Group Title: BMC Complementary and Alternative Medicine
Title: Does pharmaceutical advertising affect journal publication about dietary supplements?
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Title: Does pharmaceutical advertising affect journal publication about dietary supplements?
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Abstract: BACKGROUND:Advertising affects consumer and prescriber behaviors. The relationship between pharmaceutical advertising and journals' publication of articles regarding dietary supplements (DS) is unknown.METHODS:We reviewed one year of the issues of 11 major medical journals for advertising and content about DS. Advertising was categorized as pharmaceutical versus other. Articles about DS were included if they discussed vitamins, minerals, herbs or similar products. Articles were classified as major (e.g., clinical trials, cohort studies, editorials and reviews) or other (e.g., case reports, letters, news, and others). Articles' conclusions regarding safety and effectiveness were coded as negative (unsafe or ineffective) or other (safe, effective, unstated, unclear or mixed).RESULTS:Journals' total pages per issue ranged from 56 to 217 while advertising pages ranged from 4 to 88; pharmaceutical advertisements (pharmads) accounted for 1.5% to 76% of ad pages. Journals with the most pharmads published significantly fewer major articles about DS per issue than journals with the fewest pharmads (P < 0.01). Journals with the most pharmads published no clinical trials or cohort studies about DS. The percentage of major articles concluding that DS were unsafe was 4% in journals with fewest and 67% among those with the most pharmads (P = 0.02). The percentage of articles concluding that DS were ineffective was 50% higher among journals with more than among those with fewer pharmads (P = 0.4).CONCLUSION:These data are consistent with the hypothesis that increased pharmaceutical advertising is associated with publishing fewer articles about DS and publishing more articles with conclusions that DS are unsafe. Additional research is needed to test alternative hypotheses for these findings in a larger sample of more diverse journals.
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BMC Complementary and 0

Alternative Medicine ioed Centra


Correspondence


Does pharmaceutical advertising affect journal publication about
dietary supplements?
Kathi J Kemper* I and Kaylene L Hood2


Address: 'Department of Pediatrics and the Program for Complementary and Integrative Medicine, Wake Forest University School of Medicine,
Winston-Salem, NC, USA and 2University of Florida, Department of Nutrition, Gainesville, FL, USA
Email: Kathi J Kemper* kkemper@wfubmc.edu; Kaylene L Hood Kayhood@ufl.edu
* Corresponding author



Published: 9 April 2008 Received: 6 August 2007
8MC Complementary and Alternative Medicine 2008, 8:1 I doi: 10.1 186/1472-6882-8-1 I Accepted: 9 April 2008
This article is available from: http://www.biomedcentral.com/1472-6882/8/1 I
2008 Kemper and Hood; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Background: Advertising affects consumer and prescriber behaviors. The relationship between
pharmaceutical advertising and journals' publication of articles regarding dietary supplements (DS)
is unknown.
Methods: We reviewed one year of the issues of I I major medical journals for advertising and
content about DS. Advertising was categorized as pharmaceutical versus other. Articles about DS
were included if they discussed vitamins, minerals, herbs or similar products. Articles were
classified as major (e.g., clinical trials, cohort studies, editorials and reviews) or other (e.g., case
reports, letters, news, and others). Articles' conclusions regarding safety and effectiveness were
coded as negative (unsafe or ineffective) or other (safe, effective, unstated, unclear or mixed).
Results: Journals' total pages per issue ranged from 56 to 217 while advertising pages ranged from
4 to 88; pharmaceutical advertisements (pharmads) accounted for 1.5% to 76% of ad pages. Journals
with the most pharmads published significantly fewer major articles about DS per issue than
journals with the fewest pharmads (P < 0.01). Journals with the most pharmads published no clinical
trials or cohort studies about DS. The percentage of major articles concluding that DS were unsafe
was 4% in journals with fewest and 67% among those with the most pharmads (P = 0.02). The
percentage of articles concluding that DS were ineffective was 50% higher among journals with
more than among those with fewer pharmads (P = 0.4).
Conclusion: These data are consistent with the hypothesis that increased pharmaceutical
advertising is associated with publishing fewer articles about DS and publishing more articles with
conclusions that DS are unsafe. Additional research is needed to test alternative hypotheses for
these findings in a larger sample of more diverse journals.



