Advertising of prescription-only medicines to the public: does evidence of benefit counterbalance harm?

Pharmaceutical policies: effects of policies regulating drug marketing

BACKGROUND

The costs of developing new treatments and bringing them to the market are substantial. The pharmaceutical industry uses drug promotion to gain a competitive market share, and drive sale volumes and industry profitability. This involves disseminating information about new treatments to relevant targets. However, conflicts of interest can arise when profits are prioritised over patient care and its benefits. Drug promotion regulations are complex interventions that aim to prevent potential harm associated with these activities.

OBJECTIVES

To assess the effects of policies that regulate drug promotion on drug utilisation, coverage or access, healthcare utilisation, patient outcomes, adverse events and costs.

SEARCH METHODS

We searched Epistemonikos for related reviews and their included studies. To find primary studies we searched MEDLINE, CENTRAL, Embase, EconLit, Global Index Medicus, Virtual Health Library, INRUD Bibliography, two trial registries and two sources of grey literature. All databases and sources were searched in January 2023.

SELECTION CRITERIA

We planned to include studies that assessed policies regulating drug promotion to consumers, healthcare professionals or regulators and third-party payers, or any combination of these groups.In this review we defined policies as laws, rules, guidelines, codes of practice, and financial or administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug utilisation, coverage or access, healthcare utilisation, patient health outcomes, any adverse effects (unintended consequences), and costs. The study had to be a randomised or non-randomised trial, an interrupted time series analysis (ITS), a repeated measures (RM) study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies. When consensus was not reached, any disagreements were discussed with a third review author.  We planned to use the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials, and CBA studies, we planned to estimate relative effects, with 95% confidence intervals (CI). For dichotomous outcomes, we planned to report the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For ITS and RM, we planned to compute changes along two dimensions: change in level and change in slope. We planned to undertake a structured synthesis following EPOC guidance.  MAIN RESULTS: The search yielded 4593 citations, and 13 studies were selected for full-text review. No study met the inclusion criteria.

AUTHORS' CONCLUSIONS

We sought to assess the effects of policies that regulate drug promotion on drug use, coverage or access, use of health services, patient outcomes, adverse events, and costs, however we did not find studies that met the review's inclusion criteria. As pharmaceutical policies that regulate drug promotion have untested effects, their impact, as well as their positive and negative influences, is currently only a matter of opinion, debate, informal or descriptive reporting. There is an urgent need to assess the effects of pharmaceutical policies that regulate drug promotion using well-conducted studies with high methodological rigour.

Materialized Oppression in Medical Tools and Technologies

It is well-known that racism is encoded into the social practices and institutions of medicine. Less well-known is that racism is encoded into the material artifacts of medicine. We argue that many medical devices are not merely biased, but materialize oppression. An oppressive device exhibits a harmful bias that reflects and perpetuates unjust power relations. Using pulse oximeters and spirometers as case studies, we show how medical devices can materialize oppression along various axes of social difference, including race, gender, class, and ability. Our account uses political philosophy and cognitive science to give a theoretical basis for understanding materialized oppression, explaining how artifacts encode and carry oppressive ideas from the past to the present and future. Oppressive medical devices present a moral aggregation problem. To remedy this problem, we suggest redundantly layered solutions that are coordinated to disrupt reciprocal causal connections between the attitudes, practices, and artifacts of oppressive systems.

Evaluation of Selective Outcome Reporting Bias in Efficacy Endpoints in Print and Television Advertisements for Oncology Drugs

IMPORTANCE

Selective outcome reporting bias in oncology drug advertisements may encourage misconceptions about a drug's efficacy profile.

OBJECTIVE

We sought to determine the rates of selective outcome reporting in published cancer clinical trials and in television and print advertisements for anticancer medications. We also quantified the number of advertisements that did not include or cite any studies with mature overall survival (OS) data (i.e., data with all required patient events for final analysis).

DESIGN/SETTING/PARTICIPANTS

We conducted a cross-sectional investigation of advertisements uploaded to the AdPharm Database (repository of pharmaceutical advertisements); the clinical trials supporting the ads; and the trial registrations associated with the trials. Data were extracted by two investigators who were blinded to each other's data.

