ICC between the assessors' ratings was strong (r = 0.85) giving validity to the results.

CONCLUSION

Orthopaedic surgeons must remain sceptical about the claims made in print advertisements. High-quality evidence is required by orthopaedic surgeons to influence clinical practice and this evidence should be sought by manufacturers wishing to market a successful product.

Gender policies and advertising and marketing practices that affect women's health

BACKGROUND

The three papers of this doctoral thesis are based on the social construction of reality through the analysis of communication relating to health issues. We have analysed the contents of parliamentary, institutional, and mass media to uncover whether their communications create, transmit, and perpetuate gender biases and/or stereotypes, which may have an impact on peoples' health, with a particular focus on women.

OBJECTIVE

To analyse decision making and the creation of gender awareness policies and actions affecting women's health: (1) political debates about abortion, (2) gender awareness communication campaigns and educational actions, and (3) pharmaceutical advertising strategies.

DESIGN

Quantitative and qualitative methods were employed, and the research included observational studies and systematic reviews. To apply a gender perspective, we used the level of gender observation proposed by S. Harding, which states that: (1) gender is the basis of social norms and (2) gender is one of the organisers of the social structure.

RESULTS

Sixty percentage of the bills concerning abortion introduced in the Spanish Parliament were initiated and led by pro-choice women's groups. Seventy-nine percent of institutional initiatives aimed at promoting equality awareness and were in the form of educational actions, while unconventional advertising accounted for 6 percent. Both initiatives focused on occupational equality, and very few actions addressed issues such as shared responsibility or public policy. With regard to pharmaceutical advertising, similar traditional male-female gender roles were used between 1975 and 2005.

CONCLUSIONS

Gender sensitivity continues to be essential in changing the established gender system in Spanish institutions, which has a direct and indirect impact on health. Greater participation of women in public policy and decision-making are critical for womens' health, such as the issue of abortion. The predominance of women as the target group of institutional gender awareness campaigns proves that the gender perspective still lacks the promotion of shared responsibilities between men and women. There is a need for institutions that act as 'policy watchdogs' to control the gender biases in mass media and pharmaceutical marketing as well as to ensure the proper implementation and maintenance of Spanish equality laws.

Misleading advertising for antidepressants in Sweden: a failure of pharmaceutical industry self-regulation

BACKGROUND

The alleged efficacy of pharmaceutical industry self-regulation has been used to repudiate increased government oversight over promotional activity. European politicians and industry have cited Sweden as an excellent example of self-regulation based on an ethical code. This paper considers antidepressant advertising in Sweden to uncover the strengths and weaknesses of self-regulation.

METHODOLOGY

We analyzed all antidepressant advertisements in the Swedish Medical Journal, 1994-2003. The regulation of these advertisements was analyzed using case reports from self-regulatory bodies. The authors independently reviewed this material to investigate: (1) extent of violative advertising; (2) pattern of code breaches; (3) rate at which the system reacted to violative advertising; (4) prevalence of and oversight over claims regarding antidepressant efficacy and disease causality, and (5) costs for manufactures associated with violative advertising.

PRINCIPAL FINDINGS

Self-regulatory bodies identified numerous code breaches. Nonetheless, they failed to protect doctors from unreliable information on antidepressants, since as many as 247 of 722 (34%) advertisements breached the industry code. Self-regulatory bodies repeatedly failed to challenge inflated claims of antidepressant efficacy, lending evidence of lax oversight. On average, 15 weeks elapsed between printing and censure of a wrongful claim, and in 25% of cases 47 weeks or more elapsed. Industry paid roughly €108000 in fines for violative advertising, adding an estimated additional average cost of 11% to each purchased violative advertisement, or amounting to as little as 0.009% of total antidepressant sales of around €1.2 billion.

CONCLUSIONS

Lax oversight, combined with lags in the system and low fines for violations, may explain the Swedish system's failure to pressure companies into providing reliable antidepressants information. If these shortcomings prove to be consistent across self-regulatory settings, and if appropriate measures are not taken to amend shortcomings, many countries may want to reconsider the current balance between self-regulation, and legislative control with government oversight.

