Mixed messages

Whatalotwegot--the messages in drug advertisements

^a City Hospital NHS Trust, Birmingham B18 7QH,

Correspondence to: Dr Ferner.

Advertisers are increasingly using symbols to circumvent logical argument when trying to persuade people (the "targets" of the advertisement) to make choices that are not strictly rational. Symbols can convey covert meanings and awaken or exploit subconscious feelings, such as a desire for power or a fear of doing harm. Some of the ways in which pharmaceutical advertisements use these techniques are examined: advertising by contagion; adding to our worries; polarity of choices; teasers; idealisation. Rational prescribing should be based on logic, but advertisements do not depend on logical arguments for their most powerful effects: the advertisers may subvert us by appealing to our unconscious desires.

Readers of medical journals are "targets" for drug advertising, an important part of drug marketing. The pharmaceutical industry spends around £300m on marketing each year in the United Kingdom, and studies suggest that the money is well spent, since marketing undoubtedly influences the way that doctors prescribe.^{1 2}

Science requires the unambiguous description and logical analysis of facts. This is not the purpose of advertising, which shares with art the use of oblique visual and verbal images to convey the message it wants us to receive.³ The advertiser tries to influence our feelings and alter our perceptions and so persuade us to change our actions. We may believe that our actions are dictated by logic, but a large body of advertising theory holds that we are more strongly motivated by subconscious needs and wants, which advertising should exploit. These subconscious motives include a longing for control over the chaos of daily life; a wish to allay anxieties about our professional, social, and intellectual standing; and a need for reward. Dichter, an early advocate of motivational research in advertising, called this "the strategy desire."⁴ Prescribing driven by advertisements predicated on this strategy is unlikely to be rational prescribing.^{5 6}

The power of symbols

One way of exploiting our desires is to use evocative symbols in advertising. Symbols have complex and multiple meanings, and are able to evoke feelings on many planes. The swastika, for example, connotes enormously more than a simple angular arrangement of lines, and a pair of lips more than an arrangement of curves. The oblique messages of the advertising image can be interpreted with this in mind.^{3 7 8} Semiotics, the study of signs and their meaning, claims to analyse how the advertising message uses symbols to evoke potent feelings about a product. Advertising agencies are sufficiently convinced of the method's accuracy and validity to recruit experts in semiotics to help construct advertisements.⁹

There is always the danger that interpretation says more about the analyser than the analysed. With this caveat, we examine some of the strategies that pharma- ceutical advertisements have exploited to encode messages to potential prescribers.

Advertising by contagion

If an advertiser wishes to imbue a product with a quality that its users would desire then a standard strategy is to link the product to symbols of that quality. In this way, petrol can "put a tiger in your tank." Practitioners and patients want medicines to be strong and powerful, but controllable and gentle. Images conveying these qualities are common in pharmaceutical advertisements.

A smashed clay pigeon used in one antibiotic advertisement (fig 1) encapsulates immediacy, accuracy, and power. The antibiotic will help us smash infection. Another antibiotic (fig 2) was promoted with the message "Get in, do the job, get out intact"--the slogan of the Special Air Service.

View larger version (80K): [in this window] [in a new window]   FIG 1--Immediacy, accuracy, and power (reproduced with permission of Glaxo Pharmaceuticals UK Ltd).

View larger version (53K): [in this window] [in a new window]   FIG 2--Bringing military efficiency to the treatment of infection (reproduced with permission of Hoechst Roussel Limited).

Control is exemplified by the picture of a burette containing urine, used in an advertisement from the 1960s (fig 3). A hand is turning the tap of the burette and a steady stream of urine flows. The image not only induces a feeling of urinary urgency but reinforces the text, which claims that the diuretic's effect can be precisely regulated. And the image also says more than this--we presume it is the prescriber's hand that turns the tap, implying that the drug gives the doctor control over disease.

View larger version (61K): [in this window] [in a new window]   FIG 3--The hand that turns the tap controls the disease (reproduced with permission of Hoechst Roussel Limited).

The childhood pleasure of snuggling down to a good night's sleep with a cuddly teddy bear, and the security that goes with it, are evoked by a hypnotic advertisement that invites us to "Sleep serene ... awake refreshed." It implies that the hypnotic will allow patients to recapture the innocent sleep of childhood, safe from any adverse effects, and we are lulled into prescribing.

Adding to our worries

Some advertisements create or increase anxiety, to persuade us to use a product. One advertisement for a topical antibiotic recreates the misery of teenagers smitten by acne (fig 3). The young sufferers bow their heads, avert their faces, and finger their afflicted skin, while the others in their gang look relaxed or pitying. The advertisement holds up a mirror for us to see again FIG 4--A stark choice (reproduced with permission of Wyeth Laboratories). FIG 5--Puzzled participation (reproduced with permission of Glaxo Pharmaceuticals UK Ltd). FIG 6--An image to aspire to (reproduced with permission of Bayer plc) our spotty teenage anxieties, and invites us to see "repellent" acne as needing medical treatment.

