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Public health priorities
  1. Center for Behavioral Epidemiology
  2. and Community Health
  3. Graduate School of Public Health
  4. San Diego State University
  5. San Diego, California, USA;
  6. wahlgren{at}

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    Editor,—The 15 July 1998 issue of theJournal of the American Medical Association (JAMA) was dedicated to reports on the process of research publication. It included an article lead authored by the then editor ofJAMA, entitled “A comparison of the opinions of experts and readers as to what topics a general medical journal (JAMA) should address.”1 The study concluded that tobacco issues were of lesser importance than issues such as managed care (the polled experts' top-ranked priority) and aging (the polled readers' top-ranked priority). This prompted the letter to the editor ofJAMA that follows. It was not accepted for publication. We feel it is important to discuss this here, not only for the issues we raise in our unpublished letter, but also for the implications that their decision to not publish this letter raises.

    “Dear Editor,

    “The recent poll of expert andJAMA reader opinions regarding importance of topics to cover in the journal1 raises serious concern. In particular, the fact that tobacco was rated rather low in comparison to its public health importance (it is, remember, the number one cause of disease and death in the United States2) by both the experts and the polled readers is alarming. Further, the readers ranked it a substantially lower priority than the editors (55thv 17th of 73 total topics, respectively). The authors were so impressed by this divergence of opinion that they have ‘altered [the] manuscript acceptance process to become even more reader-friendly’1 (page 290).

     “While it is certainly important to create a publication that appeals to the readers' interests, it is also critical to retain the importance of the expertise of the editorial board in defining the goals and scope of the publication. While tobacco-related research may seem a dead-horse to readers, as long as the tobacco industry is alive and viable it may be the number one threat to the health of the world's peoples.

     “While the role of journals is certainly to keep clinicians informed about practical tools for their respective practices, it also is to inform them about new scientific discoveries not likely to be immediately useful. It also is to provide leadership in setting the agenda and responsibility for the types of problems to be given serious attention by practicing physicians. The latter two goals are not likely to be among the more popular contents, but popularity and enjoyability should not dictate scientific agendas. Nor should they result in a decision to eliminate the requirements for or availability of the information.

     “We urge the editors and AMA Board members to recall their decision to alter publication rules in light of audience preferences, especially with respect to tobacco related disease, and to explicitly affirm the policy represented by the AMA: ‘the AMA maintains an unequivocal stance against tobacco’ and ‘further efforts should be made to educate physicians, the public, and policymakers about the consequences of tobacco use, the predatory nature of the tobacco industry, and ways individuals can break their addiction to tobacco’3 (page 257).”

    After a seven month delay we received a rejection letter from Margaret Winker, MD, senior editor ofJAMA. The relevant portion was as follows:

    “In response to your concern, we continue to believe that tobacco and other extremely important public health issues are a high priority for JAMA regardless of the scores on the survey. Thus, many of our editorial priorities will not change. The reader survey emphasized that physician readers wish to know information useful for their daily practices; that is the message to which we are responding.”

     We feel that our letter, in combination with this reply, would have provided a valuable exchange of ideas for the readership of JAMA. Unfortunately, we can now hope only to preach to the choir. We wonder whether theJAMA editors will live up to this implicit commitment to continue publishing tobacco-related research, despite not making the commitment publicly. However, even if tobacco-related publication rates do not decline, we will never know how many tobacco-related submissions are rejected for publication and whether this rejection rate increases over time relative to issues rated as higher priorities by the editors and readers. We wonder who is theJAMA readership, and if their readership is even representative of all practicing physicians. Their priorities certainly don't match the best interests of public health.


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