What are the public health effects of direct-to-consumer drug advertising?

Exploring medicine classification and accessibility: a qualitative study

Background

Brunei Darussalam's medicine control governance landscape is complex, driven by legislative directives and directed by the Brunei Darussalam Medicines Control Authority (BDMCA). While the medicine dispensing system in Brunei Darussalam, across both governmental and private sectors, is a critical component of the nation's healthcare, it remains under-researched, leaving gaps in understanding its distinctions, challenges, and opportunities. This study aimed to explore deep into the perspectives of pharmacists regarding the medicine dispensing systems in Brunei Darussalam, medicine accessibility, the classification and regulation of medicines, and the growing role of pharmacists.

Methods

Using a narrative qualitative approach, we conducted in-depth one-on-one interviews with six pharmacists, delving into their personal experiences with topics such as medicine classification and the broader systems for medication provision. The collected narratives were analysed through a rigorous thematic analysis, following the framework established by Braun & Clarke.

Results

Five themes emerged from the data: nuances of Brunei Darussalam's medicine dispensing landscape across both public and private sectors; accessibility and regulatory framework of medicines both in Brunei Darussalam and abroad; prospective implementations to enhance the current system; and the evolving role and expectations of pharmacists in the current healthcare environment. Notably, a significant contribution of this study was the illumination of the differential perspectives between pharmacists operating in governmental versus private contexts.

Conclusion

This study sheds light on the previously under-explored domain of Brunei Darussalam's medicine control governance and medicine dispensing system. By drawing from the first-hand experiences of practicing pharmacists, it offers actionable insights that could guide future policy developments, optimise medicine dispensation and regulation, and shape the evolving role of pharmacists in Brunei Darussalam.

Stakeholder analysis of banning unhealthy product advertisement in Iran

BACKGROUND

The advertising of unhealthy products, including unhealthy foods, drugs with abuse potential, certain cosmetic products and services, and tobacco, has raised significant public health concerns due to its role in increasing consumption and contributing to the rise of non-communicable diseases. Policy development and enforcement in this area necessitate an in-depth analysis of the relevant stakeholders. This study aims to examine the stakeholders involved in regulating the advertisement of unhealthy products in Iran, providing critical evidence for shaping advertising regulations and reducing the societal consumption of such products.

METHODS

This qualitative study, conducted in 2022, involved 18 experts experienced in the area of unhealthy product advertisement in Iran. Participants were selected through purposive and snowball sampling methods. The stakeholders' roles, power, positions, and interests were analyzed using Schmeer's guidelines.

RESULTS

17 stakeholders were identified as relevant to the ban on unhealthy product advertisements, of whom 14 were classified as active and three as inactive. Key stakeholders included radio and television broadcasters, the Ministries of Health, Culture, and Industry, as well as political institutions. The Ministry of Health (MOHME) emerged as a leading advocate for the ban, while the Ministries of Culture and Industry, along with political institutions, were identified as possessing significant power with moderate support for the policy. In contrast, broadcasters and social media platforms were powerful opponents of the ban.

CONCLUSIONS

The study underscores the pivotal role of stakeholders with high power and medium interest in the success of policies aimed at banning unhealthy product advertisements. Key challenges included conflicts of interest, insufficient penalties for organizations violating advertising regulations, organizational disputes, limited human and financial resources, lack of clear implementation guidelines, weak community engagement, and inadequate oversight. Engaging key stakeholders effectively could mitigate these obstacles and facilitate more effective health policy interventions in the future.

Laypersons' understanding of statistical concepts commonly used in prescription drug promotion: A review of the research literature

BACKGROUND

The prevalence of direct-to-consumer (DTC) advertising for prescription drugs has led to concerns about how consumers interpret the medical information conveyed in these ads. One strategy for improving lay understanding of medical information involves incorporating quantitative information about a treatment's potential benefits and risks.

OBJECTIVE

This literature review investigates laypersons' interpretations of statistical concepts, expanding on past reviews and including terms that may be used in DTC prescription drug advertising.

