The Medical Lobby for Appropriate Marketing (MaLAM), based in Australia, asked people around the world to send complaints about medicines advertisements. MaLAM chose particularly serious complaints, and prepared a letter to the advertiser, quoting the advertisement, summarising the literature and asking the company to provide their best evidence to support the claims made in the advertisement. A copy of the letter was then sent to MaLAM’s subscribers (over 700 in 1991) and they were invited to sign and send it to the company. Most, but by no means all MaLAM subscribers were doctors²⁴². From 1998, MaLAM produced a series of newsletters called Healthy Skepticism for New Zealand GPs^243-245. Each issue critically appraised advertising for one therapeutic group, by looking at the possible interpretations of the advertisements and marking these as unjustified, borderline, or justified by the evidence. The newsletter was funded by PHARMAC (Pharmaceuticals Management Agency). PHARMAC is the New Zealand government’s drug purchasing agency. It negotiates subsidies for medicines, and is now also involved in attempting to improve medicines use. MaLAM has now changed its name to Healthy Skepticism, and it no longer sends letters critiquing specific advertisements.

Two papers report on the success of MaLAM’s letters to companies requesting evidence to support claims made in advertisements^246,247. Wade et al.²⁴⁶ report on January 1988 to June 1989. In this time 10 companies were contacted about seventeen products, and fifteen replies were received. In four cases the advertising was changed, and in one the marketing of the product in developing countries was discontinued. Mansfield²⁴⁷ reports on the July 1989 to June 1990 period. Eight companies were contacted regarding nine drugs. No response was received from two companies, two said they would withdraw the claims, one that they would withdraw the indication, one that they would reformulate the product, and two that they would withdraw the products. In May 1995, MaLAM reports²⁴⁸ on Hoechst’s discontinuation of Baralgin, presumably in response to a 1994 MaLAM letter. MaLAM operated on a very small budget, but seemed to be very effective in lobbying companies to change the worst examples of their advertising.

The Prescrire Network (described above) is also an attempt to monitor promotion. They have found that the legal requirements for sales representatives in France (that Summaries of Product Characteristics, and Transparency Commission reports be given to doctors) are frequently not met²¹⁸. The Prescrire network has identified many problems in presentations given by sales representatives to individual doctors, but there is no evaluation of the impact of the network itself.

Berings et al.¹¹⁸ report on an intervention to improve the prescribing of benzodiazepines by providing industry-independent information. They randomly allocated the 128 doctors in the study to three groups. One received no information, one received a pamphlet on rational prescribing of benzodiazepines that was similar in format to pharmaceutical company brochures, and one received the pamphlet and oral information from a visiting GP. Throughout the study, benzodiazepine prescriptions were recorded on specially designed prescription forms. During the four week follow-up period the groups which received both written and oral information prescribed 24% less benzodiazapines, those who received written information only prescribed 14% less, and the control group prescribed 3% less. There was no significant increase in the use of other psychotropics: in fact in the experimental group these also decreased. Forty of the 44 doctors who received the visit said that they would like more of these in the future.