Stealth Marketing

by: Jeanne Lenzer

Everybody knows that manufacturers of everything from cornflakes to cars pay screenwriters and producers handsomely for the placement of branded products in movies and TV shows.

It's less widely known that stealth advertising is also used by the health care industry, which frequently puts its marketing messages into the mouths of seemingly independent third parties. In this way, the third party – usually an academic physician, a professional association, or a patient group – lends credibility to the message while disguising its origin.

Public relations departments even give pet names to the entities that they use to communicate their messages. Pre-existing lay patient groups – often financed with contributions from industry – are called "grassroots" organizations. Doctors who have been wined and dined and recruited into speaker's bureaus by the industry are called KOLs (Key Opinion Leaders). And politicians and celebrities who serve as paid spokesmen are called "grasstops" entities (in contrast to those "grassroots" groups).

Organizations created out of whole cloth by the industry are known as "astroturf" groups (a neat play on AstroTurf, the fake grass product). Typically, the lay forms of these groups are established around a single disease or condition. The sponsoring drug company provides organizational funding, sometimes placing one or more of its own executives "on loan" to the group, which promotes "disease recognition" and the need for a certain drug – which by a happy circumstance is manufactured by the drug company funding the group. The professional version of front groups include some think tanks and professional associations, which will generally advocate industry-friendly policy while attacking critics (sometimes smearing them personally in order to neutralize criticism).

Front groups often adopt organizational names that sound similar to those of public interest groups. For example, the Center for Medicine in the Public Interest sounds quite like the Center for Science in the Public Interest. The latter group, CSPI, is a genuine public interest group that tracks industry activities. The former, on the other hand, is funded by industry and run by well-known pharmaceutical industry advocates. Its goals are to minimize regulation and promote "free enterprise."

So, what's wrong with all this? Isn't it helpful if a patient or celebrity who benefits from a treatment promotes that success? Isn't it smart to find doctors who can explain the benefits of a new treatment? The problem is that, as we have seen with Vioxx and a host of other discredited drugs, devices, and insurance schemes – patients, celebrities, and doctors can all be fooled.

To obtain genuinely disinterested and critical analyses of treatments, tests and devices, journalists have to ask hard questions about where sources get their money – and about the science they are promoting. Following the money trail can be daunting. But, increasingly, journalists and whistleblowers are doing just that and uncovering important connections.

In one instance, a researcher published a study claiming that lung cancer mortality could be slashed through the use of regular CT scan screening. Skeptical doctors and reporters not only raised questions about the researcher's claims, but eventually uncovered financial conflicts of interest that threw even more doubt on the study. It turns out that the study was funded by the Foundation for Lung Cancer, which had received $3.6 million from the tobacco industry.

What's the conflict? The tobacco industry stood to benefit handsomely if it could make smoking appear to be less risky, thanks to CT scan screening. It's not just drug and medical device manufacturers that use third-party techniques.

The health insurance industry, for example, faced with polls showing that a majority of physicians and the public support a single-payer universal health care system, has created its own astroturf group: the Campaign for an American Solution. The Campaign was founded by the insurance industry trade association, America's Health Insurance Plans. The Campaign plans to enroll 100,000 lay members. It just might be able to do it, too: the trade association hired Beth Leonard, a former state campaign director for former Sen. John Edwards' failed campaign for the Democratic presidential nomination, to direct field staffers and volunteers in up to 20 states. The Campaign promotes the idea that a single-payer system will limit choice and that only the continued presence of health insurance companies will ensure quality health care for all.

Ask tough, specific questions

How can journalists ferret out these frequently hidden financial conflicts of interest? Ask every source about any financial conflicts of interest they might have – but only after you've done your homework. Make your question broad and inclusive. Don't ask, "Are you receiving money from Pfizer?" Instead ask, "Have you received in the past five years, or are you now receiving, any sort of payments, grants, expense reimbursements, or any form of consideration from a drug or medical device company or do you hold any stock or stock options in one?"

