Despite all the efforts to raise the awareness of different types of COI and the significance of the disclosure, recent studies reveal that more concerted efforts are required to educate reviewers, journal editors, and publishers on issues of COI (46).

COI arises when author, reviewer or editor have connections to a particular source/organization, causing a bias in their judgment of the journal manuscript, even if the ultimate decision is not affected by such a bias. Conflicting relationships can be commercial (financial), intellectual, academic (academic competition), ideological, personal, or regional (4). There is the lack of understanding and erratic nature of COI disclosure not only among authors, but even among reviewers, and journal editorial board members (4).

The credibility of scholarly papers depends on unbiased writing, review, and editorial decisions, largely affected by apparent and concealed COIs. Therefore, it is essential that those involved in the peer review and publishing provide information on their conflicting interests openly to allow readers to judge the credibility of the papers.

Guided by the ICMJE recommendations on COI, most scientific journals have developed their own COI disclosure policies and incorporated relevant statements in the instructions for authors (5). However, the problem still lies in the lack of enforcement of the instructions and in the fact that some authors view transparent disclosure of COI as a factor, which may negatively affect the judgement of their work by evaluators (6). Particularly, we observe this situation in Japan.

The need for more studies on how reviewers perceive authors’ industry-linked financial COI disclosures and how this affects manuscript assessment is justified (7). However, despite the lack of concrete data, some journal decisions, especially concerning manuscripts with excessive COIs, may be influenced by the authors’ COI statements (4). Some journals choose not to accept review papers, which are widely quoted, or editorials, which have a great effect, from authors with many COIs in order not to confuse their readers (8). Much debate has arisen on whether a strict boundary between academic researchers and industry is in our best interest (8), questioning the fundamental purpose for COI disclosure (9).

As with all policies, it is possible for COI policies to lose their significance and authenticity. In the case of Japan, while emphasis on education on COI disclosure has been utilized as a means to enforce such policy, it is undeniable that this has yet to be uniformly implemented. In the study of how COI is managed by Japanese medical journals (10), it became apparent that approximately 70% of medical journals introduced COI policy to its authors, but only 49.6% of the journals required members of its editorial committees to disclose COI on their appointment. Furthermore, only 28.9% of the journals provided education on COI disclosure to its reviewers and editorial board members (10). This tendency to disregard the importance of COI disclosure among journal editors seems to be characteristic not only for Japanese medical journals, but also international ones (4). Despite the fact that the ICMJE Recommendations state that reviewers should recuse themselves from peer review if COI exists (11), it is the opinion of many of the author’s medical editing colleagues that there are very few cases of self-recusal among potential reviewers because of COI.

In some cases, disclosing COIs may be disadvantageous for authors. For instance, among nonnative English speakers, it common to receive help from professional medical writers (12). Although there may be negativity toward authors whose works are edited by medical writers, if the writing support and any related financial issues are disclosed, such author-medical writer relationships should be treated as ethical. Properly trained medical writers provide researchers not only with writing assistance, but also with guidance on publication ethics (13).

There is a tendency for medical journal editors to disfavor editorials or reviews written by those who disclose receiving industry payments (8). As with financial COIs, the question we need to consider is not whether or not COI exists, but how COI is managed in order to protect the joint efforts of researchers and industry, as the ultimate goal is medical advancement (14).

Currently, the updated Good Publication Practice 3 (13) known as GPP3, provides authors with detailed information on the principles for company-sponsored medical researchers, providing broader guidance on COI disclosure in such situations compared with the ICMJE Recommendations (1). It also demonstrates the role and benefits of professional medical writers.

If COI policies are to be effective, a simple yet effective code that can be understood by any health care professional internationally is essential, as there are possible variations in the understanding and perception of COI and COI disclosure, even among prominent researchers. Furthermore, the key to endorsing such COI policies, is to educate not only authors, but reviewers, and editorial board members with developments in the latest guidelines.