Direct-to-consumer television advertising exposure, diagnosis with high cholesterol, and statin use

Male Gender Expressivity and Diagnosis and Treatment of Cardiovascular Disease Risks in Men

Importance

Male gender expressivity (MGE), which reflects prevalent sociocultural pressures to convey masculinity, has been associated with health. Yet, little is known about associations of MGE with the diagnosis and treatment of modifiable cardiovascular disease (CVD) risks.

Objective

To investigate associations of MGE with modifiable CVD risk diagnoses and treatment in men.

Design, Setting, and Participants

This population-based cohort study included data from waves I (1994-1995), IV (2008-2009), and V (2016-2018) of the US National Longitudinal Study of Adolescent to Adult Health (Add Health). Participants were male adolescents (age 12-18 years) followed up longitudinally through younger adulthood (age 24-32 years) and adulthood (age 32-42 years). Data were analyzed from January 5, 2023, to August 28, 2024.

Exposure

Male gender expressivity was quantified in adolescence and younger adulthood using an empirically-derived and validated measurement technique that incorporates participants' responses to existing Add Health survey items to capture how similarly participants behave to same-gendered peers.

Main Outcomes and Measures

Outcomes included self-reported diagnoses of CVD risk conditions (hypertension, diabetes, or hyperlipidemia) in adult men with elevated blood pressure, hemoglobin A1c, or non-high-density lipoprotein cholesterol levels, and self-reported treatment with antihypertensive, hypoglycemic, or lipid-lowering medications in adults reporting hypertension, diabetes, or hyperlipidemia. Multivariable regression was used to examine associations of adolescent and younger adult MGE with adult CVD risk diagnoses and treatment, adjusting for sociodemographic covariates.

Results

Among 4230 eligible male participants, most were non-Hispanic White (2711 [64%]) and privately insured (3338 [80%]). Their mean (SD) age was 16.14 (1.81) years in adolescence, 29.02 (1.84) years in younger adulthood, and 38.10 (1.95) years in adulthood. Compared with participants whose younger adult MGE was below average, those with higher younger adult MGE were overall less likely to report hypertension (22% vs 26%; P < .001), diabetes (5% vs 8%; P < .001), and hyperlipidemia (19% vs 24%; P < .001) diagnoses and diabetes treatment (3% vs 5%; P = .02) as adults. In multivariable models, every SD increase in adolescent MGE was associated with lower probabilities of adult hypertension treatment (MGE,-0.11; 95% CI, -0.16 to -0.6) and diabetes diagnoses (MGE, -0.15; 95% CI, -0.27 to -0.03). Higher younger adult MGE was associated with lower probabilities of adult hypertension diagnoses (MGE, -0.04; 95% CI, -0.07 to -0.01), hypertension treatment (MGE, -0.07; 95% CI, -0.13 to -0.01), and diabetes treatment (MGE, -0.10; 95% CI, -0.20 to -0.01). Adolescent and younger adult MGE outcomes were not associated with other adult CVD outcomes.

Conclusions and Relevance

In this cohort study of US males, higher adolescent and younger adult MGE was associated with lower adult hypertension and diabetes diagnoses and treatment. These findings suggest that males with high MGE may bear distinctive risks and correspondingly benefit from tailored public health efforts to prevent downstream CVD.

Is exposure to pharmaceutical direct-to-consumer advertising for heart disease and diabetes associated with physical activity and dietary behavior?

CONTEXT

Scholars have suggested that direct-to-consumer advertising (DTCA) of prescription drugs may discourage or encourage changes in lifestyle to improve health. The current paper informs this debate by examining associations between estimated exposure to DTCA for drugs focused on heart disease/cholesterol and diabetes and self-reported exercise and consumption of a variety of unhealthy foods (candy, sugary drinks, alcohol, and fast food).

METHODS

We estimated exposure to DTCA by combining data from Kantar Media Intelligence (Kantar) on televised pharmaceutical DTCA airings in the U.S. from January 2003 to August 2016 (n = 7,696,851 airings) with thirteen years of data from the Simmons National Consumer Survey (Simmons), a mailed survey on television viewing patterns. We estimated associations between exposure to advertising (both overall and for advertisements with specific content) and self-reported physical activity and dietary behavior using Simmons data from January 2004 to December 2016 (n = 288,483 respondents from n = 157,621 unique households in the U.S.). Our analysis controls for many potential confounders including respondent demographics, temporal trends, and program placement to account for purposeful ad targeting to higher-risk adults.

FINDINGS

Higher estimated exposure to DTCA for heart disease and diabetes drugs were not consistently associated with meaningful differences in the frequency of engaging in regular physical activity. Greater estimated exposure to DTCA for both diseases were, linked to small but consistently higher volume of consumption of candy, sugar-sweetened beverages, alcohol, and fast food. Specific DTCA message content about diet and exercise explained very little of the observed association between overall DTCA exposure volume and study outcomes.

