Study links pharmaceutical industry payments to changes in physicians’ prescribing practices
International researchers, including U of T Associate Professor Quinn Grundy find payments and gift relationships often lead physicians to more expensive, less appropriate drugs
A new Cochrane review led by a team of international researchers including from U of T, has found that marketing strategies used by pharmaceutical companies such as payments for consulting and advisory board membership and free meals offered to physicians, can negatively influence prescribing habits.
The review compiled data from over 93 studies and included observed practices of millions of prescribers who had received either advertising and education, such as sales rep visits, gifts and payments, or free samples from pharmaceutical companies. The researchers found that these gift relationships and marketing tactics led physicians to more often prescribe the drugs a company was promoting. The data also showed that these marketing practices were strongly linked to inappropriate prescribing, meaning physicians were likely prescribing treatments that patients do not necessarily need, or that may cause harm.
Quinn Grundy is an associate professor at the Lawrence Bloomberg Faculty of Nursing and is one of the two Canadian authors involved in the review. She points out that these marketing tactics employed by pharmaceutical companies are a common practice among physicians globally, with the same multi-national companies marketing their drugs worldwide.
“In the U.S., where companies are required to report payments made to physicians in a public database, just over half of all licensed physicians have accepted a payment, including free meals from a pharmaceutical company,” says Grundy, who is also the Director of the WHO Collaborating Centre for Governance, Accountability, and Transparency in the Pharmaceutical Sector located at the University of Toronto. “This is important because it shows that companies are focusing their marketing resources on physicians who will deliver the highest return on investment, and prescribe more of their promoted drug, but it also shows that there are a large number of physicians who are choosing not to interact with pharmaceutical companies and remain independent of these influences.”
There were no Canadian studies included in the review, in part because Canada does not have a mechanism in place to track how much or why pharmaceutical companies are paying physicians or nurse practitioners. However, Grundy notes that according to surveys and qualitative research not included in this review, free meals and payments are likely common among Canadian prescribers.
“When physicians accept payments or free meals from the pharmaceutical industry we can see evidence in the data that physicians prescribe more of the promoted drug. This practice can increase the overall costs to our health system, and to patients through higher co-pays and out-of-pocket costs, when they are prescribed a brand name drug even though cost-effective alternatives exist,” says Grundy.
Grundy believes it is imperative that healthcare organizations, professional societies, and health professional schools be more aware of the influence of pharmaceutical industry promotion and address these through policy changes.
“Prescribers need independent, evidence-based sources of information to ensure their own independence in practice and to be trustworthy and accountable to the people they serve,” says Grundy.
Studies included in the review also examined the impact of conflict-of-interest policies or limitations on physician interactions with industry in the practice setting such as within medical schools and teaching hospitals. The review showed that in these instances, conflict-of-interest policies had a mitigating effect where physicians tended to prescribe less overall or prescribed more appropriate treatments. The review authors suggest that more robust conflict-of-interest policies would be an important way forward to reduce the influence of pharma on prescribers.
“These studies show that we can create practice environments that promote and preserve independence and that this is best achieved collectively, within health systems and institutions, rather than leaving it up to individual clinicians,” says Grundy.
While the available research focused on physicians in many health systems, including Canada, physicians are no longer the only prescribers. Other descriptive studies using the Open Payments data in the U.S., and which were not included in this review, found that advanced practice nurses, including nurse practitioners and clinical nurse specialists, are also targets of industry promotion.
“This is not just a problem for medicine, it affects the entire healthcare team,” says Grundy. “We need to create healthcare environments that safeguard the independence and integrity of care.”
Journal
Cochrane Database of Systematic Reviews
Article Title
Pharmaceutical industry information and promotional strategies aimed at prescribers
Article Publication Date
9-Oct-2026
Pharmaceutical company marketing negatively influences prescribing
Doctors’ prescribing habits are heavily influenced by payments, gifts, and free meals from pharmaceutical companies, leading to more expensive, less appropriate and more drugs being prescribed, a new Cochrane review finds
Cochrane
image:
This infographic details the number of meals received in 2014 versus opioid prescribing in 2015, based on Hadland et al. (2018). It visualises the meals received by physicians and the subsequent prescribing rates.
view moreCredit: Peter Homer, Creative Content Producer, Cochrane
Doctors’ prescribing habits are heavily influenced by payments, gifts, and free meals from pharmaceutical companies, leading to more expensive, less appropriate and more drugs being prescribed, a new Cochrane review finds. This can seriously harm both individual patients and health systems.
Pharmaceutical companies use a variety of strategies to market and promote their drugs. This can include one-on-one visits by sales reps to doctors' offices and hospitals, gifts and payments including for example paid meals, travel costs to conferences, entertainment, consulting fees, honoraria for participation in advisory boards, and advertising.
For all new medicines, pharmaceutical companies target prescribers with offers of free meals and other gifts and payments. These payments and gifts lead to prescribing of the company's promoted drug, which may not always be needed or be the most appropriate or affordable medicine for each patient.
Less appropriate prescribing and higher medicine costs
The review included 93 studies involving a number of different study types. Almost all of these studies observed real-world prescribing patterns rather than running controlled experiments. The majority of the studies (88%) came from the United States, in part because the Sunshine Act (2010) requires pharmaceutical companies to publicly report details of all payments to doctors, which are compiled in a publicly searchable and analyzable database.