By asking the question this way, they know you mean business. And remember, many drug companies have partnering agreements with seeming competitors to develop and distribute various drugs – so always check on all industry ties. Learning as much as possible in advance can help get the confirmation you need to ensure accuracy.

While reporting one story, I was told by two doctors that they had no financial ties to Genentech, the maker of the clot buster drug, tPA. Both doctors, while serving as experts on an American Heart Association panel, had voted to make tPA a "highly recommended" treatment for acute stroke. One doctor was the lead researcher on a Genentech-sponsored study published in the Journal of the American Medical Association (JAMA). Confronted with a copy of the JAMA article, the doctor said he "didn't realize" he was listed as the principal investigator.

The other doctor, who was in Genentech's speakers bureau, said, "I didn't realize I was officially on the speakers bureau."

• Do a PubMed search of an expert's journal articles. Look in the disclosures section by searching his or her name in the article. Remember, just because an expert doesn't declare a financial conflict doesn't mean he doesn't have one.

• Go to the subject's or source's Web site. Many universities and hospitals include the curriculum vitae (CV) and even the research history of physicians online. Look for research grants, employment history and other clues to industry ties. If his CV is not available online; request it from the doctor's secretary. You can say that you want to learn as much as you can in preparation for an interview.

• Use a standard search engine and search under the expert's name. If you suspect a tie to a certain drug company, add the company name as a search term. This will often draw up irrelevant Web pages, but occasionally can reveal that your expert gave a company-sponsored talk or received a grant.

• Check for known funding issues and conflicts of interest at the Center for Media and Democracy's SourceWatch project and the Integrity in Science database of the Center for Science in the Public Interest. SourceWatch is a superb Web site and one of my most trusted sources of information. However, it only lists people of significant stature or exposure. CSPI, on the other hand, maintains a database without regard to stature, but it is far from exhaustive and relies on past reports from journalists and others.

• Check with critics of your source. My tip about the doctor in the Genentech speakers bureau came from a critic. I was able to confirm the tie before I spoke with the doctor.

Check possible conflicts within organizations as well. When I researched a public radio show in which four experts expounded on the benefits of antidepressants, the producer of the show insisted that the show hadn't received any funding from a drug company. But that seemed suspect, since he had chosen only guests with a singular viewpoint. So I searched and searched until I found the small print on earlier episodes of the show indicating that the series had received money from a leading antidepressant drug maker, and I simply wrote that the show received an "undisclosed" amount of money. In the flap that ensued after my piece ran in Slate, the producer acknowledged that it had received $100,000 in 2006 from Eli Lilly, the maker of Prozac.

Here are some sites that can help you spot possible conflicts within organizations:

• Drug company Web sites often provide extensive information, particularly on their "information for investors" Web pages, where links to SEC filings and other financial information can be obtained.

• Use Guidestar to check the financials for non-profit organizations such as the American Cancer Society. Guidestar provides links to tax forms (990s), annual reports and financial statements and gives organizational overviews.

• For tax returns of organizations not listed with Guidestar, consult Foundation Center.

• The Source Watch project offers reliable information about funding sources of organizations. Its parent organization, Center for Media and Democracy, provides a great overview on backgrounding front organizations.

Find independent voices

Of course, simply because a researcher or an expert has a financial conflict of interest doesn't mean that his medical claim or opinion should be discounted. But the conflict should alert journalists to the increased risk of bias and spur interviews with those who do not have a vested interest in a study outcome or medical claim.

To help journalists find independent experts, journalist Shannon Brownlee and I have compiled a list of sources without industry ties HealthNewsReview.org is also an excellent Web site for journalists looking to improve their healthcare reporting. But beware: HealthNewsReview.org gives out grades on what we write.

* Jeanne Lenzer is a freelance medical investigative journalist and former Knight Science Journalism fellow.