Background other botanicals, amino acids, and substances such as
Interest in vitamins, minerals, herbs and other dietary enzymes, organ tissues, glandulars, and metabolites." DS
supplements (DS) has grown markedly in the US since the are commonly used [2,3,11,12]. In certain cases, DS are
early 1990's [1-10]. DS are defined by the US Food and medically recommended (e.g., folic acid for women of
Drug Administration as "vitamins, minerals, herbs or child-bearing age [13]). However, for most supplements


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Open Access







BMC Complementary and Alternative Medicine 2008, 8:11



there are few official recommendations, and patients
often use DS without informing their physician [2,14,15 ].
Physicians have been urged to discuss with their patients
the effectiveness and safety of DS, particularly when com-
bining use of DS with prescription medications [16-21].

In response to citizen demand and the high prevalence of
DS use, the US National Institutes of Health have funded
research to evaluate the safety and effectiveness of DS
[22]. An increasing number of research papers about DS
have been published recently, and a number of journals
specifically devoted to CAM research and education have
appeared. However, most primary care clinicians sub-
scribe to established and highly visible general medical
journals; articles in these journals are frequently cited in
professional practice guidelines and by the media to guide
the general public. Many medical journals are supported
in part by advertising revenues; however, we are unaware
of research evaluating the relationship between pharma-
ceutical advertising and publication about natural health
products, which may in some cases be viewed as compet-
itive with pharmaceutical products.

In general, the aim of advertising is to increase demand
for and purchase advertised products. Direct to consumer
pharmaceutical advertising affects consumer behavior
[23,24] ; advertising in medical journals and other mar-
keting aimed at clinicians affects clinician prescribing
behavior [25,26]. Pharmaceutical funding of research also
appears to influence authors' interpretation of results
(conclusions) about the effectiveness of these products
[27]. It is possible that advertising funds may influence
journals and their paid staff [25]. The potential conflicts
of interest between advertisers, editors and authors have
resulted in the emergence of guidelines and rules about
disclosure of potential conflicts of interest, particularly for
authors writing about the effectiveness and safety of spe-
cific products [28-34].

Because of the importance of established medical journals
in informing and influencing professional and public
behavior, the question of unintended bias favoring adver-
tisers in making editorial decisions is of great public
health as well as business interest. The purpose of this
pilot study was to begin to explore the relationship
between pharmaceutical advertising and the publication
of articles about DS. We expected that journals with more
pharmaceutical advertising would publish fewer articles
about DS because DS may at times be viewed as competi-
tors to pharmaceutical products; furthermore, we
expected that those with more pharmaceutical advertise-
ments (pharmads) would publish more articles suggest-
ing that DS were unsafe or ineffective than journals with
fewer pharmads. As a secondary question, we assessed
publications about DS in three journals devoted to com-


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elementary and alternative medicine (CAM); we expected
CAM journals would have fewer pharmads and more DS
articles; finally, we expected that fewer of the articles in
CAM journals would be unfavorable about DS than arti-
cles in the general medical and primary care journals.

Methods
Data Sources
We selected 11 major medical journals published in Eng-
lish between June 30, 2006 and June 30, 2007. Journals
were selected if they were devoted to general medicine
(American Family Physician, British Medical Journal, Cana-
dian Medical Association Journal, Journal of the American
Medical Association, and the New England Journal of Medi-
cine; internal medicine (Annals of Internal Medicine and
Archives of Internal Medicine, or pediatrics (Pediatrics,
Archives of Pediatrics and Adolescent Medicine, and Pediatric
Research). For each journal, all issues available in the Coy
C. Carpenter Library at Wake Forest University School of
Medicine (WFUSM) for the study time period were
reviewed. We used the American library version of these
journals and did not compare different versions that may
have been published for various groups of subscribers.

The WFUSM library did not subscribe to hard copies of
any CAM journals. For the secondary question about CAM
journals, we reviewed a convenience sample of three jour-
nals with issues published in the same time period as for
the other journals to which the WFUSM Program for
Holistic and Integrative Medicine at WFUSM had a sub-
scription: Journal of Alternative and Complementary Thera-
pies, Alternative Therapies in Health and Medicine, and
Explore.

Reviews
All reviews were carried out between May 21 and July 17,
2007. Journals were reviewed by two pre-medical students
using standard rating forms created for the study. Review-
ers were trained; inter-rater agreement was confirmed
through independent review of journals. Reviewers exam-
ined each page of every journal reviewed. Pages were
selected for the study if they included a) any kind of adver-
tising or b) any report regarding a DS.

