This review presents evidence about people’s attitudes to promotion, including whether doctors believe that promotion affects their prescribing. Some studies consider this as evidence of the impact of promotion⁶, but this is incorrect. The evidence in the review could be useful in designing interventions, but should not be used to describe the effects of the different forms of promotion on prescribing behaviour.

The main limitations of the studies presented here are an over-reliance on survey methods, on the use of convenience and accessible samples, and on describing the prevalence of attitudes rather than exploring their inter-relationship or relationships between attitudes and other characteristics. Qualitative studies are needed in this area.

Survey methods are extremely useful in finding out factual information about a group of people but are of less use in understanding how people think about issues, such as drug promotion. Many of the studies in this review seem to rely on participants who are easily accessible to researchers, rather than being guided by research questions. This has led to an over-emphasis on the views of trainee doctors, and their trainers, as opposed to practicing doctors; and the inclusion of patients more often than the general public. Some authors suggest that it is important to study doctors in training because this is where their attitudes are formed. However it seems more likely that this emphasis results simply from convenience. In addition, the studies described here tend to rely on small samples, and many studies have been conducted in one or two institutions. These are unlikely to represent doctors and patients in general. Some of this research also suffers from low response rates^9,57.

Qualitative research, exploring in more depth people’s feelings and beliefs about medicines promotion would be an important step forward. We need to move beyond simple surveys of attitudes to more sophisticated understandings of how people react to promotion, and how they understand their own reactions. Cognitive and social psychology may be able to make important contributions in this area. For example, some studies suggest that doctors are more likely to think that ‘doctors in general’ are influenced by promotion than they are themselves. This may be similar to other situations in which individuals sometimes regard themselves as less vulnerable to a hazard (such as HIV) than other members of a similar group. Research is needed to explore this further: why and in what ways do doctors think that they are invulnerable to promotion, how do they explain their own and others’ vulnerability or lack of it? This points to a general need for research on promotion to learn from other disciplines and research on other topics. Attitudes to promotion should be seen as a specific case of other more general phenomena.

Qualitative research could also help to explore what survey respondents mean when they say that they or others are ‘influenced’ by promotion. Do they include informed (i.e. a positive meaning) or do they interpret the question to mean ‘unduly’ or ‘negatively’ influenced?

Ethnographic research, which examines medical sub-cultures, would also be extremely helpful in exploring attitudes to promotion. It appears that doctors vary substantially in their views of, and use of, promotion. How do these differences come about? What underlies them? Do they reflect overall different political and social views? Are they reflected in different social organizations (such as professional organizations, social networks, etc)? What brings about changes in these values? Do doctors move between them during their working lives? What factors enhance or impede this movement?