Chilet-Rosell et al. BMC Public Health 2010, 10:134 http://www.biomedcentral.com/1471-2458/10/134 osteoporosis, nor for the prevention of chronic condi- tions [5] (only some institutions still challenge this line of though) [6]. Likewise, it is no longer indicated for asymptomatic menopausal women [5,7]. Consequently, there has been a steep drop in sales, documented mainly in Anglo-Saxon countries [1]. Since 2004, the Spanish Agency for Medicine and Health Care Products, in consonance with the regulatory agencies in other countries, leading health care institu- tions and most scientific societies, has considered HRT to be potentially indicated only in the treatment of severe climacteric symptoms with a negative effect on quality of life. In this case, they concur that the mini- mum effective dose should be used for the shortest pos- sible duration [7,8]. HRT is classified as a prescription-only drug in Eur- ope. That is, a medical prescription is required, and therefore advertising is only permitted where it is aimed at professionals authorised to prescribe, and not at the general public [9]. Nevertheless in some non European countries HRT direct to consumer advertising is allowed. Furthermore, online sales are illegal in the Eur- opean Union (EU). Despite this fact, online sales of drugs in Europe have risen steeply since the 1990s, becoming not only a risk to public health but also a sig- nificant source of legal conflict between countries [10]. The EU has indicted the need to review the rigour, integrity and consistency of health information pub- lished on the Internet [11]. Spain adheres to the recom- mendations given in the European Code of Good Practice in the Promotion of Medicines adopted by the European Federation of Pharmaceutical Industries and Associations (EFPIA) [12]. This Federation requires each affiliated national association to constitute a Committee in order to ensure that companies fulfil the precepts of the Code, and to undertake disciplinary proceedings when appropriate. Specifically, Farmaindustria’s Code of Practice Surveillance Unit in Spain supervises the Asso- ciation’s code and advises members [13]. Meanwhile, in Spain, it is the responsibility of the Jury of the Associa- tion for Self-Regulation of Commercial Communications to settle disputes and resolve disciplinary proceedings concerning the code. The aim of the European Code of Good Practice in the Promotion of Medicines is to ensure that all phar- maceutical promotion methods, including the Internet, comply with current legislation [13]. Other objectives include ensuring that the ethical principles of profes- sionalism and responsibility are upheld, that access to information aimed at professionals is restricted to the target audience and that the identity of the advertiser is clearly stated in the case of sponsored activities or for- mats. Furthermore, it supports the obligatory inclusion of information, comprising the Summary of Product Page 2 of 9 Characteristics and scientific information based on valid data with scrupulous respect for truth and impartiality, all within the framework of a balanced, clear explana- tion. The need to avoid ambiguity is stressed, as is the need to base advertising claims on firm scientific evi- dence and medical opinion, which the reader is able to check up on (i.e. compliance with the code requiring inclusion of bibliographic references). Likewise, exag- geration or omission of data is forbidden [13]. In order to analyse the phenomena of HRT internet advertising in Spain, this research has three main objectives: 1. To estimate compliance with these regulations on the corporate web pages of the best-selling HRT drugs in Spain, in order to identify the degree of commitment of the corresponding pharmaceutical companies. 2. To analyse references to the same drugs on non- corporate web pages, establishing the name and address of the registered company and possible sponsors, in order to identify potential connections or ties with phar- maceutical companies. 3. To evaluate and quantify whether these prescrip- tion-only drugs are being sold on the Internet to the general public via online pharmacies based in Spain or abroad. Methods In order to obtain the list of the best-selling and most frequently prescribed HRT brands in Spain, the Spanish Ministry of Health and Consumer Affairs General Direc- torate was consulted. These top eight products were Absorlent Plus, Activelle, Duofemme, Estalis, Estracomb, Merigest, Perifem and Progyluton. Using the drugs’ commercial brands, a search was car- ried out in January 2009, simulating the kind of search strategy that a typical internet user interested in locating information about these drugs would employ, using the Google search engine (the most popular search engine amongst internet users) [14]. All the web sites appearing on the first results page for each of the drugs were selected. In addition, when the first results page for each drug did not include the corporate web page, that is, the web site of the company marketing the drug in Spain, a further search was made in order to locate it, and the information about the drug analysed. The corporate web sites were analysed for compliance with the following European Code’s recommendations: 1. Restriction of the information to a specialised public (implemented through obligatory identification on behalf of the user in order to access the information). Specifi- cally, the obligation to register - supplying the profes- sional body membership number - in order to access information aimed at health care professionals, was monitored.