Advertising included pharmaceutical (including prescrip-
tion and over-the-counter medications and ads for drug-
eluting stents); classified; self-promoting (e.g., advertise-
ments for the journal itself, its parent organization or an
affiliated publication or meeting); for-profit products
(e.g., foods, automotive, office equipment), non-profit
(e.g., for schools, foundations, and associations such as
the American Heart Association), and other (e.g. US mili-
tary and other). For analytic purposes, these were col-
lapsed into two categories: pharmaceutical versus other.



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BMC Complementary and Alternative Medicine 2008, 8:11



Pages that contained advertising were counted as full, half
(0.5) or quarter (0.25) ad pages for each type of ad.

Reports about DS were included if they were found in
original manuscripts, reviews, editorials, abstracts, news,
meeting notes, patient information, or letters to the edi-
tor. These materials are referred to for purposes of this
paper as journal "articles" about DS. Indices and tables of
contents were not included in the review. DS were defined
as per the US FDA definition cited above. We excluded
articles about tobacco, marijuana, alcohol products and
about prescription medications derived from plants. We
did not include articles about specific diets such as high
fiber, low fat, low glycemic index, Mediterranean, Atkins,
or specific foods such as milk, but we did include tea and
coffee because many of these articles focused on their caf-
feine or antioxidant content. For analytic purposes, arti-
cles about DS were divided into major articles (original
research, editorials, reviews) and other (basic scientific
mechanisms, case reports, letters, fillers, news, abstracts,
meeting notes, and similar) types of articles. We divided
articles this way because original articles, reviews, and edi-
torials tend to be picked up by the media and cited in sub-
sequent review articles; even though editorials and
reviews do not often include new data, they often contrib-
ute to policy and guideline development.

For each article about DS, reviewers examined the authors'
conclusions regarding safety and effectiveness. Conclu-
sions about safety were coded as a) unsafe, b) safe, or c)
unclear or mixed or d) not discussed. For example, a con-
clusion citing "no serious adverse effects" was coded as
"safe"; a conclusion that excessive vitamin A caused liver
disease would be coded as "unsafe"; some articles that
focused solely on efficacy did not include a discussion of
side effects. Similarly, conclusions about effectiveness
were coded as a) ineffective, b) effective, or c) neutral,
mixed or insufficient evidence or d) not discussed.
Reviewers discussed cases in which there was initial disa-
greement about coding (<5% of cases); the two unre-
solved cases were referred to an attending physician for
final decision about coding. Because we were particularly
interested in negative publications, articles were catego-
rized for analysis as "unsafe" versus "other" and as "inef-
fective" versus "other."

Data about each journal's impact factor was collected for
2006 on the journal websites.

Data were entered into a MS Access Database and trans-
ferred to MS EXCEL for descriptive analysis; Stata' 8.1
software was used for statistical analysis. Comparisons
between groups of journals with the most, middle and
fewest articles per issue were made with Fisher's exact test
due to the small sizes of some cells.


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As an analysis of published materials, this study was con-
sidered exempt from human subjects review.

Results
The number of issues reviewed for each of the 11 primary
journals ranged from 12 to 52, with an average of 30
issues per journal (Table 1). The average number of pages
per issue ranged from 56 to 217. The average number of
all advertising pages (all-ads) ranged from 3.9 to 87.8 per
issue. The average number of pharmaceutical ads (phar-
mads) varied from 0.15 to over 60 pages per issue and
from 0.001 to 0.441 pharmads per average number of
journal pages per issue. We arbitrarily grouped journals
into those with less than ten pharmads in an average issue
(the fewest pharmads group; two journals with an average
impact factor 5.9); those with more than 40 pages of phar-
maceutical ads per issue (the most pharmads group; two
journals with an average impact factor 18.5), and those
that had between 10-39 pages per issue (the middle ads
group; seven journals with an average impact factor 6.9).
Although we did not set out to review the number of pages
devoted to DS advertising, reviewers noted that ads for DS
such as Centrum and Caltrate were very rare among
these 11 journals, and there were no ads for folate, indi-
vidual vitamins or for non-vitamin/mineral DS such as
glucosamine, ginkgo, or garlic in these 11 journals.

