Prescription drug advertising: trends and implications

Gender display in Scandinavian and American advertising for antidepressants

This study examines whether depiction of users of antidepressants in advertisements for antidepressants in the 1995 issues of the major medical journal in each of Denmark, Finland, Norway, and Sweden differs from that in the American Journal of Psychiatry. The results show that the people shown in the Danish, Finnish, and Norwegian journals are predominantly women, whereas depiction of users in the American and Swedish advertising is predominantly of couples. The portrayals in the 1995 advertising are of antidepressants as female gendered; a feature that was not seen in advertising for psychotropic drugs in the Nordic countries in the 1980s.

One more case of the double standard: discrepancies between drug information provided to Brazilian and American physicians

Several factors have been identified as exerting influences upon the physician prescribing behaviour. Some studies on this issue emphasize the role played by the sources of information available to physicians. A number of reports have been published on the influence of marketing strategies upon these professionals. Such strategies include advertisements in medical journals, detail-men, free samples, distribution of folders, leaflets and gifts, as well as support to congresses and symposia. The impact of the 'special' relationships that manufacturers cultivate with health authorities and physicians and considered opinion-makers should also not be underestimated. This study aimed to evaluate the quality of information provided by a widely-used Brazilian prescribing guide, the Dicionário de Especialidades Farmacêuticas(DEF) on the 44 best-selling pharmaceutical products in Brazil. WHO criteria for drug information were used as parameters of which information is of such outstanding importance that it should be included in any informative material offered to physicians. The information in the DEF was compared with that available for the same products in the PDR (Physicians' Desk Reference) and USP-DI (Drug Information for the Health Care Professional) used by prescribers in USA. Results show the absence of important data from the Brazilian manual, including contraindications, adverse effects and drug interactions. These findings suggest that poor quality information may potentially contribute to the irrational use of drugs. Copyright (c) 2000 John Wiley & Sons, Ltd.

Quality of pharmaceutical advertisements in medical journals: a systematic review

Background

Journal advertising is one of the main sources of medicines information to doctors. Despite the availability of regulations and controls of drug promotion worldwide, information on medicines provided in journal advertising has been criticized in several studies for being of poor quality. However, no attempt has been made to systematically summarise this body of research. We designed this systematic review to assess all studies that have examined the quality of pharmaceutical advertisements for prescription products in medical and pharmacy journals.

Methods and Findings

Studies were identified via searching electronic databases, web library, search engine and reviewing citations (1950 – February 2006). Only articles published in English and examined the quality of information included in pharmaceutical advertisements for prescription products in medical or pharmacy journals were included. For each eligible article, a researcher independently extracted the data on the study methodology and outcomes. The data were then reviewed by a second researcher. Any disagreements were resolved by consensus. The data were analysed descriptively. The final analysis included 24 articles. The studies reviewed advertisements from 26 countries. The number of journals surveyed in each study ranged from four to 24 journals. Several outcome measures were examined including references and claims provided in advertisements, availability of product information, adherence to codes or guidelines and presentation of risk results. The majority of studies employed a convenience-sampling method. Brand name, generic name and indications were usually provided. Journal articles were commonly cited to support pharmaceutical claims. Less than 67% of the claims were supported by a systematic review, a meta-analysis or a randomised control trial. Studies that assessed misleading claims had at least one advertisement with a misleading claim. Two studies found that less than 28% of claims were unambiguous clinical claims. Most advertisements with quantitative information provided risk results as relative risk reduction. Studies were conducted in 26 countries only and then the generalizability of the results is limited.

Conclusions

Evidence from this review indicates that low quality of journal advertising is a global issue. As information provided in journal advertising has the potential to change doctors' prescribing behaviour, ongoing efforts to increase education about drug promotion are crucial. The results from our review suggest the need for a global pro-active and effective regulatory system to ensure that information provided in medical journal advertising is supporting the quality use of medicines.

