Citation bias

The perusal of the reference lists of articles is widely used to identify additional articles that may be relevant although there is little evidence to support this methodology. The problem with this approach is that the act of citing previous work is far from objective and retrieving literature by scanning reference lists may thus produce a biased sample of studies. There are many possible motivations for citing an article. Brooks interviewed academic authors from various faculties at the University of Iowa and asked for the reasons for citing each reference in one of the authors’ recent articles (Brooks 1985). Persuasiveness, i.e. the desire to convince peers and substantiate their own point of view, emerged as the most important reason for citing articles. Brooks concluded that authors advocate their own opinions and use the literature to justify their point of view: “Authors can be pictured as intellectual partisans of their own opinions, scouring the literature for justification” (Brooks 1985).


In Gøtzsche’s analysis of trials of non-steroidal anti-inflammatory drugs in rheumatoid arthritis, trials demonstrating a superior effect of the new drug were more likely to be cited than trials with negative results (Gøtzsche 1987). Similar results were shown in an analysis of randomized trials of hepato-biliary diseases (Kjaergard 2002).  Similarly, trials of cholesterol lowering to prevent coronary heart disease were cited almost six times more often if they were supportive of cholesterol lowering (Ravnskov 1992).  Over-citation of unsupportive studies can also occur. Hutchison et al. examined reviews of the effectiveness of pneumococcal vaccines and found that unsupportive trials were more likely to be cited than trials showing that vaccines worked (Hutchison 1995).


Citation bias may affect the ‘secondary’ literature. For example, the ACP Journal Club aims to summarize original and review articles so that physicians can keep abreast of the latest evidence. However, Carter et al. found that trials with a positive outcome were more likely to be summarized, after controlling for other reasons for selection (Carter 2006).  If positive studies are more likely to be cited, they may be more likely to be located and, thus, more likely to be included in a systematic review, thus biasing the findings of the review.