CONCLUSIONS

Many Americans were regularly exposed to pharmaceutical DTCA for heart disease and diabetes from 2003 to 2016. Widespread exposure to such DTCA is associated with higher levels (though small in magnitude) of consuming alcohol, fast food, candy, and sugar-sweetened beverages.

A scoping review of empirical research on prescription drug promotion

BACKGROUND

Pharmaceutical spending on prescription drug promotion is considerable, and exposure to advertising can influence demand and behavior. The U.S. Food and Drug Administration (FDA) provides industry guidance to help ensure that communications to consumers and health care providers about prescription drug promotion are truthful, balanced, and accurately communicated. As empirical research has accelerated on this topic in the past decade, an understanding of the current landscape of the science will help inform future research.

OBJECTIVES

Using systematic methods, this rigorous scoping review of the literature over the past decade (2012-2021) (1) examined the extent to which prescription drug promotion has been empirically investigated with consumers, patients, and health care providers; (2) examined the extent to which content and features of prescription drug promotion have been empirically investigated; and (3) identified themes across the literature to better understand the current landscape of prescription drug promotion.

METHODS

Databases searched include PubMed, Web of Science, CINAHL, APA PsycInfo, Business Source Corporate, Communication Source, Cochrane Library, and ClinicalTrials.gov for original research published in English from January 1, 2012, through November 10, 2021, using terms related to direct-to-consumer advertising, prescription drugs, and outcomes of interest (e.g., attitudes, perceptions, intentions, behaviors).

RESULTS

Of 804 screened references, 151 studies addressed the first research question, and 40 studies addressed the second. The most common theme across the body of evidence focused on testing of features and content in prescription drug promotional materials (84), followed by studies examining attitudes, perceptions, and behaviors toward prescription drug promotion more generally (43). Some (27) studies focused on targeted populations, such as patients, the elderly, non-English speaking people or individuals of a non-white race/ethnicity. Twenty-four studies assessed influence of exposure to prescription drug promotion on actual clinical outcomes, while 11 studies examined emerging technologies around prescription drug promotion. Seven studies evaluated the extent to which prescription drug promotion complied with existing guidelines and requirements.

CONCLUSIONS

Findings from this scoping review suggest there has been an increase in the number of empirical studies conducted on prescription drug promotion over the past decade. Potential areas that warrant further study include examination of emerging technologies, an expanded focus on targeted populations, and construct measurement.

Maintaining a Fair Balance? Narrative and Non-Narrative Strategies in Televised Direct-to-Consumer Advertisements for Prescription Drugs Aired in the United States, 2003-2016

Televised direct-to-consumer advertising for prescription drugs (hereafter DTCA) are among the most widespread forms of health communication encountered by American adults. DTCA shape public understanding of health problems and support the commercial interests of pharmaceutical companies by offering prescription drugs as a treatment option. The U.S. Food and Drug Administration (FDA) requires DTCA to present fair and balanced information regarding drug benefits versus risks. While narrative persuasion theory suggests that narratives can enhance persuasion by facilitating message processing and reducing counter-arguing, prior assessments of the balance between drug benefits versus risk information in DTCA have largely overlooked whether the ads employ narratives and/or other evidentiary strategies that may confer a persuasive advantage. This study content analyzed narrativity in DTCA aired on television between 2003 and 2016 for four different health conditions (heart disease, diabetes, depression, and osteoarthritis). Results showed that while televised DTCA spent more time discussing drug risks than drug benefits, both narratives and factual evidence were more frequently used to communicate drug benefits than drug risks. These findings raise concerns that narratives are strategically used by DTCA to highlight drug benefits rather than drug risks, which could lead to inaccurate perceptions of drug risks among viewers.

Visual images of prescription drug benefits in direct-to-consumer television advertisements

OBJECTIVE

Images demonstrating a prescription drug's efficacy are often included in direct-to-consumer television advertisements. The current research assessed whether exaggerated efficacy images can mislead individuals, and whether providing accurate quantitative information can reduce these misperceptions.

METHODS

We conducted two experimental studies with internet panelists 60 years and older testing drug efficacy images in television ads for wet age-related macular degeneration (N = 901) and plaque psoriasis (N = 902). In each study, participants viewed one of six ads that varied in the efficacy images included (no image, accurate image, exaggerated image) and the presentation of quantitative information (absent, present). Measures included recall, perceptions, and numeracy.

RESULTS

In both studies, participants who saw exaggerated images were more likely than those who saw no image or accurate images to overestimate efficacy. Presenting quantitative information increased participants' gist and verbatim recall of drug efficacy, and in some cases, led participants to have more accurate perceptions of the drug's efficacy even in the presence of exaggerated images. Higher numeracy was associated with better gist and verbatim recall.

