The role of public participation in public health initiatives: an analysis of the WHO Framework Convention on Tobacco Control

This is a content analysis of 489 written documents and 142 hearing testimonies, submitted to the World Health Organisation (WHO), regarding the Framework Convention on Tobacco Control (FCTC) during the comment period of 2000. Our aim was to consider the benefits and limitations of inviting public participation. We found that, overall, those who offered commentary were in support of the FCTC and any ensuing treaty, especially if it protected children. The minority who opposed the treaty argued that restrictions on tobacco trade would further damage the economies of poor nations that are financially dependent upon tobacco. The FCTC that was adopted at the World Health Assembly in May 2003 addressed many of the concerns raised by the public in written commentary and hearing testimony: children and youth; advertising and sponsorship; tobacco product labelling; second-hand smoke; taxes; smuggling; liability; tobacco product regulation; and the involvement of non-government organisations (NGOs). We conclude that the benefits of public participation in public health policy formation are numerous, including levelling the playing field for public health activists and NGOs, building the expertise of advocates that can be generalised to other public health efforts, giving the political process legitimacy and credibility, as well as coalition building and grassroots momentum.

Creating a text data-mining application for use in public health informatics

Recent litigation and the Master Settlement Agreement of 1998 have made millions of tobacco industry internal documents available on the Internet (http://legacy.library.ucsf.edu). The Legacy interface, housed at the University of California, San Francisco, is based on a traditional information retrieval model in which documents are indexed and retrieved based on user-specified queries. One problem with the Legacy interface is information overload. In an attempt to ease this problem, we are developing a text-mining interface to enable exploratory analysis and discovery of information from collections of data. Users could uncover new patterns and concepts and thus text mining could result in searches that are targeted and specific, which would decrease information overload. In order to determine information needs, nine in-depth interviews with regular users of the Legacy interface were conducted. Results show that participants identified clustering as a useful tool in identifying and extracting key concepts and identified the need to recognize relationships between terms and concepts within the data. We encourage researchers who are developing text-mining interfaces to survey the users to learn what particular aspects of their research could be enhanced by text mining.

The limits of competing interest disclosures

OBJECTIVE

To assess the effectiveness of conflict of interest disclosure policies by comparing a competing interests disclosure statement that met the requirements established by the journal in a 2003 article on health effects of secondhand smoke based on the American Cancer Society CPS-I dataset with internal tobacco industry documents describing financial ties between the tobacco industry and authors of the study.

DESIGN

Descriptive analysis of internal tobacco industry documents retrieved from the Legacy Tobacco Documents Library, University of California, San Francisco.

RESULTS

Meeting the requirements for financial disclosure established by the journal did not provide the reader with a full picture of the tobacco industry's involvement with the study authors. The tobacco industry documents reveal that the authors had long standing financial and other working relationships with the tobacco industry.

CONCLUSION

These findings are another example of how simply requiring authors to disclose financial ties with the tobacco industry may not be adequate to give readers (and reviewers) a full picture of the author's relationship with the tobacco industry. The documents also reveal that the industry funds research to enhance its credibility and endeavours to work with respected scientists to advance its goals. These findings question the adequacy of current journal policies regarding competing interest disclosures and the acceptability of tobacco industry funding for academic research.

Systematic reviews of the effectiveness of quality improvement strategies and programmes

Systematic reviews provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies. The methods of systematic review of individual patient randomised trials of healthcare interventions are well developed. We discuss methodological and practice issues that need to be considered when undertaking systematic reviews of quality improvement strategies including developing a review protocol, identifying and screening evidence sources, quality assessment and data abstraction, analytical methods, reporting systematic reviews, and appraising systematic reviews. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care (EPOC) review group.

Science in regulatory policy making: case studies in the development of workplace smoking restrictions

OBJECTIVE

To study the role of science related and other arguments in the development of workplace smoking regulations.

DESIGN

Case study, content analysis

SUBJECTS

Written commentaries and hearing transcripts on proposed indoor air regulations in Maryland and Washington.

MAIN OUTCOME MEASURES

We coded each written commentary and hearing testimony for position toward the regulation, affiliation of the person submitting it, criteria used to evaluate science and scientific, ideological, economic, political, engineering and procedural arguments.

RESULTS

In both states, opposition to the regulations came primarily from the tobacco industry, small businesses, and business organisations and appeared to be coordinated. There was little coordination of public health support for the regulations. Arguments about science were used more often by those opposed to the regulations than by those in favour. Supporters emphasised the quantity of the evidence, while opponents criticised its reliability, validity, and quality. Arguments not related to science (61% of total arguments; 459/751), were more common than scientific arguments (39% of total arguments; 292/751). Economic and ideological arguments were used to a similar extent by regulation supporters and opponents.

CONCLUSIONS

Advocates can support health related regulations by submitting commentary emphasising the sound research base for regulation and countering criticisms of research. National coordination of these efforts could avoid duplication of effort and make more efficient use of limited public health resources.

Policy makers' perspectives on tobacco control advocates' roles in regulation development

OBJECTIVE

To identify, from policy makers' perspectives, strategies that enhance tobacco control advocates' effectiveness in the regulatory arena.

DESIGN

Key informant interview component of a comparative case study of regulatory agencies in the USA.

SUBJECTS

Policy makers involved in the development of four regulatory tobacco control policies (three state and one federal).

METHODS

Interviews of policy makers, field notes, and deliberation minutes were coded inductively.

RESULTS

Policy makers considered both written commentary and public testimony when developing tobacco control regulations. They triaged written commentary based upon whether the document was from a peer reviewed journal, a summary of research evidence, or from a source considered credible. They coped with in-person testimony by avoiding being diverted from the scientific evidence, and by assessing the presenters' credibility. Policy makers suggested that tobacco control advocates should: present science in a format that is well organised and easily absorbed; engage scientific experts to participate in the regulatory process; and lobby to support the tobacco control efforts of the regulatory agency.

CONCLUSIONS

There is an important role for tobacco control advocates in the policy development process in regulatory agencies.

Cigar magazines: using tobacco to sell a lifestyle

OBJECTIVE

To assess the content of two cigar "lifestyle" magazines, Cigar Aficionado and Smoke.

DESIGN

Content analysis of cigar focused articles.

SUBJECTS

Cigar focused articles (n = 353) from Cigar Aficionado and Smoke magazines.

