In this issue of the Journal, Loke and colleagues (page 291) present data from an analysis of 174 advertisements for pharmaceuticals appearing in six Australian medical publications.1 The findings are striking enough to be restated. Fewer than 8% of the advertisements contained quantitative data about the outcomes of therapy, and most of these framed the information in relative rather than absolute terms. Only 28% of the therapeutic claims in the advertisements conveyed clinical outcomes in any specific, substantive and unambiguous way. In the United States, pharmaceutical advertising is subject to the Federal Food, Drug, and Cosmetic Act,2 and Loke et al suggest that, in Australia, advertisements for drugs may be less informative than in the US. The pharmaceutical industry has long maintained that drug advertisements are an important vehicle for conveying important information about new drugs to prescribers. Is this how industry believes it should communicate with highly trained healthcare professionals? Should we really be surprised by the results of Loke et al, and, more importantly, should we be concerned?

We know that the pharmaceutical industry spends enormous sums on promoting its products (about twice the amount spent on research and development),3 but most data on the effect of advertising on prescribing are unpublished, and have been gathered by advertising companies. The Association of Medical Publishers (AMP), a US-based organisation whose membership includes the publishers of nearly 200 biomedical journals, boasts "advertising in medical publications alone... can generate sales for both new and more-established products" [original emphasis].4 AMP reports a number of studies that have shown a significant increase in market share and retail sales as a result of medical journal advertising, which is reported to provide a return on investment (ROI) of about US$5.00 for every dollar spent, greater than detailing (ROI US$1.72) and direct-to-consumer advertising (ROI US$0.19).5

Most advertisements are for new and expensive drugs, so increased use due to promotion will contribute to the financial pressures on the Pharmaceutical Benefits Scheme (PBS). Does journal advertising also lead to inappropriate practices? Although there is a substantial body of research on the effects of pharmaceutical industry promotion generally, relatively little involves printed advertisements in medical journals. In a landmark study, Avorn and colleagues studied physicians' beliefs about the efficacy of two classes of drugs (propoxyphene analgesics and central/peripheral vasodilators) that were being heavily promoted as effective, despite evidence that they lacked any efficacy and offered no advantages over existing treatments.6 The authors found that, even though doctors reported paying little attention to drug advertisements, most doctors believed that these agents were effective.

Do the results reported by Loke and colleagues have other implications? What is their relevance for the development of government policy? The Australian Competition and Consumer Commission (ACCC) is currently examining an application for reauthorisation of the Code of Conduct of the Australian Pharmaceutical Manufacturers' Association (now Medicines Australia). As part of the examination of the relationships between pharmaceutical industry participants, the ACCC is investigating claims in the media about some practices and whether they are in the best interests of the community (Lin Enright, Director, Public Relations, ACCC, personal communication). The ACCC should heed the results reported here.

It is only two years since the review of direct-to-consumer advertising of pharmaceutical products in Australia.7 Although the review recommended against direct-to-consumer advertising, the subject is under continuing review, and some within the pharmaceutical industry are still pressing for change, maintaining that such a facility would enable them to provide important educational information about drugs to the public. Similar moves to relax laws relating to direct-to-consumer advertising are also occurring in Europe and Canada.8 The information reported by Loke et al on journal advertisements suggests that direct-to-consumer advertising is likely to be uninformative and promotional rather than educational in nature.

Where should we look for guidance on appropriate standards for advertising pharmaceutical products? Medicines Australia polices a voluntary code of conduct that aims to set "standards of conduct for the activities of companies when engaged in the marketing of prescription products".9 This document places more emphasis on what not to do when promoting medicines, rather than offering guidance on how to provide balanced advice to clinicians about the efficacy and safety of medicines. Perhaps we should pay more attention to the advertising standards maintained in other industries. Generally, advertisements for technologically sophisticated products include prominent displays of their specifications, performance and selling price. Is it too much to ask that advertisements for modern drugs provide similar information? In an era of evidence-based medicine this should include data on the absolute effects of therapy, such as the response rates with and without treatment, and the number needed to treat, in order to avoid the ambiguities of relative measures such as the relative risk reduction. It would be best if this information related to comparisons with established therapies, not just placebo. Clinicians should also be told the dispensed price of the drug under the Pharmaceutical Benefits Scheme.