MAIN OUTCOME MEASURES

The first co-primary objective was to investigate selective outcome reporting between trial registrations and published trials. The second co-primary objective was to investigate selective outcome reporting between the same published trials and drug advertisements.

RESULTS

We included 74 advertisements and 48 clinical trials. Print ads were the most common (n = 66), and most print advertisements were targeted to health care providers (n = 55, 83.3%). Overall, 41/48 (85.4%) trials were registered prior to study enrollment, and 41/48 (85.4%) did not deviate from the registered primary endpoints. Across all advertisements (n = 74), statistically significant endpoints were more often reported (unadjusted risk ratio [uRR] 1.26; 95% confidence interval [CI] (1.14-1.40)) and 22/55 (40.0%) advertisements cited trials with immature overall survival data (i.e., data without the required number of events for final analysis).

CONCLUSIONS

In our sample, statistically significant endpoints were more commonly reported than nonsignificant endpoints. Immature endpoints (those analyzed before the required number of accrued patient events) were often reported. By reporting only significant endpoints and those that are immature, advertisers may encourage misconceptions about a drug's efficacy profile.

Direct-to-Consumer Advertising of Prescription Drugs and the Patient-Prescriber Encounter: A Systematic Review

We systematically reviewed the research on patients' and prescribers' perceptions of, and self-reported behaviors prompted by, exposure to direct-to-consumer advertising (DTCA) (For ease of reading we use the term "advertising" to encompass advertising and promotional labeling. Broad use of this term does not imply endorsement by FDA) of prescription drugs that occurs in the context of a clinical encounter. This research offers an important perspective on the broader goal of incorporating patient and prescriber voices in decision-making. Outcomes included patient information seeking, medication adherence, patient requests for DTCA-promoted prescription drugs, prescribing behaviors, and perceptions of the patient-prescriber relationship and interactions. We searched PubMed and other databases from 1982-2017 and identified 38 studies meeting our study criteria. Of these, 24 studies used patient-reported outcomes and 18 used prescriber-reported outcomes (four used both). Studies suggested some potential benefits of exposure to DTCA, including patients' enhanced information-seeking, increased patient requests for appropriate prescriptions (when addressing potential underuse) and patients' perceptions of higher-quality interactions with prescribers. Most prescribers perceived a neutral influence on the quality of their clinical interactions with patients regarding DTCA. Harms included patients receiving prescriptions for drugs that were not appropriate for them or that the patients did not need, and the potential for DTCA to interfere with medication adherence in some populations, such as those with mental illness. The potential benefits of DTCA on the patient-provider encounter must be balanced with the potential for harms.

Stakeholder perspectives on the challenges surrounding management and supply of essential medicines

Background Shortages of essential medicines impact patient safety and raise the costs of medicines to consumers and governments. Ongoing medicine shortages have become a critical issue that threaten global access to medicines. Objective The aim of this study was to explore key stakeholders' perspectives on the challenges surrounding management and supply of essential medicines. Setting Western Pacific, Asia, Europe, North America, and Africa. Methods In-depth, semi-structured interviews with 47 participants were conducted across seven stakeholder groups globally. Stakeholders included government, academics, consumer groups, non-profit organisations, hospital healthcare providers, manufacturers, and wholesaler/distributors. A grounded theory approach was applied to qualitative analysis. Main outcome measure Stakeholders' perspectives on the challenges surrounding management and supply of essential medicines. Results This study showed that supporting consumer demand for a wide range of therapeutic products required increased resources and coordination. Four main themes were identified: (1) consumer demand for a wide range of individual therapeutic needs cannot be sustained by the supply chain; (2) there lacked a coordinated approach to manage medicine shortages throughout the supply chain; (3) there were gaps in communication throughout the continuum of the supply chain; and (4) both international and local disruptions contributed to vulnerabilities in the supply chain. Conclusion Prioritisation of supply, logistics, and budget decisions around essential medicines need to be clearly coordinated between stakeholders to mitigate medicine shortages. Financial structures should include resilience planning to support fair and equitable access to medicines that meet consumer needs.