CONCLUSIONS

These results support visual persuasion theory. Moreover, they show that exaggerating benefits visually can mislead viewers.

PRACTICE IMPLICATIONS

Stakeholders should ensure that images in direct-to-consumer promotion are accurate and non-misleading.

Estimated televised alcohol advertising exposure in the past year and associations with past 30-day drinking behavior among American adults: results from a secondary analysis of large-scale advertising and survey data

AIMS

To estimate the volume of past-year televised alcohol advertising exposure by product category and demographic group among adults living in the United States and test associations between estimated alcohol advertising exposure and past 30-day drinking behavior.

DESIGN

Secondary analysis of data from two national-level US data sets: Kantar data on appearances of televised alcohol advertisements and data from the Simmons National Consumer Survey (NCS), a large national mail survey on television viewing patterns and consumer behavior.

SETTING

United States.

PARTICIPANTS

A total of 54 671 adults, aged 21 years and older, who were randomly selected to participate in the Simmons NCS.

MEASUREMENTS

Estimated exposure to televised advertisements for beer, wine and spirits, self-reported alcohol use in the past year and number of drinks consumed in the past 30 days.

FINDINGS

The average respondent was exposed to an estimated 576 [95% confidence interval (CI) = 570-582] televised alcohol advertisements in the year preceding their survey. Exposure was higher among males versus females and African Americans versus whites. A 1% increase in the estimated volume of advertisement exposure was associated with a 0.11 (95% CI = 0.08-0.13) percentage point increase in the odds of having at least one drink in the last 30 days and, among past 30-day drinkers, a 0.05 (95% CI = 0.04-0.07) per cent increase in the number of alcoholic drinks consumed. Associations were consistent across product categories and demographics.

CONCLUSIONS

There appears to be a small but consistent positive association between alcohol advertising exposure and drinking behavior among American adults.

Consumers' experience with and attitudes toward direct-to-consumer prescription drug promotion: a nationally representative survey

The way consumers get and seek health information reflects the current information landscape. To gather updated insights on consumer experiences with and attitudes towards direct-to-consumer (DTC) promotion of prescription drugs, we conducted a nationally representative survey of 1,744 US adults using a mail-push-to-web methodology with paper nonresponse follow-up. Results showed high exposure and indifferent attitudes to DTC promotion. Respondents reported DTC promotion has prompted action, particularly searches for more information, increased use of online resources, and some reported that they refused to take or stopped taking a prescription drug because they saw or heard about the drug's side effects.

Influence of Pharmaceutical Direct-to-Consumer Advertisement on Medical Treatment of Inflammatory Bowel Disease-An Outpatient Survey-Based Study

Background

The management of inflammatory bowel disease (IBD) has become much more complex as our understanding of the disease pathology has improved and as new novel therapeutic options come into play. A factor that has not been studied in the management of this disease is the role that Direct-To-Consumer Advertisement (DTCA) plays in patients' decisions regarding their treatment options. Here we investigate the very role this mode of television advertisement has on influencing our patients.

Methods

Following formal institutional review board approval, we devised a prospective, single institution, survey-based study in our university-based outpatient gastroenterology clinic. Surveys included major demographic features along with questions pertaining to patients' interactions with various advertisements. Surveys were collected over a 3-month period.

Results

Overall, 103 surveys were collected. The data were not normally distributed. Fifty-three patients were female, and 40 patients were male. Eighty-one percent of patients with IBD were not affected in any way by advertisements with regard to influencing their decision to start new therapies. A subgroup analysis revealed that various parameters including age, sex, and marital status played a role in how DTCA influences patients with regard to their IBD treatments.

Discussion

This study demonstrates that overall patients are not significantly influenced by DTCAs; however, some cohorts are influenced in more ways than others. This study highlights the importance of understanding the role DTCA plays in influencing our patients with IBD and sets the foundation for further inquiry into this very interesting relationship.

The Effect of Including Quantitative Information on Multiple Endpoints in Direct-to-Consumer Prescription Drug Television Advertisements