Evaluation of medicines advertising in medical journals

This work intended to analyze the advertising of medicines requiring medical prescription, divulged into three journals of the neurology and cardiology areas addressed to healthcare professionals. The analysis was based on current legislation, among other criteria, as well as specific literature. The presence of the following items was investigated: registration number, drug name, specific indications, contraindications; cautions and warnings; adverse reactions; possible side effects; posology; legibility of technical-scientific information and bibliographic references, phrases and/or expressions about the medication benefits, as compared to other drugs; safety warnings, healing promises and pictures of people smiling, and the quotations confirmation based on bibliographic references. Among the evaluated legal criteria, it was observed the absence of legibility in technical-scientific information in 85% of advertisements; absence of side effects in 23%; absence of cautions and warnings in 15%; of contraindications in 12.8%; of posology in 6.4%; of registration numbers in 2.7% and of the Common Brazilian Denomination/Common International Denomination (Denominação Comum Brasileira/Denominação Comum Internacional - DCB/DCI) in 0.6%. Out of 130 statements respecting advantages face to others drugs, 23.8% were not confirmed and out of 48 divulged safety messages, 41.7% could not be found in quoted references. The pictures of people smiling was a resource used in 42.2% of advertisements. Out of 1362 references analyzed, 19.7% were not found and 37.1% of quoted affirmations weren't confirmed.

The male heart and the female mind: a study in the gendering of antidepressants and cardiovascular drugs in advertisements in Irish medical publication

Stereotypes which suggest that cardiovascular disease and depression are related to gender can have consequences for the mental and physical health outcomes of both men and women. This study examines how these stereotypes may be reinforced by medical publications advertising for cardiovascular and antidepressant medication. A random sample of 61 (with no repeats) advertisements which appeared in Irish medical publications between July 2001 and December 2002 were analysed using both content and semiotic analysis. Results indicate that the meanings created by advertisers for cardiovascular drugs and antidepressants did in fact gender these products. Women were depicted as the predominant users of antidepressants and men as the main users of cardiovascular drugs. The images used identified two stereotyped patients: the 'male' heart patient and the depressed 'female' patient. Furthermore, the imagery and language used to promote the two categories of medication tended to strengthen gendered associations.

Gender bias in cardiovascular advertisements

RATIONALE

Women with cardiovascular disease are treated less aggressively than men. The reasons for this disparity are unclear. Pharmaceutical advertisements may influence physician practices and patient care.

AIMS AND OBJECTIVE

To determine if female and male patients are equally likely to be featured in cardiovascular advertisements.

METHODS

We examined all cardiovascular advertisements from US editions of general medical and cardiovascular journals published between 1 January 1996 and 30 June 1998. For each unique advertisement, we recorded the total number of journal appearances and the number of appearances in journals' premium positions. We noted the gender, age, race and role of both the primary figure and the majority of people featured in the advertisement.

RESULTS

Nine hundred and nineteen unique cardiovascular advertisements were identified of which 254 depicted a patient as the primary figure. A total of 20%[95% confidence interval (CI) 15.3-25.5%] of these advertisements portrayed a female patient, while 80% (95% CI 74.5-84.7%) depicted a male patient, P <0.0001. Female patient advertisements appeared 249 times (13.3%; 95% CI 8.6-18.9%) while male patient advertisements appeared 1618 times (86.7%; 95% CI 81.1-91.4%), P <0.0001. Female patient advertisements also had significantly fewer mean appearances than male patient advertisements in journals' premium positions (0.82 vs. 1.99, P=0.02). Similar results were seen when the advertisements were analysed according to predominant gender.

CONCLUSIONS

Despite increasing emphasis on cardiovascular disease in women, significant under-representation of female patients exists in cardiovascular advertisements. Physicians should be cognizant of this gender bias.

Who is portrayed in psychotropic drug advertisements?

