The potential of DTC advertising
Speaking at a symposium on “Consumerism” on 3 September,
Dr Hubertus Cranz director-general of the Association of the European
Self-Medication Industry, Belgium, stated that the increase in direct-to-consumer
(DTC) advertising has the potential to make a major impact on use of medicines
and health care services, and is highly debated globally. The United States
could be looked at as a test case. There, the first debates about DTC
advertising were in the early 1980s and the first television commercial
for a medicine appeared in 1987, although up to the mid 1990s DTC advertising
was mainly print promotion. There has been major growth in DTC advertising
in the past two to three years and an estimated US$3bn would be spent
on DTC advertising in 2002.
The US Food and Drug Administration produced guidance
for DTC advertisements on broadcast media in 1999 but was still debating
consumer-directed print media advertisements. The FDA recently conducted
a representative consumer survey about DTC advertising. The majority of
patients recalled the benefits and risks of medicines they had seen advertised.
Only 57 per cent would get additional information from their pharmacist
and 87 per cent would consult their doctor for more information. Nearly
one third of respondents had asked their doctor about a medical condition
as a result of an advertisement that they had seen. The main drugs advertisements
were for allergies, skin and hair treatments, high cholesterol and coronary
heart disease, mental health problems, osteoporosis and menopausal symptoms.
Dr Cranz argued that although the one third who asked their doctor for
advice as a result of an advertisement is a minority, DTC advertising
may have a positive public health benefit if patients are talking about
conditions with their doctors at an earlier stage than they might have
done, leading to earlier diagnoses. Eighty per cent of those who had consulted
a doctor following an advertisement had received the drug that they requested
and 80 per cent of doctors welcomed patients’ questions in response to
medicines advertisements.
The US debate has had a major impact on other countries.
The EU had been debating it for a while and it was difficult, Dr Cranz
said, to predict what member states would decide. There was currently
a proposal to review pharmaceutical legislation. “European consumer groups
are opposed. They agree that patients need more medicines information
but argue that the provider should not be the pharmaceutical industry,”
he said. It was argued that advertising of medicines could lead to a large
increase in spending on medicines, a major problem for state-funded health
systems, it could distort prescribing behaviour and did not always enable
consumers to make informed choices about medicines.
Dr Cranz said that the pros of DTC advertising included
empowerment of the consumer, encouragement to visit the doctor, increased
awareness of particular health problems and enhanced compliance with treatment.
There was also the fact that patients could use their own judgement in
conjunction with professional advice. However, the cons were possible
harm to the doctor-patient relationship, intimidation or alarm and possibly
an inflated risk-benefit expectation. “A culture of hypochondriacs may
be created and there could be an increase in health expenditure,” he said.
Dr Cranz predicted that if DTC were allowed, it
would lead to more active and demanding patients and that pharmacists
would need to deliver consumer-focused information, and improve their
pharmacy design and their communication techniques.
Deregulation of medicines
Discussing deregulation of medicines, Kevin Moody,
of Medécins Sans Frontières, the Netherlands, spoke of the need for a
balance between patient protection and patient empowerment. He said that
in industrialised countries there was too much regulation and that in
the developing world their was not enough, and although medicines were
more freely available there were considerable barriers to patient empowerment.
“We need patient protection because of the potential for harm,” he said.
In developing countries there was a need for regulation
because of problems of quality, counterfeit drugs and imports. Countries
often lacked a coherent pharmacy infrastructure. Patents were also a barrier
for developing countries. The World Trade Organization standards on patents
applied to pharmaceuticals and developing countries had to be compliant
by 2006. There had been pressure from industrialised countries to meet
standards early and they have often applied laws that are more restrictive
than WTO standards. “Pharmacists and pharmacy organisations could be advocates
to eliminate poor quality, counterfeits and problems with imports. There
is a need to be much more flexible and responsive in drug supply to developing
countries,” he concluded.
WHO criteria
Lenbit Rägo, from the World Health Organization,
Switzerland, said that the WHO had adopted criteria for advertising medicines
(www.WHO.int/medicines/library/; note this is a restricted access website).
However, different societies interpreted ethical
guidance differently and the issue in all societies was what is proper
behaviour. “There is,” he said, “a long way to go to achieve high ethical
standards for advertising worldwide.” There was increasing promotion of
prescription drugs to the public, and the industry continued to build
relationships with patient groups. Pharmacists were not enormously active
in promoting ethical criteria for drug promotion compared with consumer
groups and non-governmental organisations. Not all the pharmaceutical
industry adhered to WHO ethical guidelines and the industry spent far
more on marketing than on research and development. “There is a long way
to go before ethical standards for advertising medicines are reached worldwide,”
Mr Rägo concluded.
Information morass
Keith Johnson, of the Management Sciences for Health
Centre for Pharmaceutical Management, United States, used the example
of the recently withdrawn statin Baycol to illustrate the information
morass people found themselves in. “The story breaks, it escalates, consumer
health advocates tell their story, other companies say their products
are fine, and within days the competitors put their advert for Zocor on
the New York Times web page carrying the news about Baycol,” he said.
“The health journalists start to write commentaries and the malpractice
lawyers place their ads beside those articles. Then organised medicine
weighs in. The American Heart Association and the American College of
Cardiologists say statins are safe and patients shouldn’t interrupt their
therapy.” So what does the consumer decide? Are they or are they not dangerous?
Whom should the consumer listen to?
Pharmacists, Mr Johnson said, are in a position
to help the consumer sort through all of these information resources.
The internet gave consumers more choices but they become overloaded with
the volume of the information. “Truth today is not necessarily truth tomorrow,”
he said. Many patients relied on anecdotal individual information from
chat rooms and bulletin boards. This was not very evidence-based. No one
provided quality control. Information must be available, affordable, accessible,
and acceptable.
Pharmacists needed to use a number of strategies
for impacting access to and use of drug information, including regulatory
mechanisms as part of product registration and to ensure drug promotion
regulations are enforced. There were also professional practice and administrative
mechanisms like pharmaceutical care, guidance regarding best practice
and access to best evidence. They needed economical mechanisms to ensure
that health care providers have adequate budgets for patient education
and information access and educational mechanisms for patients and to
educate journalists, who had a great influence, especially in developing
countries.
Pharmacists must be information integrators and
marketers. “We must learn from the pharmaceutical industry and use its
techniques to educate our patients. We must educate for behaviour change.
So communication skills training is important in pharmacy schools,” he
concluded.
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