The Educational Value of Consumer-Targeted Prescription Drug Print Advertising

The appropriateness of direct-to-consumer (DTC) prescription drug advertising has been a topic of heated discussion in recent years.^1,2 This debate is likely to intensify as the drug industry’s advertising expenditures continue to increase^3,4 and the marketing channels employed expand to include television, which may not lend itself to highly informative messages, and the Internet, which is difficult to regulate.⁵ Ironically, DTC advertising proponents and opponents have most often based their positions on assumptions about the informational value of such promotions.⁶ However, empirical data on this issue are sparse.

The opponents of DTC advertising argue that the objectives of drug promotion and health education are inherently at odds.⁷ It has been noted that the aim of DTC advertising is to increase sales, not optimize health care.^8,9 It has been presumed that the profit motive discourages the provision of complete and accurate information about pharmaceuticals.¹⁰ Reports have documented violations of the public trust¹¹ and the dissemination of misleading information to health care professionals.^12,13 If even highly trained physicians are prone to influence by commercial rather than scientific sources of pharmaceutical information,¹⁴ how can consumers protect themselves from misleading claims? To make matters worse, the public may be ill equipped to fully understand such advertising, no matter how accurate its content might be.^7,15

Defenders of DTC advertising counter these arguments by suggesting that selling and educating are not necessarily incompatible goals¹⁶ and that it is in the industry’s self-interest to be truthful with consumers.¹⁷ Although instances of misleading DTC advertising can be identified, such cases are said to be rare.⁵ Proponents of DTC advertising typically attribute greater sophistication to the public than critics do,¹⁶ rejecting the notion that consumers cannot comprehend such advertising.¹⁸ In any regard, misunderstandings can be corrected by the physician, in whom the power to prescribe ultimately resides.¹ Although many physicians oppose DTC advertising, a majority feel that such advertisements might help patients become better informed about drugs,¹⁹ conjecture that has empirical support.²⁰

We have attempted to contribute to the debate on the value of DTC advertising by describing its content. In a recent JFP article,²¹ we documented the types of appeals and inducements used in these promotions. In this article we describe the scope of the educational efforts represented in advertisements appearing in consumer publications from 1989 through 1998. After identifying basic issues that most DTC advertisements should address to have educational merit, we examined the extent to which such promotions provide consumers with information about medical conditions, including their symptoms, precursors, and prevalence. It has been argued that DTC advertising increases the public’s awareness of these aspects of diseases and other health conditions. This kind of patient education is said to help people to take responsibility for their health by teaching them how to recognize disease and motivating them to seek medical attention for conditions that might otherwise be left undiagnosed and untreated.^1,22-24

We then examined the extent to which DTC advertising incorporates information about treatments for those conditions. It has been said that consumer-targeted prescription drug advertising provides the public with valuable information about available treatments that leads to a better match between patients’ needs and available drugs.²⁵ Specifically, we examined the extent to which DTC advertising offers details about promoted drugs’ mechanisms of action, the duration and success of advertised treatments, behavioral modifications that can improve the patient’s health independently or in concert with drug treatment, and competing treatments.

Methods

Sampling Procedure

Major popular magazines were ranked in terms of the average number of advertising pages sold from 1989 through 1996 (the last year for which data were available) and then grouped into an established set of categories.²⁶ The highest-ranked publication within each of 13 categories was selected for inclusion in our sample. To these magazines we added 5 publications with audiences composed of narrower segments of our population defined by ethnicity, age, and sexual orientation. Thus, we garnered our sample of advertisements from 18 diverse publications Table 1. All the advertisements promoting a specific, named prescription drug that appeared in these magazines from January 1989 through December 1998 were photocopied. Advertisements for the same brand often differed in nonsubstantive ways and were thus coded as a single case based on detailed rules that are available from the authors. After aggregating essentially identical advertisements, 320 remained for analysis covering 101 distinct brands.

Medical Conditions Classification

Each advertisement was grouped in one of 14 medical condition categories based on the indication of the marketed drug. The numbers of advertisements and brands within each of these categories were as follows: allergies (46 advertisements, 8 brands); cancer (2, 2); cardiovascular disease (36, 10); dermatologic conditions (37, 12); diabetes (9, 4); gastrointestinal/nutritional disorders (17, 7); human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS; 33, 11); infections, non-HIV (16, 6); musculoskeletal disorders (17, 7); obstetric/gynecologic conditions (45, 10); psychiatric/neurologic disorders (17, 7); respiratory disorders (3, 3); tobacco addiction (23, 6); and urologic conditions (19, 8).

Advertisement Coding

Two coders independently analyzed each advertisement. Our goal for this classification effort was to determine whether each advertisement contained 5 kinds of information pertaining to the focal medical condition and 6 types of drug treatment information Table 2.

Statistical Analyses

We examined each of the 11 education codes listed in Table 2 and computed 3 more general measures. We created a condition information index by summing the number of medical condition codes present within each advertisement (theoretical range=0-5). Likewise, a treatment information index was computed by summing the number of treatment codes present within each advertisement (theoretical range=0-6). A combined education index was created by adding the condition and treatment information variables (theoretical range=0-11).

The reliability of coding was assessed with the k statistic, a measure of inter-rater agreement with a range of 0 to 1.0.²⁷ The mean k value for the variables reported was 0.91 (range=0.88-1.0). Landis and Koch²⁸ suggest that k values in this range can be considered “almost perfect.”

We employed 2 units of analyses. For our descriptive analyses, the advertisement served as the unit of analysis (N=320). We relied on the brand (N=101) as the unit of analysis when computing cross-tabulations and one-way analyses of variance. Using the advertisement as the unit for inferential statistical analyses would have violated the assumption of independence of observations,²⁹ because most advertisements for a particular brand represent alterations of earlier promotions for that brand. The advertisements for each brand were aggregated into a single case by weighting; each advertisement was assigned a weight of 1/n, with n representing the number of advertisements for that brand. When a significant chi-square value was obtained for a cross-tabulation, the source of significance within the table was determined by examining the cell-adjusted standardized residuals using a P <.05 criterion.³⁰

Results

The Figure shows the percentage of advertisements for which the 5 medical condition information codes and 6 treatment information codes were present. These results have been ordered in the Figure on the basis of frequency of occurrence.