Quality of pharmaceutical advertising and gender bias in medical journals (1998-2008): a review of the scientific literature

OBJECTIVE

To review the scientific literature on pharmaceutical advertising aimed at health professionals in order to determine whether gender bias has decreased and the quality of information in pharmaceutical advertising has improved over time.

METHODS

We performed a content analysis of original articles dealing with medical drug promotion (1998-2008), according to quality criteria such as (a) the number, validity and accessibility of bibliographic references provided in pharmaceutical advertising and (b) the extent to which gender representations were consistent with the prevalence of the diseases. Databases: PUBMED, Medline, Scopus, Sociological Abstract, Eric and LILACS.

RESULTS

We reviewed 31 articles that analyzed advertising in medical journals from 1975-2005 and were published between 1998 and 2008. We found that the number of references used to support pharmaceutical advertising claims increased from 1975 but that 50% of these references were not valid. There was a tendency to depict men in paid productive roles, while women appeared inside the home or in non-occupational social contexts. Advertisements for psychotropic and cardiovascular drugs overrepresented women and men respectively.

CONCLUSIONS

The use of bibliographic references increased between 1998 and 2008. However, representation of traditional male-female roles was similar in 1975 and 2005. Pharmaceutical advertisements may contribute to reinforcing the perception that certain diseases are associated with the most frequently portrayed sex.

Adherence of pharmaceutical advertisements in medical journals to FDA guidelines and content for safe prescribing

BACKGROUND

Physician-directed pharmaceutical advertising is regulated in the United States by the Food and Drug Administration (FDA); adherence to current FDA guidelines is unknown. Our objective was to determine adherence rates of physician-directed print advertisements in biomedical journals to FDA guidelines and describe content important for safe prescribing.

METHODS AND FINDINGS

Cross-sectional analysis of November 2008 pharmaceutical advertisements within top U.S.-based biomedical journals publishing original research. We excluded advertisements for devices, over the counter medications, and disease awareness. We utilized FDA guideline items identifying unique forms of advertisement bias to categorize advertisements as adherent to FDA guidelines, possibly non-adherent to at least 1 item, or non-adherent to at least 1 item. We also evaluated advertisement content important for safe prescribing, including benefit quantification, risk information and verifiable references. All advertisements were evaluated by 2 or more investigators, with differences resolved by discussion. Twelve journals met inclusion criteria. Nine contained pharmaceutical advertisements, including 192 advertisements for 82 unique products; median 2 per product (range 1-14). Six "teaser" advertisements presented only drug names, leaving 83 full unique advertisements. Fifteen advertisements (18.1%) adhered to all FDA guidelines, 41 (49.4%) were non-adherent with at least one form of FDA-described bias, and 27 (32.5%) were possibly non-adherent due to incomplete information. Content important for safe prescribing was often incomplete; 57.8% of advertisements did not quantify serious risks, 48.2% lacked verifiable references and 28.9% failed to present adequate efficacy quantification. Study limitations included its focus on advertisements from a single month, the subjectivity of FDA guidelines themselves, and the necessary subjectivity of determinations of adherence.

CONCLUSIONS

Few physician-directed print pharmaceutical advertisements adhere to all FDA guidelines; over half fail to quantify serious risks. The FDA could better protect public health by creating new more objective advertisement guidelines requiring transparent presentation of basic safety and efficacy information.

College activities and the ethics of advertising

OBJECTIVES

The aim of this paper is to examine whether advertising in the College journals and at RANZCP Congress, in particular from pharmaceutical companies, gives rise to a conflict of interests, and to discuss how this should be managed.

CONCLUSIONS

While advertising will often represent a conflict of interests, banning advertising from the College journals or Congress is unlikely to the best way to manage this. Conflicts of interest may be better managed by development of clear policies on advertisements, broadening the advertising base (i.e. beyond pharmaceutical companies), checking the accuracy of advertisements, and, in the case of Congress, ceasing sponsored symposia.