MAIN OUTCOME MEASURES

Primary focus; mention of health effects, environmental tobacco smoke, or scientific research; quotation and description of individuals; characteristics such as sex, age, ethnicity, smoking status, affiliation, and stance towards cigars; and overall image of cigars.

RESULTS

Cigar business-focused articles were the largest category (40%, n = 143), followed by articles about cigar events (12%, n = 42). Notable were articles featuring cigar benefits to raise money for health charities. Celebrities were featured in 34% (n = 121) of articles and 96% (n = 271) favoured cigar use. Only four (1%) articles featured health effects of cigars as a primary focus.

CONCLUSIONS

Cigar Aficionado and Smoke broke new ground in tobacco marketing by combining promotion of product, lifestyle, and industry in the same vehicle and linking the medium directly to product related events that extended its reach. The creation and marketing of new tobacco use sites challenges the increasing "isolation" of smokers, and positions cigar use as a socially welcome relief from restrictions. Public health advocates should anticipate and challenge other new tobacco marketing vehicles as communications technologies advance and public spaces for smoking shrink.

Taking advantage of the explosion of systematic reviews: an efficient MEDLINE search strategy

CONTEXT

Systematic reviews of the literature are an important resource for clinicians. Unfortunately, the few published strategies for identifying these articles involve MEDLINE interfaces not widely available outside of academic medicine. In addition, the performance of these strategies is unknown.

OBJECTIVE

To develop and evaluate a search strategy for identifying systematic reviews by using a publicly available MEDLINE interface (PubMed).

DESIGN

Diagnostic test assessment. DEFINITION OF SENSITIVITY: The proportion of recognized systematic reviews (indexed in the Cochrane Library's Database of Abstracts of Reviews of Effectiveness [DARE] or in ACP Journal Club) that are identified by the search strategy. DEFINITION OF POSITIVE PREDICTIVE VALUE: The proportion of articles identified in one of three sample searches (screening for colorectal cancer, thrombolytic therapy for venous thromboembolism, and treatment of dementia) that meet a minimum definition of systematic review.

RESULTS

Our PubMed search strategy identified 93 of 100 DARE-indexed systematic reviews, a sensitivity of 93% (95% CI, 86% to 97%). For the sample of systematic reviews drawn from ACP Journal Club (n = 103), the PubMed strategy achieved a sensitivity of 97% (CI, 91% to 99%). When the three sample search strings were used, approximately 50% of retrieved articles met our minimum definition of systematic review. In contrast, the similar precision of a PubMed search restricted to review-type articles (as indexed by MEDLINE) was less than 10%.

CONCLUSIONS

This search strategy identified most systematic reviews without over-whelming users with numerous false-positive results. A "single-click" filter based on this strategy is now available as part of the Clinical Queries feature of PubMed.

Lessons learned from the tobacco industry's efforts to prevent the passage of a workplace smoking regulation

OBJECTIVES

This study assessed the implementation of tobacco industry strategies to prevent a workplace smoking regulation.

METHODS

Tobacco industry internal documents were identified; hearing transcripts for the affiliations, arguments, and positions regarding the regulation of testifiers were coded; and media coverage was analyzed.

RESULTS

Tobacco industry strategies sought to increase business participation and economic discussions at public hearings and to promote unfavorable media coverage of the regulation. The percentage of business representatives opposing the regulation grew from 18% (5 to 28) to 57% (13 of 23) between the hearings. Economic arguments opposing the regulation rose from 25% (7 of 28) to 70% (16 of 23). Press coverage was neutral and did not increase during the period of the regulatory hearings.

CONCLUSIONS

The tobacco industry was successful in implementing 2 of its 3 strategies but was not able to prevent passage of the comprehensive workplace regulation.

Assessing faculty financial relationships with industry: A case study

CONTEXT

A growing number of academic researchers receive industry funding for clinical and basic research, but little is known about the personal financial relationships of researchers with their industry sponsors.

OBJECTIVES

To assess the extent to which faculty researchers have personal financial relationships with the sponsors of their research, the nature of those financial relationships, and efforts made at the institutional level to address disclosed financial relationships and perceived conflicts of interest.

DESIGN AND SETTING

Case study of the University of California, San Francisco (UCSF). Data sources included disclosure forms and official documents maintained by the UCSF Office of Research Administration from December 1980 to October 1999, including decisions made by the UCSF Chancellor's Advisory Panel on Relations with Industry.

MAIN OUTCOME MEASURES

Number and types of personal financial relationships with external sponsors (positive financial disclosures from all clinical, basic, or social science faculty who were principal investigators), amount of annual income received from sponsors, and decisions and management strategies used by the advisory panel.

RESULTS

By 1999, almost 7.6% of faculty investigators reported personal financial ties with sponsors of their research. Throughout the study period, 34% of disclosed relationships involved paid speaking engagements (range, $250-$20, 000 per year), 33% involved consulting agreements between researcher and sponsor (range, <$1000-$120,000 per year), and 32% involved the investigator holding a position on a scientific advisory board or board of directors. Fourteen percent involved equity ownership, and 12% involved multiple relationships. The advisory panel recommended managing perceived conflicts of interest in 26% of the cases, including recommending the sale of stock, refusing additional payment for talks, resigning from a management position, or naming a new principal investigator for a project.

CONCLUSIONS

Faculty researchers are increasingly involved in financial relationships with their research sponsors. Guidelines for what constitutes a conflict and how the conflict should be managed are needed if researchers are to have consistent standards of behavior among institutions. JAMA. 2000;284:2209-2214.

Cigars, youth, and the Internet link

OBJECTIVES

This study examined the accessibility and appeal to youth of cigar marketing sites on the Internet.

METHODS

Sites marketing cigars (n = 141) were examined for age restrictions, prices, health warnings, and other elements.

RESULTS

Although it is illegal for minors to purchase tobacco, only 36 sites (25.5%) prohibited purchases by minors. Sites offered low prices, and 32% accepted money orders, cashier's checks, or cash-on-delivery (COD) orders. Almost 30% of the sites included elements with potential youth appeal; only 3.5% displayed health warnings.

CONCLUSIONS

The unregulated promotion of cigars on the Internet has the potential to attract youth, and there are few barriers to Internet tobacco purchases by minors.

Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes

BACKGROUND

In recent years pharmacists' roles have expanded from simply packaging and dispensing medications to working with other health care professionals and the public.