Information About Medical Conditions

The medical condition name was provided in virtually all of the advertisements (95%). This information was excluded in 1 “teaser ad” that simply showed a bottle of tablets for a forthcoming treatment, in 7 advertisements alerting patients of a new formulation of a drug already prescribed for them, and in 9 advertisements notifying patients of an alternative delivery system for an established treatment. Sixty percent of the advertisements described at least one symptom of the condition treated by the promoted drug or explicitly stated that the condition could be a “silent disease”. Among those advertisements that omitted symptom information, 54% were targeted to individuals who had already been diagnosed with the condition and were presumably aware of its symptoms. The remaining advertisements tended to be for conditions with well-known symptoms (eg, pregnancy, impotence, and tobacco addiction). Information about a precursor to the condition such as a cause or risk factor was provided in 27% of the advertisements. A total of 6% of advertisements provided precursor information by means of a set of diagnostic questions, such as a quiz that readers could use to assess their risk of being or becoming affected by the condition (data not diagramed). Information about condition prevalence (12% of advertisements) and clarifications about a condition-related misconception (9%) was rarely provided.

Information About Treatments

The Figure also displays the percentage of advertisements reporting each of the 6 types of treatment information. Most often present was information about a drug’s mechanism of action, found in 36% of the advertisements. An acknowledgement of the existence of one or more competing treatments was offered in 29% of the advertisements. Supportive behaviors such as changes in diet, physical activity, and sleeping patterns were reported in 24% of the advertisements. In our judgment, relevant supportive behaviors are often recommended by physicians for most of the conditions addressed in these advertisements. Readers were given information about time to onset of action in 20% of the advertisements and typical required treatment duration in 11%. A success rate estimate was rarely reported (9%).

Three of these treatment information codes were significantly associated with the medical conditions variable (all P values=.02). Supportive behaviors that could be used alone or to enhance the effectiveness of therapy were more likely to be found in diabetes and tobacco cessation treatments (75% and 67% of brands, respectively). Time to onset of action information was especially likely to be offered in advertisements for dermatological and urological problems (58% and 50%, respectively). Information about treatment duration was most often found in advertisements for infection and dermatological treatments (50% and 33%, respectively).

Indexes

For summative purposes we examined the condition information, treatment information, and overall education indexes for each of the 14 medical condition categories, using the drug brand as the unit of analysis. The average brand provided only 2.1 of the 5 types of information about the condition for which the drug was marketed. Only 1.2 of the 6 types of treatment information we coded was provided in the average brand-weighted advertisement. Summing across the condition and treatment information variables, the average number of educational codes present for these 101 brands was only 3.2 out of a possible score of 11 (range=1.0-7.3).

Next we categorized the brands under the medical condition category for which each was promoted Table 3. Despite weak statistical power, a significant difference across the 14 medical conditions was found for 2 of the 3 indexes, the condition information index (F [13,87]=3.05, P=.001) and the combined education index (F [13,87]=2.39, P=.008). On the basis of post hoc comparisons, both effects could be attributed to the greater provision of information in promotions for urologic brands than in HIV/AIDS brand advertisements.

Information Formats

Information about conditions and treatments was typically provided in narrative form. Tabular data or charts (eg, bar, pie, or column charts) were rarely used to provide information about the drug (2% of advertisements) or the medical condition (<1%). Diagrams and pictures were also rarely used to provide information about the effectiveness of the treatment (2% of advertisements) or the nature of the condition (7%).

Other Sources of Information

One view of DTC advertising is that it simply provides an introduction to a treatment and that more detailed patient education is best provided in other ways, such as with brochures and videotaped presentations or through the Internet. An explicit offer of printed or audiovisual information was provided in 35% of the advertisements, and a toll-free information telephone number was found in 73%. Increasingly, the Internet is being used as a means through which interested readers can obtain more information about advertised products. In 1996, 1997, and 1998, the percentages of advertisements that provided a Web site address were 14%, 33%, and 57%, respectively. Most telephone numbers were numeric (55%), but some of these and all Web addresses referenced a benefit of use (eg, 1-800-5-SHUT-EYE for a treatment of insomnia), the treated body part (eg, www.kidsears.com for a treatment of ear infections), the medical condition treated (eg, 1-800-66-ANGINA), the brand name of the drug (eg, www.atrovent.com), or the drug company’s name (eg, 1-800-GLAXO-RX).

Discussion

A time may come when DTC advertising is recommended for its educational value, but that day is not yet at hand. The advertisements that have appeared during the past decade have been superficial in their coverage of medical conditions and their treatments. Although most provide the name of the treated medical condition and its associated symptoms, the large majority do not inform potential patients about such basic matters as the risk factors for the condition or its prevalence. Likewise, these advertisements seldom educate patients about the mechanism of action by which the drug treats a particular condition, its success in doing so, alternative treatments, and behavioral changes that could augment or supplant treatment. To their credit, most of these promotions do offer the reader alternative ways of learning more about their condition and the advertised drug.

The medical community should exert pressure on the drug industry to incorporate more information about conditions and treatments in its advertising. It is in the industry’s best interest to do so. Advertising that incorporates quality health and drug information will have greater credibility, and deservedly so. Also, consumers are less likely to be influenced by messages that appear to be more promotional than informational.³¹ Thus, providing complete and accurate information is the right thing to do and may even enhance the effectiveness of DTC advertising. If such information is not provided voluntarily by the industry in future advertising, the medical establishment should lobby for regulation.

