As recently described by Rosenthal et al, spending on prescription drugs has now become the fastest growing component of the health care budget. While her comments were aimed at the U.S. market, this phenomenon is one of worldwide significance.
One factor that is probably contributing to this increased spending is direct-to-consumer (DTC) advertising. As aptly coined by Leacock almost 80 years ago, advertising is “superior to reality” and involves “…the science of arresting human intelligence long enough to get money from it…”. And what better targets for advertising than health care and prescription drugs, as so many of us have become, to various degrees, “healthy hypochondriacs” who spend inordinate amounts of unproductive time worrying about things that we often cannot change. As Moynihan et al describe, DTC advertising of prescription drugs is driven in part by the recognition that substantial profits can be made from healthy people who can be made to believe they are sick.
The spending on DTC advertising in the US alone was reported to be about $2.5 billion in 2000, and this represents a 300% increase over the preceding 4 years. To put this into context, this represents only 15% of the total funds spent on drug promotion in the United States. By comparison, the total research and development expenditures reported by all companies in Canada for 2001 was only $1.06 billion CAN (~$0.7 billion US).
So why does industry spend ever increasing amounts of money on DTC advertising of prescription drugs? Because it works. Patients who are exposed to DTC advertising request more advertised drugs, and these products are prescribed even when recognized by physicians as not necessarily being the treatment of choice. DTC advertising is expensive, so manufacturers carefully determine how much money to spend on this form of product promotion on the basis of the number of potential customers, the estimated proportion of these customers that might be persuaded to use their product, the volume of physicians that are likely to prescribe that drug and the monetary return per prescription. The latter is at least partially based upon intended duration of therapy. The longer the customer needs to use the product, the greater the return.
And what drugs do manufacturers typically aim their resources at? As Mintzes points out, the products of interest are new expensive drugs intended for chronic use by a large population of patients. In 2000, 20 drugs accounted for about 60% of the total US spending on DTC advertising. Included in the target list were drugs aimed at weight loss, erectile-dysfunction, birth control, genital herpes and toenail fungal infections. What an intriguing mix of pharmaceuticals, and an interesting commentary about the ailments of our society.
So what’s wrong with advertising a product to the people who are ultimately going to consume it? After all, isn’t that what free enterprise is all about? Let’s list some of the possible pros and cons.
- DTC advertising may lead to a more health conscious, informed and empowered public
- DTC advertising may reduce underdiagnosis and undertreatment of diseases
- DTC advertising may result in earlier management of more serious, costly conditions that consumers typically ignore, or chose not to treat when symptoms appear to be minor or non-acute
- DTC advertising information may increase the dialogue between patient and health care workers about drugs and medical conditions
- DTC advertising may encourage compliance with prescription drug treatment regimens
- DTC advertising may result in the promotion of emotional, rather than educational content
- DTC advertising may lead to medicalisation of normal human experiences and disease mongering, resulting in increased use of drugs in healthy patient populations
- DTC advertising may stimulate inappropriate prescribing
- DTC advertising may contribute to an undesirable shift in the relative use of prescription drugs versus over the counter products and non-drug therapies
- DTC advertising may lead to the increased use of drugs for the prevention of medical problems, even when the risk of contracting the medical problem is low and possibly less serious than the adverse effects (both physiological and economic) of the drug itself
- DTC advertising may involve the provision of imbalanced information that leads to erroneous perceptions and “glamorization” of the benefits of a particular drug, while downplaying the potential complications
- DTC advertising may contribute to the increased treatment of poorly correlated surrogate endpoints rather than the targeting of meaningful clinical endpoints
- DTC advertising may result in patients requesting a specific medicine that has been advertised, even though this is not necessarily the best choice
- DTC advertising may produce a negative effect on the pharmacist/patient and doctor/patient relationships by creating conflicts between the patient’s desire and the caregivers more informed judgement
- DTC advertising may result in higher costs of care, without necessarily improving quality of life
As stated by Mintzes, the question is not whether consumers should obtain information about treatment options; the question is whether drug promotion can provide the type of information consumers need. DTC advertising, in all its direct and indirect forms, is not going to cease. it is just going to become a little more sophisticated, a little more stealthy.
Where do I personally stand on this issue? Overall, I’m not in favour of it. While there may be some benefits related to increased health awareness and enhanced communication with health care professionals that may result from DTC advertising, there are certainly better ways to addresses these important issues without inviting the fox into the henhouse. Separating drug fact from fiction is something we health care professionals struggle with everyday, and most patients just don’t have the tools to compete with the manufacturers in this regard. I suspect there is a net negative impact associated with the promotion of prescription drugs directly to the public. I continue to believe that patients should seek prescription drug information from objective and qualified sources who have no vested interest in the sales of a particular product. This excludes the manufacturers, and unfortunately, the occasional health care professional. As I have already stated, advertising costs money. A lot of money. Wouldn’t it be great if the manufacturers redirected these funds towards reduced drug prices, or even better, drug research and development? Now that’s a novel idea…and what an advertising gimmick that could be in itself.
I would be very interested in your opinions on this subject. In the interim, consumer beware.