Background. Previous research found that adding a single piece of quantitative information about prescription drug benefits to direct-to-consumer (DTC) ads helps consumers understand how well the drug works. However, drug information often includes quantitative information on multiple benefit outcomes and risks. Thus, we examined whether consumer understanding was similarly improved when DTC television ads include varying amounts of quantitative information. Methods. We randomly assigned participants (945 Internet panelists ≥ 60 years old) to view 1 of 9 fictitious prescription drug television ads that varied the presentation of quantitative information for benefits (none, single outcome, 2 outcomes) and risks (none, 1 risk category, 3 risk categories) and then measured gist and verbatim recall/estimation and drug perceptions. Results. Adding a single benefit outcome and a single risk category replicated past results. Compared with an ad containing no quantitative information, presenting 2 benefit outcomes and multiple risk categories increased gist and verbatim recall and affected drug perceptions. Compared with presenting a single benefit outcome, presenting 2 benefit outcomes increased verbatim recall for the second outcome but decreased verbatim recall for the first outcome. Likewise, compared with presenting a single risk category, presenting multiple risk categories increased gist and verbatim recall for the multiple risk categories but decreased gist recall for a concept more closely associated with the single risk category. Adding multiple risk categories decreased risk perceptions even more than did the single risk category. Limitations. This study may have limited generalizability because it examined an ad for only 1 medical condition. Conclusions. There are tradeoffs to adding multiple quantitative benefit outcomes in DTC ads. However, presenting multiple quantitative risk categories helps consumers better understand a drug's risks.

The Use of Traditional Media for Public Communication about Medicines: A Systematic Review of Characteristics and Outcomes

A systematic review was conducted to identify, appraise, and synthesize data from original research investigating the use of traditional media for public communication about medicines. Databases were searched for studies conducting quantitative or qualitative analyses between the years 2007 and 2017. Data extraction and assessment of the quality of the resulting studies was conducted by one reviewer and checked for accuracy by a second reviewer. A total of 57 studies met the inclusion criteria. Studies were grouped as follows: "newspapers and other print media" (n = 42), "television" (n = 9), and "radio and a combination of media" (n = 6). Content analysis (n = 34) was the most frequent research design, followed by surveys or interviews (n = 14) and randomized controlled trials (RCTs) (n = 9). Advertising, public awareness, and health administration were the most common themes, and the medicines most analyzed were vaccines, particularly human papillomavirus (HPV) and influenza. Studies conducted in the United States were the most frequent, followed by other high-income countries such as Canada and the United Kingdom. The lack of consistent studies of the effects of media campaigns stresses the importance of the use of standardized research methodologies. Theoretical and practical implications of the findings for further research are discussed.

Communicating Risk Information in Direct-to-Consumer Prescription Drug Television Ads: A Content Analysis

Direct-to-consumer (DTC) television ads for prescription drugs are required to disclose the product's major risks in the audio or audio and visual parts of the presentation (sometimes referred to as the "major statement"). The objective of this content analysis was to determine how the major statement of risks is presented in DTC television ads, including what risk information is presented, how easy or difficult it is to understand the risk information, and the audio and visual characteristics of the major statement. We identified 68 DTC television ads for branded prescription drugs, which included a unique major statement and that aired between July 2012 and August 2014. We used subjective and objective measures to code 50 ads randomly selected from the main sample. Major statements often presented numerous risks, usually in order of severity, with no quantitative information about the risks' severity or prevalence. The major statements required a high school reading level, and many included long and complex sentences. The major statements were often accompanied by competing non-risk information in the visual images, presented with moderately fast-paced music, and read at a faster pace than benefit information. Overall, we discovered several ways in which the communication of risk information could be improved.

Testimonials and Informational Videos on Branded Prescription Drug Websites: Experimental Study to Assess Influence on Consumer Knowledge and Perceptions

Background

Direct-to-consumer (DTC) promotion of prescription drugs can affect consumer behaviors and health outcomes, and Internet drug promotion is growing rapidly. Branded drug websites often capitalize on the multimedia capabilities of the Internet by using videos to emphasize drug benefits and characteristics. However, it is unknown how such videos affect consumer processing of drug information.

Objective

This study aimed to examine how videos on prescription drug websites, and the inclusion of risk information in those videos, influence consumer knowledge and perceptions.

Methods

We conducted an experimental study in which online panel participants with acid reflux (n=1070) or high blood pressure (n=1055) were randomly assigned to view 1 of the 10 fictitious prescription drug websites and complete a short questionnaire. On each website, we manipulated the type of video (patient testimonial, mechanism of action animation, or none) and whether the video mentioned drug risks.

Results

Participants who viewed any video were less likely to recognize drug risks presented only in the website text (P≤.01). Including risk information in videos increased participants’ recognition of the risks presented in the videos (P≤.01). However, in some cases, including risk information in videos decreased participants’ recognition of the risks not presented in the videos (ie, risks presented in text only; P≤.04). Participants who viewed a video without drug risk information thought that the website placed more emphasis on benefits, compared with participants who viewed the video with drug risk information (P≤.01). Compared with participants who viewed a video without drug risk information, participants who viewed a video with drug risk information thought that the drug was less effective in the high blood pressure sample (P=.03) and thought that risks were more serious in the acid reflux sample (P=.01). There were no significant differences between risk and nonrisk video conditions on other perception measures (P>.05). In addition, we noted a few differences among the types of videos.

