Synopsis: Since FDA rules on prescription drug advertising were loosened in 1997, the amount of advertising has mushroomed. However, there is still controversy over whether that’s good for patients, and now the American Medical Association has come out for an ad ban. Experts discuss the pro’s and cons of direct to consumer advertising and its effect on patients and physicians.
Host: Reed Pence. Guests: John Kamp, Executive Director, Coalition for Healthcare Communication; Dr. Sidney Wolfe, Founder, Public Citizen Health Research Group; Dr. Joel Lexchin, Professor of Health Policy, York University and emergency physician, University Health Network, Toronto; Dr. Brad Shapiro, Assistant Professor of Marketing, University of Chicago Booth School of Business.
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16-16 Direct To Consumer Drug Advertising
Reed Pence: If you watch TV very much at all, you can’t avoid the commercials saying “talk to your doctor” about erectile dysfunction, arthritis, depression, high cholesterol, and more. Since the rules were loosened on direct to consumer drug advertising in 1997, spending on those ads has mushroomed. Between 2012 and 2014, spending rose almost a third, to nearly five billion dollars a year. Some groups such as the American Medical Association want to ban those so-called DTC ads. But the pharmaceutical industry says those commercials have an important role, they’re informational and educational.
John Kamp: I think direct to consumer advertising has a very positive beneficial effect for most cases. Now, that doesn’t mean that I love every ad, I probably cringe at some ads just like anybody else does.
Pence: John Kamp is Executive Director of the Coalition for Healthcare Communication.
Kamp: Generally, direct to consumer advertising helps patients be more involved in their care and tells them about options that may be available to them as well as the benefits and concentrations of other drugs and thereby increases the quality of conversations they have with their doctors. Remember, we’re talking about drugs here that you can’t prescribe to yourself. You have to have a conversation with your doctor, and these conversations actually help inform the patient about what’s going on. In fact, we also know that from some of the studies that have been done on DTC that direct-to-consumer advertising helps people be better engaged in their care and do a better job of taking the drugs as prescribed.
Pence: The United States and New Zealand are the only countries where direct to consumer drug ads are allowed. And while most experts agree that informed health consumers are a good thing, especially today, they disagree about whether sales pitches qualify.
Kamp: The rest of the world looks at this country and thinks that we’re crazy because we’re essentially encouraging companies to overstate the benefits and understate the risks of their drugs and make all sorts of money as a result of the increased amount of advertising.
Pence: Dr. Sidney Wolfe is founder of the Public Citizen Health Research Group.
Dr. Sidney Wolfe: The industry says, “Well it’s educational, it helps empower patients, and so forth,” I just don’t believe that. There’s no evidence. The best evidence by far has been duplicated by many different groups and people in academics is that in direct proportion to how much direct to consumer advertising, you sell more drugs. There’s no question about that, and since that’s the main purpose of it, it seems to work. There’s a very interesting study showing that in different parts of the country, where there’s different market penetration, television marketing penetration for a certain drug, the drug sells more. Whereas in another part of the country where there isn’t as much TV exposure, it sells less. So that’s the clear unequivocal finding from research on drug to consumer advertising. It sells drugs and, guess what? That’s the whole purpose of it.
Dr. Joel Lexchin: We have to recognize that direct to consumer advertising is just that. It’s advertising, it’s not information about the products.
Pence: Dr. Joel Lexchin is Professor of Health Policy at York University and an emergency physician at the University Health Network in Toronto.
Lexchin: Advertising has one main goal, which is to sell products either directly, so if you see an ad for a car or a computer, laundry detergent, or in the case of medications indirectly because it’s the doctor who has to prescribe it. But it’s still advertising.
Pence: And as advertising, Lexchin and Wolfe think it’s prone to be unbalanced.
Lexchin: When the negatives about the product are being mentioned, you don’t see people lying in coffins or in hospital departments, emergency rooms. You see them walking through fields or chatting with their neighbors or, in general, looking like they’re having a pretty good time so you’re getting this list of things, you know, don’t take this product if X or Y, watch out for signs of A and B, ect. ect. But the images that you get on those ads don’t convey the seriousness of the side effects that you may encounter.
Wolfe: Direct to consumer advertising accentuates the positive, the benefits. It doesn’t eliminate but certainly downplays the risk and makes it seem that the drug in balance is much better than it is. And whether it’s that or the Canadian economist Leacock saying that the purpose of advertising is to arrest human intelligence long enough to get money from it, the includes the intelligence of the patients and, I’m afraid, some doctors who don’t really do their homework and they are unduly influenced not just by TV ads but by some of the print ads that they see.