METHODS

We searched six databases for articles published from January 2000 to October 2021. Articles were included if they were in English and examined general or lay audiences' comprehension of quantitative or statistical concepts, without limiting the context of the studies to medical situations.

RESULTS

We identified 25 eligible articles. The evidence suggests that likelihood ratios, odds ratios, probabilities, numbers needed to treat/harm, and confidence intervals hinder comprehension of quantitative information. The results are mixed for information presented as frequencies, percentages, absolute risk reduction, and relative risk reduction. The mixed findings could be due to numeracy, framing as risks or benefits, and operationalization of the outcomes. We found no studies examining interpretations of minimum, maximum, central tendency, power, statistical significance, or hazard ratio.

CONCLUSION

Studies spanning several decades have examined how laypeople interpret statistical concepts. While a few terms are consistently studied, many questions still remain on how to make risk information more understandable to lay audiences, particularly those with low numeracy.

Exploring Therapeutic Digestive Enzyme Landscape in India: Current Evidence, Profit Motives, Regulations, and Future Perspectives

This analysis critically examines the profit-driven marketing of digestive enzymes as over-the-counter (OTC) supplements in the context of India, expressing ethical concerns regarding pharmaceutical companies prioritizing financial gain over genuine public health needs within the lucrative OTC supplement market. The review delves into various enzymes, their mechanisms of action, uses, adverse drug reactions, and provides evidence from various studies. The research method involves the exploration of profit-driven strategies employed by pharmaceutical companies, addressing regulatory challenges, investigating the gap between dietary supplements and pharmaceutical drugs, and emphasizing the impact of direct-to-consumer advertising on self-diagnosis and overuse. Additionally, the study reviews various e-pharmacy platforms in India, assessing formulations and pricing. Key findings highlight the diverse formulations on these platforms, exposing insights into cost variations and indicating a regulatory gap that necessitates a comprehensive re-evaluation by Indian and international authorities. The analysis emphasizes the influence of direct-to-consumer advertising on behavior and potential health risks, raising ethical concerns about oversimplified health claims that overlook the necessity for individualized treatment plans. In conclusion, the study underscores the ethical complexity of prioritizing profit over public health and advocates for regulatory re-evaluation, exploring broader implications such as cultural influences and alternative therapies. The evolving landscape, featuring plant-based and microbe-derived alternatives, is presented as transformative, particularly in conditions like celiac disease.

Maintaining a Fair Balance? Narrative and Non-Narrative Strategies in Televised Direct-to-Consumer Advertisements for Prescription Drugs Aired in the United States, 2003-2016

Televised direct-to-consumer advertising for prescription drugs (hereafter DTCA) are among the most widespread forms of health communication encountered by American adults. DTCA shape public understanding of health problems and support the commercial interests of pharmaceutical companies by offering prescription drugs as a treatment option. The U.S. Food and Drug Administration (FDA) requires DTCA to present fair and balanced information regarding drug benefits versus risks. While narrative persuasion theory suggests that narratives can enhance persuasion by facilitating message processing and reducing counter-arguing, prior assessments of the balance between drug benefits versus risk information in DTCA have largely overlooked whether the ads employ narratives and/or other evidentiary strategies that may confer a persuasive advantage. This study content analyzed narrativity in DTCA aired on television between 2003 and 2016 for four different health conditions (heart disease, diabetes, depression, and osteoarthritis). Results showed that while televised DTCA spent more time discussing drug risks than drug benefits, both narratives and factual evidence were more frequently used to communicate drug benefits than drug risks. These findings raise concerns that narratives are strategically used by DTCA to highlight drug benefits rather than drug risks, which could lead to inaccurate perceptions of drug risks among viewers.