Conclusions

Including risks in branded drug website videos may increase in-video risk retention at the expense of text-only risk retention.

If my cholesterol is…then I foresee…: patient accounts of uncertainty

The author examines the talk of patients with high cholesterol as they discuss their experiences of adding a statin to their treatment regimen. The primary objective was to understand patients’ expectations of statins, and their beliefs and feelings as they continued or discontinued use, and to better understand why adherence to a statin regimen is particularly low. While numerous studies report reasons for nonadherence, few apply theory to provide plausible explanations. Analysis of the focus group data revealed three major themes. First, patients do not view high cholesterol as serious in light of other major health problems like diabetes and cancer within the household. Second, patients believe statins are effective in lowering cholesterol but risky. Third, many patients do not understand how high levels of cholesterol are produced in the body and how statins interrupt that process. Problematic integration theory is used to explain the uncertainty patients experience when given a diagnosis of high cholesterol, the use of statins to control it, and the quality of information received about both cholesterol and statins.

Underuse of Effective Cardiac Medications Among Women, Middle-Aged Adults, and Racial/Ethnic Minorities With Coronary Artery Disease (from the National Health and Nutrition Examination Survey 2005 to 2014)

Given the proven effectiveness of several cardiac medications for patients with coronary artery disease (CAD), we examined the national use of 4 classes of effective medications, overall and by age, sex, and race/ethnicity in 2005 to 2014. We used data from the National Health and Nutrition Examination Survey, including a self-reported diagnosis of CAD and independently verified medication use. Weighting procedures extrapolated our data to the adult US population with CAD. Analyses included 1,789 US adults aged ≥45 years with a history of CAD. The average age of this population was 68 years; 40% were women and 79% were non-Hispanic whites. In 2005 to 2014, 53.2% (standard error [SE] = 1.5) reported use of angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, 58.5% (SE = 1.5) β blockers, and 67.2% (SE = 1.4) statins. Two of these medications were used by 64.1% (SE = 1.5) of the study population and all 3 by 29.1% (SE = 1.3). In 2011 to 2014, 68.5% (SE = 2.4) of American adults with a history of CAD reported use of aspirin. The use of statins increased from 63.1% in 2005/2006 to 76.8% in 2013/2014. Adults aged 45 to 64 years old, women, and racial/ethnic minorities had lower use of effective cardiac medications compared with older adults, men, and non-Hispanic whites. In conclusion, the use of statins, but not other medications, has increased over the past 10 years among American adults with previously diagnosed CAD. Continued targeted efforts are needed to increase the receipt of effective cardiac medications among all US adults with CAD, especially those aged 45 to 64 years, women, and racial/ethnic minorities.

Vitamin panacea: Is advertising fueling demand for products with uncertain scientific benefit?

This study examines the effect of advertising on demand for vitamins-products with spiraling sales despite little evidence of efficacy. We merge seven years (2003-2009) of advertising data from Kantar Media with the Simmons National Consumer Survey to estimate individual-level vitamin print and television ad exposure effects. Identification relies on exploiting exogenous variation in year-to-year advertising exposure by controlling for each individual's unique media consumption. We find that increasing advertising exposure from zero to the mean number of ads increases the probability of consumption by 1.2 and 0.8% points (or 2 and 1.4%) in print and television respectively. Stratifications by the presence of health conditions suggests that in print demand is being driven by both healthy and sick individuals.

Attention to and Distraction from Risk Information in Prescription Drug Advertising: An Eye Tracking Study

Direct-to-consumer (DTC) television ads must disclose a drug's most important risks. Currently, the risks must be in audio at a minimum. Studies have shown that presenting information with both audio and superimposed risk text (dual-modality) improves recall beyond that of using audio alone. However, distracting elements in DTC ads may draw attention away from the superimposed risk text. This study combined eye-tracking data with questionnaire data to examine whether distracting elements decrease attention to the risk text in DTC ads, in turn affecting risk retention and risk perceptions. The authors randomly assigned 300 U.S. opt-in panel members to view either a low-distraction or a high-distraction DTC television ad. The authors found that distracting elements during risk presentation drew attention away from the risk text and, in turn, reduced retention of drug risk information. Risk perceptions were not affected. These results suggest that even if dual-modality is used to increase consumer's comprehension of drug risk information, distracting visuals should still be avoided in order to help consumers focus on key information in the ad.

Effect of Direct-to-Consumer Advertising on Statin Use in the United States

IMPORTANCE

The value of direct-to-consumer advertising (DTCA) of prescription drugs is widely debated, as is the effect of DTCA on prescription sales and health care utilization.