Analyzing millions of prescribers, the authors grouped industry interactions into three distinct categories to examine how each one affects a doctor's prescribing habits. These were advertising and education, gifts and payments, and free samples. The authors also looked at conflict-of-interest policies as a mitigation strategy.
Advertising and education, such as sales rep visits, seemed linked to prescribing that was less clinically suitable and pricier, with fairly strong evidence that it also drove up prescription volume.
The largest and most consistent body of evidence covered gifts and payments. Gifts and payments were also linked to less appropriate prescribing, more prescriptions, and probably increased costs.
The evidence was too sparse or weak to draw clear conclusions on free drug samples and whether promotion affects hospitals’ approved formularies, although what little exists suggests it might.
“Overall, when doctors have more contact with drug company promotion, prescribing tends to become less appropriate, more frequent, and more expensive”, says study author Dr Lisa Bero from the University of Colorado Anschutz, USA. “This is problematic for a number of reasons and it matters because it directly affects patient care. These less appropriate, more expensive drugs can have fewer benefits or more side-effects than alternatives, or simply be unnecessary in the clinical context.”
The overprescription of opioids is the most infamous example of pharmaceutical companies’ promotion exaggerating benefits and minimizing harms. This review found that even inexpensive meals increased opioid prescribing and that the more payments a doctor received from opioid manufacturers, the more likely they were to prescribe dangerously high opioid doses. The widespread inappropriate overprescribing of opioids has led to an epidemic of addiction and deaths from overdoses.
“Patients should be offered the most appropriate treatment for their condition, based on clinical evidence not industry marketing,” adds Dr Bero. “The opioid crisis in North America was perhaps the most egregious example of inappropriate over-prescribing, but this was not an isolated incident. It was high-profile due to the significant harms involved, but the systems that enabled it are unfortunately considered business-as-usual within the industry. Interactions between pharmaceutical companies and prescribing physicians are widespread, and the harms they cause are rarely so visible.”
More meals paid for, more drugs prescribed
Notably, the research shows a clear dose-response relationship between paid-for meals and inappropriate prescriptions. The more meals a doctor received from a company, the more of the company's drug they prescribed. This was true for a range of different types of drugs, from drugs for high blood pressure and cholesterol to antidepressants and opioid painkillers.
The authors also point out that this practice is seen as normal and unproblematic in the medical field.
“It's very common for doctors to receive free meals from companies,” says lead author, Dr Barbara Mintzes from the University of Sydney, Australia. “Doctors often think that this is trivial and doesn’t influence them, that they ‘can’t be bought for the price of a sandwich’, but the data shows this is an effective marketing strategy. The more free meals a doctor receives, the more likely they are to prescribe less appropriate or more expensive drugs.”
Restricting industry interactions may improve prescribing
Some hospitals and medical centres have rules or institutional restrictions in place, also known as conflict-of-interest policies, to limit how much contact industry reps can have with doctors or what gifts or samples they are allowed to provide. The review found that these can mitigate the negative impact of pharma strategies on doctors’ prescribing habits.
“It’s encouraging to see that robust conflict-of-interest policies in place tended to be effective,” Dr Mintzes says. “The data shows that they probably improve prescribing appropriateness and possibly reduce the number of prescriptions.”
While this review found that drug promotion negatively influences prescribing within a broad range of drugs and clinical settings, the authors wish to emphasize that this is not about a few "bad apples”, but about improving the system and a key positive finding is that strict conflict-of-interest policies are a way forward.
Journal
Cochrane Database of Systematic Reviews
Method of Research
Systematic review
Subject of Research
People
Article Title
Pharmaceutical industry information and promotional strategies aimed at prescribers
Article Publication Date
8-Oct-2026
COI Statement
Barbara Mintzes (BM): BM is a member of Health Action International (HAI-Europe Association) and the Therapeutics Initiative. She is an Associate Editor with UK Drug & Therapeutics Bulletin, and serves as General Secretary for the International Society of Drug Bulletins (ISDB) from 2023 to 2028. These organisations produce independent information on medicines and do not receive any funding from the pharmaceutical industry. She hasalso acted as an expert witness for Health Canada and for Australia's Therapeutic Goods Administration. Alice Fabbri (AF): AF is currently working as a public health physician at the Hygiene and Public Health Unit in Ravenna, Department of Public Health, Azienda Sanitaria Locale (AUSL) Romagna, Italy. Quinn Grundy (QG): QG served as consultant to the Government of Canada Competition Bureau in 2025. Geoffrey Spurling (GS): none known Joel Lexchin (JL): Between 2023-2026, Joel Lexchin received payments for writing a brief for a legal fi rm on the role of promotion in generating prescriptions for opioids and for co-writing an article for a peer-reviewed medical journal on semaglutide. He is a member of the Board of the Canadian Health Coalition. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. He has received funding from the Canadian Institutes of Health Research in the past. Riaz Qureshi (RQ): RQ is faculty with Cochrane Eyes and Vision, which has no relation to this review topic. RQ was not funded for the work on this article. Lisa Bero (LB): LB is Research Integrity Editor, Cochrane, for which she receives payment. She was not involved in the editorial process for this article. LB, BM, QG, AF, and JS were authors of studies screened for eligibility for inclusion. They were not involved in screening studies which they authored. None of the included studies were authored by any of the review authors.
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