Constructing the Gendered Risk of Illness in Lyrica Ads for Fibromyalgia: Fear of Isolation as a Motivating Narrative for Consumer Demand

Direct-to-consumer television advertisements for Lyrica in the United States create narratives of gendered domestic normalcy to which women with fibromyalgia are encouraged to aspire through pharmaceutical intervention. This paper unpacks images and narratives within these advertisements to demonstrate that they rely on metaphors that represent gendered expectations in order to evoke guilt and provoke a desire for what Joseph Dumit calls "health as risk reduction," and what I argue is an attempt to show disability being erased. Following Stuart Hall's Encoding/Decoding model of communication, viewers play a role in constructing societal expectations for women with chronic pain and for themselves.

The Use of Direct-to-Consumer (DTC) Pharmaceutical Advertisements in Televised and Print Formats as a Teaching Tool in a Pharmacy Curriculum

The overall goal of this study was to employ direct-to-consumer advertisements (DTCAs) as a teaching tool in a Doctor of Pharmacy (PharmD) curriculum. The objectives of this pilot study were to investigate the following questions: 1. Do DTCAs generate student curiosity about the advertised drug and associated disease? 2. Can DTCAs help students understand and reinforce various pharmacological aspects of the drug? 3. How do students perceive DTCAs? A DTCA-based teaching tool was employed in a pharmacology course taken by P2 (second professional year) PharmD and final year (U4) Bachelor of Science (BS) in Pharmacology–Toxicology students. A voluntary online survey was administered to students to determine the effectiveness of this tool. Survey data were analyzed quantitatively and qualitatively. 70–85% of responding students indicated that this teaching tool was an effective visual aid for learning pharmacology and correlating the drug to disease state, mechanism of action, and adverse effects. Moreover, themes identified from the qualitative analysis suggest that this teaching tool may be useful to enhance patient counseling skills in students. The initial implementation of this DTCA-based teaching tool proved to be successful, and a similar approach can be easily implemented in other pharmacotherapy and laboratory courses. Further studies are needed to determine if this approach can improve patient counseling skills.

Use of High-Dose Influenza and Live Attenuated Influenza Vaccines by US Primary Care Physicians

BACKGROUND

Several different types of influenza vaccine are licensed for use in adults in the USA including high-dose inactivated influenza vaccine (HD-IIV) and live attenuated influenza vaccine (LAIV). HD-IIV is licensed for use in adults ≥ 65 years, and recommendations for use of LAIV have changed several times in recent years.

OBJECTIVE

We sought to examine family physicians' (FPs) and general internal medicine physicians' (GIMs) perceptions, knowledge, and practices for use of HD-IIV and LAIV during the 2016-2017 and 2018-2019 influenza seasons.

DESIGN

E-mail and mail surveys conducted February-March 2017, January-February 2019.

PARTICIPANTS

Nationally representative samples of FPs and GIMs.

MAIN MEASURES

Surveys assessed HD-IIV practices (2017), knowledge and perceptions (2019), and LAIV knowledge and practices (2017, 2019).

KEY RESULTS

Response rates were 67% (620/930) in 2017 and 69% (642/926) in 2019. Many physicians believed HD-IIV is more effective than standard dose IIV in patients ≥ 65 years (76%) and reported their patients ≥ 65 years believe they need HD-IIV (67%). Most respondents incorrectly thought ACIP preferentially recommends HD-IIV for adults ≥ 65 years (88%); 65% "almost always/always" recommended HD-IIV for adults ≥ 65 years. Some physicians incorrectly thought ACIP preferentially recommends HD-IIV for adults < 65 years with cardiopulmonary disease (38%) or immunosuppression (48%); some respondents recommended HD-IIV for these groups (25% and 28% respectively). In 2017, 88% of respondents knew that ACIP recommended against using LAIV during the 2016-2017 influenza season, and 4% recommended LAIV to patients. In 2019, 63% knew that ACIP recommended that LAIV could be used during the 2018-2019 influenza season, and 8% recommended LAIV.

CONCLUSIONS

Many physicians incorrectly thought ACIP had preferential recommendations for HD-IIV. Physicians should be encouraged to use any available age-appropriate influenza vaccine to optimize influenza vaccination particularly among older adults and patients with chronic conditions who are more vulnerable to severe influenza disease.