The purpose of our study was to determine who is portrayed in psychotropic drug advertisements across time in three national psychiatric journals. All psychotropic drug advertisements portraying people were collected from the American Journal of Psychiatry, the British Journal of Psychiatry, and the Canadian Journal of Psychiatry at three time intervals (1981, 1991, and 2001). The advertisements were classified according to patient demographics, patient portrayal, and product information. Chi-square analysis was used to test for statistically significant associations among the variables. Fifty-seven percent of the psychotropic drug advertisements featured women, and 88% portrayed white patients. Statistically significant associations were detected between gender and the setting in which the patient was portrayed (chi(2) = 13.54, df = 3, p < 0.004), and gender and role (chi(2) = 29.41, df = 3, p < 0.001). Disproportionate gender representation was most notable in the 2001 time interval in the American Journal of Psychiatry. Women and white patients were overrepresented compared with psychiatric epidemiologic data in all three countries. The effect of these advertisements on physician perception, diagnosis, and prescribing is unknown but may be substantial. Future advertisements for psychotropic drugs should seek more balanced representations of gender and race.

Anúncios de medicamentos em revistas médicas: ajudando a promover a boa prescrição?

Ante a inexistência de estudos no Brasil, este trabalho se propôs a fazer uma avaliação dos anúncios com base nos critérios sugeridos pela OMS e que deveriam incluir-se em qualquer material de divulgação. Foram avaliados todos os anúncios contidos nas edições de agosto/2000 a fevereiro/2001 do Jornal de Pediatria, Revista Brasileira de Medicina e Jornal Brasileiro de Medicina, averiguando a presença nos mesmos de: nome genérico, mecanismos de ação, efeito farmacológico, indicação, contra-indicação, posologia, reações adversas, interações, superdosagem, apresentação e fabricante/importador. Em um total de 1.774 páginas, 539 (30,4%) se destinavam a anúncios, compreendendo 649 ao todo. Nenhum dos critérios propostos pela OMS esteve presente em todas as propagandas, e apenas em cerca de 20% delas há referência a reações adversas, contra-indicações e interações. Os produtos mais anunciados foram antibióticos, hipotensores e os à base da associação de vários fármacos. Omitindo dados importantes, em especial contra-indicações, reações adversas e interações, os anúncios são tendenciosos, atendendo a propósitos mercadológicos, não sendo um meio que subsidie a prescrição e a utilização correta e segura dos produtos anunciados.

The construction of gender and mental health in Nordic psychotropic-drug advertising

The authors examine the advertisements for psychotropic drugs in the major medical journals of Denmark, Finland, Norway, and Sweden in 1975, 1985, and 1995, with the object of illuminating the gender construction of the portrayed user. Using both a longitudinal and a cross-sectional approach, the study looked for a common Nordic gender display and whether it varied over time. The Nordic journals clearly conveyed a message that psychotropics are a gendered product, but without any uniform pattern. In 1975, men dominated the gender portrayals in Finland and Denmark, and women in Norway and Sweden. In 1985, the pattern was reversed: women dominated in Finland and Denmark, and men in Sweden and Norway. By 1995, the advertisements were mainly for antidepressants, and women were portrayed as the predominant users in Denmark, Finland, and Norway; the Swedish journal displayed couples only. In advertisements with dual-gender positions, however, the focus was on the female; they showed that the drug would assist her in fulfilling the expected supportive female gender behavior.

Benefit and risk information in prescription drug advertising: review of empirical studies and marketing implications

As pharmaceutical companies began to advertise prescription drugs directly to consumers as well as to physicians, understanding the impact of benefit and risk information in drug advertising on physicians and consumers has become more critical. This paper reviews previous empirical studies that examined the content of benefit and risk information in drug advertising and its potential effects on physicians' subsequent prescribing behaviors. It also reviews studies that investigated how consumers process information on a drug's efficacy and side effects. Based on the findings of these studies, implications are discussed for effective marketing information development as well as for government regulation.