OBJECTIVE

We examined the association between DTCA intensity for statin medications and prescription sales and cholesterol-related health care utilization.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an ecological study for 75 designated market areas from 2005 to 2009 in the United States using linked data regarding televised DTCA volume, non-DTCA marketing and promotion, retail, mail order and long-term care prescription drug sales, prescription drug and ambulatory care health care utilization, and contextual factors such as health care density and socioeconomic status. Main outcomes and measures were volume of sales, number of dispensed prescriptions, and high cholesterol-related outpatient visits. Analyses were conducted in 2016.

RESULTS

The intensity of rosuvastatin and atorvastatin ad exposures per household varied substantially across designated market areas. After adjustment for socioeconomic, demographic, and clinical characteristics, each 100-unit increase in advertisement viewership was associated with a 2.22% [95% confidence interval (CI), 0.30%-4.19%] increase in statin sales. Similar patterns were observed between DTCA and statin dispensing among the commercially insured. DTCA was associated with increases in high cholesterol-related outpatient visits among adults 18-45 years of age (3.15% increase in visits per 100-unit increase in viewership, 95% CI, 0.98%-5.37%) but not among those 46-65 years of age (0.51%, 95% CI, -1.49% to 2.55%).

CONCLUSION

DTCA for statins is associated with increases in statin utilization and hyperlipidemia-related outpatient visits, especially for young adults.

Direct-to-Consumer Promotion of Prescription Drugs on Mobile Devices: Content Analysis

Background

US Food and Drug Administration (FDA) regulations state that any prescription drug promotion that presents drug benefits to consumers must also disclose certain information about the drug’s risks in a similar manner. Nearly three-quarters of all US mobile phone subscribers use a smartphone, and over half report receiving mobile advertisements on their device.

Objective

The objective of this project was to investigate how prescription drugs are being promoted to consumers using mobile technologies. We were particularly interested in the presentation of drug benefits and risks, with regard to presence, placement, and prominence.

Methods

We analyzed a sample of 51 mobile promotional communications and their associated linked landing pages. We assessed the content and format of the mobile communications and landing pages with regard to presentation of drug benefits and risks.

Results

Of the 51 mobile communications we coded, 41% (21/51) were product claim communications (includes the drug name, benefits, and risks), 22% (11/51) were reminder communications (includes drug name only), and 37% (19/51) were help-seeking communications (includes information about the medical condition but not the drug name). Some of the product claim communications (5/21, 24%) required scrolling to see all the benefit information; in contrast, 95% (20/21) required scrolling to see all the risk information. Of the 19 product claim communications that presented both benefits and risks, 95% (18/19) presented benefits before risks and 47% (9/19) used a bigger font for benefits than for risks. Most mobile communications (35/51, 69%) linked to branded drug websites with both benefits and risks, 25% (13/51) linked to a landing page with benefits but no visible risks, and 6% (3/51) linked to a landing page with risks but no visible benefits. Few landing pages (4/51, 8%) required scrolling to see all the benefit information; in contrast, 51% (26/51) required scrolling to see all the risk information. Of the 35 landing pages with both benefit and risk information, 71% (25/35) presented benefits before risks and 51% (18/35) used a bigger font for benefits than for risks.

Conclusions

These results indicate that, while risks and benefits are both represented in mobile communications and their associated landing pages, they are not equally prominent and accessible. This has implications for compliance with FDA fair balance regulations.

Mixed Messages, Mixed Outcomes: Exposure to Direct-to-Consumer Advertising for Statin Drugs is Associated with More Frequent Visits to Fast Food Restaurants and Exercise

This study examines whether exposure to direct-to-consumer advertising (DTCAs) for statin drugs is associated with non-pharmaceutical behaviors to prevent cardiovascular disease. We focus on the relationship between statin drug DTCA exposure and the frequency of (a) visits to fast-food restaurants and (b) exercise. We combine data on the televised broadcast availability of statin drug DTCAs in large media markets in the United States with 18 waves of the Simmons National Consumer Survey (NCS; n = 120, 229) from 2001 to 2009. We find that statin drug DTCA exposure is associated, in a dose-response pattern, with modest increases in the frequency of exercise and large increases in the frequency of fast-food-restaurant visits. The relationship between statin DTCA exposure and fast-food-restaurant visits were largely consistent in direction but differed in magnitude between those without a previous diagnosis of high cholesterol and those treating high cholesterol with a statin. We conclude with a discussion of the implications of these results for future research on pharmaceutical DTCA and population health.

Optimistic bias, advertising skepticism, and consumer intentions for seeking information about the health risks of prescription medicine

Based on a survey of prescription drug users (N = 408), this study revealed that: (a) the frequency of consumers' personal experience of prescription medicine adverse reactions negatively related to the extent of their optimistic bias about the chances of such events, (b) consumers' perceived personal control over adverse reactions positively related to optimistic bias, and (c) optimistic bias related more negatively to intentions to seek risk information when consumer skepticism toward direct-to-consumer advertising was high. When skepticism was low to average, optimistic bias did not inhibit such intentions. Implications and recommendations for the practice of direct-to-consumer advertising are provided.