PrEP4Love: The Role of Messaging and Prevention Advocacy in PrEP Attitudes, Perceptions, and Uptake Among YMSM and Transgender Women

BACKGROUND

Despite high efficacy, use of pre-exposure prophylaxis (PrEP) remains low among young men who have sex with men (MSM) and transgender women (TW), primarily because of barriers such as stigma and resource awareness. We evaluated a social marketing campaign known as PrEP4Love that works to eliminate PrEP stigma; and awareness gaps through targeted advertising.

SETTING

Chicago, Illinois.

METHODS

Participants were enrolled within a cohort study of young MSM and TW (RADAR). Data were collected between June 2017 and April 2018 from HIV-negative individuals attending a follow-up visit. Surveys assessed demographics, PrEP attitudes and perceptions, and PrEP4Love campaign awareness. Associations between PrEP4Love awareness and PrEP perceptions, uptake, and behaviors were assessed using multiple logistic regression controlling for age, race/ethnicity, gender, sexual identity, and ever having used PrEP.

RESULTS

Of 700 participants, the majority (75.9%) indicated seeing PrEP4Love ads in Chicago. Those who had seen ads were more likely to be out to their providers (odds ratio = 1.95; 95% confidence interval: 1.17 to 3.23) than those who had not, and those who had conversations were significantly more likely to have initiated the conversation themselves. Individuals who had seen ads were more likely to have taken PrEP in the last 6 months (odds ratio = 1.87; 95% confidence interval: 1.15 to 3.16) and more likely to believe their friends and the general public approved of and used PrEP.

CONCLUSION

Social marketing campaigns are promising interventions that have the potential to alleviate barriers to HIV prevention, particularly among MSM and TW. Future research should evaluate the impact of these initiatives at multiple time points.

Evaluation of Selective Outcome Reporting Bias in Efficacy Endpoints in Print and Television Advertisements for Oncology Drugs

IMPORTANCE

Selective outcome reporting bias in oncology drug advertisements may encourage misconceptions about a drug's efficacy profile.

OBJECTIVE

We sought to determine the rates of selective outcome reporting in published cancer clinical trials and in television and print advertisements for anticancer medications. We also quantified the number of advertisements that did not include or cite any studies with mature overall survival (OS) data (i.e., data with all required patient events for final analysis).

DESIGN/SETTING/PARTICIPANTS

We conducted a cross-sectional investigation of advertisements uploaded to the AdPharm Database (repository of pharmaceutical advertisements); the clinical trials supporting the ads; and the trial registrations associated with the trials. Data were extracted by two investigators who were blinded to each other's data.

MAIN OUTCOME MEASURES

The first co-primary objective was to investigate selective outcome reporting between trial registrations and published trials. The second co-primary objective was to investigate selective outcome reporting between the same published trials and drug advertisements.

RESULTS

We included 74 advertisements and 48 clinical trials. Print ads were the most common (n = 66), and most print advertisements were targeted to health care providers (n = 55, 83.3%). Overall, 41/48 (85.4%) trials were registered prior to study enrollment, and 41/48 (85.4%) did not deviate from the registered primary endpoints. Across all advertisements (n = 74), statistically significant endpoints were more often reported (unadjusted risk ratio [uRR] 1.26; 95% confidence interval [CI] (1.14-1.40)) and 22/55 (40.0%) advertisements cited trials with immature overall survival data (i.e., data without the required number of events for final analysis).

CONCLUSIONS

In our sample, statistically significant endpoints were more commonly reported than nonsignificant endpoints. Immature endpoints (those analyzed before the required number of accrued patient events) were often reported. By reporting only significant endpoints and those that are immature, advertisers may encourage misconceptions about a drug's efficacy profile.