The number of articles of any type about any DS in each
journal ranged from four to 61 (Table 2). The journals
with the most pharmads published fewer major articles
about DS per issue than journals with a middle number of
ads (0.08 versus 0.21 per major articles per issue, P <
0.05); and journals with the middle number of pharmads
published fewer major DS articles per issue than journals
with the fewest pharmads (0.21 versus 0.43, P < 0.05),
consistent with a dose-effect response. There was no
apparent relationship between journals' impact factor and
either their number of ads or their number of publications
about DS. None of the 35 articles published about DS in
the two journals with the most pharmads were clinical tri-
als or observational cohort studies.

The DS that were covered the most often in these medical
journals were (Table 3): folate and other B vitamins; cal-
cium and vitamin D; iron; essential fatty acids such as
omega three fatty acids; and caffeinated beverages such as
coffee and green tea. There were fewer articles about pro-
biotics, glucosamine, individual herbs (garlic, ginkgo, gin-
seng, St. Johns wort, lavender, tea tree oil) or combination
herbal products.

Safety concerns were raised less often in clinical trials or
cohort studies than in other articles. Specifically, concerns
about unsafe DS were cited in 1/44 (2%) clinical trials or
cohort studies versus 3/34 (10%) of editorials or reviews,


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BMC Complementary and Alternative Medicine 2008, 8:11


Table I: journal advertising Total pages and Pharmaceutical Ads (Pharmads)


No. of issues Average No. of
reviewed Pages per issue


182.9
143.4
108.4
78.8
217.3
109
117.7
86.1
124.8
56.1
137.5

123.8


Average No. of
All Ad pages
per issue


87.8
86.7
85.0
53.2
63.6
21.7
21.0
22.2
30.8
3.9
10.5


Average No.
Pharmads
per issue


66.3
63.2
39.4
22.8
24.7
15.7
15.4
15.2
10.5
0.15
0.15


Percent
Pharmad pages
per issue


75.5
72.9
46.4
42.8
38.9
72.3
73.3
67.5
34.0
3.9
1.5


43.04


Pharmads
(DS ads) p
er issue


0 (1.8)
0 (0)
0(12.3)


Percent
pharmads
(DS ads)


0(23)
0 (0)
0(52)


Table 2: Articles about Dietary Supplements (DS)


Characteristics


Number of
issues reviewed


Number of ANY
articles about DS


Clinical Trials or
Cohort Studies


Editorials Reviews


TOTAL MAJOR
ARTICLES
(PER ISSUE)*


Most Pharmads (2 journals;
average impact factor 6.9)
TOTALS
Number per issue
Middle Pharmads (7 journals;
average impact factor 18.5)
Totals
Number per issue
Fewest Pharmads (2 journals;
average impact factor 5.9)
Totals
Number per issue

CAM JOURNALS
Number per issue


220


2 2


0.02 0.02
15 2


0.07 0.01
II 3


0.17 0.05

2 6
0.09 0.27


*Overall differences in rates of publishing major articles about DS are statistically significant with P < 0.001. The rate for those with the most
pharmads (0.08) is significantly lower than those with middle pharmads (0.21, P < 0.05). The rate for those with the middle pharmads (0.21) is
significantly lower than those with the fewest pharmads (0.43, P < 0.05). The rate for the CAM journals (0.86) is significantly higher than that for the
general medical journals with the fewest pharmads (<0.01)







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Journal





A
B
C
D
E
F
G
H
I
J
K


OVERALL
AVERAGE for
major medical
journals

CAM journals


No. of
Pharmads
per Pages in
Avg. issue

0.362
0.44 I
0.363
0.289
0.114
0.144
0.13 1
0.177
0.084
0.003
0.001


0.192


4


(0.08)*
47


(0.2 1)*
28


(0.43)*

19
(0.86)*


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BMC Complementary and Alternative Medicine 2008, 8:11



Table 3: Dietary Supplements Most Often Covered in Major Medical journals


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Supplement

Folate and other B vitamins
Coffee, green tea, caffeine
Calcium and/or Vitamin D
Iron
Omega-3 fatty acids
Multivitamins or multiple vitamin/nutrient mixtures
Lavender/tea tree
Vitamin A
Zinc


Number of Articles

37
20
18
II
9
6


Other DS included probiotics, olive oil, antioxidants, garlic, Vitamins C, E, and K chondroitin, and black cohosh


and 20/177 (11%) of other kinds of articles. Journals with
the most pharmads were significantly more likely to pub-
lish major articles concluding that DS were unsafe than
journals with middle or fewest pharmads (67% versus 7%
and 4%, respectively, P < 0.005 Table 4).

