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Direct-to-Consumer Advertising of Pharmaceuticals
(Released March 2008)

 
  by Amy Shaw  

Review

Key Citations

Resources

Glossary

Editor
 
The DTC Advertising Debate

Contents

PhRMA argues that DTC advertisements educate consumers about health and available treatments, empowering them to become more active participants in their own care. For example, thanks to an advertisement from Pfizer, many people who had been experiencing persistent thirst may have learned that thirst is a symptom of diabetes (Bradford, 2006). PhRMA also asserts that these advertisements foster "important doctor-patient conversations about health that might otherwise not have happened" (PhRMA, 2005). Silvia Bonaccorso and Jeffrey Sturchio of the pharmaceutical company Merck argue that while these advertisements might shift the balance of control in a doctor-patient consultation, they will "not diminish the role of the doctor." Rather, the knowledge the patient obtains from a DTC advertisement will enhance the consultation (2002).

graph of benefits
What were the beneficial effects?

Although many doctors are skeptical of the value of these advertisements, recent research on physicians' attitudes toward DTC advertising has become mixed or more positive (Huh and Langteau, 2007). For example, Robinson (2004) reported that a majority of physicians believe that DTC advertising has motivated patients to seek medical care. A 2006 survey of members of the National Medical Association (NMA), the nation's oldest association of physicians of color, reveals that their perceptions of the positive benefits of these advertisements far outweigh negative perceptions (Morris et al, 2007). Three FDA surveys conducted in 1999 and 2002 show mixed results, revealing that 53% of physicians found these advertisements resulted in better discussions with patients and 42% of physicians believed that patients were more aware of available treatments (Rados, 2004).

Aside from individual doctor-patient visits, the advertisements can improve the public's knowledge of health (Sheehan, 2007). The 2006 survey of NMA physicians revealed that they believed this form of advertising provides "notable educational benefits" (Morris et al, 2006). Prescription drugs often have Web sites directed to consumers, offering extensive information on particular medical conditions. DTC Web sites, such as the one for Chantix, a prescription medicine to help smokers quit (Chantix, 2005), can give consumers a high degree of control and could improve their decision-making.

Among patients who visited doctors and asked for a prescription drug by brand name because of an advertisement, 88% actually had the condition the drug treats (Rados, 2004). And if a patient sees a physician earlier as a result of an advertisement, the physician may be in a better position to provide treatment (Finlayson, 2005). DTC advertisements can also make a condition seem less embarrassing (Rados, 2004), which advocates say can make people more likely to get help and speak openly with their doctors. And from an economic perspective, supporters assert that these advertisements lead to increased competition and lower prescription drug prices (Huh and Langteau, 2007).

DTC opponents, such as the American College of Physicians, contend that such advertising undermines the doctor-patient relationship (Spake and Joseph, 2007) while others argue that it creates a demand for prescription drugs that may not be appropriate (Huh and Langteau, 2007). According to Ed Mierzwinski, consumer program director for U.S. PIRG, DTC advertisement caused the "overprescription of drugs for conditions people weren't even aware of. . . [and] has resulted in massive profits for the industry by preying on consumers' emotions" (Lazarus, 2008). Most physicians indicate that DTC advertisements rarely provide enough information about the cost, alternative treatments, or adverse effects, according to a study by Robinson et al (2004). A cross-sectional survey of a nationally representative sample of U.S. physicians found that more than half had a negative response to the increase in advertising prescription drugs directly to consumers (Murray et al, 2003).

During medical visits, critics say, physicians are forced to take time away from important aspects of patient care to explain why a treatment the patient saw on TV is not appropriate. Even so, in at least 40% of visits in which discussion about a DTC-advertised drug takes place, the physician prescribes the advertised drug. And in more than half of these cases, physicians claim to have prescribed drugs to accommodate the patient's request (Metzl, 2007).

