Author: Gunther Eysenbach
Position: Associate Professor
Institution: University of Toronto
E-mail: geysenba@uhnres.utoronto.ca
Submitted Date: November 22, 2007
Published Date: November 26, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

One of the fundamental problems of this study, which the authors call "unique" and "the first of its kind", is that it muddles together two separate policy issues - the issue of spamming, and the issue of online pharmacies. Spammers are not the online pharmacies itself, but usually third parties ("affiliates") who earn a commission for each customer following a personalized link. The notion that "products were ordered from spammers", and that the online pharmacies listed in Table 1 are actually the spammers themselves, is grossly misleading. These online pharmacies might be guilty of indirectly encouraging spamming by paying commissions to referring "affiliates" (something that Amazon and other Web companies do as well), but they are not necessarily the spammers themselves, and their affiliate agreements will most likely also forbid spamming. For a paper that sets out to shed light on "health-related spam and the spammers behind it" these mechanisms are surprisingly little explored and explained.

The authors searched Medline and concluded that little is known about spam. Medline is not the ideal place to look for evidence on spam. Industry reports are available which regularly monitor the amount and nature of spam. Health-related spam was previously reported to be in the 7-10% range [1, 2], which is different from what the authors report (one-third). A meta-analysis of the existing spam reports might have been more elucidating than classifying emails from a personal sample, which will be biased, in particular if the email owner works in the health industry (email harvesting robots gather email addresses from the web and classify them according to their context, to enable spammers to target their message).

Plenty of evidence is also available on the nature of online pharmacies, and test orders have been conducted before [3,4]. Medline lists almost 30 articles discussing online pharmacies.

In summary, the study is unique in looking at two policy issues together, but for each of these issues separately much more evidence is available than acknowledged or recognized by the authors.

References

1. Spam Statistics 2006
http://spam-filter-review...
http://www.webcitation.or...
2. Spam Statistics 2003
http://www.nospam-pl.net/...
http://www.webcitation.or...
3. ONLINE PHARMACIES: What the doctor downloaded.
http://www.accessmylibrar...
http://www.webcitation.or...
4. Eysenbach G. Online Prescribing of Sildanefil (Viagra) on the World Wide Web. J Med Internet Res 1999;1(2):e10. http://www.jmir.org/1999/...