In the 11 primary journals, 68/254 (26%) articles about
DS concluded they were ineffective; only 10 of these arti-
cles were clinical trials or cohort studies. Conclusions
about ineffective DS were less common in journals with
fewest pharmads than in journals with more pharmads.
For example, half (50%) of the editorials from journals
with the most pharmads concluded that DS were ineffec-
tive, compared with 33% of editorials from journals with
middle amounts of pharmaceutical advertising and 27%
of editorials from the journals with the least pharmaceuti-



Table 4: Articles concluding DS are Unsafe or Ineffective

Characteristics N Unsafe/All DS arti- Among Clinical or
cles (%) Cohort Trials


cal advertising (Table 4); these differences were not statis-
tically significant.

For the secondary question about the three CAM journals,
the number of advertisements ranged from 5.7 to 24
pages per issue (Table 1). There were no advertisements
for prescription pharmaceuticals in any of the CAM jour-
nals. However, there were ads for DS; the number of pages
of ads for DS ranged from 0 to 12.3 with an overall aver-
age of 5.5 ads for DS per issue. The CAM journals carried
significantly more articles about DS than any group of the
primary journals (P < 0.01). The CAM journals published
over twice as many clinical trials or cohort studies as the
journals with the fewest pharmads (0.5 versus 0.22 per
issue); the number of major articles per issue was signifi-
candy higher among CAM journals than among the gen-
eral medical journals with the fewest ads (0.86 versus 0.43


Among Editorials Among Reviews


N UnsafelTOTAL
MAJOR ARTICLES


UNSAFE


Most Pharmads
Middle Pharmads
Fewest Pharmads

CAM journals


5/35 (14)
16/142 (1 I1)
3/77 (4)

1/88 (1)


0/0 (0)
1/30 (3)
0/14 (0)

0


I/I (100)
0/15 (0)
I/I 1(9)

0


1/2 (50)
0/2 (0)
0/3 (0)

0


2/3 (67)*
1/47 (7)
1/27 (4)

0/19 (0)


INEFFECTIVE N Ineffective/AII DS
articles (%)


Most Pharmads
Middle Pharmads
Fewest Pharmads

CAM Journals


12/35 (34)
35/142 (25)
2 1/77 (27)

11/88 (13)


N Ineffective/TOTAL
MAJOR ARTICLES


0/0
8/31 (26)
2/14 (14)

I/I I(9)


1/2 (50)
5/15 (33)
3/11 (27)

0/2 (0)


0/2 (0)
1/2 (50)
0/3 (0)

1/6 (17)


1/4 (25)
14/47 (30)
5/27 (19)

2/19 (I I)


* General medical journals with the most pharmads published a significantly higher percentage of major articles concluding that DS were unsafe than
the journals with middle or fewest pharmads or the CAM journals (P < 0.005).
The differences in rates of articles concluding that DS were ineffective among the different pharmad groups were not statistically significant.


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BMC Complementary and Alternative Medicine 2008, 8:11



P < 0.05). Although CAM journals published more origi-
nal science about DS, the proportion of major articles
concluding that DS were unsafe or ineffective was not sig-
nificantly different from general journals with middle or
fewest pharmads (Table 4).

Discussion
This is the first study to examine the relationship between
advertising in medical journals and the publication of
articles in those journals about DS. The results are consist-
ent with the hypothesis that pharmaceutical advertising
biases journals against non-drug therapies. Journals with
the most pharmads per issue published significantly fewer
major articles about DS than journals with fewer phar-
mads. For example, the two journals with the most phar-
mads published no clinical trials or cohort studies about
DS. Furthermore, journals with the most pharmads were
more likely to publish articles concluding that DS were
unsafe than journals with fewer pharmads. CAM journals
had no pharmaceutical ads, and they published signifi-
cantly more original science articles about DS; however,
they were not significantly less likely to publish major
articles suggesting that DS were unsafe or ineffective than
general medical journals with middle or few pharmads.

These results are generally consistent with a substantial
body of research suggesting that advertising influences
behavior. Advertising influences consumer behavior
[23,24]. Advertising, particularly in the forms of gifts and
samples, also influences physician prescribing behavior
[26,35,36]. This study extends those findings, and it sup-
ports growing efforts to minimize potential conflicts of
interest or at least make them more transparent, if elimi-
nating them entirely is not feasible [28,37,38].

