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

Implied Claims in Drug Advertising: A Review of Recent Literature and Regulatory Actions

Federal agencies and self-regulatory bodies help to ensure prescription and nonprescription drug promotion contains accurate information; however, false or misleading claims may cause people to have inaccurate perceptions of a drug and inhibit their ability to make informed decisions. We conducted a systematic review assessing evidence from 2012-2021 on how consumers and healthcare providers (HCPs) interpret claims made indirectly or through inference (implied or implicit claims) as well as synthesizing prescription and nonprescription drug advertising claims that have been the subject of regulatory actions from 2017-2021. Our search identified 16 studies from the peer-reviewed literature and 26 letters or case reports issued by the Food and Drug Administration (FDA) or National Advertising Division (NAD). Results from peer-reviewed studies suggest that implied claims can result in inferences that may not be warranted by the material facts about the drug. Perceptions of a drug's efficacy and, to a lesser extent, risk, are influenced by implied and explicitly false claims in prescription drug promotion. Claims related to implied superiority and overstatement of efficacy were the most prevalent claims flagged for review and examined in the literature. These types of claims were also the subject of many of the compliance actions by the FDA and case reports from the NAD. More research is needed to understand how people interpret varying types of implied claims and the impact of such claims on key outcomes. From a policy standpoint, understanding how people interpret implied claims can inform how the FDA approaches these claims in the marketplace.

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.

Assessing the Inclusion of Foil Items in a Scale to Measure Recognition of Health Messages

Researchers frequently measure recognition of information in health messages by presenting participants with statements that were or were not in a message and then asking them to identify which were presented and which were not. Recognition scales are then calculated by summing the correct responses to both the true items and foils, or by summing the correct responses to the true items only. We used a sequence of psychometric analyses, including factor analysis and item response theory (IRT) analysis, to evaluate two recognition measures of this type, using data from previously published studies. We found that foils are less associated with true items than true items are with one another, or more practically, that foils are less associated with the underlying dimension of interest. These results provide researchers with insight into how recognition items function, as well as a better analytic approach for use in future studies.

Experimental evidence of consumer and physician detection and rejection of misleading prescription drug website content

BACKGROUND

Consumers and primary care physicians (PCPs) sometimes encounter deceptive promotional claims about prescription drugs. Whether consumers and PCPs can detect deceptive claims or whether those claims negatively affect medical decision making, however, remain important, unanswered research questions.

OBJECTIVES

This article explores (1) the ability of consumers and PCPs to identify deceptive prescription drug promotion at various levels of deception, (2) the influence of such tactics on obstructing risk recognition, and (3) whether perceived deception mediates relationships between exposure to deceptive tactics and various outcomes (including false-claim acceptance, attitudes, information-seeking intentions, and interest toward the promoted drug).

METHODS

Two experiments-1 with consumers (N = 366) and 1 with PCPs (N = 378)-were conducted to determine whether participant exposure to deceptive prescription drug website content corresponds to detection and acceptance (or rejection) of claims and tactics. In each experiment, the number of deceptive claims and tactics on a consumer- or PCP-targeted website for a fictitious chronic pain medication were varied, in a 1 × 3 (none, fewer, more) between-subjects design.

RESULTS

Among consumers, exposure to more deceptive claims or tactics did not increase suspicion about the veracity of the website (relative to fewer claims and tactics) and actually had a limited positive direct effect on false-claim acceptance and attitudes toward the drug. Among PCPs, a mediation effect existed such that exposure to more deceptive claims and tactics resulted in higher perceived website deceptiveness relative to those in the fewer deceptive claims condition, which, in turn, resulted in lower acceptance of deceptive claims and tactics, lower perceived drug effectiveness, more negative attitudes toward the drug, and lower interest and intentions.

CONCLUSION

These experiments demonstrate potential differences between consumers and PCPs as well as implications for consumer and PCP vulnerability to website deception.

A Revised Model of Trust in Internet-Based Health Information and Advice: Cross-Sectional Questionnaire Study

BACKGROUND

The internet continues to offer new forms of support for health decision making. Government, charity, and commercial websites increasingly offer a platform for shared personal health experiences, and these are just some of the opportunities that have arisen in a largely unregulated arena. Understanding how people trust and act on this information has always been an important issue and remains so, particularly as the design practices of health websites continue to evolve and raise further concerns regarding their trustworthiness.

