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Direct Drug Advertising to Consumers: When Pharma Plays Doctor

The University of Chicago, Chicago, IL

To the Editor: One cannot read a newspaper or magazine, nor watch television, without seeing advertisements for allergy medicines, lipid-lowering agents, and antihypertensives, as well as medications for erectile dysfunction, gastroesophogeal reflux disease (GERD), and a multitude of other disorders. The pharmaceutical industry has turned its sales effort away from physicians to target consumers. I believe it is time to confront the pharmaceutical industry’s use and abuse of direct-to-consumer advertising (DTCA). Many of my colleagues and I have done little to object to DTCA beyond carping about it among ourselves and perhaps remonstrating with the industry’s sales representatives. The goals of drug manufacturers are not always coincident with those of health care providers, and DTCA may make it more difficult to deliver effective and economical health care by wasting two of our most precious patient care resources: time and money.

The goal of product marketing is to create a perceived need for a product or its benefits—to drive sales. One can view DTCA advertisements and quickly note that they are not an effective means of disseminating educational information. For example, an ad about the proton-pump inhibitor, Nexium (AstraZeneca Pharmaceuticals LP, Wilmington, DE), would need to be about an hour long to properly inform viewers of the role of acid production in GERD, the cost and efficacy of various remedies, and the risks posed by the untreated condition. If the ad’s purpose is education, shouldn’t it also discuss weight loss, alcohol use, and eating habits, rather than create an instant association between the fact that GERD is bad, painful, and even dangerous, and the claim that Nexium can make it go away? The geographic imagery almost seems to promote the use of Nexium to transform the Dakota Badlands into productive agricultural land.

I recently saw a televised ad for Neulasta (Amgen, Thousand Oaks, CA). I have several problems with this ad. First, it implies that a practicing oncologist administered potent chemotherapy without counseling the patient about myelosuppression; the patient in the ad says, "I didn’t know that it would destroy my white blood cells." Second, this phrasing implies the harmful effects of myelosuppression are permanent by failing to mention their transient nature, thus linking chemotherapy and death from infection in the mind of the consumer. The ad does not differentiate well among various types or potencies of chemotherapy. Of course, explanations of this type would go beyond the scope of a commercial—further evidence that ads for prescription drugs cannot truly inform or educate the public. Finally, this ad may cause patients or their family members to expect that Neulasta will be administered for all types of chemotherapy. How can we withhold this medication from a patient who requests it, even if it is not indicated, when the patient has been informed that chemotherapy without Neulasta means possible death from infection?

In my opinion, DTCA is harmful, not helpful. It misleads and misinforms the public by providing just enough information to create the thought, "I need/want that." It costs money that would best be used elsewhere. A report by the National Conference of State Legislatures states, "At an estimated annual cost of $2.5 billion, pharmaceutical advertising to consumers has indeed made drug companies and their brand products household names."¹ This expenditure drains money from the economy in order to promote sales. These drains on precious public resources constitute a public harm; arguments that these ads perform a public service are specious and misleading. DTCA creates a consumer-driven market, giving the patient enough information to create a demand but nowhere near enough information to permit analysis and thorough understanding. My patients watch television; they do not read The Medical Letter.

Advertising is carefully selected information in which the omissions may be more informative than the presented material. Elsewhere in the world, free societies have decided that DTCA may be deleterious; DTCA is only permitted in the United States and New Zealand. This past fall, the European Parliament rejected a proposal to relax the ban on advertising prescription-only medicines to the public.

I firmly believe people have the right to information about things that directly affect their lives. The PDR is freely available, and abundant information is available online. The public should be free to ask questions and get answers as detailed as it wishes. But an ad or television commercial is not an answer to a question; it is a tightly controlled display of information, and the information might be misleading.

As recently reported, Peiró et al ² found that "In 45 claims (44.1%; 95% CI, 34.3 to 54.3) the promotional statement was not supported by the reference, most frequently because the slogan recommended the drug in a patient group other than that assessed in the study." These were ads targeting physicians; I expect less accuracy and more misleading conclusions when the ads are for the lay public. My expectations are supported with information supplied by Jennifer Warner of Medscape Medical News, who reported that the US government’s General Accounting Office issued a report on December 4, 2002, stating, "The FDA issued 88 regulatory letters and four warning letters between August 1997 and August 2002 for DTC advertisements that violated its standards."³

DTCA directly obviates the physician prescription system, creates consumer demand, and drives up healthcare costs by promoting newer brand-name drugs. It serves only to increase drug sales and does nothing to truly inform. It is banned in most of the world and should be banned in the United States, not in an attempt to hinder consumer knowledge, but because it is wasteful and misleading.

REFERENCES

1. Direct-to-consumer advertising of pharmaceuticals. http://www.healthyskepticism.org/reports/2002/dtca020205.htm

2. Peiró, et al: Accuracy of pharmaceutical advertisements in medical journals. Lancet 361:27–32, 2003[CrossRef][Medline]

3. Misleading drug ads persist. http://www.medscape.com/viewarticle/445686

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