Pence: That’s right. Drug advertising can be so good that Wolfe says some doctors are unduly influenced, perhaps negating some of the gatekeeper function that keeps patients safe.
Wolfe: This kind of scenario is not an exaggerations, I think just a simple way of describing what happens when a patient who has a certain disease sees an ad that makes it appear that this new drug sort of eclipses all the older drugs in terms of benefits and it doesn’t have any risk and they go to the doctor and say, “Say, doc, I saw this ad that really makes this drug really look better.” And the doc will often say, “You know, I saw the ad too and maybe it’s worth trying, let’s try it.” So, the only recipients of direct to consumer advertising are not patients, doctors see them, and to the extent that they’re often misleading, the doctor also gets misled and doctors don’t have as much time as we used to have in the old days to talk with patients. We say, “Oh! Ten minutes, another patient because I’m only getting paid X amount per patient.” The easy way of ending a discussion with a patient that probably should take much longer and includes some education is, “Okay, let’s just try this. I’ll write a prescription for it.”
Pence: Lexchin studied what happens in the doctor’s office when patients ask for a drug by name- tracking one location in Canada, where advertising is banned and one in the US.
Lexchin: When patients requested medications, which they did directly more often in the United States, the doctors in both countries were more likely to exceed to their demands, in other words to issue a prescription for the product that they were requesting. Now this didn’t happen all the time, but it was frequent enough that it was noticeable.
Pence: Now that might not be a problem if the drug is the right one for whatever ails the patient. But Lexchin’s study shows that’s not always the case.
Lexchin: One of the things that we ask the doctors after the encounter was, if you issued a prescription to a patient in response to a request, how confident were you that was the first-line drug for what the patient’s problem actually was? And a fair number of times, the doctor said that they didn’t think that was necessarily the most appropriate thing. So that, as a doctor, that bothers me because I don’t think that people should be getting a prescription for a second-line product if something else is better for them.
Pence: However, other studies are conflicting. John Kamp of the Coalition for Healthcare Communication says one has found that asking for a specific drug can result in more appropriate care.
Kamp: They did a very serious study of DTC and what they found is that in the area of depression, that when patients asked for a drug, they were more likely to get the standard of care. When they didn’t ask for the drug, 52% of the patients who had major depressive symptoms got the standard of care, when they asked for the drug, 90% of patients got the standard of care. They didn’t necessarily get the drug that they asked for or any drug at all, they just got better care because they essentially probed their doctor on what needed to be done and what were the options available to them and how best to treat the problem.
Lexchin: Now I’m not gonna deny that some of the time when people ask for a drug, that turns out to be the right one for them, but I think that far more often what you’re going to see is you’re going to find that doctors are using up the time that they have with patients to tell them why a product that they’re requesting isn’t necessary. That they’re going to have to explain why the doctors think that another particular drug or no drug at all is really the appropriate treatment for the patient.
Pence: Among all the controversies, cost is the AMA’s biggest complaint. They say that all those commercials shift spending to expensive drugs. They say it’s a big reason prescription costs are so high. But is it true?
Shapiro: My research has actually suggested that the first point is overblown, that drug ads actually do increase prescriptions both to expensive brands and to cheap generics. And to the second question, the existing evidence has seemed to have shown that there’s no clear effect of ads on drug prices.
Pence: That’s Dr. Brad Shapiro, Assistant Professor of Marketing at the University of Chicago Booth School of Business.
Shapiro: Before somebody can actually get a drug, they have to get a prescription from a doctor. So if they’re completely convinced by a commercial that they need a particular type of drug, they have to go to the doctor and the doctor might well prescribe them something entirely different that he or she believes is more appropriate. Alternatively, between the time you watch the ad and are convinced, you might actually forget the name of the brand that you saw. So you can think about this through economic theory. One is that the advertising is actually increasing the total pie, that it’s driving more patients to the physician and causing more prescriptions, so that actually increases the incentive for each company to try to compete over these patients, so it might actually produce a little bit of downward price pressure. But secondly, the main effects that most research has found for the effect of advertising on prescriptions is that it’s pretty small, actually. So even if there were a link between ads and prices, it probably wouldn’t be that big.
Pence: Despite all the alleged negatives–and the lobbying muscle of the AMA– Shapiro says direct to consumer ads probably won’t be going anywhere. Kamp, a former constitutional law professor, says a ban would be unconstitutional. Other experts say the FDA could more heavily regulate advertising. But in the years since DTC ads mushroomed, the staff to do that has been reduced. So the deluge of confusing drug ads is likely to continue.
You can find out more about all of our guests on our website, radiohealthjournal.net, where you can also find archives of our programs. They’re also available on iTunes and Stitcher.
I’m Reed Pence.