OBJECTIVES

To assess the effects of expanding outpatient pharmacists' roles on health services utilisation, the costs of health services, and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE, EMBASE, Pharmline, International Pharmaceutical Abstracts and reference lists of articles up to December 1995. We also searched the published abstracts of three meetings and hand searched five journals and two bibliographies.

SELECTION CRITERIA

Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of interventions comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus no intervention; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; and 4. Pharmacist services targeted at health professionals versus no intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Fourteen studies were included involving more than 1991 patients. In the one study identified for comparison 1 the relative changes in professional outcome measures ranged from a 24% increase in clinic visits to a 16% decrease in hospital admissions. Relative differences in patient outcome measures were not statistically significant. Seven studies were identified for comparison 2. Four measured process of care and demonstrated decreases in health services utilisation from -67% for hospital admissions to -564% for total ambulatory care visits, as well as decreases in the numbers and costs of drugs compared to control patients. Five measured patient outcomes and consistently reported improvements in the targeted patient condition. In the one study identified for comparison 3 the intervention delivered by the pharmacist was less successful than that delivered by physician counsellors in decreasing inappropriate antibiotic prescribing. All six studies identified for comparison 4 demonstrated that the pharmacist intervention produced the intended effect on physician prescribing practices. These studies did not measure patient outcomes.

REVIEWER'S CONCLUSIONS

The limited number of studies analysed support the expanded roles of pharmacists in patient counselling and physician education. However, doubts about the generalisability of the studies, the poorly defined nature of the interventions tested, and the lack of studies including cost assessments and patient outcome data indicate that more rigorous research is needed to document the effects of outpatient pharmacist interventions.

Printed educational materials: effects on professional practice and health care outcomes

BACKGROUND

It is often assumed that merely providing information in an accessible form will influence practice. Although such a strategy is still widely used in an attempt to change behaviour, there is a growing awareness that simply providing information may not lead to appropriate changes in the practice of health care professionals.

OBJECTIVES

To assess the effects of printed educational materials in improving the behaviour of health care professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, reference lists of articles, and contacted content area experts.

SELECTION CRITERIA

Randomised trials, interrupted time series analyses and non equivalent group designs with pre-post measures of interventions comparing 1. Printed educational materials versus a non-intervention control; and 2. Printed educational materials plus additional implementation strategies versus printed educational materials alone. The participants were any health care professionals provided with printed educational materials aimed at improving their practice and/or patient outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Eleven studies were included involving more than 1848 physicians. It proved impractical to examine the impact of interventions quantitatively because of poor reporting of results and inappropriate primary analyses. Nine studies examined comparison 1. Estimates of the benefit from printed educational materials ranged from -3% to 243.4% for provider outcomes, and from -16.1% to 175.6% for patient outcomes, although the practical importance of these changes is, at best, small. Six studies (seven comparisons) examined comparison 2. Benefits attributable to additional interventions ranged from -11.8% to 92.7% for professional behaviour, and -24.4% to 74.5% for patient outcomes. Two of the 14 estimates of professional behaviour, and two of the 11 estimates of patient outcomes were statistically significant.

REVIEWER'S CONCLUSIONS

The effects of printed educational materials compared with no active intervention appear small and of uncertain clinical significance. These conclusions should be viewed as tentative due to the poor reporting of results and inappropriate primary analyses. The additional impact of more active interventions produced mixed results. Audit and feedback and conferences/workshops did not appear to produce substantial changes in practice; the effects in the evaluations of educational outreach visits and opinion leaders were larger and likely to be of practical importance. None of the studies included full economic analyses, and thus it is unclear to what extent the effects of any of the interventions may be worth the costs involved.

Print media coverage of research on passive smoking

OBJECTIVE

To assess the extent and content of newspaper and magazine coverage of research on passive smoking.

DESIGN

Content analysis of newspaper and magazine articles.

SUBJECTS

Articles reporting on passive smoking research published in newspapers (n = 180) or magazines (n = 92) between January 1981 and December 1994.

MAIN OUTCOME MEASURES

Numbers of articles, conclusions of articles, sources quoted, numbers and characteristics of research studies cited, presence of tobacco advertising.

RESULTS

The number of newspaper and magazine articles reporting on passive smoking research increased from four in 1981 to 57 in 1992 and 32 in 1994. Sixty-two per cent (168/272) of articles concluded that the research on passive smoking is controversial. Tobacco industry representatives were quoted significantly more often in newspaper articles (52%, 94/180) than magazine articles (12%, 11/92) (p<0.0001). Of 121 different research studies cited in the lay press articles, only 15 were from tobacco-industry sponsored projects or publications. In magazines, acceptance of tobacco industry advertising was associated with the conclusion that research on passive smoking is controversial (p<0.0001).

CONCLUSIONS

Although research on the harmful effects of passive smoking accumulated between 1981 and 1994, lay press coverage of the research maintained that the science was controversial. Few research studies were cited to support the industry's claim that passive smoking is not harmful to health. However, tobacco industry representatives who were critical of the research methods used to study the health effects of passive smoking were frequently quoted.

Publication bias and research on passive smoking: comparison of published and unpublished studies

CONTEXT

The results of reviews may be biased by delays in publication and failure to publish nonsignificant results.

OBJECTIVE

To determine the extent of unpublished results on the health effects of passive smoking and whether passive smoking studies with statistically nonsignificant results would have longer time to publication than those with statistically significant results.

DESIGN

Semistructured telephone interviews of principal investigators of published or unpublished studies funded between 1981 and 1995, identified by information obtained from 76 (85%) of 89 organizations contacted that potentially funded research on passive smoking.

PARTICIPANTS

Seventy-eight investigators were eligible and could be located; 65 (83%) responded. They had conducted 61 studies of the health effects of passive smoke in humans or animals between 1981 and 1995 that met the criteria for the analysis of time to publication.

MAIN OUTCOME MEASURE

Time to publication for published studies and statistical significance of results of published and unpublished studies.

RESULTS

Fourteen of the 61 studies were unpublished. Median time to publication was 5 years (95% confidence interval [CI], 4-7 years) for statistically nonsignificant studies and 3 years (95% CI, 3-5 years) for statistically significant studies (P=.004). Statistically significant results (P=.004), experimental study design (P=.01), study size less than or equal to 500 (P=.01), and animals as subjects (P=.03) were predictive of time to publication. When the studies with human participants were analyzed separately, only statistically significant data were predictive of publication (P=.007). Multivariate analysis of all studies indicated that statistical significance (P=.001) and study design (P=.01) were the only independent predictors of time to publication, while for the human studies only statistical significance was predictive of publication (P=.007).