These results also highlight an important opportunity for professional organizations to contribute to consumer education on prescription drugs. According to the National Institute for Health Care Management, the most successfully promoted drugs fall into 5 categories: antidepressants, cholesterol-lowering agents, gastric acid reducers, oral antihistamines, and antihypertensives.³² Organizations such as the American Academy of Family Physicians and the American College of Physicians already produce patient informational materials, but these efforts could be intensified so physicians would have a ready source of “counter-detailing.” Patients requesting drugs for which the indications are questionable could be given a handout and told, “This is what my professional society has to say about _________. This information is produced by the best experts in the field and provides a more balanced view than what you will find in profit-motivated advertisements. Look it over, and let’s talk about this at our next visit.”

If the industry were to be prodded into taking a more educational stance in its consumer-targeted prescription drug advertising, the impact of this shift on physician-patient interactions would need to be investigated. A more educated patient may take less time to treat and counsel, might show greater adherence to treatment regimens, and could assume greater responsibility for his or her health. On the other hand, educational promotions may lead to requests from more determined patients for drugs that are not medically indicated, requiring time-consuming re-education by their physicians.

Limitations

Our study has limitations. We have evaluated the educational qualities of these advertisements by imposing a common set of standards for each promotion. A stronger approach would have been to convene a panel of experts for each of the many conditions treated by the promoted drugs to identify the specific details that consumers need to know about the condition and its treatment. Resource constraints prevented us from developing expert-based educational standards for each condition or disease. However, it is reasonable to expect the drug industry to provide to consumers basic information about the treatments being promoted and the conditions these drugs address. We acknowledge that particular content analytic codes may have been irrelevant to certain conditions. For instance, precursor information does not need to be provided when the causes of the condition are obvious (eg, advertisements for contraceptive drugs); mention of supportive lifestyle changes should not be demanded when helpful behavioral changes do not exist (eg, advertisements for hair loss treatments); and references to the presence of competing treatments should not be expected in the rare event that such treatments are nonexistent. Such exceptions aside, we believe that the 11 codes assessed are both fundamental and relevant to the vast majority of the conditions covered by these advertisements.

Also, with this preliminary investigation we sought only to assess the extent to which the industry is making an effort to provide information about medical conditions and treatments for those conditions. We did not examine the educational quality of these efforts, including the completeness and accuracy of information provided about conditions and treatments. Such assessments will require input from medical and pharmaceutical experts selected for their specialized knowledge.

Conclusions

We acknowledge that instances of informative advertising can readily be found in our sample of advertisements. Thus, although DTC advertising in general is not serving the information needs of consumers, there are companies and individuals within the industry who are motivated to treat their advertising as vehicles for effective health promotion through quality education. Billions of dollars will be spent in the next few years on consumer-targeted prescription drug promotions.⁴ Consumers will be very receptive to those advertisements that address their personal health needs and concerns³³; many will talk to their primary care physicians as a result of these promotions.³⁴ The drug industry thus has a tremendous opportunity to silence its critics and improve the public’s health by providing objective medical and drug information.³⁵

Acknowledgments

We wish to acknowledge the contributions made by Ronald Emerick, Robert LaGreca, Love Lord, and Sarah Shaw in the collection and coding of advertisements and by 2 anonymous peer reviewers for their thoughtful evaluations.

Related Resources:

• U.S. Food & Drug Administration, Center for Drug Evaluation and Research, Division of Drug Marketing, Advertising and Communications www.fda.gov/cder/ddmac/
• Public Citizen Health Research Group “Drugs” page, listing numerous government documents that describe recommendations for drug use, sales and marketing. http://www.citizen.org/hrg/publications/drugs.htm
• AARP Executive Summary: Are Consumers Well Informed About Prescription Drugs? The Impact of Printed Direct-to-Consumer Advertising http://research.aarp.org/health/2000_04_advertising_1.html
• drkoop.com-Perspective: ‘Direct-to-Consumer’ Advertising of Prescription Drugs is More Harmful than Helpful to Consumers www.drkoop.com/news/focus/november/dtc_no.html

The appropriateness of direct-to-consumer (DTC) prescription drug advertising has been a topic of heated discussion in recent years.^1,2 This debate is likely to intensify as the drug industry’s advertising expenditures continue to increase^3,4 and the marketing channels employed expand to include television, which may not lend itself to highly informative messages, and the Internet, which is difficult to regulate.⁵ Ironically, DTC advertising proponents and opponents have most often based their positions on assumptions about the informational value of such promotions.⁶ However, empirical data on this issue are sparse.

The opponents of DTC advertising argue that the objectives of drug promotion and health education are inherently at odds.⁷ It has been noted that the aim of DTC advertising is to increase sales, not optimize health care.^8,9 It has been presumed that the profit motive discourages the provision of complete and accurate information about pharmaceuticals.¹⁰ Reports have documented violations of the public trust¹¹ and the dissemination of misleading information to health care professionals.^12,13 If even highly trained physicians are prone to influence by commercial rather than scientific sources of pharmaceutical information,¹⁴ how can consumers protect themselves from misleading claims? To make matters worse, the public may be ill equipped to fully understand such advertising, no matter how accurate its content might be.^7,15

Defenders of DTC advertising counter these arguments by suggesting that selling and educating are not necessarily incompatible goals¹⁶ and that it is in the industry’s self-interest to be truthful with consumers.¹⁷ Although instances of misleading DTC advertising can be identified, such cases are said to be rare.⁵ Proponents of DTC advertising typically attribute greater sophistication to the public than critics do,¹⁶ rejecting the notion that consumers cannot comprehend such advertising.¹⁸ In any regard, misunderstandings can be corrected by the physician, in whom the power to prescribe ultimately resides.¹ Although many physicians oppose DTC advertising, a majority feel that such advertisements might help patients become better informed about drugs,¹⁹ conjecture that has empirical support.²⁰

