Direct-to-Consumer Advertising: Is It Too Late to Manage the Risks?

• Drug industry
• prescriptions, drug
• public health
• health education
• primary health care
• physician-patient relations
• marketing, television, consumer health information

Pharmaceutical spending on television commercials nearly doubled from $654 million in 2001 to a staggering $1.19 billion in 2005. Nearly one third of the 2005 spending was on only 1 category: sleep medicines.¹ Yet, sleep disorders, however problematic and serious they may be, are almost inconsequential when compared with the major causes of the death in the United States: cardiovascular disease, cancer, and unintentional injuries.² No matter how much the industry claims its advertising provides public health benefits, the amount spent promoting drugs for conditions of varying severity begs the question of whether the industry truly is acting for the public benefit.

As Frosch et al show in this issue,³ nearly all pharmaceutical ads are based on emotional appeals, not facts, and few provide necessary details about the causes of a medical condition, risk factors, or lifestyle changes that may be appropriate alternatives to pharmaceutical intervention.

Although none of these findings are surprising, they should be disturbing.

As physicians, we know that even the most effective pharmaceutical may not be right for every patient. Physicians consider everything from individual risk factors and medical history to lifestyle and insurance status before writing a prescription. Yet, when patients walk in the door having just seen a television ad showing a miserable allergy sufferer dancing through a weed-filled field, they expect that a simple stroke of a pen onto a prescription pad will solve whatever their problems may be. Patients learn for the first time about conditions they never worried about before and ask physicians for new medicines by trade name because they saw it on television.

Patients have always expected simple answers to complex questions, but direct-to-consumer (DTC) advertising has elevated this problem to new heights, because patients in some ways now rely on Madison Avenue as a provider of health information. There is nothing wrong with pharmaceutical companies communicating directly with consumers, but they should adhere to the standards and ethics of medicine, not the standards and ethics of selling soap or some other consumer product that presents minimal risks.

Pharmaceutical companies like to say that DTC ads make people aware of medical conditions they did not know they had. Industry spokesman Paul Antony told a Senate hearing in 2005, “DTC advertising can be a powerful tool in educating millions of people and improving health.”⁴

Even if health education is true theoretically, it does not appear to be true in practice. Furthermore, one might question the societal benefit should such communications result in millions more people with conditions being diagnosed that are not major factors in morbidity and mortality. There likely would be strong support for pharmaceutical advertising if it led to millions more conditions diagnosed and people being treated for diabetes or heart disease.

What is equally important is the possibility—the likelihood—that consumers who make health decisions based on what they learn from television commercials ultimately take medicines they may not need, spend money on brand medicines that may be no better than alternatives, or avoid healthy behaviors because they falsely think a medicine is all they need.

In general, the ads that consumers see do not contain the right balance of information to provide any meaningful health education. The facts gleaned from DTC ads are minimal at best, which is an unsurprising consequence of condensing decades of research into a 60-second commercial. Moreover, findings from patients’ and physicians’ surveys show that the messages that patients take from DTC ads and into their physicians’ offices are often wrong.⁵ The pharmaceutical companies have done a skillful job of portraying complex medicines in the simplest terms—even if doing so creates inaccurate perceptions in the minds of our patients.

One fact is unquestionable: DTC ads do not effectively or consistently convey important information about product risks and benefits. When the Food and Drug Administration surveyed a sampling of primary care and specialty physicians in 2002, 41% of all physicians said they believed their patients were confused about a drug’s efficacy because of DTC ads they saw; 22% of primary care physicians and 13% of specialists said they felt “somewhat” or “very” pressured to prescribe a drug when a patient requested it.⁶ Even if physicians resist this pressure, the possibility of risk remains.

Under increased scrutiny, major pharmaceutical companies last year announced new advertising guidelines and pledged to portray serious health conditions seriously and to disclose risks, side effects, and warnings adequately.⁷ Although these efforts may be a step in the right direction, physicians, consumers, and policy makers must take further action so that the facts about medicines are not lost in the advertising fog. As Frosch et al correctly point out, the consequences of poor judgments are quite different for drugs than they are for soap.

• Received for publication October 20, 2006.
• Accepted for publication October 23, 2006.

• © 2007 Annals of Family Medicine, Inc.