Quality of pharmaceutical advertisements in medical journals: a systematic review

Background

Journal advertising is one of the main sources of medicines information to doctors. Despite the availability of regulations and controls of drug promotion worldwide, information on medicines provided in journal advertising has been criticized in several studies for being of poor quality. However, no attempt has been made to systematically summarise this body of research. We designed this systematic review to assess all studies that have examined the quality of pharmaceutical advertisements for prescription products in medical and pharmacy journals.

Methods and Findings

Studies were identified via searching electronic databases, web library, search engine and reviewing citations (1950 – February 2006). Only articles published in English and examined the quality of information included in pharmaceutical advertisements for prescription products in medical or pharmacy journals were included. For each eligible article, a researcher independently extracted the data on the study methodology and outcomes. The data were then reviewed by a second researcher. Any disagreements were resolved by consensus. The data were analysed descriptively. The final analysis included 24 articles. The studies reviewed advertisements from 26 countries. The number of journals surveyed in each study ranged from four to 24 journals. Several outcome measures were examined including references and claims provided in advertisements, availability of product information, adherence to codes or guidelines and presentation of risk results. The majority of studies employed a convenience-sampling method. Brand name, generic name and indications were usually provided. Journal articles were commonly cited to support pharmaceutical claims. Less than 67% of the claims were supported by a systematic review, a meta-analysis or a randomised control trial. Studies that assessed misleading claims had at least one advertisement with a misleading claim. Two studies found that less than 28% of claims were unambiguous clinical claims. Most advertisements with quantitative information provided risk results as relative risk reduction. Studies were conducted in 26 countries only and then the generalizability of the results is limited.

Conclusions

Evidence from this review indicates that low quality of journal advertising is a global issue. As information provided in journal advertising has the potential to change doctors' prescribing behaviour, ongoing efforts to increase education about drug promotion are crucial. The results from our review suggest the need for a global pro-active and effective regulatory system to ensure that information provided in medical journal advertising is supporting the quality use of medicines.

Do advertisements for antihypertensive drugs in Australia promote quality prescribing? A cross-sectional study

Background

Antihypertensive medications are widely prescribed by doctors and heavily promoted by the pharmaceutical industry. Despite strong evidence of the effectiveness and cost-effectiveness of thiazide diuretics, trends in both promotion and prescription of antihypertensive drugs favour newer, less cost-effective agents. Observational evidence shows correlations between exposure to pharmaceutical promotion and less ideal prescribing. Our study therefore aimed to determine whether print advertisements for antihypertensive medications promote quality prescribing in hypertension.

Methods

We performed a cross-sectional study of 113 advertisements for antihypertensive drugs from 4 general practice-oriented Australian medical publications in 2004. Advertisements were evaluated using a quality checklist based on a review of hypertension management guidelines. Main outcome measures included: frequency with which antihypertensive classes were advertised, promotion of thiazide class drugs as first line agents, use of statistical claims in advertisements, mention of harms and prices in the advertisements, promotion of assessment and treatment of cardiovascular risk, promotion of lifestyle modification, and targeting of particular patient subgroups.

Results

Thiazides were the most frequently advertised drug class (48.7% of advertisements), but were largely promoted in combination preparations. The only thiazide advertised as a single agent was the most expensive, indapamide. No advertisement specifically promoted any thiazide as a better first-line drug. Statistics in the advertisements tended to be expressed in relative rather than absolute terms. Drug costs were often reported, but without cost comparisons between drugs. Adverse effects were usually reported but largely confined to the advertisements' small print. Other than mentioning drug interactions with alcohol and salt, no advertisements promoted lifestyle modification. Few advertisements (2.7%) promoted the assessment of cardiovascular risk.

Conclusion

Print advertisements for antihypertensive medications in Australia provide some, but not all, of the key messages required for guideline-concordant care. These results have implications for the regulation of drug advertising and the continuing education of doctors.