[(Mis)information on drugs: the double standard practiced by pharmaceutical companies]

Different factors have been identified as influencing drug prescribers. Some studies emphasize the role played by sources of information available to physicians. Reports have been published on the influence of marketing strategies on these health professionals. Such strategies include advertisements in medical journals, sales representatives, free samples, leaflets, distribution of gifts and prizes, etc. The research reported here aimed to identify information provided by a commonly used Brazilian prescription handbook, the Dicionário de Especialidades Farmacêuticas (DEF), in relation to the 44 most frequently sold pharmaceutical products in Brazil, using as parameters the WHO guidelines for information to be included in informative materials offered to physicians. The information was then compared to that included in the PDR (Physicians' Desk Reference) and USP-DI (Drug Information for the Health Care Professional) used by prescribers in the United States. The results showed lack of data in the Brazilian publication (contraindications, side effects, drug interaction), suggesting lack of reliability in prescription quality and thus in the ultimate utilization of drugs.

Health-related messages in consumer magazine advertising

OBJECTIVE

To characterize the patterns of health-related messages in consumer advertising from U.S. magazines.

DESIGN

Observational survey of advertisements occupying a third of a page or more from the January 1994 issues of the 11 most popular consumer magazines.

MEASUREMENTS AND MAIN RESULTS

Health messages were present in 22.8% (85/372) of all the advertisements reviewed. Of the advertisement categories (prescription medication, over-the-counter medication, exercise-related product, health service, health device, diet/health-related food, and other), over-the-counter medications were the most common among the advertisements that had health messages (32.9%, 28/85) (7.5% of the total advertisements, 28/372). The five advertisements for prescription medications were duplications of two different advertisements, one for a hair promotion product and one for hormone replacement therapy. Products related to diet and exercise together represented 29.4% (25/85) of all advertisements with health messages. Three advertisements (3.5%) were for health devices, and five (5.9%) were for health services.

CONCLUSIONS

Health-related messages are frequent in consumer advertising. The effects of health marketing on consumer protection, health care costs, and the physician-patient relationship are discussed.

Social pharmacology: unresolved critical issues

This article describes and analyzes decision-making by patients, physicians, and drug information providers about registered medical drugs. Based on a cognitive psychology perspective, cognitive variables (the individual's mediating system) are assumed to be critical factors determining both patient and physician behavior. The individual's psychological functioning is seen as a continuous reciprocal interaction between behavioral, cognitive, and environmental influences; i.e., an interactional paradigm is applied. The importance of research models including cognitive and situation variables to guide the search for appropriate research methods is stressed. An intensive research strategy with a small sample of respondents will often be necessary. Also, respondents should be asked to describe their reactions to specific medical situations. The drug information sender has to select a set of goals for disseminating information to patients. Among the goals most often selected are: message comprehension, receiver satisfaction, changes in knowledge, attitudes, and drug behavior, as well as health effects. More research is needed on how the patient's mediating system, the actual situation, and the perceived situation steer his search for the use of new drug information. A different set of factors influence the patient's decision to start a medicinal or drug treatment than the factors that influence his decision to continue a treatment. The latter factors include forgetfulness, misunderstandings, and the patient's interpretation of physiological signs. More cognitive-oriented research about drug compliance must be undertaken. In such studies the mediating systems of a group of patients could be considered before and after intervention. There are a great number of types of inappropriate (irrational) prescribing. However, a physician may prescribe rationally in one area but irrationally in another. Face-to-face education of physicians has been shown to be effective in reducing inappropriate prescribing in a number of studies. "Overprescribing" of benzodiazepine has been an issue of intensive professional debate during the last decades. The two groups who criticize and defend the existing use of benzodiazepines build their views on different assumptions about the interaction between mind and brain as well as making different value assumptions regarding the use of a psychotropic drug. There is a need for prescription studies where a cognitive and interactional perspective is combined with an information-processing and a normative perspective. The benzodiazepines dependency problem has provoked lively discussion among professionals and the general public. Long-term benzodiazepine use and personality disorders increase the risk of the patient becoming dependent. A great number of research models have been suggested for the analysis of prescription drug dependency and as guides to the treatment of dependency.(ABSTRACT TRUNCATED AT 400 WORDS)

