Covert pharmaceutical promotion in free medical journals.

534 CMAJ, March 22, 2011, 183(5) © 2011 Canadian Medical Association or its licensors The influence of the promotional practices of pharmaceutical manufacturers on the prescribing behaviour of physicians has long been recognized. Since the early 1980s, studies of this phenomenon have repeatedly shown that physicians’ knowledge of drug properties is more consistent with sales information than with the evidence published in the medical literature, even though physicians generally deny such an influence. Over the past decade, the direct-to-physician promotion of pharmaceuticals has led to the widespread inappropriate use of drugs such as rofecoxib, rosiglitazone and certain anti psychotic drugs, which in turn has resulted in increased morbidity and mortality for patients. Commercial sources of information for these and other products have consistently overstated their benefits and underestimated their risks. In response, experts on health policy have called for better oversight of the interactions between physicians and the pharmaceutical industry, and some institutions have placed stringent limits on the interactions between physicians and marketing representatives. Efforts to stem the influence of marketing strategies on the prescribing behaviour of physicians may be limited because some strategies occur beyond the authority of regulators and public watchdogs. For example, insiders from one pharmaceutical manufacturer recently alleged that websites maintained by third parties but funded and controlled by the manufacturer promoted unapproved off-label uses of the product. Some physicians have pointed to nominally independent private organizations that hold continuing medical education (CME) conferences and have suggested that receiving funding from the pharmaceutical industry makes these organizations susceptible to the delivery of inappropriate promotional messages. In this issue of CMAJ, Becker and colleagues provide an in-depth look at another potential source of the covert promotion of pharmaceuticals: the free (“controlled-circulation”) medical journal. The authors focus on publications from Germany, but there are versions of these journals in virtually every other major medical marketplace. In the United States, these publications may be sent to the membership lists of the American Medical Association (AMA) or a specialty society. Controlled-circulation publications are disseminated without subscription because they are funded entirely by advertising revenue. Many provide summaries of previously published peerreviewed research in easily read formats that may appeal to busy physicians. Some articles are specifically intended for CME purposes and may provide physicians with the opportunity to apply for the credits required by regulatory authorities that show their ability to absorb the information contained in the articles. For many physicians, obtaining CME credits in this manner may be less expensive and more convenient than attending a course or conference. The autonomy of controlled-circulation publications has been a perennial subject of debate. In the 1970s, Richard Crout, head of the Bureau of Drugs at the US Food and Drug Administration, testified before Congress that there was “evidence of ghostwritten articles and heavily biased therapeutic reviews in controlled circulation journals that included quizzes at the end that could be mailed in to receive AMA-accredited CME credits.” When the editors of peer-reviewed journals discuss their policies on advertising, free publications act as examples of what not to do by showing how editorial independence might be lost. Earlier this year, a well-known psychiatrist posted links to a free publication in which supplements for CME Covert pharmaceutical promotion in free medical journals