CONCLUSION

There is a publication delay for passive smoking studies with nonsignificant results compared with those with significant results.

Why review articles on the health effects of passive smoking reach different conclusions

OBJECTIVE

To determine whether the conclusions of review articles on the health effects of passive smoking are associated with article quality, the affiliations of their authors, or other article characteristics.

DATA SOURCES

Review articles published from 1980 to 1995 were identified through electronic searches of MEDLINE and EMBASE and from a database of symposium proceedings on passive smoking.

ARTICLE SELECTION

An article was included if its stated or implied purpose was to review the scientific evidence that passive smoking is associated with 1 or more health outcomes. Articles were excluded if they did not focus specifically on the health effects of passive smoking or if they were not written in English.

DATA EXTRACTION

Review article quality was evaluated by 2 independent assessors who were trained, followed a written protocol, had no disclosed conflicts of interest, and were blinded to all study hypotheses and identifying characteristics of articles. Article conclusions were categorized by the 2 assessors and by one of the authors. Author affiliation was classified as either tobacco industry affiliated or not, based on whether the authors were known to have received funding from or participated in activities sponsored by the tobacco industry. Other article characteristics were classified by one of the authors using predefined criteria.

DATA SYNTHESIS

A total of 106 reviews were identified. Overall, 37% (39/106) of reviews concluded that passive smoking is not harmful to health; 74% (29/39) of these were written by authors with tobacco industry affiliations. In multiple logistic regression analyses controlling for article quality, peer review status, article topic, and year of publication, the only factor associated with concluding that passive smoking is not harmful was whether an author was affiliated with the tobacco industry (odds ratio, 88.4; 95% confidence interval, 16.4-476.5; P<.001).

CONCLUSIONS

The conclusions of review articles are strongly associated with the affiliations of their authors. Authors of review articles should disclose potential financial conflicts of interest, and readers of review articles should consider authors' affiliations when deciding how to judge an article's conclusions.

How consumers and policymakers can use systematic reviews for decision making

Systematic reviews can be a very useful decision-making tool because they objectively summarize large amounts of information, identify gaps in medical research, and identify beneficial or harmful interventions. Consumers can use systematic reviews to help them make health care decisions. Policymakers can use systematic reviews to help them make decisions about what types of health care to provide. Despite the potential value of systematic reviews, little evidence of their direct impact on the decisions made by consumers and policymakers is available. We discuss strategies for optimizing the use of systematic reviews by increasing the awareness and identification of reviews, learning to critically evaluate the findings of reviews, and overcoming barriers to the incorporation of reviews into the decision-making process. In addition, the participation of consumers and policymakers in the design, conduct, and reporting of systematic reviews can help to produce reviews that are relevant and understandable to target audiences. Because decisions that involve health care policies and issues are complex processes in which information (such as that provided by systematic reviews) plays only a part, strategies for increasing the use of systematic reviews should be evaluated for their usefulness in the decision-making process.

Scientific quality of original research articles on environmental tobacco smoke

OBJECTIVE

To evaluate the scientific quality of original research articles on the health effects of environmental tobacco smoke; to determine whether poor article quality is associated with publication in non-peer-reviewed symposium proceedings or with other article characteristics.

DESIGN

Cross sectional study of original research articles on the health effects of environmental tobacco smoke published in peer reviewed journals and non-peer-reviewed symposium proceedings from 1980 to 1994. Article quality was assessed by two independent reviewers who used a valid and reliable instrument, were unaware of study hypotheses, were blinded to identifying characteristics of articles, and had no disclosed conflicts of interest.

PARTICIPANTS

All symposium articles (n = 68) and a random sample of peer reviewed journal articles (n = 68) that satisfied inclusion/exclusion criteria.

MAIN OUTCOME MEASURE

Mean quality scores, which could range from 0 (lowest quality) to 1 (highest quality).

RESULTS

Using multivariate regression analysis, symposium articles were of poorer scientific quality than peer reviewed journal articles when controlling simultaneously for the effects of study design, article conclusion, article topic, and source of funding acknowledged (P = 0.027). Article quality was not associated with either source of funding acknowledged or article conclusion in multivariate analyses.

CONCLUSIONS

In published reports on environmental tobacco smoke, non-peer-reviewed symposium articles tend to be of poor quality. These articles should not be used in scientific, legal, or policy settings unless their quality has been independently assessed.

Characteristics of materials distributed by drug companies. An evaluation of appropriateness

OBJECTIVES

To describe material distributed to physicians by pharmaceutical companies; to describe characteristics of the drugs discussed in the material; to determine whether the material complies with Food and Drug Administration (FDA) regulations and whether it contains promotional and educational characteristics.

DESIGN

Cross-sectional study.

SETTING

An academic internal medicine residency program, a private internist's office, and a health maintenance organization (HMO).

PATIENTS/PARTICIPANTS

A consecutive sample of 486 items, excluding gifts and drug samples, distributed by drug companies between August 11, 1993 and March 1, 1994.

MEASUREMENTS AND MAIN RESULTS

Of the 486 items collected, 207 were reprints, 196 were advertisements, 51 were general information, and 32 were other. Reprints were delivered to residents significantly more often than to the HMO (p < .001) or to the private internist's office (p < .001). By contrast, the internist's office received a greater proportion of personal correspondence compared with the other locations (p < .001 for both). Of the drugs publicized, 10] were substantial improvements over other therapeutic choices. Forty-two percent of the items failed to comply with at least one of three FDA regulations assessed, including 17 items that discussed unapproved uses for drugs. Advertisements, as well as items that were not obviously promotional, contained promotional characteristics. Thirty-nine percent of the items offered scientific support for their claims.

CONCLUSIONS

Little of the material distributed by pharmaceutical companies to physicians conveys information about important therapeutic breakthroughs; some of it fails to comply with FDA regulations. The material contains both educational and promotional characteristics.

The quality of drug studies published in symposium proceedings

OBJECTIVE

To compare the quality, relevance, and structure of drug studies published in symposium proceedings that are sponsored by drug companies with 1) articles from symposia with other sponsors and 2) articles in the peer-reviewed parent journals of symposium proceedings; and to study the relation between drug company sponsorship and study outcome.

DESIGN

Cross-sectional studies of clinical drug studies published in symposium proceedings or their parent medical journals.