We have attempted to contribute to the debate on the value of DTC advertising by describing its content. In a recent JFP article,²¹ we documented the types of appeals and inducements used in these promotions. In this article we describe the scope of the educational efforts represented in advertisements appearing in consumer publications from 1989 through 1998. After identifying basic issues that most DTC advertisements should address to have educational merit, we examined the extent to which such promotions provide consumers with information about medical conditions, including their symptoms, precursors, and prevalence. It has been argued that DTC advertising increases the public’s awareness of these aspects of diseases and other health conditions. This kind of patient education is said to help people to take responsibility for their health by teaching them how to recognize disease and motivating them to seek medical attention for conditions that might otherwise be left undiagnosed and untreated.^1,22-24

We then examined the extent to which DTC advertising incorporates information about treatments for those conditions. It has been said that consumer-targeted prescription drug advertising provides the public with valuable information about available treatments that leads to a better match between patients’ needs and available drugs.²⁵ Specifically, we examined the extent to which DTC advertising offers details about promoted drugs’ mechanisms of action, the duration and success of advertised treatments, behavioral modifications that can improve the patient’s health independently or in concert with drug treatment, and competing treatments.

Methods

Sampling Procedure

Major popular magazines were ranked in terms of the average number of advertising pages sold from 1989 through 1996 (the last year for which data were available) and then grouped into an established set of categories.²⁶ The highest-ranked publication within each of 13 categories was selected for inclusion in our sample. To these magazines we added 5 publications with audiences composed of narrower segments of our population defined by ethnicity, age, and sexual orientation. Thus, we garnered our sample of advertisements from 18 diverse publications Table 1. All the advertisements promoting a specific, named prescription drug that appeared in these magazines from January 1989 through December 1998 were photocopied. Advertisements for the same brand often differed in nonsubstantive ways and were thus coded as a single case based on detailed rules that are available from the authors. After aggregating essentially identical advertisements, 320 remained for analysis covering 101 distinct brands.

Medical Conditions Classification

Each advertisement was grouped in one of 14 medical condition categories based on the indication of the marketed drug. The numbers of advertisements and brands within each of these categories were as follows: allergies (46 advertisements, 8 brands); cancer (2, 2); cardiovascular disease (36, 10); dermatologic conditions (37, 12); diabetes (9, 4); gastrointestinal/nutritional disorders (17, 7); human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS; 33, 11); infections, non-HIV (16, 6); musculoskeletal disorders (17, 7); obstetric/gynecologic conditions (45, 10); psychiatric/neurologic disorders (17, 7); respiratory disorders (3, 3); tobacco addiction (23, 6); and urologic conditions (19, 8).

Advertisement Coding

Two coders independently analyzed each advertisement. Our goal for this classification effort was to determine whether each advertisement contained 5 kinds of information pertaining to the focal medical condition and 6 types of drug treatment information Table 2.

Statistical Analyses

We examined each of the 11 education codes listed in Table 2 and computed 3 more general measures. We created a condition information index by summing the number of medical condition codes present within each advertisement (theoretical range=0-5). Likewise, a treatment information index was computed by summing the number of treatment codes present within each advertisement (theoretical range=0-6). A combined education index was created by adding the condition and treatment information variables (theoretical range=0-11).

The reliability of coding was assessed with the k statistic, a measure of inter-rater agreement with a range of 0 to 1.0.²⁷ The mean k value for the variables reported was 0.91 (range=0.88-1.0). Landis and Koch²⁸ suggest that k values in this range can be considered “almost perfect.”

We employed 2 units of analyses. For our descriptive analyses, the advertisement served as the unit of analysis (N=320). We relied on the brand (N=101) as the unit of analysis when computing cross-tabulations and one-way analyses of variance. Using the advertisement as the unit for inferential statistical analyses would have violated the assumption of independence of observations,²⁹ because most advertisements for a particular brand represent alterations of earlier promotions for that brand. The advertisements for each brand were aggregated into a single case by weighting; each advertisement was assigned a weight of 1/n, with n representing the number of advertisements for that brand. When a significant chi-square value was obtained for a cross-tabulation, the source of significance within the table was determined by examining the cell-adjusted standardized residuals using a P <.05 criterion.³⁰

Results

The Figure shows the percentage of advertisements for which the 5 medical condition information codes and 6 treatment information codes were present. These results have been ordered in the Figure on the basis of frequency of occurrence.

Information About Medical Conditions

The medical condition name was provided in virtually all of the advertisements (95%). This information was excluded in 1 “teaser ad” that simply showed a bottle of tablets for a forthcoming treatment, in 7 advertisements alerting patients of a new formulation of a drug already prescribed for them, and in 9 advertisements notifying patients of an alternative delivery system for an established treatment. Sixty percent of the advertisements described at least one symptom of the condition treated by the promoted drug or explicitly stated that the condition could be a “silent disease”. Among those advertisements that omitted symptom information, 54% were targeted to individuals who had already been diagnosed with the condition and were presumably aware of its symptoms. The remaining advertisements tended to be for conditions with well-known symptoms (eg, pregnancy, impotence, and tobacco addiction). Information about a precursor to the condition such as a cause or risk factor was provided in 27% of the advertisements. A total of 6% of advertisements provided precursor information by means of a set of diagnostic questions, such as a quiz that readers could use to assess their risk of being or becoming affected by the condition (data not diagramed). Information about condition prevalence (12% of advertisements) and clarifications about a condition-related misconception (9%) was rarely provided.

Information About Treatments

The Figure also displays the percentage of advertisements reporting each of the 6 types of treatment information. Most often present was information about a drug’s mechanism of action, found in 36% of the advertisements. An acknowledgement of the existence of one or more competing treatments was offered in 29% of the advertisements. Supportive behaviors such as changes in diet, physical activity, and sleeping patterns were reported in 24% of the advertisements. In our judgment, relevant supportive behaviors are often recommended by physicians for most of the conditions addressed in these advertisements. Readers were given information about time to onset of action in 20% of the advertisements and typical required treatment duration in 11%. A success rate estimate was rarely reported (9%).

