The American Medical Association’s 2015 recommendation to ban direct-to-consumer advertising (DTCA) of prescription drugs reflected a strong consensus that this form of marketing is a significant contributor to increased drug costs. It is well documented that many patients request drugs they have seen advertised on television and that physicians often acquiesce to these requests.1, 2, 3, 4 But the possibility that physicians can be influenced as viewers of this advertising has escaped academic and policy-making attention. This omission is noteworthy because watching repetitive highly motivational sales-oriented messages on television might result in the same prescribing bias that prompted revision of ethical guidelines in 2008. Physicians were previously exposed to brand names and “educated” about the benefits of prescription drugs by ever-present drug detailers (sales representatives) who dispensed free advice, free samples, and an endless supply of logo-imprinted office and personal gift items. Now, marketers can potentially achieve the same objectives by broadcasting DTCA with a similar promotional message directly into a physician’s home.
In 1997 the Food and Drug Administration clarified rules that made the US and New Zealand the only 2 countries that allow DTCA. Although consumers can now be targeted directly, prescriptions for these medicines are still required, and competition for physicians’ attention has remained intense and expensive. In 2012, the pharmaceutical industry spent 27 billion dollars on marketing. Most of the promotional budget was directed toward prescribers using traditional means: face-to-face contacts, direct mailings, ads in academic journals, continuing medical education, and digital advertising. But 3 billion of these marketing dollars (11%) was spent on DTCA. During that same year, the drug with the single largest promotional expenditures in the US spent almost 40% of its budget on consumer advertising.5
There are compelling arguments for and against continued use of direct-to-consumer advertising.1, 6 Proponents correctly argue that DTCA motivates patients to participate in their own care, educates them about treatment options, and encourages conversation with doctors about medical concerns. They also believe that compliance improves when patients have requested their own treatments and that consumers have the right to receive unfiltered product information directly from the manufacturer. Critics are equally correct when they argue that the real purpose of DTCA is to increase sales and there are better ways to educate consumers. They believe that sales-oriented advertising emphasizes a drug’s benefits, minimizes its risks, and creates unrealistic expectations for successful treatment. They are especially concerned that DTCA drives up costs by promoting use of brand-name rather than comparable generic or lower-priced drugs, and that these medicines are more likely to be prescribed for nonessential and sometimes questionable indications.1, 6 Federal and state legislators have noted that DTCA has proven so effective at popularizing brand name drugs that they are revisiting the possibility of curtailing these ads to decrease local pharmaceutical costs.7
Variations in viewers’ preferences, competition for advertising dollars, and frequent changes in marketing objectives make it difficult to accurately quantify a physician’s exposure to DTCA and to correlate exposure with outcome.8 Despite these limitations, it should not be assumed that medical training and ethical intent will fully immunize clinicians against the effects of viewing ubiquitous skillfully crafted promotional messages interspersed with favorite television programs. The casual setting and a recreational mindset might hinder critical evaluation of the message, contribute to lower prescribing thresholds, and increase acquiescence to patient requests.
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-Jeffrey L. Brown, MD
This article originally appeared in the June 2017 issue of The American Journal of Medicine.