MEASUREMENTS

The proportion of articles with no methods sections (which are necessary to assess quality); methodologic quality and clinical relevance scores; and the proportion of articles with outcomes favoring the drug of interest.

RESULTS

Symposia sponsored by single drug companies had more articles without methods sections (10%; 108 of 1064) than did symposia that had other sponsors (3%; 58 of 2314) or symposia that had no mentioned sponsor (2%; 29 of 1663) (P < 0.001). The mean methodologic quality and relevance scores of articles were similar both by type of sponsorship and between articles published in symposia sponsored by single drug companies and articles from the parent journals. Significantly more articles with drug company support (98%; 39 of 40) than without drug company support (79%; 89 of 112) had outcomes favoring the drug of interest (P = 0.01).

CONCLUSIONS

Articles in symposia sponsored by single drug companies were similar in quality and clinical relevance to articles with other sponsors and to articles published in the parent journals. Articles with drug company support are more likely than articles without drug company support to have outcomes favoring the drug of interest.

Improving the use of information in medical effectiveness research

There is increased emphasis on improving the quality of health care by obtaining and disseminating information about the effectiveness and outcomes of care and by facilitating more consumer input participation in decision-making. We examine barriers to information use and the challenges that these barriers pose for effectiveness research. We divide our discussion into four goals of effectiveness research. These are: (1) to provide more information so that consumers, providers and policymakers can make "rational" decisions; (2) to incorporate patient preferences into health care decisions; (3) to develop guidelines that incorporate both individual perspectives and societal perspectives; (4) to use information to improve the practice of health care. We discuss four recommendations for improving the use of information: (1) the evidence on how people actually make decisions should be used to inform the design and implementation of effectiveness research; (2) decision-making should be structured through guidelines and policies; (3) criteria should be developed for determining which guidelines should fully incorporate patient preferences; (4) safeguards should be established to guard against misuse of information.

Influences on the quality of published drug studies

To practice evidence-based medicine, physicians need data on the clinical effectiveness, toxicity, convenience, and cost of new drugs compared with available alternatives. We give examples of published drug studies that are defective, sometimes because pharmaceutical industry funding has affected their content and quality. We make recommendations on how to avoid these defects.

Industry-funded research and conflict of interest: an analysis of research sponsored by the tobacco industry through the Center for Indoor Air Research

The Center for Indoor Air Research (CIAR) was created by three United States tobacco companies in 1988. Its stated mission is to fund high-quality, objective research related to indoor air, including studies of environmental tobacco smoke (ETS). Because CIAR is financed by the tobacco industry and funds research related to tobacco, it fosters an inherent conflict of interest. We consider whether this conflict of interest has affected the content, quality, or use of research funded by CIAR. We hypothesize that the tobacco industry might be using CIAR to develop scientific data to support its position that ETS is not harmful to health. CIAR funds two types of projects: "Peer-reviewed" projects are awarded after peer review by a group of scientists, whereas "special-reviewed" projects are awarded directly by tobacco industry executives. CIAR's special-reviewed projects are more likely than its peer-reviewed projects to be related to ETS, to support the tobacco industry position, and to be used by the industry to argue that smoking should not be regulated in public places. Our findings suggest that the tobacco industry is funding special-reviewed projects through CIAR to develop scientific data that it can use in legislative and legal settings. The industry may be financing peer-reviewed projects through CIAR to enhance its credibility, to provide good publicity, and to divert attention from ETS as an indoor air pollutant. CIAR's stated mission of funding high-quality, objective research has been compromised by conflict of interest, and at least some of CIAR's projects are being used to promote the tobacco industry's agenda.

Environmental tobacco smoke. The Brown and Williamson documents

OBJECTIVE

To examine the tobacco industry's public and private responses to rising concern over the health effects of environmental tobacco smoke (ETS).

DATA SOURCES

Documents from Brown and Williamson Tobacco Corporation (B&W), the British American Tobacco Company (BAT), and other tobacco interests provided by an anonymous source, obtained from Congress, and received from the private papers of a former BAT officer.

STUDY SELECTION

All available materials, including confidential reports regarding research and internal memoranda exchanged between tobacco industry lawyers.

CONCLUSIONS

Privately, B&W and BAT began conducting research related to ETS in the mid 1970s. BAT researchers appear to have determined that sidestream smoke produces irritation, that it contains toxic substances including N-nitrosamines, and that it is "biologically active" (eg, carcinogenic) in laboratory tests. During the 1980s, the primary purpose of BAT's research related to ETS was to develop a new cigarette that emitted less irritating and less biologically active sidestream smoke. Publicly, the tobacco industry has denied that exposure to ETS has been proven dangerous to health. It has criticized the methodology of published research on ETS, even when some of its own consultants have privately acknowledged that the research was valid. In addition, the industry has funded scientific research with the stated purpose of anticipating and refuting the evidence against ETS. The tobacco industry's strategy regarding passive smoking has been remarkably similar to its strategy regarding active smoking. It has privately conducted internal research, at least some of which has supported the conclusion that passive smoking is dangerous to health, while it has publicly denied that the hazards have been proven.

Nicotine and addiction. The Brown and Williamson documents

OBJECTIVE

To learn how nicotine has been regarded by a major tobacco company.

DATA SOURCES

Documents from Brown and Williamson Tobacco Corporation (B&W), the British American Tobacco Company (BAT), and other tobacco interests provided by an anonymous source, obtained from Congress, and received from the private papers of a former BAT officer.

STUDY SELECTION

All available materials, including confidential reports regarding research and internal memoranda exchanged between tobacco industry lawyers.

CONCLUSIONS

During a period of 22 years (1962 to 1984), employees of B&W and BAT conducted research and commented on the pharmacology of nicotine. They consistently regarded nicotine as the pharmacological agent that explained tobacco use. In the early part of the period under study, officials of the companies wrote about nicotine addiction explicitly. Inhalation of cigarette smoke by the consumer was recognized throughout the period as necessary for the normal function of a cigarette. The documents contain little indication that research was conducted on either the taste or the flavor of nicotine. The documents reveal an intention on the part of B&W and its corporate parent to affect the function of the body with nicotine.

Environmental tobacco smoke. The Brown and Williamson documents

OBJECTIVE

To examine the tobacco industry's public and private responses to rising concern over the health effects of environmental tobacco smoke (ETS).

DATA SOURCES

Documents from Brown and Williamson Tobacco Corporation (B&W), the British American Tobacco Company (BAT), and other tobacco interests provided by an anonymous source, obtained from Congress, and received from the private papers of a former BAT officer.