Three of these treatment information codes were significantly associated with the medical conditions variable (all P values=.02). Supportive behaviors that could be used alone or to enhance the effectiveness of therapy were more likely to be found in diabetes and tobacco cessation treatments (75% and 67% of brands, respectively). Time to onset of action information was especially likely to be offered in advertisements for dermatological and urological problems (58% and 50%, respectively). Information about treatment duration was most often found in advertisements for infection and dermatological treatments (50% and 33%, respectively).

Indexes

For summative purposes we examined the condition information, treatment information, and overall education indexes for each of the 14 medical condition categories, using the drug brand as the unit of analysis. The average brand provided only 2.1 of the 5 types of information about the condition for which the drug was marketed. Only 1.2 of the 6 types of treatment information we coded was provided in the average brand-weighted advertisement. Summing across the condition and treatment information variables, the average number of educational codes present for these 101 brands was only 3.2 out of a possible score of 11 (range=1.0-7.3).

Next we categorized the brands under the medical condition category for which each was promoted Table 3. Despite weak statistical power, a significant difference across the 14 medical conditions was found for 2 of the 3 indexes, the condition information index (F [13,87]=3.05, P=.001) and the combined education index (F [13,87]=2.39, P=.008). On the basis of post hoc comparisons, both effects could be attributed to the greater provision of information in promotions for urologic brands than in HIV/AIDS brand advertisements.

Information Formats

Information about conditions and treatments was typically provided in narrative form. Tabular data or charts (eg, bar, pie, or column charts) were rarely used to provide information about the drug (2% of advertisements) or the medical condition (<1%). Diagrams and pictures were also rarely used to provide information about the effectiveness of the treatment (2% of advertisements) or the nature of the condition (7%).

Other Sources of Information

One view of DTC advertising is that it simply provides an introduction to a treatment and that more detailed patient education is best provided in other ways, such as with brochures and videotaped presentations or through the Internet. An explicit offer of printed or audiovisual information was provided in 35% of the advertisements, and a toll-free information telephone number was found in 73%. Increasingly, the Internet is being used as a means through which interested readers can obtain more information about advertised products. In 1996, 1997, and 1998, the percentages of advertisements that provided a Web site address were 14%, 33%, and 57%, respectively. Most telephone numbers were numeric (55%), but some of these and all Web addresses referenced a benefit of use (eg, 1-800-5-SHUT-EYE for a treatment of insomnia), the treated body part (eg, www.kidsears.com for a treatment of ear infections), the medical condition treated (eg, 1-800-66-ANGINA), the brand name of the drug (eg, www.atrovent.com), or the drug company’s name (eg, 1-800-GLAXO-RX).

Discussion

A time may come when DTC advertising is recommended for its educational value, but that day is not yet at hand. The advertisements that have appeared during the past decade have been superficial in their coverage of medical conditions and their treatments. Although most provide the name of the treated medical condition and its associated symptoms, the large majority do not inform potential patients about such basic matters as the risk factors for the condition or its prevalence. Likewise, these advertisements seldom educate patients about the mechanism of action by which the drug treats a particular condition, its success in doing so, alternative treatments, and behavioral changes that could augment or supplant treatment. To their credit, most of these promotions do offer the reader alternative ways of learning more about their condition and the advertised drug.

The medical community should exert pressure on the drug industry to incorporate more information about conditions and treatments in its advertising. It is in the industry’s best interest to do so. Advertising that incorporates quality health and drug information will have greater credibility, and deservedly so. Also, consumers are less likely to be influenced by messages that appear to be more promotional than informational.³¹ Thus, providing complete and accurate information is the right thing to do and may even enhance the effectiveness of DTC advertising. If such information is not provided voluntarily by the industry in future advertising, the medical establishment should lobby for regulation.

These results also highlight an important opportunity for professional organizations to contribute to consumer education on prescription drugs. According to the National Institute for Health Care Management, the most successfully promoted drugs fall into 5 categories: antidepressants, cholesterol-lowering agents, gastric acid reducers, oral antihistamines, and antihypertensives.³² Organizations such as the American Academy of Family Physicians and the American College of Physicians already produce patient informational materials, but these efforts could be intensified so physicians would have a ready source of “counter-detailing.” Patients requesting drugs for which the indications are questionable could be given a handout and told, “This is what my professional society has to say about _________. This information is produced by the best experts in the field and provides a more balanced view than what you will find in profit-motivated advertisements. Look it over, and let’s talk about this at our next visit.”

If the industry were to be prodded into taking a more educational stance in its consumer-targeted prescription drug advertising, the impact of this shift on physician-patient interactions would need to be investigated. A more educated patient may take less time to treat and counsel, might show greater adherence to treatment regimens, and could assume greater responsibility for his or her health. On the other hand, educational promotions may lead to requests from more determined patients for drugs that are not medically indicated, requiring time-consuming re-education by their physicians.

Limitations

Our study has limitations. We have evaluated the educational qualities of these advertisements by imposing a common set of standards for each promotion. A stronger approach would have been to convene a panel of experts for each of the many conditions treated by the promoted drugs to identify the specific details that consumers need to know about the condition and its treatment. Resource constraints prevented us from developing expert-based educational standards for each condition or disease. However, it is reasonable to expect the drug industry to provide to consumers basic information about the treatments being promoted and the conditions these drugs address. We acknowledge that particular content analytic codes may have been irrelevant to certain conditions. For instance, precursor information does not need to be provided when the causes of the condition are obvious (eg, advertisements for contraceptive drugs); mention of supportive lifestyle changes should not be demanded when helpful behavioral changes do not exist (eg, advertisements for hair loss treatments); and references to the presence of competing treatments should not be expected in the rare event that such treatments are nonexistent. Such exceptions aside, we believe that the 11 codes assessed are both fundamental and relevant to the vast majority of the conditions covered by these advertisements.

