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Physician Exposure to Direct-to-Consumer Pharmaceutical Marketing: Potential for Creating Prescribing Bias

  • Jeffrey L. Brown
    Correspondence
    Requests for reprints should be addressed to Jeffrey L. Brown, MD, 10 Walnut Court, White Plains, NY 10605.
    Affiliations
    Department of Pediatrics, New York Medical College, Valhalla

    Department of Pediatrics in Psychiatry, Weill Cornell Medical College, New York, NY
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Published:January 14, 2017DOI:https://doi.org/10.1016/j.amjmed.2016.12.023
      The American Medical Association's 2015 recommendation to ban direct-to-consumer advertising (DTCA) of prescription drugs reflected a strong consensus that this form of marketing is a significant contributor to increased drug costs. It is well documented that many patients request drugs they have seen advertised on television and that physicians often acquiesce to these requests.
      • Weinmeyer R.
      Direct-to-consumer-advertising of drugs.

      Aiken K, Swasy J, Bramin A. Patient and physician attitudes and behaviors associated with DTC promotion of prescription drugs – summary of FDA survey research results. Executive summary. November 19, 2004. Available at: http://www.fda.gov/downloads/Drugs/ScienceResearch/ResearchAreas/DrugMarketingAdvertisingandCommunicationsResearch/UCM152890.pdf. Accessed June 11, 2015.

      • Mintzes B.
      • Barer M.
      • Kravitz R.
      • et al.
      How does direct-to-consumer advertising (DTCA) affect prescribing? a survey in primary care environments with and without legal DTCA.
      • Wazana A.
      Physicians and the pharmaceutical industry. Is a gift ever just a gift?.
      But the possibility that physicians can be influenced as viewers of this advertising has escaped academic and policy-making attention. This omission is noteworthy because watching repetitive highly motivational sales-oriented messages on television might result in the same prescribing bias that prompted revision of ethical guidelines in 2008. Physicians were previously exposed to brand names and “educated” about the benefits of prescription drugs by ever-present drug detailers (sales representatives) who dispensed free advice, free samples, and an endless supply of logo-imprinted office and personal gift items. Now, marketers can potentially achieve the same objectives by broadcasting DTCA with a similar promotional message directly into a physician's home.
      In 1997 the Food and Drug Administration clarified rules that made the US and New Zealand the only 2 countries that allow DTCA. Although consumers can now be targeted directly, prescriptions for these medicines are still required, and competition for physicians' attention has remained intense and expensive. In 2012, the pharmaceutical industry spent 27 billion dollars on marketing. Most of the promotional budget was directed toward prescribers using traditional means: face-to-face contacts, direct mailings, ads in academic journals, continuing medical education, and digital advertising. But 3 billion of these marketing dollars (11%) was spent on DTCA. During that same year, the drug with the single largest promotional expenditures in the US spent almost 40% of its budget on consumer advertising.

      Cegedim Strategic Data, 2012. US pharmaceutical company promotional spending (revised 2013). Available at: http://www.skainfo.com/health_care_market_reports/2012_promotional_spending.pdf. Accessed May 17, 2015.

      There are compelling arguments for and against continued use of direct-to-consumer advertising.
      • Weinmeyer R.
      Direct-to-consumer-advertising of drugs.

      Porter DM. Direct-to-consumer (DTC) pharmaceutical marketing: impacts and policy implications. SPNHA Rev. 2011;7(1):Article 5. Available at: http://scholarworks.gvsu.edu/spnhareview/vol7/iss1/5. Accessed May 17, 2015.

      Proponents correctly argue that DTCA motivates patients to participate in their own care, educates them about treatment options, and encourages conversation with doctors about medical concerns. They also believe that compliance improves when patients have requested their own treatments and that consumers have the right to receive unfiltered product information directly from the manufacturer. Critics are equally correct when they argue that the real purpose of DTCA is to increase sales and there are better ways to educate consumers. They believe that sales-oriented advertising emphasizes a drug's benefits, minimizes its risks, and creates unrealistic expectations for successful treatment. They are especially concerned that DTCA drives up costs by promoting use of brand-name rather than comparable generic or lower-priced drugs, and that these medicines are more likely to be prescribed for nonessential and sometimes questionable indications.
      • Weinmeyer R.
      Direct-to-consumer-advertising of drugs.

      Porter DM. Direct-to-consumer (DTC) pharmaceutical marketing: impacts and policy implications. SPNHA Rev. 2011;7(1):Article 5. Available at: http://scholarworks.gvsu.edu/spnhareview/vol7/iss1/5. Accessed May 17, 2015.

      Federal and state legislators have noted that DTCA has proven so effective at popularizing brand name drugs that they are revisiting the possibility of curtailing these ads to decrease local pharmaceutical costs.

      National Conference of State Legislatures. October 2013. Marketing and direct-to-consumer advertising (DTCA) of pharmaceuticals. Available at: http://www.ncsl.org/research/health/marketing-and-advertising-of-pharmaceuticals.aspx. Accessed May 31, 2015.

