Education and debate

Direct to consumer advertising is medicalising normal human experience

In direct to consumer advertising, drug companies target advertisements for prescription drugs directly at the public. Barbara Mintzes argues that this type of advertising risks medicalising normal human conditions, with the drug companies raking in increasingly healthy profits. Silvia N Bonaccorso and Jeffrey L Sturchio argue that, through advertising, drug companies can enable patients to make better informed choices about their health and treatment

For

Barbara Mintzes, graduate researcher. 

Centre for Health Services and Policy Research, University of British Columbia, 429-2194 Health Services Mall, Vancouver, BC, Canada V6T 1Z3

bmintzes{at}chspr.ubc.ca

In October 2001, GlaxoSmithKline ran an advertisement in the New York Times Magazine for paroxetine (known as Paxil in the United States). A woman is walking on a crowded street, her face strained, in a crowd otherwise blurred. The headline reads, "Millions suffer from chronic anxiety. Millions could be helped by Paxil."

No doubt many New Yorkers felt anxious in the aftermath of the attack on the World Trade Center, experiencing symptoms highlighted in the advertisement, such as worry, anxiety, or irritability. At what point does an understandable response to distressing life events become an indication for drug treatmentand a market opportunity?

Kawachi and Conrad describe medicalisation as a "process by which non-medical problems become defined and treated as medical problems, usually in terms of illnesses and disorders," decontextualizing human problems and turning attention from the social environment to the individual.¹ They point out the negative consequences, chiefly the extension of the sick role and diversion from other solutions.

Does direct to consumer advertising of prescription drugs, currently allowed only in the United States and New Zealand, broaden the domain of medicine beyond justifiable bounds?

Promotion of drug use among healthy people

Liz Coyle of the market research firm IMS Health suggests instead that "Consumers often ignore, or choose not to treat, symptoms that seem `minor' or that are not in acute stages," and that advertising "can help them improve their health and avoid more serious, costly conditions down the road." She is describing US disease oriented advertising for hair loss, menopause, obesity, osteoporosis, and acne.² New Zealand's pharmaceutical industry similarly claims that direct to consumer advertising "encourages people to seek medical attention for conditions or symptoms that might otherwise go untreated, including asymptomatic diseases."³

Charles Medawar of Social Audit UK argues that the most dangerous effect of direct to consumer advertising is to encourage healthy people to believe they need medical attention. He quotes Lewis Thomas: "The new danger to our well-being, if we continue to listen to all the talk, is in becoming a nation of healthy hypochondriacs, living gingerly, worrying ourselves half to death."⁴

Many advertising campaigns focus on fears of death or disability. In Better Homes and Gardens (April 2000), Merck, manufacturer of alendronic acid, told older US women, "See how beautiful 60 can look? See how invisible osteoporosis can be?" The advertisement urges women aged 60 or older to go for a bone density test, citing a nearly 1 in 2 chance of having osteoporosis, leading to broken bones and dowager's hump"no matter how healthy you look on the outside." Bone mineral density testing is a poor predictor of future fractures⁵ but an excellent predictor of start of drug use.⁶ For healthy people, benefits may not outweigh risks: in pre-marketing trials 1.5% of users of alendronic acid experienced oesophageal ulcers.⁷

Relatively healthy people are targeted because of the need for adequate returns on costly advertising campaigns. Consistently, around 40% of spending on direct to consumer advertising is on only 10 drugs, mainly new, expensive drugs for long term use by large population groups. In 2000, they were drugs for allergy, ulcer/reflux, anxiety, obesity, arthritis, impotence, and high cholesterol levels. Morais suggests that manufacturers assess whether a product-specific campaign is worth pursuing based on numbers of potential patients, the "persuadable" percentage, the proportion of doctors who will prescribe, and the value per patient (return per script multiplied by the duration of use).⁸

Advertising campaigns can lead to shifts in the pattern of use of healthcare services. The Dutch Health Inspectorate reported dramatic increases in consultations for toenail fungus after a three month unbranded media campaign.⁹ In 1998, during a campaign for finasteride (Propecia), visits to US doctors for baldness increased by 79% compared with 1997 levels, to 850 000 (Scott Levin, press release, 31 November 1998).

Even when the focus is on prevention of serious disease, many advertising campaigns cast too wide a net. Lipid lowering drugs, for example, reduce mortality in men with heart disease yet there is under-prescribing in this population group. However, it is more lucrative to promote primary prevention as many more people are affected, despite the lack of significant reduction in mortality.¹⁰ In Chatelaine magazine in October 2001, Pfizer used the tagged toe of a corpse to promote cholesterol testing among women in their 50s without heart disease.¹¹

Companies are under intense pressure to garner and retain market share, leading to what the World Health Organization has called "an inherent conflict of interest between the legitimate business goals of manufacturers and the social, medical and economic needs of providers and the public to select and use drugs in the most rational way."¹² Doctors with greater reliance on promotion prescribe less appropriately,¹³ and the patients who are exposed more to direct to consumer advertising request more advertised drugs. These requested drugs are usually prescribed, often despite doctors' reservations about treatment choice.¹⁴

Both critics and supporters of direct to consumer advertising agree that it is likely to expand drug treatment in healthier populations. This can occur through broader disease definitions, based on physiological measures rather than on clinical events; through promotion of drugs for disease prevention; and through prescription drug use for symptoms previously treated with over the counter remedies or non-drug approaches. An additional effect, observed in the United States at a population level, is substitution of newer for older drugs among those already receiving treatment.

Newer drugs are not necessarily better

Evidence on clinical outcomes is often inadequate when drugs first come on to the market, at times leading to false impressions. COX 2 inhibitors, for example, were widely believed to be safer than other non-steroidal anti-inflammatories when first launched. An assessment of the full experience of serious adverse events in comparative trials suggests the contrary.¹⁵

This type of comparative information does not reach the public in direct to consumer advertisements. In a 10 year analysis of advertising in US magazines, 91% of advertisements omitted information about the likelihood of treatment success and 71% failed to mention any other possible treatments.¹⁶

A powerful cumulative effect

With more than $2.5bn (£1.8bn; 2.9bn) spent on direct to consumer advertising in the United States last year, the cumulative message may be stronger than any individual campaign. A market researcher estimated that in late 1999, Americans on average saw nine prescription drug advertisements a day on television. To an unprecedented degree they portrayed the educational message of a pill for every illand increasingly an ill for every pill.

Acknowledgments

Charles Medawar, Joel Lexchin, Ken Bassett, and Lisa Hayes reviewed a draft of this article.

Footnotes

Competing interests: None declared.

References

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