The construction of patienthood in medical advertising

The purpose of this study was to investigate the dominant symbolic elements, themes, and discourses used in drug advertisements published in a weekly magazine directed toward physicians. The discussion is concerned with both the visual signs and textual format of the advertisements, analyzing their attempts to create images around the drugs that appeal to the medical readership of the magazine. With the premise that the producers of the advertisements drew upon shared knowledge and belief systems of their medical audience to create a meaningful image for the drugs, the focus of the article is upon the portrayal of patients in the advertisements, with particular interest in gendered representations. The author argues that the way in which patients are portrayed visually and verbally in such advertisements is revealing of the ideological dimension of the doctor-patient relationship within the biomedical system of healing, including notions of the mechanical man and the vulnerable woman as archetypal patients.

Advertisements for medicines in leading medical journals in 18 countries: a 12-month survey of information content and standards

The information content of 6,710 advertisements for medicines in medical journals was surveyed to provide a baseline for monitoring the effect of WHO's Ethical Criteria for Medicinal Drug Promotion. The advertisements (ads) appeared during 12 months (1987-1988) in 23 leading national medical journals in 18 countries. Local participants, mostly doctors or pharmacists, examined them. The presence or absence in each ad of important information was noted. In most ads the generic name appeared in smaller type than the brand name. Indications were mentioned more often than the negative effects of medicines. The ads gave less pharmacological than medical information. However, important warnings and precautions were missing in half, and side effects and contraindications in about 40 percent. Prices tended to be given only in countries where a social security system pays for the medicines. The information content of ads in the developing countries differed surprisingly little from that in the industrialized countries. Almost all the ads (96 percent) included one or more pictures; 58 percent of these were considered irrelevant. The authors believe it is a mistake to regard ads as trivial. If they are not considered seriously they will influence the use of medicines as they are intended to do, but read critically they can provide useful information.

Prescribing and drug costs in the province of Ontario

The Report of the Pharmaceutical Inquiry of Ontario documented dramatic increases in the cost of the Ontario Drug Benefit (ODB) program. This article demonstrates that the rise in ODB costs for those 65 and over is due to two factors: more intensive prescribing--physicians prescribing to the elderly more often and writing more prescriptions each time they see an elderly patient--and physicians writing prescriptions for more expensive drugs. Neither of these two changes in prescribing behavior has resulted in any demonstrable improvement in the health of the elderly. Efforts to control costs through some form of copayment or by eliminating some drugs from the ODB formulary should not be undertaken since they probably will result in a reduction in the use of medically necessary drugs. Ultimately, drug costs will only be controlled by improving the appropriateness of physicians' prescribing.

Gender Differences in Drug (Prescription, Non-Prescription, Alcohol and Tobacco) Advertising: Trends and Implications

An overview of the literature regarding drug (prescription, nonprescription, alcohol and tobacco) advertising and the targeting of the genders was presented Prescription drug advertisements of the late 1980s contained less sexual stereotyping than that of the previous decade. In the only article that dealt directly with gender differences in nonprescription drug advertising, it was found that the advertising of specific therapeutic categories was targeted differentially toward men and women. Few investigators have focused on the targeting of special groups in the advertisement of alcoholic beverages. In contrast, there has been a greater research interest in tobacco advertising gender differences. The literature indicates that different tobacco products and advertising messages were targeted for men and women. The authors suggest that the public will become more reluctant to accept the unrestricted advertising of products which are deleterious to health.

Doctoring medicine: Reading between the lines of drug advertisements

With the aid of techniques of art and literary criticism, I investigate the ideological function of drug advertisements. I propose that the deleterious effects of advertising practices on medical care extend well beyond the usual level of critical awareness of physicians.