Medicines Information and the Regulation of the Promotion of Pharmaceuticals

Many factors contribute to the inappropriate use of medicines, including not only a lack of information but also inaccurate and misleading promotional information. This review examines how the promotion of pharmaceuticals directly affects the prescribing and use of medicines. We define promotion broadly as all actions taken directly by pharmaceutical companies with the aim of enhancing product sales. We look in greater detail at promotion techniques aimed at prescribers, such as sales representatives, pharmaceutical advertisements in medical journals and use of key opinion leaders, along with the quality of information provided and the effects thereof. We also discuss promotion to the public, through direct-to-consumer advertising, and its effects. Finally, we consider initiatives to regulate promotion that come from industry, government and nongovernmental organizations.

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.

Impact of a direct-to-consumer information campaign on prescription patterns for overactive bladder

Background

Direct-to-consumer information (DTCI) campaign is a new medium to inform and empower patients in their decision-making without directly promoting specific drugs. However, little is known about the impact of DTCI campaigns, expanding rapidly in developed countries, on changes in prescription patterns. We sought to determine whether a DTCI campaign on overactive bladder increases the prescription rate for overactive bladder treatment drugs.

Methods

We performed a 3-year retrospective cohort study of 1332 participants who were diagnosed overactive bladder but not prescribed treatment drugs prior to the examined DTCI campaign (exposure), using the health insurance claims dataset of the Japan Medical Data Center (November 19, 2010 to November 18, 2013). The DTCI campaign for overactive bladder included television, Internet, and print advertising (November 19, 2011 to December 22, 2011). We divided the study period into Pre-Campaign Year (2010–2011), Year 1 (2011–2012), and Year 2 (2012–2013). Each year began on November 19 and included Period 1 (weeks 1–5) through Period 10 (weeks 46–50). The main outcome was first-time prescription of the treatment drug for each patient, measured by 5-week periods. Using Period 10 in the Pre-Campaign Year as the referent period, we applied the Cox proportional hazard model for each period. Additionally, we performed the interrupted time series analysis (ITSA) for the first-time prescription rate per 5-week period.

Results

Following the DTCI campaign, patients were about seven times more likely to receive a first prescription of a treatment drug during Period 4 in Year 1 (hazard ratio 7.09; 95% CI, 2.11–23.8; p-value<.01) compared with the reference period. Similar increases were also observed for subsequent Periods 5 and 6 in Year 1. The ITSA confirmed the DTCI campaign impact on the level of prescription rate (one-time increase in the regression-intercept) that increased by 1128.1 [per standardized 100,000 persons] (p < .05) during Period 4 in Year 1.

Conclusions

The examined DTCI campaign appeared to increase the prescription rate among patients with overactive bladder for 15 weeks with a 15-week delay. Clinical outcomes of the patients with targeted diseases need to be monitored after DTCI campaigns by a future study.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3147-1) contains supplementary material, which is available to authorized users.

Direct-to-Consumer Broadcast Advertisements for Pharmaceuticals: Off-Label Promotion and Adherence to FDA Guidelines

BACKGROUND

Direct-to-consumer (DTC) advertisements for prescription drugs in the United States are regulated by the Food and Drug Administration (FDA). Off-label promotion, or the advertisement of a drug for an indication not approved by the FDA, is prohibited. Our objective was to examine the presence of off-label promotion in broadcast DTC ads and to assess their adherence to FDA guidelines mandating fair balance in presentation of risks and benefits and prohibiting misleading advertisement claims.

METHODS

All English-language broadcast DTC ads for prescription drugs that aired in the United States from January 2015 to July 2016 were obtained from AdPharm, an online collection of healthcare advertisements. Ad length was measured and adherence to FDA guidelines was assessed for several categories: key regulatory items, indicators of false or misleading ads, and indicators of fair balance in presentation of risks and benefits.

RESULTS

Our sample included 97 unique DTC ads, representing 60 unique drugs and 67 unique drug-indication combinations. No ads described drug risks quantitatively, whereas drug efficacy was presented quantitatively in 25 (26%) ads. Thirteen (13%) ads, all for diabetes medications, suggested off-label uses for weight loss and blood pressure reduction. The most commonly advertised drugs were indicated for the treatment of inflammatory conditions (n = 12; 18%), diabetes or diabetic neuropathy (n = 11; 16%), bowel or bladder dysfunction (n = 6; 9%), and infections or allergic reaction (n = 6; 9%). More than three-quarters (n = 51; 76%) advertised drugs to treat chronic conditions.