The accuracy of psychiatric medication advertisements in medical journals

Psychiatric medications are frequently advertised in medical journals, yet no study has addressed the veracity of claims made in these advertisements. The present study examined the accuracy of 69 medical journal advertisements for psychiatric medications and the availability of sources cited in these advertisements. Just over half of claims made in advertisements (50.2%) provided no attainable source that could be used to check the veracity of the claim. When sources were attained, they supported the cited claims 65% of the time (95% CI: 61.0-69.1). Claims regarding the efficacy of medications were only supported by obtained cited sources on 53.2% of occasions (95% CI: 46.2-60.2). Attempts to obtain cited data on file from sponsoring drug companies were rarely successful. Given the relatively poor empirical substantiation of claims made in medical journal psychiatric drug advertisements and that most claims provided no attainable sources, increased regulation of such advertising is warranted.

Is content of medical journals related to advertisements? Case-control study

AIM

To assess the relatedness of journal content to paid advertisements published in the journal.

METHODS

The case-control study was performed on a convenience sample of 7 journals subscribed by Central Medical Library in Moscow--4 international (American Journal of Hypertension, British Journal of General Practice, The Lancet, and New England Journal of Medicine) and 3 Russian peer reviewed journals (Terapevticheskii Arkhiv, Khirurgiia, and Voeno-Meditsinskii Zhurnal). In each issue containing a paid advertisement, classifieds excluded, we searched for articles related to the advertised product and compared this issue with a control issue - the next or a later issue without this advertisement.

RESULTS

In American Journal of Hypertension (33 issues from 2002-2004) 94 placements of advertisements were found, 7 of which were closely related to the article topic in the same issue (7/94) vs 2/66 in the control issue. The odds ratio (OR) and 95% confidence interval (CI) for advertisements to be accompanied by related articles was OR, 2.6; 95%CI, 0.5-13). In British Journal of General Practice (27 issues from 2003-2005) there were 7/63 advertisements related to the article topic vs 0/28 in the control issue (OR, 7.2; 95% CI, 1.3 to 44). In The Lancet (49 issues from 2004) there were 8/162 advertisements related to the article topic vs 8/104 in the control issue (OR, 0.6; 95% CI, 0.3-1.5). In New England Journal of Medicine (37 issues from 2004) there were 12/81 advertisements related to the article topic vs 8/75 in the control issue (OR, 1.5; 95% CI, 0.56-3.79). In Terapevticheskii Arkhiv (10 issues from 2004) there were 38/93 advertisements related to the article topic vs 1/83 in the control issue (OR, 56.66; 95% CI, 4.4-253). In Khirurgiia (25 issues from 2003-2005) there were 3/83 advertisements related to the article topic vs 0/70 in the control issue (OR, 2.7; 95% CI, 0.3-26). In Voeno-Meditsinskii Zhurnal (33 issues from 2003-2005) there were 17/31 advertisements related to the article topic vs 2/31 in the control issue (OR,17.6; 95% CI, 3.6-87).

CONCLUSIONS

The strong relatedness between the content of the articles and advertisements placed in 3 of 7 journals and explicit placement of the advertisements face to face or overleaf the related research articles support the hypothesis that journal content is manipulated to place more emphasis on the advertisements.

Financial conflicts of interest in psychiatry

The issue of conflicts of interest has brought clinical medicine to an unprecedented crisis of credibility. The situation of psychiatry does not appear to be different from other areas of medicine. The problems caused by the increasing financial ties between the pharmaceutical industry and researchers and clinicians can be addressed only by a complex effort encompassing both the establishment of lines of support of independent researchers who are free of substantial conflicts of interest and better disclosure policies and conduct regulations as to financial ties. Such effort requires a bold shift from current, largely inadequate strategies. In the long run it may entail, however, substantial advantages to patients, clinicians, researchers, the health industry and the civil society at large. Psychiatry, in view of its humanistic and social roots, may lead this effort.