Patient advocacy groups such as Care to Live are spurring the FDA to speed the release of new drugs into the market to increase treatment options (Roan, 2007). Typically, DTC drugs are new to the market, so they lack a proven safety record (Finlayson and Mullner, 2005), as was the case with Merck's anti-inflammatory drug Vioxx, which earned the title of blockbuster drug after its sales began exceeding $1 billion per year. DTC advertisements, particularly those for new drugs, faced increasing criticism after Vioxx was linked to a significant increase in heart attacks and strokes and withdrawn from the market (Donohue et al, 2007). The Institute of Medicine issued a report in 2006 strongly advocating a moratorium on DTC advertising to address safety concerns regarding new prescription drugs (Morris et al, 2007). While PhRMA has produced voluntary guidelines for pharmaceutical companies to address this issue, critics such as the AIDS Healthcare Foundation argue that this self-regulation is not working as many drug companies continue to begin advertising campaigns for the most heavily promoted drugs within a year after FDA approval (NEJM, 2007).

In addition to safety concerns, these newer drugs tend to be more expensive than generic drugs or older versions of a given medication. The much-promoted medications Avandia and Actos used to treat type 2 diabetes were found to be no more effective--or safe--than older drugs, yet they are much more expensive ("CR Report," 2007). And a study that examined the economic implications of antipsychotic drug prescribing practices in America found that compared with newer drugs such as Zyprexa, Seroquel, and Risperdal, older medication used to treat schizophrenia was found to be equally effective and as much as $600 a month cheaper (Vedantam, 2006).

DTC advertisements can also prompt consumer requests for products that are unneeded. Helen Darling, president of the National Business Group on Health, asserts that "'[E]veryone, including the company, agreed that not everybody ought to be getting Vioxx…[b]ut the ads implied that there was a widespread need for it'" (Freudenheim, 2007).

Despite their complaints about the television advertisements, doctors are also influenced by marketing from pharmaceutical companies. Targeted through a marketing technique called detailing, physicians receive visits from representatives of pharmaceutical companies to give them details of their products and encourage prescribing. Generally, these visitors bring free samples. Cooperative physicians also receive other perks from these companies, such as free food, reimbursement for the cost of conferences, or money for giving speeches to convince other doctors to use companies' drugs (Miller, 2007). Some researchers wonder whether DTC is any worse than the distortion brought about by detailing (Bradford, 2006).

Aside from potentially undermining the doctor-patient relationship, these advertisements can convey misleading information about the drugs, exaggerating the benefits and understating the risks. One such advertisement, called "Videogame," was for Strattera, a psychotropic drug approved for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). The television advertisement by Eli Lilly and Company received a regulatory letter from the FDA for minimizing the serious risks of the drug and failing to communicate the Attention Deficit Disorder (ADD) indication for it (Strattera, 2005). This is not the only commercial accused of understating the risks. A 2007 study in the Journal of Health Communication found that the average DTC commercial devotes less time to side effects than to benefits (Kritz, 2008), thus ignoring the fair balance requirement.

On a broader level, some critics say these advertisements contribute to the medicalization of what was previously considered part of the normal range of human experience (Frosch et al, 2007). Normal variation in sexual performance among men is now the target of the lifestyle drug Viagra (Conrad and Leiter, 2004). Lifestyle drugs are medications used to treat non-life-threatening conditions such as hair loss, obesity, and wrinkles. By focusing on selling lifestyle drugs like Viagra, which provide higher profit margins, drug companies leave fewer resources for developing drugs that are more medically necessary (Cunningham and Iyer, 2005). The pharmaceutical industry's output of such lifestyle drugs contrasts sharply with the shortage of drugs in development for chronic and emerging diseases (Croghan and Pittman, 2004).

By promoting a drug as the solution to a health problem, these advertisements can lead viewers to believe that adopting healthy behaviors, such as good diet and exercise, would be ineffective or unnecessary. Advertisements might suggest that health improvement comes from medication, perhaps in combination with healthy activities, but never from behavior modification alone (Frosch et al, 2007). However, in response to these concerns, PhRMA's guidelines recommend that these advertisements include information about "other options such as diet and lifestyle changes where appropriate for the advertised condition" (PhRMA, 2005).

Opponents also call for more stringent oversight to protect consumers from detrimental and socially undesirable effects of DTC advertisements (Huh and Langteau, 2007). For example, the GAO has questioned the FDA's effectiveness in limiting false and misleading consumer exposure to DTC advertising (United States, 2006).

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