STUDY SELECTION

All available materials, including confidential reports regarding research and internal memoranda exchanged between tobacco industry lawyers.

CONCLUSIONS

Privately, B&W and BAT began conducting research related to ETS in the mid 1970s. BAT researchers appear to have determined that sidestream smoke produces irritation, that it contains toxic substances including N-nitrosamines, and that it is "biologically active" (eg, carcinogenic) in laboratory tests. During the 1980s, the primary purpose of BAT's research related to ETS was to develop a new cigarette that emitted less irritating and less biologically active sidestream smoke. Publicly, the tobacco industry has denied that exposure to ETS has been proven dangerous to health. It has criticized the methodology of published research on ETS, even when some of its own consultants have privately acknowledged that the research was valid. In addition, the industry has funded scientific research with the stated purpose of anticipating and refuting the evidence against ETS. The tobacco industry's strategy regarding passive smoking has been remarkably similar to its strategy regarding active smoking. It has privately conducted internal research, at least some of which has supported the conclusion that passive smoking is dangerous to health, while it has publicly denied that the hazards have been proven.

Health care cost effects of public use of a regional poison control center

Poison control centers in the United States are threatened with closure, and attempts at a cost-benefit analysis of these services have been indeterminate. The purpose of this study was to compare the operating costs of a regional poison control center resulting from public use of its telephone hotline services with those of hypothetical alternative sources of advice and care. We conducted a follow-up telephone survey among 589 public callers to the San Francisco Bay Area Regional Poison Control Center who had been managed at home without medical referral after an unintentional poisoning. All survey respondents were asked what alternative action they would have taken had the poison control center not been available to assist them by telephone consultation. We then surveyed emergency departments and physicians' offices cited as alternatives by the callers to determine their response and charges for evaluating a suspected poisoning case. A total of 464 (79%) of the callers surveyed would have sought assistance from their local emergency health care system had the poison control center not been available. We conservatively estimated that the total charges for such evaluations would be +71,900. Comparatively, the total actual operating cost of services provided by the poison control center for all 589 poisoning cases was +13,547. Most of the study subjects (429 [73%]) had private insurance coverage. Direct public access to these services probably reduces the use of emergency health care resources, thus lowering health care costs.

Inappropriate and appropriate selection of 'peers' in grant review

OBJECTIVE

To assess the members of the California Tobacco Related Diseases Research Program Behavioral and Public Health Research on Tobacco Study Section and those of the Agency for Health Care Policy and Research (AHCPR) Dissemination Study Section as "peers" to review tobacco policy research. Both study sections reviewed a similar grant application on tobacco policy research written by one of us (S.A.G.).

DESIGN

Search of MEDLINE for 1989 through 1993 with the keyword tobacco for Tobacco Related Diseases Research Program and AHCPR reviewers. As a control, the National Institutes of Health Cardiovascular Study Section, which reviewed a ventricular function grant submitted by the same author with the keyword heart, was analyzed.

SETTING

Not applicable.

PATIENTS OR OTHER PARTICIPANTS

Study section members.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Publications by study section members in areas germane to the proposal being reviewed.

RESULTS

Six (33%) of 18 Tobacco Related Diseases Research Program reviewers had no "tobacco" publications (median, two publications; interquartile range, zero to four). The members' "tobacco" publications concentrated on well-controlled experimental interventions on smoking cessation and prevention strategies, not tobacco policy. Only one member had primary expertise in tobacco policy research. None of the AHCPR reviewers had "tobacco" publications. All 31 (100%) of the National Institutes of Health reviewers had "heart" publications (median, nine publications; interquartile range, seven to 19). Five members had a primary interest in the subject of the National Heart, Lung, and Blood Institute application.

CONCLUSIONS

Study section members' professional interests play a critical role in the level of interest and enthusiasm they will have for a proposal, which affects the priority score. In contrast to the study section that reviewed the heart grant, the study sections that reviewed the tobacco control grant were not "peers." The membership of these review committees has effectively precluded research on tobacco control policy.

Publication bias and public health policy on environmental tobacco smoke

OBJECTIVE

To examine the tobacco industry's claim that publication bias against negative studies invalidates the risk assessment of environmental tobacco smoke (ETS) conducted by the US Environmental Protection Agency and other reviews of the health effects of ETS.

DESIGN

Determination of the number of published original research articles that tested the hypothesis that ETS exposure is associated with adverse health effects and that reported statistically significant ("positive") or nonsignificant ("negative") results; the number of articles that concluded that ETS is a health risk; and unpublished studies on the effects of ETS on health.

PARTICIPANTS

Articles identified by a computerized search of the medical literature supplemented with material obtained from the tobacco industry and hand searching. Articles were classified as peer-reviewed journal articles or articles from sponsored symposia.

MAIN OUTCOME MEASURE

The statistical significance of results reported in the article and whether or not the article concluded that ETS exposure is a health risk.

RESULTS

More symposium articles than journal articles were reviews (46% vs 6%; P = .0001). More original journal articles than original symposium articles reported the use of statistical tests (96% vs 54%; P = .0001). Of articles with statistical analyses, similar proportions of journal articles and symposium articles reported statistically significant results (57% vs 47%; P = .329). The conclusions of 80% of the original journal articles were positive, compared with 51% of the original symposium articles (P = .006).

CONCLUSIONS

There is no publication bias against statistically nonsignificant results on ETS in the peer-reviewed literature. The high proportion of articles in symposia that reach the conclusion that ETS is not harmful primarily results from the inclusion of review articles.