CONCLUSIONS

Few broadcast DTC ads were fully compliant with FDA guidelines. The overall quality of information provided in ads was low, and suggestions of off-label promotion were common for diabetes medications. The impact of current DTC ads and off-label marketing on patient and prescriber decisions merits further scrutiny.

Trends and effects of pharmaceutical DTCA

Purpose

The purpose of this paper is to investigate the current trend of pharmaceutical direct-to-consumer advertising (DTCA) in the USA and its effect to patients, physicians and drug utilization. The DTCA of pharmaceutical firms is defined as an attempt of pharmaceutical companies to advertise product directly to patients.

Design/methodology/approach

The methodology used is literature review complemented with a semi-structured interview.

Findings

Pharmaceutical DTCA showed a reduction in total spending, whereas the online channel experienced growth. DTCA affected the physician–patient relationship and patient satisfaction. Patients who received medication associated with DTCA showed higher satisfaction. DTCA of second-line drugs resulted in an increase of first-line drug utilization. Benefits of pharmaceutical DTCA include enhancing appropriate drug utilization and increasing awareness. DTCA might cause harm by interfering with physician’s decisions regarding drug choice.

Research limitations/implications

Limitations include limited available information of DTCA spending from pharmaceutical companies and lack of quantitative data on the effect of pharmaceutical DTCA. In addition, DTCA is sometimes affected by research bias.

Practical implications

Improvement in the physician–patient relationship and patient satisfaction, as well as in the quality of care provided may be demonstrated.

Social implications

Pharmaceutical firms using DTCA marketing advertisement methodologies can increase awareness of underdiagnosed conditions and affect medication costs and the utilization of appropriate drug utilization.

Originality/value

Review highlights current relationships between DTCA, patients, physicians and drug utilization to explore the effects DTCA on consumers.

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.

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.

How Did Erectile Dysfunction Become "Natural"? A Review of the Critical Social Scientific Literature on Medical Treatment for Male Sexual Dysfunction

This article reviews the multidisciplinary social science literature assessing the social consequences of medical treatment for male sexual dysfunction. This literature applies medicalization theory and social constructionist approaches to gender to assert that Euro-American cultural ideals of masculinity and sexuality, as well as ageism and ableism, determine which sexual changes and experiences get defined as "dysfunction" and shape the marketing and use of medical treatments for those changes. These medical responses assuage the suffering of men who become unable to meet cultural ideals for sexuality but in the process make reductive norms for male sexuality seem biologically natural. In addition, the critical social science research suggests that an economic logic underlies the process of redefining diversity and change in men's sexual function as medical pathology. However, comparative qualitative data on men's and their sexual partners' experiences of sexuality and aging across world regions suggest that people do not universally accept the narrow ideals of male sexuality embedded in medical discourse regarding men's sexual dysfunction. The diversity in people's sexual desires across the life course and their responses to sexual function change highlight the cultural nature of medical definitions of sexual dysfunction.

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.

Feeling Is Believing: Evaluative Conditioning and the Ethics of Pharmaceutical Advertising

A central goal in regulating direct-to-consumer advertising of prescription pharmaceuticals (DTCA) is to ensure that explicit drug claims are truthful. Yet imagery can also alter viewer attitudes, and the degree to which this occurs in DTCA is uncertain. Addressing this data gap, we provide evidence that positive feelings produced by images can promote favourable beliefs about pharmaceuticals. We had participants view a fictitious anti-influenza drug paired with unrelated images that elicited either positive, neutral or negative feelings. Participants who viewed positive images rated the influenza drug as significantly more effective, safe, and beneficial than did participants who viewed negative images. This effect, known as evaluative conditioning, is well described in experimental social psychology but has not previously been shown with pharmaceuticals. We discuss how evaluative conditioning in DTCA may compromise viewer autonomy, and canvass possible regulatory responses.

Direct-to-consumer Marketing to People with Hemophilia

Adriane Fugh-Berman and colleagues describe how strategies similar to those used to market drugs to physicians are directed towards people with hemophilia.

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.