Trends in Urological Direct-to-Consumer Advertising during Prime-Time Television News Programs

INTRODUCTION

The purpose of this study is to characterize contemporary trends in direct-to-consumer advertising of urological pharmaceutical products on American prime-time television programs. Television is the highest expenditure segment of the consumer drug marketing industry. The extent of advertising in urology and its potential impact on patients are not well understood.

METHODS

We retrospectively analyzed an indexed database of prime-time news broadcasts on 5 national networks in the United States. The database was queried with the names of 77 urological pharmaceutical products to identify all commercials that aired during a 36-month period between 2010 and 2013. Noncommercial segments were excluded. Descriptive and linear regression analysis was performed.

RESULTS

We analyzed 4,574 broadcasts, representing 3,067.5 hours of prime-time television. A total of 2,068 commercials for 8 products and 4 urological indications were aired, including sildenafil and tadalafil for erectile dysfunction; 2 testosterone products for hypogonadism; fesoterodine, oxybutynin and solifenacin for overactive bladder; and sipuleucel-T for metastatic castration resistant prostate cancer. Commercials for male oriented indications accounted for 90% of the sample. At least 1 urological advertisement was contained in 1,744 broadcasts (38%). The introduction of television marketing for newly approved testosterone supplementation products in 2012 corresponded to strongly linear growth in overall urological advertising, reaching peak levels in 2013.

CONCLUSIONS

Urological pharmaceutical products have been consistently advertised on television. Commercials have extensively targeted male oriented indications. Viewers of national news programs were exposed to urological advertising during about 40% of broadcasts with steadily increasing exposure since 2012. Providers should be aware of these trends to contextualize demand and monitor prescribing patterns.

Are Disease Awareness Links on Prescription Drug Websites Misleading? A Randomized Study

We sought to determine whether links from branded prescription drug websites to websites containing disease information mislead participants about drug benefits and whether nonsponsorship disclosures diminish this potential effect. We randomly assigned online panelists with depression (N = 1,071) to view a fictitious prescription drug website that had (a) no link to a disease information website (control), (b) a link with no disclosure, (c) a link with a simple nonsponsorship disclosure, or (d) a link with a detailed nonsponsorship disclosure. If participants in the link conditions did not click the link, they were returned to the drug website and encouraged to click it. All participants then completed an online questionnaire assessing recall, perceptions, and intentions. Few participants (12%) clicked the link without prompting; 67% did so when prompted. Compared with control participants, participants in link conditions were more likely to confuse disease information with drug benefits and to recall fewer true drug benefits. Disclosures did not diminish these effects, and exposure to disease information did not affect other perceptions or intentions. Consumers seem to confuse information on disease websites with information on branded prescription drug websites. Disclosures may not adequately help consumers to distinguish between the 2 types of information.

Trends in Statin Use in Seniors 1999 to 2013: Time Series Analysis

PURPOSE

To examine HMG-CoA reductase inhibitor (statin) drug dispensing patterns to Nova Scotia Seniors' Pharmacare program (NSSPP) beneficiaries over a 14-year period in response to: 1) rosuvastatin market entry in 2003, 2) JUPITER trial publication in 2008, and 3) generic atorvastatin availability in 2010.

METHODS

All NSSPP beneficiaries who redeemed at least one prescription for a statin from April 1, 1999 to March 31, 2013 were included. Aggregated, anonymous monthly prescription counts were extracted by the Nova Scotia Department of Health and Wellness (Nova Scotia, Canada) and changes in dispensing patterns of statins were measured. Data were analyzed using descriptive analyses and interrupted time series methods.

RESULTS

The percentage of NSSPP beneficiaries dispensed any statin increased from 5.3% in April 1999 to 20.7% in March 2013. In 1999, most NSSPP beneficiaries were dispensed either simvastatin (29.5%) or atorvastatin (28.7%). When rosuvastatin was added to the NSSPP Formulary in August 2003, prescriptions dispensed for simvastatin, lovastatin, pravastatin, and fluvastatin declined significantly (slope change, -0.0027; 95% confidence interval (CI), (-0.0046, -0.0009)). This significant decline continued following the publication of JUPITER (level change, -0.1974; 95% CI, (-0.2991, -0.0957)) and the availability of generic atorvastatin (level change, -0.2436; 95% CI, (-0.3314, -0.1558)). Atorvastatin was not significantly affected by any of the three interventions, although it maintained an overall decreasing trend. Only upon the availability of generic atorvastatin did the upward trend in rosuvastatin use decrease significantly (slope change, -0.0010, 95% CI, (-0.0015, -0.0005)).