Also, with this preliminary investigation we sought only to assess the extent to which the industry is making an effort to provide information about medical conditions and treatments for those conditions. We did not examine the educational quality of these efforts, including the completeness and accuracy of information provided about conditions and treatments. Such assessments will require input from medical and pharmaceutical experts selected for their specialized knowledge.

Conclusions

We acknowledge that instances of informative advertising can readily be found in our sample of advertisements. Thus, although DTC advertising in general is not serving the information needs of consumers, there are companies and individuals within the industry who are motivated to treat their advertising as vehicles for effective health promotion through quality education. Billions of dollars will be spent in the next few years on consumer-targeted prescription drug promotions.⁴ Consumers will be very receptive to those advertisements that address their personal health needs and concerns³³; many will talk to their primary care physicians as a result of these promotions.³⁴ The drug industry thus has a tremendous opportunity to silence its critics and improve the public’s health by providing objective medical and drug information.³⁵

Acknowledgments

We wish to acknowledge the contributions made by Ronald Emerick, Robert LaGreca, Love Lord, and Sarah Shaw in the collection and coding of advertisements and by 2 anonymous peer reviewers for their thoughtful evaluations.

Related Resources:

• U.S. Food & Drug Administration, Center for Drug Evaluation and Research, Division of Drug Marketing, Advertising and Communications www.fda.gov/cder/ddmac/
• Public Citizen Health Research Group “Drugs” page, listing numerous government documents that describe recommendations for drug use, sales and marketing. http://www.citizen.org/hrg/publications/drugs.htm
• AARP Executive Summary: Are Consumers Well Informed About Prescription Drugs? The Impact of Printed Direct-to-Consumer Advertising http://research.aarp.org/health/2000_04_advertising_1.html
• drkoop.com-Perspective: ‘Direct-to-Consumer’ Advertising of Prescription Drugs is More Harmful than Helpful to Consumers www.drkoop.com/news/focus/november/dtc_no.html

The appropriateness of direct-to-consumer (DTC) prescription drug advertising has been a topic of heated discussion in recent years.^1,2 This debate is likely to intensify as the drug industry’s advertising expenditures continue to increase^3,4 and the marketing channels employed expand to include television, which may not lend itself to highly informative messages, and the Internet, which is difficult to regulate.⁵ Ironically, DTC advertising proponents and opponents have most often based their positions on assumptions about the informational value of such promotions.⁶ However, empirical data on this issue are sparse.

The opponents of DTC advertising argue that the objectives of drug promotion and health education are inherently at odds.⁷ It has been noted that the aim of DTC advertising is to increase sales, not optimize health care.^8,9 It has been presumed that the profit motive discourages the provision of complete and accurate information about pharmaceuticals.¹⁰ Reports have documented violations of the public trust¹¹ and the dissemination of misleading information to health care professionals.^12,13 If even highly trained physicians are prone to influence by commercial rather than scientific sources of pharmaceutical information,¹⁴ how can consumers protect themselves from misleading claims? To make matters worse, the public may be ill equipped to fully understand such advertising, no matter how accurate its content might be.^7,15

Defenders of DTC advertising counter these arguments by suggesting that selling and educating are not necessarily incompatible goals¹⁶ and that it is in the industry’s self-interest to be truthful with consumers.¹⁷ Although instances of misleading DTC advertising can be identified, such cases are said to be rare.⁵ Proponents of DTC advertising typically attribute greater sophistication to the public than critics do,¹⁶ rejecting the notion that consumers cannot comprehend such advertising.¹⁸ In any regard, misunderstandings can be corrected by the physician, in whom the power to prescribe ultimately resides.¹ Although many physicians oppose DTC advertising, a majority feel that such advertisements might help patients become better informed about drugs,¹⁹ conjecture that has empirical support.²⁰

We have attempted to contribute to the debate on the value of DTC advertising by describing its content. In a recent JFP article,²¹ we documented the types of appeals and inducements used in these promotions. In this article we describe the scope of the educational efforts represented in advertisements appearing in consumer publications from 1989 through 1998. After identifying basic issues that most DTC advertisements should address to have educational merit, we examined the extent to which such promotions provide consumers with information about medical conditions, including their symptoms, precursors, and prevalence. It has been argued that DTC advertising increases the public’s awareness of these aspects of diseases and other health conditions. This kind of patient education is said to help people to take responsibility for their health by teaching them how to recognize disease and motivating them to seek medical attention for conditions that might otherwise be left undiagnosed and untreated.^1,22-24

We then examined the extent to which DTC advertising incorporates information about treatments for those conditions. It has been said that consumer-targeted prescription drug advertising provides the public with valuable information about available treatments that leads to a better match between patients’ needs and available drugs.²⁵ Specifically, we examined the extent to which DTC advertising offers details about promoted drugs’ mechanisms of action, the duration and success of advertised treatments, behavioral modifications that can improve the patient’s health independently or in concert with drug treatment, and competing treatments.

Methods

Sampling Procedure

Major popular magazines were ranked in terms of the average number of advertising pages sold from 1989 through 1996 (the last year for which data were available) and then grouped into an established set of categories.²⁶ The highest-ranked publication within each of 13 categories was selected for inclusion in our sample. To these magazines we added 5 publications with audiences composed of narrower segments of our population defined by ethnicity, age, and sexual orientation. Thus, we garnered our sample of advertisements from 18 diverse publications Table 1. All the advertisements promoting a specific, named prescription drug that appeared in these magazines from January 1989 through December 1998 were photocopied. Advertisements for the same brand often differed in nonsubstantive ways and were thus coded as a single case based on detailed rules that are available from the authors. After aggregating essentially identical advertisements, 320 remained for analysis covering 101 distinct brands.