OBJECTIVE

The aim of this study was to identify the key factors influencing US and UK citizens' trust and intention to act on advice found on health websites and to understand the role of patient experiences.

METHODS

A total of 1123 users took part in an online survey (625 from the United States and 498 from the United Kingdom). They were asked to recall their previous visit to a health website. The online survey consisted of an updated general Web trust questionnaire to account for personal experiences plus questions assessing key factors associated with trust in health websites (information corroboration and coping perception) and intention to act. We performed principal component analysis (PCA), then explored the relationship between the factor structure and outcomes by testing the fit to the sampled data using structural equation modeling (SEM). We also explored the model fit across US and UK populations.

RESULTS

PCA of the general Web trust questionnaire revealed 4 trust factors: (1) personal experiences, (2) credibility and impartiality, (3) privacy, and (4) familiarity. In the final SEM model, trust was found to have a significant direct effect on intention to act (beta=.59; P<.001), and of the trust factors, only credibility and impartiality had a significant direct effect on trust (beta=.79; P<.001). The impact of personal experiences on trust was mediated through information corroboration (beta=.06; P=.04). Variables specific to electronic health (eHealth; information corroboration and coping) were found to substantially improve the model fit, and differences in information corroboration were found between US and UK samples. The final model accounting for all factors achieved a good fit (goodness-of-fit index [0.95], adjusted goodness-of-fit index [0.93], root mean square error of approximation [0.50], and comparative fit index [0.98]) and explained 65% of the variance in trust and 41% of the variance in intention to act.

CONCLUSIONS

Credibility and impartiality continue to be key predictors of trust in eHealth websites. Websites with patient experiences can positively influence trust but only if users first corroborate the information through other sources. The need for corroboration was weaker in the United Kingdom, where website familiarity reduced the need to check information elsewhere. These findings are discussed in relation to existing trust models, patient experiences, and health literacy.

The Use of Narratives to Deliver Information in Direct-To-Consumer Prescription Drug Commercials: A Content Analysis

Information communicated through a narrative format is typically processed and evaluated differently compared to non-narrative formats. Therefore, differences in the use of narratives across various information categories within direct-to-consumer prescription drug advertisements (DTCA) could have significant implications for consumers' processing of that information. Such differences could have further implications regarding the "fair balance" rule put forth by the Food and Drug Administration (FDA). This study sought to document the presence and nature of narrative and non-narrative messages in a content analysis of 61 U.S.-based broadcast DTCA airing during 2016. Specific narrative styles (classic drama, vignette, first person, second person, third person) were distinguished from non-narrative styles (lecture, directive, endorsement, graphic/demonstration) according to key characteristics of each (chronology and character, showing versus telling). Results indicated widespread use of narrative styles in DTCA overall, but the styles used differed substantially between different types of information. Narrative styles were delivered prominently to present health condition and drug benefits information while non-narrative styles primarily reinforced drug benefits and presented drug risks. These differences offer a new frame through which to view an imbalanced presentation of drug risks and benefits and provide a foundation for future research to test the effects of various narrative and non-narrative forms on patient understanding and message recall.

Medical Marketing in the United States, 1997-2016

IMPORTANCE

Manufacturers, companies, and health care professionals and organizations use an array of promotional activities to sell and increase market share of their products and services. These activities seek to shape public and clinician beliefs about laboratory testing, the benefits and harms of prescription drugs, and some disease definitions.

OBJECTIVE

To review the marketing of prescription drugs, disease awareness campaigns, health services, and laboratory tests and the related consequences and regulation in the United States over a 20-year period (1997-2016).

EVIDENCE

Analysis (1997-2016) of consumer advertising (Kantar Media data for spending and number of ads); professional marketing (IQVIA Institute for Human Data Science, Open Payments Data [Centers for Medicare & Medicaid Services]); regulations and legal actions of the US Food and Drug Administration (FDA), Federal Trade Commission (FTC), state attorneys general, and US Department of Justice; and searches (1975-2018) of peer-reviewed medical literature (PubMed), business journals (Business Source Ultimate), and news media (Lexis Nexis) for articles about expenditures, content, and consequences and regulation of consumer and professional medical marketing. Spending is reported in 2016 dollars.

