Direct to consumer advertising

The challenge for governments evaluating direct advertising of prescription only drugs to the consumer is how to achieve maximum benefits for health and wealth while minimising harm. New Zealand's health minister, Annette King, has taken the advice of New Zealand's health professional and consumer groups and has decided that the potential benefits of “direct to consumer advertising” do not justify the harms and so plans to ban it from 2005.^w1 That will leave the United States as the only industrialised country allowing full direct to consumer advertising of prescription medicines. An Australian review of drug legislation in 2001 concluded that prohibiting such advertising produces a net benefit for the community as a whole.¹ In 2002, the European Parliament rejected a proposal to allow advertising for drugs used to treat asthma, AIDS, and diabetes directly to the consumer. A 2004 Canadian parliamentary inquiry recommended against direct to consumer advertising because “Drug advertisements could endanger rather than empower consumers by minimizing risk information and exaggerating benefits” and “could contribute to increased or inappropriate drug consumption.”²

Direct to consumer advertising increases the use of drugs and medical services and increases wealth for pharmaceutical, advertising, and media companies.³ It increases prescribers' workloads and increases expenditure by patients, taxpayers, insurers, and large employers. For example, General Motors USA has identified direct to consumer advertising as a major cost driver increasing payments for health care for its workers and thus increasing the cost of building cars.^w2 Such increased costs might be worth while if direct to consumer advertising delivered value for money by improving health.

Unfortunately, the situations where direct to consumer advertising could be most beneficial (by stimulating appropriate use of drugs for high priority health needs) do not often match the situations where it is most profitable. As one advertising industry executive explains: “Direct to consumer is suited for things where patients have a greater interest than doctors. Non-life threatening conditions, such as erectile dysfunction...”^w3 Such promotion may be beneficial as well as harmful. For example, while the promotion of sildenafil and its competitors may motivate men, who might not do so otherwise, to see a general practitioner, and possibly address other health needs, it has been shown to increase distress if it raises expectations that are unfulfilled^w4 and is a haphazard approach to health promotion for populations. Direct to consumer advertising is most profitable for expensive new drugs.⁴ Because the long term health effects of new drugs are unknown it is often difficult to know whether the increased costs are justified. There are also opportunity costs when advertising stimulates rapid adoption of new drugs without established advantages over cheaper alternatives, especially in public health systems with finite resources.

Proponents of direct to consumer advertising claim it increases public knowledge. This might be so if it delivered reliable balanced information. Such advertising does increase awareness of drugs, but its purpose, as with all advertising, is to persuade rather than to inform. Direct to consumer advertising leaves many people with exaggerated perceptions of the benefits of drugs.⁵ Providing balanced information about harms, alternatives, and costs is likely to reduce efficacy and profitability of advertisement. Demand stimulated by such advertising creates dilemmas for doctors who aspire to be both patient centred and evidence based. For this reason, many health professionals and their representative organisations strongly oppose advertising directly to consumers.⁶

In countries where full direct to consumer advertising is illegal, drug companies are increasingly pushing the limits of regulatory systems, with disease oriented advertising, public relations campaigns, reminders, and unbranded direct to consumer advertising.^w3 Requirements to provide any balancing information do not exist because such advertising has arisen by default via regulatory loopholes. For example, in Canada a price advertising clause from 1978 has been used to allow reminder advertisements, including advertising in July 2004 for a contraceptive patch by name without warnings about adverse effects.^{7 w5} Earlier this year Glaxo-SmithKline paid a celebrity, Impotence Australia, and a couple who had used vardenafil to promote the drug via the Australian news media.⁸ The brand name was mentioned without appropriate balancing information. In 2003 staff of the World Health Organization expressed concern that disease oriented advertisements in France that were funded by Pfizer, manufacturer of atorvastatin, “contained misleading statements and omissions likely to lead to unjustified medicine use.”⁹ They recommended that governments “urgently increase vigilance with respect to drug promotion.” Few if any governments seem to be heeding this advice. In 2004, Canada's health minister, Pierre Pettigrew, indicated that a nearly identical advertisement was not subject to regulation because it fell outside the legal definition of product specific advertising.^w6

Two studies of unbranded advertising directly to consumers have been published. Prescribing of sumatriptan was higher in cities in the United States that had been exposed to a campaign in 1993 recommending that people ask their doctor about a “surprisingly effective” new treatment for migraine.¹⁰ Novartis's unbranded television advertisements in the Netherlands increased consultations for onychomycosis and prescribing of terbinafine while decreasing use of its competitor.¹¹ The country's health inspectorate tried to stop this campaign, but a court allowed it because neither the product nor the company was named.

Governments are under pressure to create business friendly environments for politically powerful industries to invest.¹² At the same time they must manage health services to give priority to health needs. Policy on direct to consumer advertising is at the crossroads of those competing pressures. In the face of unsuccessful attempts at legislative change to allow advertising directly to the consumer, lax enforcement of existing laws may ease pressure on governments from those politically powerful industries, but it is contrary to democratic principles and may harm both public health and national wealth.

The public is ill served when governments allow promotion of prescription drugs that stretches the limits of the law—and beyond. No country has been successful at regulating any type of direct to consumer advertising to ensure the public obtains reliable balanced information on drug benefits and risks.³,⁶ Repeated breaches by companies speak for themselves.³ The potential awareness raising benefits of direct to consumer advertising could be better targeted and sustained at lower cost with less harm through publicly funded and accountable drug information services and health campaigns.