An advertisement for an H2 antagonist, showing a volcano at first quiescent and then in fiery eruption, warns doctors to "consider an ulcer extinct at your patient's peril." This is an emotionally compelling invitation to long term maintenance therapy, even if the rationalists believe that such treatment is "best suited to those with frequent severe recurrences and to the elderly who suffer ulcer complications."¹⁰

Black or white

Another standard marketing technique is to present a series of choices, of which the most appealing is to buy the marketed product. This usually entails restricting the series of choices being offered and often introduces an element of anxiety: "Buy an Afterlife Assurance Bond, or die penniless." Pharmaceutical advertisements can present just such a limited set of choices to the prescriber. One advertisement that does this through symbols depicts an array of stylised faces. Forty one are miserable and coloured blue. The 42nd is cheerful and coloured yellow. This happy state has been achieved by exercising "the simple choice" to use the antidepressant whose name is underlined in yellow and juxtaposed with a stylised yellow sun. There is no question of using other antidepressants, or non-drug approaches, to solve our patients' problems.

A more obviously unpleasant choice faces the doctor when an advertisement asks, "Which would you rather prescribe to a potential osteoporosis sufferer?" (fig 4). Shown below the question are the stark alternatives. To the left, in colour, is the picture of a packet of hormone replacement tablets, and to the right, in black and white, is the picture of a wheelchair. The images ask the coded question: "Would you rather prescribe our drug, or condemn your patient to a wheelchair?" This is a false dichotomy: all postmenopausal women are "potential osteoporosis sufferers" but fortunately only a very few end up in wheelchairs for want of hormone replacement.

View larger version (52K): [in this window] [in a new window]   FIG 4--A stark choice (reproduced with permission of Wyeth Laboratories).

Teasers

A recent series of posters consisted of anagrams of the name of a lager, and an advertising campaign for a brand of cigarettes has been designed around verbal and pictorial crossword clues. We are led inexorably into participating, and the advertisers hold us until we have solved the puzzle.

Pharmaceutical advertisements occasionally use this device. For example, advertisements for an H2 receptor antagonist show rugged landscapes in which are hidden the initial letter of the product's brand name (fig 5). At another level, the rugged countryside reinforces the text, proclaiming "I've got the power," a message that is helpfully ambiguous, since it could refer to the product or to the prescriber.

View larger version (84K): [in this window] [in a new window]   FIG 5--Puzzled participation (reproduced with permission of Glaxo Pharmaceuticals UK Ltd).

Ourselves and others

A more direct approach is to show the targets of advertising as they wish to see themselves. We have already seen how advertisements can suggest that a drug will give the prescriber more control over the patient's illness. They can also show the prescriber empowered. An antibiotic advertisement portrays a man in a white tuxedo reaching inside his jacket, perhaps for his Beretta. Behind him stands a silver Aston Martin; the legend is "Licensed to kill in bacterial infections." The prescriber is invested with all James Bond's charisma and given that special right to kill legitimate targets.

The confident face of a handsome and intelligent general practitioner stares out from another series of advertisements. The doctor is mature enough to make the right decision but still young enough to be attractive; well dressed but not ostentatious; kindly but firm. We are all presumed to aspire to this image. And the woman general practitioner in one of the advertisements relies on the antibiotic "for her vulnerable bronchitics" (fig 6). It is a persuasive message, though she may not be right: problems have been reported in using the antibiotic to treat upper respiratory tract infections due to Streptococcus pneumoniae.¹¹

View larger version (58K): [in this window] [in a new window]   FIG 6--An image to aspire to (reproduced with permission of Bayer plc).

Discussion

These simple analyses do not represent an exhaustive catalogue of all possible uses of symbols in pharmaceutical advertisements, and any of the advertisements shown could be analysed on several levels. We can be reasonably sure that much thought went into the construction of each one. People will have made conscious decisions about the message to put across, the visual images, the colours, the words, the typography and the intended audience, which may well represent only a subset of prescribers. This effort is expended with the aim of persuading us to prescribe a given drug, so that the company that makes it can profit.

Companies exist to make profits for their shareholders, so that is an entirely legitimate aim. However, we should be on our guard. Advertisers use symbols in a way that implies a careful analysis of doctors' subconscious motives and aspirations. Doctors may themselves be reluctant to acknowledge these hidden feelings, but this reluctance makes them vulnerable. Rational prescribing should be based on logic, but advertisements do not depend on logical arguments for their most powerful effects: the advertisers may subvert us by appealing to our unconscious desires.

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