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CMAJ • September 2, 2003; 169 (5)
© 2003 Canadian Medical Association or its licensors

Editorial
Français à la page suivante

Ads and prescription pads

In 2000, pharmaceutical firms in the United States spent US$2.5 billion on direct-to-consumer advertising (DTCA) — more than 3 times the amount they had spent in 1996, and 35% more than in the previous year.1 From a business perspective, this money was well spent: for example, it has been claimed that each dollar spent on consumer advertising for the allergy drug Claritin has brought in $3.50 in increased sales.2 In this issue, Barbara Mintzes and colleagues report on the effects of DTCA on patients and physicians3 (see pages 405 and 425). It seems that DTCA has a primary and a secondary effect: patients are susceptible to advertisers' claims, and physicians are susceptible to patients' requests for advertised drugs.

Is this necessarily a bad thing? Some common illnesses such as asthma and diabetes are undertreated, whether through underdiagnosis or poor "compliance," and a substantial proportion of the general adult population has pharmaceutically treatable risk factors such as hypertension and hyperlipidemia. An argument can be made that underprescribing is a medical error (of omission).4

Arguments in favour of DTCA also speak of "empowering" the patient by means of providing information on the treatment choices available. Those wonderfully cryptic "reminder" and "help-seeking" ads one sees on television these days (which slide under the regulatory radar in Canada by naming either a condition or a treatment but not both together in what might be construed as a "product claim" — see page 421) may raise awareness of some health problems and reduce stigma, thus helping to break down resistance against seeking information, diagnosis and treatment. Insofar as DTCA is informative, who are physicians and regulators to say it isn't good for patients?

The trouble with DTCA is not that it is directed to patients, who have every right to know about the therapeutic products potentially available to them. The problem is simply that it is advertising, whose purpose is to deliver messages, not information. Those messages are intended to promote the use of newer, more expensive drugs (even if older, cheaper, ones work as well) and to increase brand recognition (but not an awareness of side effects, or of nonpharmacologic options for treatment and prevention). Their purpose is to create demand by delivering a double message of anxiety and hope, encouraging a belief that a condition — hair loss, acne, shyness, allergies or osteoporosis — is not only "widespread [and] serious" but "treatable."5 In addition to raising general consumer awareness, they carve out new and sometimes questionable market niches (e.g., through a Viagra ad campaign aimed at younger men).1 The fact that DTCA is subject to government regulation and voluntary standards gives some reassurance, but not much. Advertising standards are as tricky to interpret and enforce as marketing gurus are creative; moreover, the very fact that DTCA is subject to government regulation and advisory-board approval has the paradoxical effect of increasing its credibility.1

But perhaps the most noteworthy point about DTCA is that word "consumer." By being marketed in media traditionally used to flog cars, fast food and shampoo, prescription drugs have become name-brand commodities, enveloped in the kind of fantasy and desire that surrounds the purchase of lifestyle products. At the same time, the constant barrage of DTCA contributes to the "medicalization" of normal human experience by which the authority of medicine and our modern inability to accept the normality of illness and death has turned us into "two-legged bundles of diagnoses."6 Moreover, what Ivan Illich so forcefully described in 19767 as an iatrogenic phenomenon has now gone corporate: "The social construction of disease is being replaced by the corporate construction of disease."5

One launches into such critiques at the risk of sounding hysterical. And so we hold back from an alarmist stance that assumes that no patient is capable of responding to an advertisement skeptically. But consider the following: if US-style, "product claim" DTCA were permitted in Canada (the only other country that allows it is New Zealand), pharmaceutical firms might spend about Cdn$360 million a year and expect drug sales to increase by as much as $1.2 billion. These additional costs will be added almost entirely to the cost of medicare. Do we know enough about the RCT-proven benefits of the advertised drugs to decide whether this is a wise use of our resources? Those resources might be better spent in providing unbiased "consumer" information about drugs and alternative non-drug therapies and prevention. — CMAJ

References

  1. US National Institute for Health Care Management. Prescription drugs and mass media, 2000. Washington: The Institute; 2001. Available: www.google.ca/search?q=cache:Mql7xCnuyc4J:www.nihcm.org/DTCbrief.pdf+Prescription+drugs+and+mass+media,+2000.+&hl=en&ie=UTF-8(accessed 2003 Aug 11).
  2. Pill pushers. Economist 2001; Apr. 21. p. 58-9.
  3. Mintzes B, Barer ML, Kravitz RL, Bassett K, Lexchin J, Kazanjian A, et al. How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA. CMAJ 2003;169(5):405-12.[Abstract/Free Full Text]
  4. Committee on Quality Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001.
  5. Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ 2002;324:886-91.[Free Full Text]
  6. Illich I. Death undefeated. BMJ 1995;311:1652-3.[Free Full Text]
  7. Illich I. Limits to medicine. In: Medical nemesis: the expropriation of health. Toronto: McClelland and Stewart; 1976.




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