A former editor of the British Medical Journal (BMJ) claims that medical journals are an extension of the marketing arm of pharmaceutical companies, placing editors in difficult positions as company-funded trials are becoming increasingly popular.
Richard Smith, now chief executive of UnitedHealth Europe, made his comments in an outspoken essay published in the open access international health journal PloS Medicine.
Smith is not the only editor to express concerns about the power and influence of the industry. In March 2004, Richard Horton, editor of the Lancet, wrote that "Journals have devolved into information laundering operations for the pharmaceutical industry."
Likewise, Marcia Angell, former editor of the New England Journal of Medicine, condemned the industry for becoming "primarily a marketing machine" and co-opting "every institution that might stand in its way."
Smith, who was an editor for the BMJ for 25 years and editor and chief executive of the BMJ Publishing Group for the last 13 of those years, argued that the most evident example of medical journals' dependence on the pharmaceutical industry is the substantial income from advertising. However he thought this was "the least corrupting form of dependence," since the ads were "there for all to see and criticise."
The bigger problem lies with clinical trials, published by journals. Smith thought that readers would see randomised controlled trials as one of the highest forms of evidence and a large trial published in a major journal would have the journal's stamp of approval. Smith was concerned that the quality of the journal would bless the quality of the drug.
He said: "For a drug company, a favourable trial is worth thousands of pages of advertising, which is why a company will sometimes spend upwards of a million dollars on reprints of the trial for worldwide distribution."
Perhaps the major concern of this practice was the creditability of the results obtained. "Fortunately from the point of view of the companies who fund these trials-but unfortunately for the credibility of the journals who publish them-these trials rarely produce results that are unfavourable to the companies' products." Smith cites evidence from a total of 86 studies that the results of a trial are influenced by who funds it.
Smith went as far as to comment that the evidence was strong that companies were getting the results they want, and this is especially worrying because between two thirds and three quarters of the trials published in the major journals were funded by the industry.
The evidence is strong and especially worrisome because, according to Smith, between two-thirds and three-quarters of the trials published in the major journals Annals of Internal Medicine, JAMA, Lancet, and New England Journal of Medicine are funded by the industry.
For the BMJ, it's only one-third, partly, perhaps, because the journal has less influence than the others in North America, which is responsible for half of all the revenue of drug companies, and partly because the journal publishes more cluster-randomised trials (which are usually not drug trials).
Smith added that journal editors were well aware that company-funded trials bought in thousands of dollars in reprint sales. Editors are increasingly responsible for the budgets of their journals and for producing a profit for their owners. "An editor may thus face a frighteningly stark conflict of interest: publish a trial that will bring $100,000 of profit or meet the end of year budget by firing an editor."
How can the cycle of dependency between journals and drug companies be broken? "Firstly, we need more public funding of trials, particularly of large head to head trials of all the treatments available for treating a condition," Smith said.
Smith recommended: "Secondly, journals should perhaps stop publishing trials. Instead, the protocols and the results should be made available on regulated websites. Only such a radical step would, I think, stop journals being beholden to companies. Instead of publishing trials journals could concentrate on critically describing them."