The Tip of the Iceberg of Misleading Online Advertising Comment on "Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters"

Kim's overview of Food and Drug Administration (FDA) regulatory actions from 2005 to 2014 is a comprehensive analysis of the US regulatory experience with online direct-to-consumer advertising (DTCA) of prescription medicines. This experience is of relevance internationally as online DTCA reaches the English-speaking public globally, despite the illegality of DTCA in most countries. The most common violations were omissions or minimizations of risk information, overstatements of efficacy, unsubstantiated claims, and promotion of unapproved ("off-label") use. Nearly one fourth of violations involved cancer drugs, raising additional concerns about patient vulnerability, limited treatment advance, and high costs. Based on content analyses of online DTCA, these cases likely reflect a small proportion of unbalanced and misleading promotional information available on the web. The FDA is only able to review a small proportion of promotional materials submitted to them, due to limited staffing, and the delay between first posting and regulatory action means that many people may be exposed to messages that are found to be inaccurate and misleading. The sheer volume of online DTCA, combined with the ability for content to shift continually, poses unique regulatory challenges.

Disease Information in Direct-to-Consumer Prescription Drug Print Ads

Direct-to-consumer (DTC) prescription drug advertisements sometimes include information about the disease condition in addition to information about the advertised product. Although the intent of such information is to educate about the disease condition, in some cases consumers may mistakenly assume that the drug will address all of the potential consequences of the condition mentioned in the ad. We investigated the effects of adding disease information to DTC prescription drug print ads on consumer product perceptions and understanding. Participants (4,064 adults) viewed 1 of 15 DTC print ads for fictitious prescription drugs indicated to treat chronic obstructive pulmonary disease, anemia, or lymphoma that varied in disease information presence, type, and format. Participants answered questions that assessed risk and benefit memory, perception, and behavioral intention. Results indicate that exposure to disease information as part of DTC prescription drug ads can promote the impression that the drug addresses consequences of the condition that are not part of the drug's indication.

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.

Understanding Health Information Seeking from an Actor-Centric Perspective

This paper presents a conceptual approach for discussing health information seeking among poor households in Africa and Asia. This approach is part of a larger research endeavor aimed at understanding how health systems are adapting; with possibilities and constraints emerging. These health systems can be found in a context of the changing relationships between states, markets and civil society in low and middle income countries. The paper starts from an understanding of the health sector as a “health knowledge economy”, organized to provide people with access to knowledge and advice. The use of the term “health knowledge economy” draws attention to the ways the health sector is part of a broader knowledge economy changing the way individuals and households obtain and use specialist information. The paper integrates an actor centric approach with the theory of planned behavior. It seeks to identify the actors engaged in the health knowledge economy as a precursor to longer term studies on the uptake of innovations integrating health services with mobile phones, commonly designated as mHealth, contributing to an understanding of the potential vulnerabilities of poor people, and highlighting possible dangers if providers of health information and advice are strongly influenced by interest groups.

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.

The effect of competing direct-to-consumer advertising campaigns on the use of drugs for benign prostatic hyperplasia: time series analysis

BACKGROUND

Direct-to-consumer advertising (DTCA) remains a controversial issue, with concerns that it leads to unnecessary and inappropriate prescribing. Whether DTCA shifts prescribing from first-line (guideline-recommended) therapy to second-line drugs has not been studied.

OBJECTIVE

The purpose of this study was to determine the impact of sequential DTCA campaigns for two drugs used to treat benign prostatic hyperplasia (BPH): one newer agent, dutasteride (Avodart(®)), and one older first-line agent, tamsulosin (Flomax(®)).

DESIGN

Interrupted time series analysis was used to assess the impact of each DTCA campaign using data on consumer "response" from Google Trends and dispensed prescriptions from IMS Health.

PARTICIPANTS

We analyzed data for the United States from January 2003 to December 2007.

INTERVENTION

DTCA for dutasteride and tamsulosin commenced on July, 2005 and April, 2006, respectively.

MAIN MEASURES

Monthly Internet search volume (scaled from 0 to 100) for the advertised trade name of each drug and monthly U.S. prescription rates per 1,000 population were analyzed.