CONCLUSIONS

The type and rate of statins dispensed to NSSPP beneficiaries changed from 1999 to 2013 in response to the availability of new agents and publication of the JUPITER trial. The overall proportion of NSSPP beneficiaries dispensed a statin increased approximately 4-fold during the study period. In 2013, rosuvastatin was the most commonly dispensed statin (44.1%) followed by atorvastatin (39.1%).

Prescription Drug Promotion from 2001-2014: Data from the U.S. Food and Drug Administration

The volume of prescription drug promotion over time is often measured by assessing changes in ad spending. However, this method obscures the fact that some types of advertising are more expensive than others. Another way to measure the changes in prescription drug promotion over time is to assess the number of promotional pieces submitted to the U.S. Food and Drug Administration (FDA). Form FDA 2253 collects information such as the date submitted and the type of material submitted. We analyzed data from Forms FDA 2253 received from 2001–2014. We examined the frequency of submissions by audience (consumer and healthcare professional) and type of promotional material. There was a noted increase in prescription drug promotion submissions across all media in the early 2000s. Although non-Internet promotion submissions have since plateaued, Internet promotion continued to increase. These results can help public health advocates and regulators focus attention and resources.

Effects of exposure to direct-to-consumer television advertising for statin drugs on food and exercise guilt

OBJECTIVE

Pharmaceutical direct-to-consumer advertising (DTCA) is widely prevalent on US television. This study tests the relationship between estimated exposure to DTCA for statin drugs, which often feature mixed messages about the efficacy of diet and exercise in reducing risk of cholesterol and heart disease, and guilty feelings regarding food and exercise.

METHODS

A series of repeated cross-sectional surveys of the US population between 2001 and 2007 (N=106,859 adults aged 18 and older) were combined with data on the frequency of DTCA appearances on national, cable, and local television during the same time period.

RESULTS

Adjusting for potential confounders with ordinary least squares (OLS) regression, increased potential exposure to statin DTCA was associated with increased food guilt (in a dose-response pattern) and exercise guilt (in a threshold pattern).

CONCLUSION

This study provides new evidence that DTCA has potential to influence emotional well-being as well as direct behavioral responses emphasized in previous academic research.

PRACTICE IMPLICATIONS

Health practitioners should be prepared to encounter and counsel patients who are prompted by DTCA to feel guilty about their food and exercise behaviors, feelings which may impact the likelihood of adherence to prescribed behavioral modification for weight management.

Do Prescription Drug Ads Tell Consumers Enough About Benefits and Side Effects? Results From the Health Information National Trends Survey, Fourth Administration

Direct-to-consumer prescription drug advertising (DTCA) is a major source of consumer information about prescription drugs. The present study updates 2002 U.S. Food and Drug Administration phone survey questions that found that 44% and 61% of consumers thought that DTCA did not include enough information about benefits and risks, respectively. The present study was administered by mail using a nationally representative sample, and provides a more in-depth understanding of how these beliefs relate to demographic and health characteristics. Data collected from 3,959 respondents to the National Cancer Institute's 2011 Health Information National Trends Survey find results similar to the 2002 survey: 46% and 52% of respondents thought that DCTA did not include enough information about benefits and risks, respectively. Respondents fell into four groups: 23% agreed that DTCA tells enough about drug benefits and risks, 41% disagreed, 18% expressed no opinion, and 18% had discordant beliefs. DTCA attitudes were negatively associated with education, income, and whether respondents purchase prescription drugs; attitudes were positively associated with whether respondents understand prescription drug information. This study confirms that a plurality of Americans believe that DTCA does not include enough information about benefits and risks, suggesting that the educational effect of DTCA could be improved.

Statin induced diabetes and its clinical implications

Statins are one of the most commonly used drugs in the world based on their potential to prevent adverse cardiovascular events. These cholesterol-lowering drugs received a US Food and Drug Administration warning, in February 2012, regarding increased risk of incident diabetes and impaired glycemic control in patients who already have diabetes. The possible association of diabetes with statin therapy has started a wave of discussion in the medical community. A number of meta-analyses conducted in recent years have demonstrated that the association is real although causality has not been proved yet. Individual statins differ with respect to their diabetogenic property; women and elderly persons appear to be at increased risk. Various aspects of statin's adverse effect on glycemic control remain to be explored. As further research in this area continues, physicians might still take some precautions to make risk benefit ratio more favorable for the patients.

Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial

IMPORTANCE

Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment.

OBJECTIVE

To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California.

INTERVENTIONS

DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control).

MAIN OUTCOMES AND MEASURES

Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted.

RESULTS

Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control,  0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control,  0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control,  0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority).

CONCLUSIONS AND RELEVANCE

A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01144104.