Advertising for psychotropic drugs in the Nordic countries: metaphors, gender and life situations

Advertisements for psychotropic drugs which appeared in the leading medical journals in Finland, Sweden and Denmark were analyzed to identify the picture content and trends in advertising between 1975 and 1985. The most common picture was a metaphor, the frequency of which increased in the 1980s. The second largest picture category was a patient, the rate of which remained constant during the study period. Both the use of a metaphor and a patient was related to the low sales of the drug in respective country whereas picture of a drug package was related to a stable market position of a drug in the country. The patients were increasingly depicted as men in the Danish and Swedish journal whereas the pictures of females were most common in the Finnish one. The portrayal of working persons, especially office workers and teachers, was a new feature in the advertisements in the 1980s. It is argued that the drug industry still uses gender as a device to expand their market of psychotropic drugs in a new way.

Towards a sociology of tranquillizer prescribing

This paper outlines a sociological approach to benzodiazepine tranquillizer prescribing. The analysis focuses on both the micro level of the doctor-patient relationship and the macro level of those political, economic and cultural factors which structure the prescribing process. This makes it possible to account for both the overall decline in benzodiazepine prescriptions in the 1980's and the fact that they are still being prescribed on a long-term basis to a significant number of people.

'Codes' and practice: information in drug advertisements--an example from Sri Lanka

The amount of scientific information that should appear in an advertisement for a drug has been discussed for over 20 years. The information should promote the rational use of the drug. There is a lack of data from developing countries. We analysed all drug advertisements in the Ceylon Medical Journal (CMJ) 1985-1986. Conformity with the existing WHO guidelines and IFPMA code was also assessed. The 111 advertisements constituted 42% of the pages in the CMJ. Thirty-one of 34 companies were from the industrialized nations. Twenty-one per cent of the advertisements did not have the generic name; 94% had information on indications, whereas only 23 and 22% had information on adverse effects and contraindications. Only 16% provided information on generic name, indications, dosage, adverse effects and contraindications. Despite this 68% satisfied the criteria of the WHO guidelines and IFPMA code mainly under an ill defined 'reminder advertisement' clause. The existing guidelines are insufficient to ensure the minimum scientific information in drug advertisements.

Doctors and detailers: therapeutic education or pharmaceutical promotion?

Pharmaceutical companies in industrialized countries generally view detailers as the most crucial element in the promotion of their products, with the result that over 50 percent of expenditures on promotion are devoted to detailers. Publicly the companies make claims for the scientific knowledge of detailers and for their role in passing on information to physicians, but the main purpose of detailers is to sell their company's products. This emphasis on sales is evident from statements of detailers themselves, from advertisements for detailers, from company documents, and by looking at the groups of physicians that companies specially target for visits by detailers. A variety of explanations are offered as to why physicians see detailers, but on examination none of the reasons is justifiable. Studies from a number of industrialized countries have shown that over 90 percent of physicians see detailers and a substantial percentage rely heavily on detailers as sources of information about therapeutics. Detailers are highly successful in altering physicians' prescribing habits, but almost all the literature available shows that the more reliant doctors are on commercial sources of information, the less appropriate they are as prescribers. Widespread use of DES (diethylstilbestrol) and the Dalkon Shield was encouraged by detailers. Although detailers have received the endorsement of both physicians' groups and government bodies, seeing detailers is detrimental to the practice of good medicine, and the best interests of doctors and their patients would be served if physicians had nothing further to do with detailers.

Prescription drug advertising trends: a study of oral hypoglycemics

A content analysis of oral hypoglycemic drug advertisements was performed in selected medical journals published in the United States from 1963 to 1986. The 665 advertisements subsequently examined were studied for certain predetermined parameters in order to indicate trends. The trend results may be summarized as follows. As an extension of prescription drug advertising trends in general, oral hypoglycemic drug advertising showed an increasing length along with a subsequent decrease in the amount of space devoted to the copy portion of the advertisement. They also showed a decrease in the use of statistical information and rarely made references to competitors. Nongender specific, colored advertisements with product and use related appeals have become more common with the passage of time. Although the rationale and purpose behind advertising is unchanged, the format has changed considerably. These changes are primarily due to the enhancement of print technology and to some extent, the changing social environment.