KEY RESULTS

The dutasteride campaign was associated with an increase in Internet searches for both "Avodart" (level change +31.3 %, 95 % CI: 27.2-35.4) and "Flomax" (level change +8.3 %, 95 % CI: 0.9-15.7), whereas the tamsulosin campaign was associated with increased "Flomax" searches (level change +25.3 %, 95 % CI: 18.7-31.8). The dutasteride campaign was associated with an increase in the prescription of dutasteride (trend = 0.45/month, 95 % CI: 0.33-0.56), but a larger impact was observed with tamsulosin prescriptions (trend = 0.76/month, 95 % CI: 0.02-1.50). Similarly, the tamsulosin campaign was associated with an immediate fourfold increase in the prescribing of tamsulosin (level change +5.76 units, 95 % CI: 1.79-9.72) compared to dutasteride (level change +1.47 units, 95 % CI: 0.79-2.14).

CONCLUSIONS

DTCA was associated with the utilization of drugs to treat symptomatic BPH. However, both campaigns were associated with greater increases in the use of the guideline-recommended first-line agent. DTCA campaigns may increase the overall levels of guideline-recommended treatments to a greater extent than the specific advertised agents.

Compliance of disease awareness campaigns in printed Dutch media with national and international regulatory guidelines

Background

The European legislation prohibits prescription-only medicines' advertising but allows pharmaceutical companies to provide information to the public on health and diseases, provided there is no direct or indirect reference to a pharmaceutical product. Various forms of promotion have become increasingly common in Europe including “disease-oriented” campaigns.

Objectives

To explore examples of disease awareness campaigns by pharmaceutical companies in the Netherlands, by assessing their compliance with the World Health Organization (WHO) Ethical Criteria for medicinal drug promotion and the Dutch guidelines for provision of information by pharmaceutical companies.

Methods

Materials referring to health/disease and treatments published in the most widely circulated newspapers and magazines were collected from March to May 2012. An evaluation tool was developed based on relevant underlying principles from the WHO ethical criteria and Dutch self-regulation guidelines. Collected disease awareness advertisements were used to pilot the evaluation tool and to explore the consistency of information provided with the WHO and Dutch criteria.

Findings

Eighty materials met our inclusion criteria; 71 were published in newspapers and 9 in magazines. The large majority were news items but 21 were disease awareness advertisements, of which 5 were duplicates. Fifteen out of the 16 disease awareness campaigns were non-compliant with current guidelines mainly due to lack of balance (n = 12), absence of listed author and/or sponsor (n = 8), use of misleading or incomplete information (n = 5) and use of promotional information (n = 5). None mentioned a pharmaceutical product directly.

Conclusion

Disease Awareness Campaigns are present in Dutch printed media. Although no brand names were mentioned, the lack of compliance of disease awareness campaigns with the current regulations is alarming. There were information deficiencies and evidence of information bias. A key concern is that the context in which the information is provided, mostly through indirect referral, is likely to support treatment with the sponsor's product.

Then and Now: Examining How Consumer Communication and Attitudes of Direct-to-Consumer Pharmaceutical Advertising Have Changed in the Last Decade

This study examines changes over a 10-year period in consumer reports of communication with health care providers about direct-to-consumer advertised (DTCA) medications. Two rounds of survey data were collected in 2003 and 2012 using repeated cross-sectional procedures to examine consumer willingness to discuss DTCA medications, content and tone of those conversations, and attitudes about the advertisements. In total, 472 surveys were analyzed. Generally, we found physician-patient conversations, attitudes, and behaviors regarding DTCA have changed. Consumers in 2012 reported talking significantly less about the names of the advertised drug, comparing the advertised drug with their current medication, and sharing general information than consumers in 2003. Attitudes toward the advertisements were significantly more negative in 2012 compared to 2003. Of those who specifically asked for a prescription, the proportion of patients who received the prescription was significantly lower in 2012, despite research suggesting increased rates of prescriptions. These results are interpreted in light of previous research about the lack of research examining the actual communication between physicians and patients on this topic. Limitations of the study are provided along with directions for future research about DTCA and physician-patient communication.

