Studies published in medical journals are an important way to provide evidence of the effectiveness of pharmaceuticals. Respected in the industry, journals like the Lancet or the New England Journal of Medicine (NEJM) are written for a scientific audience, peer-reviewed, and provide disclosures of conflicts of interests of the paper authors.
But there is one conflict of interest medical journals often don’t disclose—their own. Journals often won’t give information on their streams of revenue, so for instance it’s hard to tell how much of their income comes from advertising, subscriptions, and other sources.
While some of the influences—for instance, advertisements or sponsorships from drug makers—are more visible, there are indirect ways in which journals are incentivized to publish studies that show the positive impact of drugs. Income from study reprints is a particularly complicated one.
Reprints make money
A reprint is a reproduction of a study or paper published in a journal, often purchased in bulk. When a study shows positive outcomes associated with a drug, the pharmaceutical company that made it often will buy reprints to disseminate in the industry, often to promote the use of the drug among doctors and other prescribers.
The sales of copies of a study might not seem like a gateway to riches, but the reprint purchases can add up to more than $2 million each. That is significant revenue, especially for large journals. The Lancet’s revenue total annual is estimated to be about $40 million a year, while NEJM generates around $100 million—of which about a third is profit. Reprints are also more profitable than advertising because the production costs are much lower, according to Richard Smith, the former editor of the British Medical Journal and a longtime advocate for more transparency in how the drug industry influences journal publications.
Medical journals are published by medical societies—for instance, the Massachusetts Medical Society owns NEJM)—or specialized companies that own one or more publications, such as Dutch company Elsevier, which owns The Lancet and other medical and scientific publications. They are edited and managed by researchers experts in the field, who evaluate paper submissions by scientists and decide which ones are worth accepting for publication. These papers are then sent to other scientists for peer review, then work on the feedback with the authors. Peer reviews can lead to changes (although they often don’t), and occasionally cause papers to be withdrawn.
This, Smith explains, puts editors of journals in a complicated position when it comes to publishing studies that assess the benefits of a drug through trials that are sponsored exclusively, or in part, by the drugmaker. If publishing a hypothetical industry-funded article could offer a return of $700,000 in reprints, declining to publish it—or even requesting more data with the risk that another publication might publish the study instead—means forgoing a big chunk of revenue.
“It’s a significant amount of income for journals. It sounds like it’s just a little add-on, but in 2011, 41% of the Lancet’s income came from the sale of reprints, so it’s not a minor issue,” says John Abramson, a Harvard Medical School professor and the author of Sickening, a book on the role of big pharma’s pursuit of profit in American healthcare.
The 2011 analysis of the Lancet’s income is one of the few that was able to obtain any data on reprint revenue, and it is likely many journals earned even more from reprints but didn’t disclose their data. But although the conflict of interest associated with sales of reprints has been well known for a long time, there has been no improvement in journals’ transparency.
“I think what it points at is the utter lack of transparency,” says Ivan Oransky, the founder of Retraction Watch and a professor of medical journalism at New York University. “Here are these journals that universally require—and this is a good thing—significant transparency and significant disclosure from their authors…but are not in any way transparent themselves.”
The Lancet, the Journal of the American Medical Association (JAMA), and the International Committee of Medical Journal Editors didn’t respond to Quartz’s request for data and comment. NEJM said it does not share the revenue of individual publications of the Massachusetts Medical Society.
Citations create impact
Complicating the issue further is that studies on the effectiveness of drugs based exclusively on industry-supported trials are more likely to be published, making up to 32% of the total number of studies published. And because they are often positive, they are cited more often, as they need to be referred to in following studies building upon their findings.
Journals derive benefits by being largely cited. Their relevance is quantified through the so-called impact factor, which is a reflection of the volume of citations of articles of a specific journal. So the more a study is likely to be cited, the more it is in the interest of a publication to publish it because it will bring up its impact factor.
This makes industry-sponsored studies all the more appealing to journals. “It creates a conflict of interest in the medical journal industry, because they then have a financial incentive not to demand all the data, not to review as critically as they might if they had no opportunity for financial gain,” says Abramson.