It is possible that there might have been greater apparent
impact on publication decisions if the analysis had been
restricted to DS that are typically used to replace pharma-
ceutical products. The great majority of the articles about
DS reviewed here were about caffeinated beverages and
vitamins or other essential nutrients (minerals and essen-
tial fatty acids) which are not competitors of prescription
medications. For the most part, recent research suggests
that the DS most often used, including multivitamins, cal-
cium, iron and folate, are those often recommended by
professionals or those known to be deficient in the diet
[39-41]. Furthermore, many vitamins are manufactured
by pharmaceutical companies, thus reducing these com-
panies' potential bias against DS. For example, Centrum
products and Caltrate are manufactured by Wyeth, the
maker of Advil, Alavert, Effexor and I rlhrit.I among
many other products. These facts would tend to favor the
null hypothesis.


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On the other hand, non-vitamin/mineral supplements,
such as glucosamine, echinacea, garlic, ginseng, and
ginkgo are also frequently used by the public, often con-
currently with prescription medications [12,20], yet the
primary 11 journals included in the survey published few
research studies, editorials or reviews on these DS. Future
research will need to focus on publication about DS that
may be viewed as greater threats to the pharmaceutical
industry (such as non-vitamin/mineral products that are
used by the public to promote weight loss, improve sexual
or athletic performance, relieve joint or back pain, or to
improve memory, cardiovascular health or GI health).
Such research will need a large sample size of many types
of journals; furthermore, such research will also need to
account for potential confounding by research funding by
DS manufacturers.

This pilot study has several limitations. It included only a
few of the many clinical medical journals available and
used only the American library version of these journals,
but it did focus on those with very high readership that are
often quoted by professional organizations, the media
and policymakers. Results from the smaller secondary
analysis of the CAM journals would be enhanced by larger
sample of more diverse CAM publications. The review did
not specifically address the funding for different trials or
evaluate the methodologic quality of the published trials.
This study was not a survey of journal editors regarding
the number of submissions of different types they receive
or how they decide which articles to include. An alterna-
tive hypothesis that might explain these findings is that
journals with a high number of pharmaceutical ads
receive few submissions about dietary supplements; fur-
thermore, it is possible that a large number of articles
about dietary supplements are of poor quality and do not
deserve publication. It is also possible that the observed
associations are due to another underlying factor ; for
example, one recent study reported that in high impact
journals, European journals were approximately twice as
likely as American journals to publish positive articles
about complementary therapies [42]. In addition, this
study used the number of issues per journal as the study
denominator rather than the total number of articles per
issue; future studies could use the number of articles per
issue as the denominator to address the related question
of whether journals with more advertising per issue also
have fewer articles of all types and hence fewer articles
about dietary supplements. Future studies on this topic to
explore alternative hypotheses for our findings should
include a larger number of journals and more diverse
journals; additional studies might also survey journal edi-
tors to determine the number of articles submitted for
consideration for publication and ask about the percent-
age of submissions related to dietary supplements.



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BMC Complementary and Alternative Medicine 2008, 8:11




Conclusion
These findings support the hypothesis that in major med-
ical journals, more pharmaceutical advertising is associ-
ated with publishing fewer articles about DS and having
more negative conclusions about DS safety. While await-
ing future definitive studies to confirm these findings in a
larger, more diverse sample of journals and to explore
alternative explanations, these data support current efforts
to reduce conflicts of interest in medical publishing and to
make any such conflicts more transparent. The impact of
advertising on publications appears to be non-trivial; the
ultimate impact of this bias on professional guidelines,
health care, and health policy is a matter of great public
concern and underscores the need for additional health
services research on this topic.


Competing interests
The authors) declare that they have no competing inter-
ests.

Authors' contributions
KK conceived of the project, designed the data collection
form, reviewed data analysis, drafted and revised the man-
uscript

KH reviewed journals, entered data, assisted with data
analysis and manuscript preparation

Both authors read and approved the final manuscript.


Acknowledgements
We thank Elizabeth Hankinson from Wake Forest University for her help
in reviewing articles. We thank Paula Gardiner for her constructive feed-
back on earlier versions of this manuscript. EH and PG received no financial
compensation for contributing to this work. Support: Dr. Kemper is sup-
ported by NIH NCCAM Mid-Career Award K24-AT00022207. The con-
tents of this manuscript are solely the responsibility of the authors and do
not necessarily represents the official views of the NCCAM or the National
Institutes of Health.

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