Mefenamic Acid induced nephrotoxicity: an animal model

PURPOSE

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for the treatment of many joint disorders, inflammation and to control pain. Numerous reports have indicated that NSAIDs are capable of producing nephrotoxicity in human. Therefore, the objective of this study was to evaluate mefenamic acid, a NSAID nephrotoxicity in an animal model.

METHODS

Mice were dosed intraperitoneally with mefenamic acid either as a single dose (100 or 200 mg/kg in 10% Dimethyl sulfoxide/Palm oil) or as single daily doses for 14 days (50 or 100 mg/kg in 10% Dimethyl sulfoxide/Palm oil per day). Venous blood samples from mice during the dosing period were taken prior to and 14 days post-dosing from cardiac puncture into heparinized vials. Plasma blood urea nitrogen (BUN) and creatinine activities were measured.

RESULTS

Single dose of mefenamic acid induced mild alteration of kidney histology mainly mild glomerular necrosis and tubular atrophy. Interestingly, chronic doses induced a dose dependent glomerular necrosis, massive degeneration, inflammation and tubular atrophy. Plasma blood urea nitrogen was statistically elevated in mice treated with mefenamic acid for 14 days similar to plasma creatinine.

CONCLUSION

RESULTS from this study suggest that mefenamic acid as with other NSAIDs capable of producing nephrotoxicity. Therefore, the study of the exact mechanism of mefenamic acid induced severe nephrotoxicity can be done in this animal model.

Direct-to-Consumer Advertising

Direct-to-consumer advertising of prescription-only medications is big business for pharmaceutical manufacturers and has altered the relationship between patients and health professionals. Seeing promotional messages from the manufacturer of a pharmaceutical can have both positive and negative impacts. These are discussed along with current efforts to control activities in this area as well as possible future developments.

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

BACKGROUND

While statin drugs are recommended for secondary prevention of coronary heart disease (CHD), there is no medical consensus on whether or not a statin should be added to lifestyle change efforts for primary prevention of CHD. Previous research suggests that exposure to direct-to-consumer advertising (DTCA) increases drug demand among those at comparatively low risk. Research has yet to examine whether individual-level DTCA exposure may influence statin use among men and women at high, moderate, or low risk for future cardiac events.

OBJECTIVE

To determine the relationship between estimated exposure to DTCA for statin drugs and two clinical variables: diagnosis with high cholesterol and statin use.

DESIGN

We used logistic regression to analyze repeated cross-sectional surveys of the United States population, merged with data on the frequency of DTCA appearances on national, cable, and local television, between 2001 and 2007.

PARTICIPANTS

American adults (n=106,685) aged 18 and older.

MAIN MEASURES

Levels of exposure to statin DTCA, based on ad appearances and TV viewing patterns; self-reports of whether or not a respondent has been diagnosed with high cholesterol, and whether or not a respondent took a statin in the past year.

KEY RESULTS

Adjusting for potential confounders, we estimate that exposure to statin ads increased the odds of being diagnosed with high cholesterol by 16 to 20 %, and increased statin use by 16 to 22 %, among both men and women (p<0.05). These associations were driven almost exclusively by men and women at low risk for future cardiac events. There was also evidence of a negative association between DTCA exposure and statin use among high-risk women (p<0.05) CONCLUSIONS: This study provides new evidence that DTCA may promote over-diagnosis of high cholesterol and over-treatment for populations where risks of statin use may outweigh potential benefits.

"When diet and exercise are not enough": an examination of lifestyle change inefficacy claims in direct-to-consumer advertising

Previous research suggests that direct-to-consumer (DTC) advertisements for pharmaceutical drugs have the potential to influence consumers' perceptions of whether symptoms should be treated medically and/or through behavior change. However, the relative frequency of messages emphasizing these approaches in pharmaceutical advertising remains largely unknown. A content analysis of print and television advertisements for cholesterol management medication between 1994 and 2005 (for print) and between 1999 and 2007 (for television) was conducted. First, the extent to which established theoretical constructs drawn from health communication scholarship are depicted in the content of DTC cholesterol advertisements is quantified. Second, specific claims about behavior change inefficacy when a pharmaceutical alternative is available are identified. Findings indicate that DTC ads offer many mixed messages about the efficacy of diet and exercise in reducing cholesterol and risk of heart disease. Theoretical and practical implications of this work are discussed.