Sponsored symposia on environmental tobacco smoke

OBJECTIVE--To test the hypothesis that symposia on environmental tobacco smoke (ETS) are more likely to present unbalanced data and be authored by tobacco industry-affiliated individuals than journal articles on ETS. To compare the publication records and affiliations of authors of symposia with the authors of scientific consensus documents on ETS. DESIGN--Content analysis of articles; computerized literature searches of English-language publications (except for one symposium) supplemented with additional sources. PARTICIPANTS (ARTICLES)--All 297 symposium articles on ETS and a random sample of 100 journal articles on ETS published between January 1, 1965, and March 31, 1993; the 1986 Surgeon General's report on ETS; and the 1986 National Research Council's report on ETS. MAIN OUTCOME MEASURES--For each article, regardless of whether it had a methods section, agreement with the tobacco industry position that ETS is not harmful; topic; funding source(s); affiliation(s) of author; and publication records of authors. RESULTS--Of the symposium articles 41% were reviews, compared with 10% of journal articles. A total of 83% of original symposium articles and 100% of journal articles contained methods sections (P = .0001). Symposium articles were more likely to agree with the tobacco industry position (46% vs 20%), less likely to assess the health effects of ETS (22% vs 49%), less likely to disclose their source of funding (22% vs 60%), and more likely to be written by tobacco industry-affiliated authors (35% vs 6%) than journal articles (P = .0001). Symposium authors published a lower proportion of peer-reviewed articles (71% vs 81%) (P = .0001) and were more likely to be affiliated with the tobacco industry (50% vs 0%) than consensus document authors (P = .0004). CONCLUSIONS--Symposium articles on ETS differ from journal articles and consensus documents in ways that suggest that symposia are not balanced.

Assessing the appropriateness of physician prescribing for geriatric outpatients. Development and testing of an instrument

OBJECTIVE

In a randomized, controlled trial evaluating the impact of clinical pharmacists' consultations on physicians' prescribing decisions, a seven-member physician/pharmacist panel developed an instrument to characterize and quantify the full range of drug-prescribing problems. The instrument was tested for validity and reliability.

SAMPLE

The instrument was applied in reviewing prescribing for 236 geriatric outpatients.

METHODS

To ensure internal validity of the instrument, five panel meetings were devoted to reaching a consensus on procedures, categories, criteria, and scoring. Each case was evaluated independently by two reviewers and each drug in the regimen was evaluated for drug-drug interactions, dosage, schedule, allergic reactions, therapeutic duplication, use of drugs without established diagnoses, and inappropriate drugs for the patient's clinical conditions; discrepancies were adjudicated by the panel chairperson. Self-reported adverse effects of 60 study patients who were interviewed, and hospital readmissions of all study patients were used to test the external validity of the instrument.

RESULTS

Inter-rater reliability improved over time, reaching a high of 97.1 percent after six months. A positive association was determined between the prescribing scores and the number of reported adverse effects (rho = 0.28, p = 0.02). Although the number of patients with drug-related hospital readmissions was too few to establish a significant association between the prescribing scores and readmissions, the findings were expected.

CONCLUSIONS

Given current requirements for drug utilization reviews in hospitals, health maintenance organizations, and Medicaid programs, this instrument may prove to be very useful.

The publication of sponsored symposiums in medical journals

BACKGROUND

An increasing proportion of spending by the pharmaceutical industry has gone to funding symposiums that are published by peer-reviewed medical journals. This study tests the hypothesis that such sponsorship, particularly by a single pharmaceutical company, is associated with a promotional orientation of the symposium and a distortion of the peer-review process.

METHODS

We counted the symposiums published in 58 journals of clinical medicine and surveyed the journal editors regarding their policies for symposium issues. We analyzed the symposium issues that appeared in the 11 journals that published the most symposiums in order to determine the sponsor or sponsors, the topics, whether the titles were misleading, whether brand names were used, and whether the featured drugs were classified by the Food and Drug Administration as innovative or approved.

RESULTS

The number of symposiums published per year increased steadily from 1966 through 1989. Forty-two percent of those analyzed (262 of 625) had a single pharmaceutical company as the sponsor. These symposiums were more likely than those with other sponsors to have misleading titles (P less than 0.001) and to use brand names (P less than 0.001), and less likely to be peer-reviewed in the same manner as other articles in the parent journal (P less than 0.001). Of the 161 symposiums that focused on a single drug, 51 percent concerned unapproved therapies; 14 percent concerned drugs classified as bringing important therapeutic gains.

CONCLUSIONS

Symposiums sponsored by drug companies often have promotional attributes and are not peer-reviewed. Financial relations among symposium participants, sponsors, and journals should be completely disclosed, symposiums should be clearly identified, and journal editors should maintain editorial control over contributions from symposiums.

The impact of clinical pharmacists' consultations on physicians' geriatric drug prescribing. A randomized controlled trial

The impact of clinical pharmacists' consultations on geriatric drug prescribing was studied in a prospective randomized controlled trial of patients 65 years of age and over discharged on 3 or more medications for chronic conditions from a 450-bed community hospital. The pharmacists provided consultation to experimental patients and their physicians at hospital discharge and at periodic intervals for 3 months postdischarge. Using a standardized tool, a physician-pharmacist panel, blinded to study group assignment of patients, evaluated the appropriateness of prescribing for a random sample of 236 patients. Eighty-eight percent had at least one or more clinically significant drug problems, and 22% had at least one potentially serious and life-threatening problem. Drug-therapy problems were divided into six categories: 1) inappropriate choice of therapy; 2) dosage; 3) schedule; 4) drug-drug interactions; 5) therapeutic duplication; and 6) allergy. Experimental patients were less likely to have one or more prescribing problems in any of the categories (P = 0.05) or in the appropriateness (P = 0.02) or dosage (P = 0.05) categories. A summary score, measuring the appropriateness of the patient's total drug regimen, indicated that experimental patients' regimens were more appropriate than those of controls (P = 0.01). Results of this trial reveal that clinical pharmacists can improve the appropriateness of geriatric drug prescribing in outpatient settings.

Characterization of geriatric drug-related hospital readmissions

Although some factors placing geriatric patients at risk for hospitalization have been identified, little is known about drug-related problems that contribute to admissions. This study describes a protocol for characterizing drug-related problems that are associated with hospital readmissions. The protocol achieves significant improvements over other studies because geriatric readmissions to a community hospital are classified and the type of drug-related problem and relative contribution of the problem to the readmission are assessed. Thirty-five percent of study patients (n = 706) were readmitted within 6 months of their former discharge and 45 of the readmissions were drug-related. The assessments of three reviewers working independently agreed for 82% of the readmissions (kappa = 0.64). Eighteen percent of the cases identified as drug-related using the protocol were also classified as drug-related according to the hospital ICD-9 coding procedure. One percent of the readmissions classified according to the protocol as not drug-related received ICD-9 codes indicating drug-related problems. These findings suggest that the protocol identified drug-related hospital readmissions with good reliability and sensitivity. The most frequently identified drug-related problems were unexpected adverse drug reactions (n = 10), patient noncompliance (10), overdose (8), lack of a necessary drug therapy (6) and underdose (5). Drug-related factors were a major reason, rather than a contributory reason, for readmission in half of the cases. The study identifies specific drug-related problems that could become targets for preventive interventions. The majority (76%) of the problems identified were potentially preventable and the types of problems found indicate that interventions should be focused on both physicians and patients.

