59 The International Committee of Medical Journal Edi- tors (ICMJE) has outlined ethical guidelines concern- ing the advertising practices of peer-reviewed journals that briefly discuss issues of excessive and dispropor- tionate advertising. The authors evaluated these guide- lines using quantitative data, assessing the types and frequencies of advertising in 2001 print issues of NEJM and JAMA, two principal members of ICMJE. Advertis- ing ratios (ratio of advertisements to editorial content) were near unity in NEJM and 0.30 in JAMA, compared with reported ratios of 0.15 among low-circulation specialty science journals and 0.80 among high-circu- lation consumer magazines. In both journals, five cor- porations placed more than 50% of all display adver- tisements. The findings suggest a dissonance between the ethical guidelines and the de facto advertising practices of arguably the two most important member journals of the ICMJE. There is a need to define and apply standards for excessive and disproportionate advertising. Key words: advertising; readership; editors; ethics, peer review. INT J OCCUP ENVIRON HEALTH 2006;12:59–64 T he International Committee of Medical Journal Editors (ICMJE) has outlined a series of uni- form requirements for manuscripts submitted to biomedical journals. The requirements discuss vari- ous ethical and practical issues of publication relating to manuscripts, authors, editors, and journals. Editors from both New England Journal of Medicine (NEJM) and Journal of the American Medical Association (JAMA) helped write the guidelines. 1 The guidelines state: Journals should not be dominated by advertising, but editors should be careful about publishing advertisements from only one or two advertisers as readers may perceive that the editor has been influ- enced by these advertisers. 1 There is uncertainty as to a measurable definition of “dominated by advertisements.” Furthermore, the ICMJE guidelines to not discuss whether the criterion for disproportionate advertising that is restricted to one or two companies adequately addresses the com- plexity of publisher–advertiser relationships and the potential influence of any large advertising account irrespective of how many other accounts may buy space in a journal. Advertising in peer-reviewed journals introduces physicians to new treatments 2,3 and provides both jour- nals and publishing companies revenue that helps ensure their survival in a very competitive and increas- ingly costly industry. But there may be discord between the financial motivations of the advertisers and the objectives of the peer-reviewed science journals to pro- vide impartial and accurate information. 4 NEJM and JAMA are frequently cited by the lay press and are a primary reference for physicians.5–7 There- fore, there is a case for investigating whether NEJM and JAMA adhere to the ethical principles set forth by the ICMJE. But more important, by evaluating the advertis- ing practices in these two flagship journals we can better assess the adequacy of the ICMJE advertising guidelines through the use of quantitative measures. In this study, we assessed the type and frequency of adver- tising in both journals in order to begin to better define what constitutes excessive and disproportionate advertising. METHODS We selected NEJM and JAMA because they have the highest reported circulations among general medicine journals, 8 and are the most frequently cited general medicine journals both in peer-reviewed journals 9 and in the lay literature. 5,6 We reviewed all the advertise- ments placed in print 2001 issues of NEJM and Commentaries Excessive and Disproportionate Advertising in Peer-reviewed Journals LEE S FRIEDMAN, MS, ELIHU D RICHTER, MD, MPH Received from The Social Policy Research Institute, Skokie, Illi- nois (LSF); the University of Illinois School of Public Health, Chicago, Illinois (LSF); and Hebrew University–Hadassah School of Community Medicine and Public Health, Unit of Occupational and Environmental Medicine, Injury Prevention Center, Jerusalem, Israel (EDR). Address correspondence and reprint requests to: Lee Friedman, Director, The Social Policy Research Institute, 8423 Monticello Avenue, Skokie, IL 60076, U.S.A.; telephone: (847.) 530.7926; fax: (847) 673.3505, e-mail: <lfriedman@tspri.org>.