Medical Conditions Classification

Each advertisement was grouped in one of 14 medical condition categories based on the indication of the marketed drug. The numbers of advertisements and brands within each of these categories were as follows: allergies (46 advertisements, 8 brands); cancer (2, 2); cardiovascular disease (36, 10); dermatologic conditions (37, 12); diabetes (9, 4); gastrointestinal/nutritional disorders (17, 7); human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS; 33, 11); infections, non-HIV (16, 6); musculoskeletal disorders (17, 7); obstetric/gynecologic conditions (45, 10); psychiatric/neurologic disorders (17, 7); respiratory disorders (3, 3); tobacco addiction (23, 6); and urologic conditions (19, 8).

Advertisement Coding

Two coders independently analyzed each advertisement. Our goal for this classification effort was to determine whether each advertisement contained 5 kinds of information pertaining to the focal medical condition and 6 types of drug treatment information Table 2.

Statistical Analyses

We examined each of the 11 education codes listed in Table 2 and computed 3 more general measures. We created a condition information index by summing the number of medical condition codes present within each advertisement (theoretical range=0-5). Likewise, a treatment information index was computed by summing the number of treatment codes present within each advertisement (theoretical range=0-6). A combined education index was created by adding the condition and treatment information variables (theoretical range=0-11).

The reliability of coding was assessed with the k statistic, a measure of inter-rater agreement with a range of 0 to 1.0.²⁷ The mean k value for the variables reported was 0.91 (range=0.88-1.0). Landis and Koch²⁸ suggest that k values in this range can be considered “almost perfect.”

We employed 2 units of analyses. For our descriptive analyses, the advertisement served as the unit of analysis (N=320). We relied on the brand (N=101) as the unit of analysis when computing cross-tabulations and one-way analyses of variance. Using the advertisement as the unit for inferential statistical analyses would have violated the assumption of independence of observations,²⁹ because most advertisements for a particular brand represent alterations of earlier promotions for that brand. The advertisements for each brand were aggregated into a single case by weighting; each advertisement was assigned a weight of 1/n, with n representing the number of advertisements for that brand. When a significant chi-square value was obtained for a cross-tabulation, the source of significance within the table was determined by examining the cell-adjusted standardized residuals using a P <.05 criterion.³⁰

Results

The Figure shows the percentage of advertisements for which the 5 medical condition information codes and 6 treatment information codes were present. These results have been ordered in the Figure on the basis of frequency of occurrence.

Information About Medical Conditions

The medical condition name was provided in virtually all of the advertisements (95%). This information was excluded in 1 “teaser ad” that simply showed a bottle of tablets for a forthcoming treatment, in 7 advertisements alerting patients of a new formulation of a drug already prescribed for them, and in 9 advertisements notifying patients of an alternative delivery system for an established treatment. Sixty percent of the advertisements described at least one symptom of the condition treated by the promoted drug or explicitly stated that the condition could be a “silent disease”. Among those advertisements that omitted symptom information, 54% were targeted to individuals who had already been diagnosed with the condition and were presumably aware of its symptoms. The remaining advertisements tended to be for conditions with well-known symptoms (eg, pregnancy, impotence, and tobacco addiction). Information about a precursor to the condition such as a cause or risk factor was provided in 27% of the advertisements. A total of 6% of advertisements provided precursor information by means of a set of diagnostic questions, such as a quiz that readers could use to assess their risk of being or becoming affected by the condition (data not diagramed). Information about condition prevalence (12% of advertisements) and clarifications about a condition-related misconception (9%) was rarely provided.

Information About Treatments

The Figure also displays the percentage of advertisements reporting each of the 6 types of treatment information. Most often present was information about a drug’s mechanism of action, found in 36% of the advertisements. An acknowledgement of the existence of one or more competing treatments was offered in 29% of the advertisements. Supportive behaviors such as changes in diet, physical activity, and sleeping patterns were reported in 24% of the advertisements. In our judgment, relevant supportive behaviors are often recommended by physicians for most of the conditions addressed in these advertisements. Readers were given information about time to onset of action in 20% of the advertisements and typical required treatment duration in 11%. A success rate estimate was rarely reported (9%).

Three of these treatment information codes were significantly associated with the medical conditions variable (all P values=.02). Supportive behaviors that could be used alone or to enhance the effectiveness of therapy were more likely to be found in diabetes and tobacco cessation treatments (75% and 67% of brands, respectively). Time to onset of action information was especially likely to be offered in advertisements for dermatological and urological problems (58% and 50%, respectively). Information about treatment duration was most often found in advertisements for infection and dermatological treatments (50% and 33%, respectively).

Indexes

For summative purposes we examined the condition information, treatment information, and overall education indexes for each of the 14 medical condition categories, using the drug brand as the unit of analysis. The average brand provided only 2.1 of the 5 types of information about the condition for which the drug was marketed. Only 1.2 of the 6 types of treatment information we coded was provided in the average brand-weighted advertisement. Summing across the condition and treatment information variables, the average number of educational codes present for these 101 brands was only 3.2 out of a possible score of 11 (range=1.0-7.3).

Next we categorized the brands under the medical condition category for which each was promoted Table 3. Despite weak statistical power, a significant difference across the 14 medical conditions was found for 2 of the 3 indexes, the condition information index (F [13,87]=3.05, P=.001) and the combined education index (F [13,87]=2.39, P=.008). On the basis of post hoc comparisons, both effects could be attributed to the greater provision of information in promotions for urologic brands than in HIV/AIDS brand advertisements.

Information Formats

Information about conditions and treatments was typically provided in narrative form. Tabular data or charts (eg, bar, pie, or column charts) were rarely used to provide information about the drug (2% of advertisements) or the medical condition (<1%). Diagrams and pictures were also rarely used to provide information about the effectiveness of the treatment (2% of advertisements) or the nature of the condition (7%).