Identification of endogenous opioid receptor components in rat brain using a monoclonal antibody

A monoclonal antibody generated against the tertiary structure of a partially purified opioid binding protein was used to probe the structure of the dynorphin and beta-endorphin receptors. The Fab fragment 3B4F11 inhibited completely the binding of 125I-beta-endorphin and [3H]dynorphin to rat brain P2 membranes with IC50 values of 26 ng/ml and 40 ng/ml, respectively. To explore further the interaction of 3B4F11 with the beta-endorphin receptor, the effect of the Fab fragment on 125I-beta-endorphin cross-linking to rat brain membranes was examined. 125I-beta-endorphin was covalently bound to three major species of approximate molecular weights 108,000, 73,000, and 49,000. The delta-selective ligand D-Pen2, D-pen5enkephalin was least effective at inhibiting the cross-linking of beta-endorphin, whereas the micro-selective ligand Tyr-D-Ala-Gly-NMe-Phe-Gly-ol and kappa-selective ligand U50488 inhibited beta-endorphin cross-linking to the 108,000 and 73,000 Da species. Both 3B4F11 and beta-endorphin prevented the covalent binding of 125I-beta-endorphin to all three labeled species. These findings suggest that micro and kappa receptor types might have some structural similarities, whereas the delta receptor type might differ in molecular size. In addition, the micro, kappa, and delta ligands might have different primary sequences, whereas their tertiary structures might share regions of molecular homology with all three receptor constituents labeled by 125I-beta-endorphin. 3B4F11 will be a valuable tool for the purification and isolation of the several components of the beta-endorphin receptor complex.

Early ontogeny of kappa-opioid receptor regulation of prolactin secretion in the rat

Although both mu- and kappa-opioid components of prolactin (PRL) secretion have been identified in the adult rat, the neural pathways through which these multiple receptor subtypes modulate PRL secretion have not been thoroughly investigated. The present study utilizes the differential ontogeny of opioid systems which alter PRL release to examine the mechanisms by which mu- and kappa-receptors regulate prolactin. The responses of PRL, corticosterone and growth hormone to opioid receptor subtype-specific agonists were studied in neonatal rats. The PRL response to the kappa-agonist, U50488, preceded the response to the mu-agonist, morphiceptin. Like adults, neonates demonstrated a growth hormone, but not a PRL, response to the delta agonist, [D-pen2,pen5]enkephalin. U50488-induced PRL secretion was not attenuated by cyproheptadine in adults or neonates, suggesting that the kappa-opioid mechanism operates independently of serotonin. In contrast, the PRL response to morphine was attenuated in adult rats. In addition, U50488 decreased median eminence dopamine synthesis in both adults and neonates. These findings suggest that the early developing, serotonin-independent opioid regulation of PRL is mediated through kappa-receptors, while the later-developing mechanism which requires intact serotonergic transmission works through mu-receptors. kappa-Receptors appear to regulate PRL secretion by directly inhibiting the activity of tuberoinfundibular dopamine neurons, while mu-receptors might regulate the tonic dopaminergic inhibition of PRL through a serotonergic pathway.

Differential ontogeny of opioid, dopaminergic and serotonergic regulation of prolactin secretion

The goal of this study was to determine if the opioid system which is stimulatory to prolactin (PRL) secretion develops before the serotonergic system which regulates PRL release. The opioid and serotonergic systems were chosen for comparison because evidence exists that functional serotonergic neurons are necessary for opiate-induced PRL secretion in adult rats. Haloperidol and morphine produced a dose-related stimulation of PRL release in animals of all ages. In contrast, the serotonin agonists, quipazine and m-chlorophenylpiperazine, and the serotonin-releasing drug p-chloroamphetamine produced dose-related increases in PRL release in adult rats, but not in neonatal rats. The PRL response to the serotonin precursor 5-hydroxytryptophan was potentiated by fluoxetine only in animals 15 days of age or older. PRL secretion induced by these serotonergic agents was blocked by cyproheptadine, a serotonin receptor antagonist. Unlike PRL, corticosterone and growth hormone secretion were stimulated by quipazine and 5-hydroxytryptophan plus fluoxetine in both adult and neonatal rats. These findings suggest that stimulatory opioid control of PRL secretion and the dopaminergic mechanism which tonically inhibits PRL release are intact in the neonatal rat. In contrast, the stimulatory serotonergic mechanism is not functional until between 10 to 15 days of age. This late maturation appears to be specific to the serotonergic neurons regulating PRL release because the corticosterone and growth hormone responses to serotonergic stimulation develop early in ontogeny.

Role of serotonin in opiate-induced prolactin secretion and antinociception in the developing rat

Our laboratory has demonstrated previously that the ability of opiates to stimulate prolactin (PRL) release during ontogeny precedes the appearance of a PRL response to serotonergic drugs. The present study tests the hypothesis that opiates stimulate PRL secretion through a serotonergic mechanism in adult rats, but a nonserotonergic mechanism in neonatal rats. Morphine stimulated PRL secretion in adult and neonatal (10-day-old) rats and this increase was blocked with the opiate antagonist naloxone. Ten-day-old or adult rats were pretreated with the serotonin antagonist, cyproheptadine (CYPRO), or the neurotoxin, 5,7-dihydroxytryptamine (5,7-DHT). Both CYPRO and 5,7-DHT attenuated the PRL response to morphine in adult but not neonatal rats. 5,7-DHT decreased serotonin and 5-hydroxyindoleacetic acid substantially in the hypothalamus. When rats were pretreated with 5,7-DHT several weeks before morphine challenge, serotonin depletion was more pronounced, but the PRL response to morphine was not decreased. In addition, the PRL response to 5-hydroxytryptophan was greatly potentiated, suggesting that functional supersensitivity developed in the 5,7-DHT-treated animals. The ability of CYPRO and 5,7-DHT to block the serotonergic component of a different morphine-induced behavior in the neonate was tested using the tail immersion test for analgesia. Morphine produced profound antinociception in the rat pup which was attenuated markedly by 5,7-DHT and CYPRO. These studies demonstrate that opiates mediate their stimulatory effects on PRL release, at least in part, through a serotonergic mechanism in adult rats.(ABSTRACT TRUNCATED AT 250 WORDS)