      Variations in viewers' preferences, competition for advertising dollars, and frequent changes in marketing objectives make it difficult to accurately quantify a physician's exposure to DTCA and to correlate exposure with outcome.
      • Brownfield E.D.
      • Bernhardt J.M.
      • Phan J.L.
      • Williams M.V.
      • Parker R.M.
      Direct-to-consumer drug advertisements on network television: an exploration of quantity, frequency, and placement.
      Despite these limitations, it should not be assumed that medical training and ethical intent will fully immunize clinicians against the effects of viewing ubiquitous skillfully crafted promotional messages interspersed with favorite television programs. The casual setting and a recreational mindset might hinder critical evaluation of the message, contribute to lower prescribing thresholds, and increase acquiescence to patient requests.
      Sidney Wolfe
      • Wolfe S.M.
      Direct-to-consumer advertising—education or emotion promotion?.
      editorialized that “There is evidence that many drug advertisements are not balanced or accurate and duped gatekeepers may not adequately resist patients' exhortations to write a prescription.” And an experienced pharmaceutical marketing strategist writing in a trade newsletter reports that, “… we know that consumers generally tune out the part of the TV ad that follows the promotional message … It's too fast, it's not specific to (the viewer), and it is accompanied by pretty visuals of a couple and a dog walking happily on a beach. You take away almost nothing.”

      Smith J. How to make DTC ad warnings more effective. MMM online. April 7, 2015. Available at: http://www.mmm-online.com/pharmaceutical/how-to-make-dtc-ad-warnings-more-effective/article/407671/. Accessed June 11, 2015.

      These discordant feel-good images and calming voice-overs might be reassuring, but they can dangerously blunt the impact of important and sometimes life-threatening warnings. The disturbing image of a cyanotic patient clutching his chest after taking a cardiotoxic drug would be more likely to get the viewer's attention.
      Physician-viewers should be wary that DTCA might also trivialize some treatments and complex medical conditions by making them seem familiar and commonplace. Psychotropic drugs are advertised so frequently

      Becker SJ, Madoun MM. Effects of direct-to-consumer advertising on patient prescription requests and physician prescribing: a systematic review of psychiatry-relevant studies. J Clin Psychiatry. 2016;77(10):e1293-e1300. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27631149. Accessed September 29, 2016.

      that it might lead to more casual prescribing and follow-up. And when pharmacologic treatments are popularized by using benign-sounding terms like “E.D.” for erectile dysfunction, and using celebrity endorsements to convey medical information, it might seem less important to screen patients for treatable causes of their condition like depression, diabetes, arteriosclerosis, and low testosterone levels (now popularized as “Low T”). Equally troubling is the possibility that there might be a delay in making a correct diagnosis if the patient's symptoms initially respond to the prescribed medicine without first determining their cause. The ad's directive to “discuss this product with your doctor” doesn't pertain when the viewer is the doctor.
      Referring to this form of marketing as “direct-to-consumer” hides its potential for overt or covert marketing of prescription drugs direct to prescribers. Regardless of intent, the possibility that viewing DTCA can adversely affect a physician's prescribing behavior deserves further discussion and formal study. In the interim, physicians and policymakers should add these concerns to their list of potentially negative consequences from marketing pharmaceuticals directly to consumers, and prescribers should increase professional vigilance when viewing this advertising in a nonprofessional setting.

      References

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        Direct-to-consumer-advertising of drugs.
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        • Mintzes B.
        • Barer M.
        • Kravitz R.
        • et al.
        How does direct-to-consumer advertising (DTCA) affect prescribing? a survey in primary care environments with and without legal DTCA.
        CMAJ. 2003; 169: 405-412
        • Wazana A.
        Physicians and the pharmaceutical industry. Is a gift ever just a gift?.
        JAMA. 2000; 283: 373-380
      2. Cegedim Strategic Data, 2012. US pharmaceutical company promotional spending (revised 2013). Available at: http://www.skainfo.com/health_care_market_reports/2012_promotional_spending.pdf. Accessed May 17, 2015.

      3. Porter DM. Direct-to-consumer (DTC) pharmaceutical marketing: impacts and policy implications. SPNHA Rev. 2011;7(1):Article 5. Available at: http://scholarworks.gvsu.edu/spnhareview/vol7/iss1/5. Accessed May 17, 2015.

      4. National Conference of State Legislatures. October 2013. Marketing and direct-to-consumer advertising (DTCA) of pharmaceuticals. Available at: http://www.ncsl.org/research/health/marketing-and-advertising-of-pharmaceuticals.aspx. Accessed May 31, 2015.

        • Brownfield E.D.
        • Bernhardt J.M.
        • Phan J.L.
        • Williams M.V.
        • Parker R.M.
        Direct-to-consumer drug advertisements on network television: an exploration of quantity, frequency, and placement.
        J Health Commun. 2004; 9: 491-497
        • Wolfe S.M.
        Direct-to-consumer advertising—education or emotion promotion?.
        N Engl J Med. 2002; 346: 524-526
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      6. Becker SJ, Madoun MM. Effects of direct-to-consumer advertising on patient prescription requests and physician prescribing: a systematic review of psychiatry-relevant studies. J Clin Psychiatry. 2016;77(10):e1293-e1300. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27631149. Accessed September 29, 2016.