Pharma’s promotional strategies have been slammed in a paper published today in the influential, open-access journal PLoS Medicine.

The authors claim that "misleading promotion can be a major threat to health" and called for wide-ranging reforms – including the end of one-to-one rep visits and company-funded education. Health professionals, they argue, should “understand their responsibility to avoid pharmaceutical and device promotion”.

The recommendations derive from an iterative E-mail discussion among representatives of four advocacy groups: the American Medical Student Association; Healthy Skepticism Inc; No Free Lunch; and PharmAware.

The authors comment that pharma “promotion causes much more harm than is generally realised”. The paper cites two examples of “misleading promotion”: rofecoxib (Vioxx) and claims that HRT prevented cardiovascular disease before “one single clinical trial” with appropriate outcomes had been performed. They suggest that rofecoxib caused between 88 000 and 140 000 excess cases of serious coronary artery disease across the USA. Because HRT was used for longer they suggest that “the number of women harmed by severe adverse effects … may have been even larger”. However, they could not find any reliable estimates of the harm produced.

The paper calls for four changes that “are necessary but not sufficient for removing the adverse influence of promotion on health professionals”. Firstly, health professionals should be educated about the best way to make decisions, and how to evaluate evidence and promotional material, encompassing relevant areas from psychology, logic, economics, ethics and statistics. They point to a worldwide survey suggesting that most medical and pharmacy students receive half a day or less on rational use of drug and information about marketing strategies.

Secondly, they called for more help for health professionals “to understand that there is no proven method for enabling them to gain more benefit than harm from promotion”. The authors claim that “there is strong evidence that exposure to pharmaceutical promotion correlates with medically inappropriate and wasteful use of pharmaceuticals”. Many doctors, they claim are overconfident about their ability to distinguish between justified and unjustified messages. They suggest helping professionals “move from overconfidence … to understanding that they are vulnerable”.

Thirdly, health professionals should “understand their responsibility to avoid pharmaceutical and device promotion”. The authors believe that “because all health professionals are vulnerable to being misled … they have a professional, ethical and fiduciary responsibility to patients to take all practical steps to avoid drug and device promotion”. This includes gifts and one-to-one visits from reps. Group meetings, they claim, are unlikely “to do more good than harm compared to no such meetings”. Furthermore, the paper suggests that “education for health professionals should never, we believe, be funded by companies promoting drugs or devices”. The only exception to including promotion is if it is “immediately debunked”.

Finally, health professionals should be “educated explicitly about the most reliable sources of information” and know its availability, strengths and weaknesses. Health professionals should also keep themselves up-to-date based on “the best information available”, provided by professional associations and governments.

The authors suggest that these reforms may not be enough to remove promotion’s “adverse influence”, and advocate “improved regulation and redesigned incentive systems”. In the meantime, they add that their hypothesis, that the “recommendations will lead to improved health-care outcomes and earn increased public trust in the ability of health professionals to provide optimal treatment - deserves to be tested”.

By Mark Greener