1. The role of journals in promoting prevention (beyond the publication of original research) Richard Smith Editor, BMJ Marbella, April 2003 www.bmj.com/talks

2. Or, “Can journals change the world?”

3. No

4. What I want to talk about What can journals do and what can’t they do? Can journals lead or must they follow? What journals have tried to do to contribute to the prevention of cardiovascular disease? How can we make change happen? What more might journals do?

5. What can journals do and what can’t they do? They rarely lead directly to change in behaviour Information on paper rarely changes practice on its own We know this from the Cochrane review of what changes practice, but all those involved in the business of making change happen know it

6. What can journals do and what can’t they do? “Know how does not transfer as information transfers. Know how comes from learning.” “Innovation spreads through people not on paper.” “Imagine trying to get somebody to learn to tie their shoes through writing it down and publishing it in the BMJ” Peter Senge (fellow at MIT and inventor of the learning organisation)

7. Examples of change resulting directly from publication I Photodynamic therapy with a new drug might cause severe burns Hettiaratchy S, Clarke J, Taubel J, Besa C. Burns after photodynamic therapy. BMJ 2000; 320: 1245

10. Examples of change resulting directly from publication II The use of albumin in critically ill patients may be dangerous Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: a systematic review of randomised controlled trials. BMJ 1998; 317: 235-240

12. Examples of change resulting directly from publication III Minocycline should not be used as the first line treatment of acne Made the front page of the Daily Mail, which might be Britain’s most influential newspaper Gough A, Chapman S, Wagstaff K, Emery P, Elias E. Minocycline induced autoimmune hepatitis and systemic lupus erythematosus-like syndrome. BMJ 1996;312:169-72

14. What can journals do? Promote debate: “Where there is much desire to learn there of necessity will be much arguing, much writing, many opinions; for opinion in good men is but knowledge in the making.” John Milton

15. What can journals do? Set agendas “This is something that you should know and think about. It may affect you.” Legitimise “This is something that it’s important and legitimate for you to think about”

16. Can journals lead or must they follow? George Lundberg, editor of JAMA, JAMA –Promoting a tobacco free society –Preventing nuclear war –Drawing attention to the plight of the uninsured in America, Promoting the control of violence –Promoting research into peer review New England Journal of Medicine –Describing and deploring the industrialisation of medicine –Drawing attention to the importance of conflict of interest

17. Can journals lead or must they follow? George Lundberg, editor of JAMA, BMJ –Fighting tobacco –Improving the standard of statistics in medical journals. Lancet –Reducing the risk of nuclear war –Encouraging the internationalisation of medicine. Canadian Medical Association Journal –Critical appraisal of scientific papers.

18. Can journals lead or must they follow?

19. "We judge as important what the media judge as important." Maxwell McCombs and Donald Shaw, authors of the theory of "agenda setting" "The press may not be successful much of the time in telling people what to think, but it is stunningly successful in telling its readers what to think about.” Bernard Cohen, a political scientist from the University of Wisconsin, “A subject that needs reform should be kept before the public until it demands reform Hugh Clegg, editor, BMJ

20. Can journals lead or must they follow? McCombs and Shaw analysed the 1968 presidential race between Nixon and Hupert Humphrey by looking at 9 print and broadcast media used by Chapel Hill residents Ranked stories by position and length They considered five major issues: foreign policy, law and order, fiscal policy, public welfare, and civil rights. They then looked at how undecided voters ranked these issues and found that they ranked exactly the same as the media

21. Can journals lead or must they follow? But which came first the media agenda or the voters' agenda? There have been many subsequent studies, and the general finding is that the media interest comes first. Agenda setting works best when people are interested in a subject but very uncertain about what to think. For example, I own a cat and hence am interested in animal experimentation, but I am very uncertain about what the risks and benefits might be.

22. Tentative conclusion Journals may be able to lead rather than simply reflect But perhaps only by a nose Get too far ahead of the troops and you’re dead meat

23. What journals have tried to do to contribute to the prevention of cardiovascular disease beyond publishing original research?

24. What have journals done? A tsunami of anti-smoking material Ever since we knew the dangers of smoking: initially with the idea that once people knew the dangers everybody would stop Political editorials supporting price increases, bans on advertising, reduction of outlets Advocacy material Advice to doctors on how to help patients stop smoking

25. What have journals done? A whole journal: Tobacco Control Can’t be listed in Index Medicus--”doesn’t give both sides”; Should a cancer journal include pro-cancer material? No coverage for libel

26. What have journals done? Held a vote on whether the editor of the BMJ should resign from a chair at Nottingham University because the university took £3.8m from BAT for a centre for corporate responsibility “A cheap publicity stunt to promote an ailing journal”: University vice- chancellor Worldwide publicity

28. What have journals done? Some similar material on nutrition and the food industry--but journals (like medicine generally) are poor on nutrition, and the pressure on the industry has been much less than on the tobacco industry We did have an ABC of nutrition. Our ABCs are designed to be very practical-- guidance on what to do Confusing coverage on alcohol (I was a rabid anti-alcohol campaigner in 1982, now I’m “a bottle of Fleuri with dinner” man)

29. What have journals done? Rather haphazard coverage of obesity and exercise A fair bit of editorial coverage on statins--but probably all irrelevant compared with the power of drug companies ABCs on diabetes, hypertension, etc Quality improvement reports--not original research but attempts to make change happen; concentration on methods and lessons rather than results

30. Moving beyond journals to make change happen: sorry if this sounds like advertising-- but it is a bit

32. Making change happen Provide people with what the evidence says--”a necessary but not sufficient condition”--Clinical Evidence, a compendium of evidence based answers to common clinical questions “Just in time information”--Clinical Evidence Interactive Learning (education is a dirty word)--BMJ Learning

33. Making change happen Give the evidence directly to patients--Besttreatments.org, a resource to be used simultaneusly by physicians and patients Promote the methods of improvement--Quality and Safety in Healthcare, international forums on improvement

34. What more could journals do? More investigative journalism Get smarter with spin/public relations Be more strategic in promoting prevention: a campaign A global theme issue on prevention of cardovascular disease ABC of prevention of cardiovacular disease Any suggestions from you?

35. Conclusions Journals have limited power to make change happen They are better at setting agendas, promoting debate, stirring people up They have been fairly energetic in combating the harm of tobacco Less effective with other preventive issues; could do better

36. Conclusion Don’t worry--in a few weeks the BMJ will publish some papers that will “solve the problem of heart disease” You can cancel the next conference and start looking for other jobs