Other Sources of Information

One view of DTC advertising is that it simply provides an introduction to a treatment and that more detailed patient education is best provided in other ways, such as with brochures and videotaped presentations or through the Internet. An explicit offer of printed or audiovisual information was provided in 35% of the advertisements, and a toll-free information telephone number was found in 73%. Increasingly, the Internet is being used as a means through which interested readers can obtain more information about advertised products. In 1996, 1997, and 1998, the percentages of advertisements that provided a Web site address were 14%, 33%, and 57%, respectively. Most telephone numbers were numeric (55%), but some of these and all Web addresses referenced a benefit of use (eg, 1-800-5-SHUT-EYE for a treatment of insomnia), the treated body part (eg, www.kidsears.com for a treatment of ear infections), the medical condition treated (eg, 1-800-66-ANGINA), the brand name of the drug (eg, www.atrovent.com), or the drug company’s name (eg, 1-800-GLAXO-RX).

Discussion

A time may come when DTC advertising is recommended for its educational value, but that day is not yet at hand. The advertisements that have appeared during the past decade have been superficial in their coverage of medical conditions and their treatments. Although most provide the name of the treated medical condition and its associated symptoms, the large majority do not inform potential patients about such basic matters as the risk factors for the condition or its prevalence. Likewise, these advertisements seldom educate patients about the mechanism of action by which the drug treats a particular condition, its success in doing so, alternative treatments, and behavioral changes that could augment or supplant treatment. To their credit, most of these promotions do offer the reader alternative ways of learning more about their condition and the advertised drug.

The medical community should exert pressure on the drug industry to incorporate more information about conditions and treatments in its advertising. It is in the industry’s best interest to do so. Advertising that incorporates quality health and drug information will have greater credibility, and deservedly so. Also, consumers are less likely to be influenced by messages that appear to be more promotional than informational.³¹ Thus, providing complete and accurate information is the right thing to do and may even enhance the effectiveness of DTC advertising. If such information is not provided voluntarily by the industry in future advertising, the medical establishment should lobby for regulation.

These results also highlight an important opportunity for professional organizations to contribute to consumer education on prescription drugs. According to the National Institute for Health Care Management, the most successfully promoted drugs fall into 5 categories: antidepressants, cholesterol-lowering agents, gastric acid reducers, oral antihistamines, and antihypertensives.³² Organizations such as the American Academy of Family Physicians and the American College of Physicians already produce patient informational materials, but these efforts could be intensified so physicians would have a ready source of “counter-detailing.” Patients requesting drugs for which the indications are questionable could be given a handout and told, “This is what my professional society has to say about _________. This information is produced by the best experts in the field and provides a more balanced view than what you will find in profit-motivated advertisements. Look it over, and let’s talk about this at our next visit.”

If the industry were to be prodded into taking a more educational stance in its consumer-targeted prescription drug advertising, the impact of this shift on physician-patient interactions would need to be investigated. A more educated patient may take less time to treat and counsel, might show greater adherence to treatment regimens, and could assume greater responsibility for his or her health. On the other hand, educational promotions may lead to requests from more determined patients for drugs that are not medically indicated, requiring time-consuming re-education by their physicians.

Limitations

Our study has limitations. We have evaluated the educational qualities of these advertisements by imposing a common set of standards for each promotion. A stronger approach would have been to convene a panel of experts for each of the many conditions treated by the promoted drugs to identify the specific details that consumers need to know about the condition and its treatment. Resource constraints prevented us from developing expert-based educational standards for each condition or disease. However, it is reasonable to expect the drug industry to provide to consumers basic information about the treatments being promoted and the conditions these drugs address. We acknowledge that particular content analytic codes may have been irrelevant to certain conditions. For instance, precursor information does not need to be provided when the causes of the condition are obvious (eg, advertisements for contraceptive drugs); mention of supportive lifestyle changes should not be demanded when helpful behavioral changes do not exist (eg, advertisements for hair loss treatments); and references to the presence of competing treatments should not be expected in the rare event that such treatments are nonexistent. Such exceptions aside, we believe that the 11 codes assessed are both fundamental and relevant to the vast majority of the conditions covered by these advertisements.

Also, with this preliminary investigation we sought only to assess the extent to which the industry is making an effort to provide information about medical conditions and treatments for those conditions. We did not examine the educational quality of these efforts, including the completeness and accuracy of information provided about conditions and treatments. Such assessments will require input from medical and pharmaceutical experts selected for their specialized knowledge.

Conclusions

We acknowledge that instances of informative advertising can readily be found in our sample of advertisements. Thus, although DTC advertising in general is not serving the information needs of consumers, there are companies and individuals within the industry who are motivated to treat their advertising as vehicles for effective health promotion through quality education. Billions of dollars will be spent in the next few years on consumer-targeted prescription drug promotions.⁴ Consumers will be very receptive to those advertisements that address their personal health needs and concerns³³; many will talk to their primary care physicians as a result of these promotions.³⁴ The drug industry thus has a tremendous opportunity to silence its critics and improve the public’s health by providing objective medical and drug information.³⁵

Acknowledgments

We wish to acknowledge the contributions made by Ronald Emerick, Robert LaGreca, Love Lord, and Sarah Shaw in the collection and coding of advertisements and by 2 anonymous peer reviewers for their thoughtful evaluations.

Related Resources:

• U.S. Food & Drug Administration, Center for Drug Evaluation and Research, Division of Drug Marketing, Advertising and Communications www.fda.gov/cder/ddmac/
• Public Citizen Health Research Group “Drugs” page, listing numerous government documents that describe recommendations for drug use, sales and marketing. http://www.citizen.org/hrg/publications/drugs.htm
• AARP Executive Summary: Are Consumers Well Informed About Prescription Drugs? The Impact of Printed Direct-to-Consumer Advertising http://research.aarp.org/health/2000_04_advertising_1.html
• drkoop.com-Perspective: ‘Direct-to-Consumer’ Advertising of Prescription Drugs is More Harmful than Helpful to Consumers www.drkoop.com/news/focus/november/dtc_no.html