FINDINGS

From 1997 through 2016, spending on medical marketing of drugs, disease awareness campaigns, health services, and laboratory testing increased from $17.7 to $29.9 billion. The most rapid increase was in direct-to-consumer (DTC) advertising, which increased from $2.1 billion (11.9%) of total spending in 1997 to $9.6 billion (32.0%) of total spending in 2016. DTC prescription drug advertising increased from $1.3 billion (79 000 ads) to $6 billion (4.6 million ads [including 663 000 TV commercials]), with a shift toward advertising high-cost biologics and cancer immunotherapies. Pharmaceutical companies increased DTC marketing about diseases treated by their drugs with increases in disease awareness campaigns from 44 to 401 and in spending from $177 million to $430 million. DTC advertising for health services increased from $542 million to $2.9 billion, with the largest spending increases by hospitals, dental centers, cancer centers, mental health and addiction clinics, and medical services (eg, home health). DTC spending on advertising for laboratory tests (such as genetic testing) increased from $75.4 million to $82.6 million, although the number of ads increased more substantially (from 14 100 to 255 300), reflecting an increase in less expensive electronic media advertising. Marketing to health care professionals by pharmaceutical companies accounted for most promotional spending and increased from $15.6 billion to $20.3 billion, including $5.6 billion for prescriber detailing, $13.5 billion for free samples, $979 million for direct physician payments (eg, speaking fees, meals) related to specific drugs, and $59 million for disease education. Manufacturers of FDA-approved laboratory tests paid $12.9 million to professionals in 2016. From 1997 through 2016, the number of consumer and professional drug promotional materials that companies submitted for FDA review increased from 34 182 to 97 252, while FDA violation letters for misleading drug marketing decreased from 156 to 11. Since 1997, 103 financial settlements between drug companies and federal and state governments resulted in more than $11 billion in fines for off-label or deceptive marketing practices. The FTC has acted against misleading marketing by a single for-profit cancer center.

CONCLUSIONS AND RELEVANCE

Medical marketing increased substantially from 1997 through 2016, especially DTC advertising for prescription drugs and health services. Pharmaceutical marketing to health professionals accounted for most spending and remains high even with new policies to limit industry influence. Despite the increase in marketing over 20 years, regulatory oversight remains limited.

Disease awareness campaigns in printed and online media in Latvia: cross-sectional study on consistency with WHO ethical criteria for medicinal drug promotion and European standards

BACKGROUND

European legislation prohibits direct-to-consumer advertising of prescription medicines, but allows drug manufacturers to provide information to the public on health and diseases. Our aim was to measure the frequency of disease awareness campaigns in Latvian media and assess their compliance with international and European standards.

METHODS

Materials on health/disease and treatments were collected between April and September 2015 from 12 newspapers and magazines and six online portals. Disease awareness campaigns were assessed using a previously developed instrument based on the WHO Ethical Criteria for Medicinal Drug promotion and European standards (EU law and pharmaceutical industry self-regulatory guidelines). Collected materials were used to examine the information provided on medical conditions and their diagnosis and treatment. The inter-rater reliability was calculated.

RESULTS

We collected 263 materials from print (n = 149) and online media (n = 114); 94 were news items and 169 were disease-awareness advertisements. Cancer, cardiovascular problems, allergies and respiratory diseases were common topics. Of the 157 campaigns assessed, non-compliance was identified in 149 cases (inter-rater reliability 90%), mainly due to misleading or incomplete information, lack of balance and the absence of a listed author/sponsor. Six disease awareness campaigns directly mentioned a pharmaceutical product by brand name and other four included the logo or name of a manufacturer, referred to a condition and indirectly mentioned a treatment, all in contravention with European law.

CONCLUSIONS

The compliance of disease awareness campaigns in Latvian media with international and European standards is low. This raises concerns about the nature of information being conveyed. Through lack of balance, missing sponsorship information, and misleading or incomplete information, these campaigns could contribute to inaccurate self-diagnosis and generate demand among those who might not need medical treatment.

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.