Direct-to-Consumer Advertising of Prescription Drugs and the Patient-Prescriber Encounter: A Systematic Review

We systematically reviewed the research on patients' and prescribers' perceptions of, and self-reported behaviors prompted by, exposure to direct-to-consumer advertising (DTCA) (For ease of reading we use the term "advertising" to encompass advertising and promotional labeling. Broad use of this term does not imply endorsement by FDA) of prescription drugs that occurs in the context of a clinical encounter. This research offers an important perspective on the broader goal of incorporating patient and prescriber voices in decision-making. Outcomes included patient information seeking, medication adherence, patient requests for DTCA-promoted prescription drugs, prescribing behaviors, and perceptions of the patient-prescriber relationship and interactions. We searched PubMed and other databases from 1982-2017 and identified 38 studies meeting our study criteria. Of these, 24 studies used patient-reported outcomes and 18 used prescriber-reported outcomes (four used both). Studies suggested some potential benefits of exposure to DTCA, including patients' enhanced information-seeking, increased patient requests for appropriate prescriptions (when addressing potential underuse) and patients' perceptions of higher-quality interactions with prescribers. Most prescribers perceived a neutral influence on the quality of their clinical interactions with patients regarding DTCA. Harms included patients receiving prescriptions for drugs that were not appropriate for them or that the patients did not need, and the potential for DTCA to interfere with medication adherence in some populations, such as those with mental illness. The potential benefits of DTCA on the patient-provider encounter must be balanced with the potential for harms.

Raising Placebo Efficacy in Antidepressant Trials Across Decades Explained by Small-Study Effects: A Meta-Reanalysis

BACKGROUND

Recent meta-analyses reported placebo response rate in antidepressant trials to be stable since the 1970s. These meta-analyses however were limited in considering only linear time trends, assessed trial-level covariates based on single-model hypothesis testing only, and did not adjust for small-study effects (SSE), a well-known but not yet formally assessed bias in antidepressant trials.

METHODS

This secondary meta-analysis extends previous work by modeling nonlinear time trends, assessing the relative importance of trial-level covariates using a multimodel approach, and rigorously adjusting for SSE. Outcomes were placebo efficacy (continuous), based on the Hamilton Depression Scale, and placebo response rate.

RESULTS

Results suggested that any nonlinear time trends in both placebo efficacy (continuous) and response rate were best explained by SSE. Adjusting for SSE revealed a significant gradual increase in placebo efficacy (continuous) from 1979 to 2014. A similar observation was made for placebo response rate, but did not reach significance due higher susceptibility to SSE. By contrast, trial-level covariates alone were found to be insufficient in explaining time trends.

CONCLUSION

The present findings contribute to the ongoing debate on antidepressant placebo outcomes and highlight the need to adjust for bias introduced by SSE. The results are of clinical relevance because SSE may affect the evaluation of success or failure in antidepressant trials.

A governance framework for development and assessment of national action plans on antimicrobial resistance

Strengthening governance is an essential strategy to tackling antimicrobial resistance (AMR) at all levels: global, national, regional, and local. To date, no systematic approach to governance of national action plans on AMR exists. To address this issue, we aimed to develop the first governance framework to offer guidance for both the development and assessment of national action plans on AMR. We reviewed health system governance framework reviews to inform the basic structure of our framework, international guidance documents from WHO, the Food and Agriculture Organization, the World Organisation for Animal Health, and the European Commission, and sought the input of 25 experts from international organisations, government ministries, policy institutes, and academic institutions to develop and refine our framework. The framework consists of 18 domains with 52 indicators that are contained within three governance areas: policy design, implementation tools, and monitoring and evaluation. To consider the dynamic nature of AMR, the framework is conceptualised as a cyclical process, which is responsive to the context and allows for continuous improvement and adaptation of national action plans on AMR.

Lifestyle determinants of behavioural outcomes triggered by direct-to-consumer advertising of prescription medicines: a cross-sectional study

OBJECTIVE

Direct-to-consumer advertising of prescription medicines encourages individuals to search for or request advertised medicines, can stimulate taking medications rather than making lifestyle behaviour changes, and may target individuals with poorer demographic and socioeconomic status and riskier health-related behaviours. This study thus explored whether responses to medicine advertising vary as a function of lifestyle behaviours, and demographic and socioeconomic factors.

METHODS

Data were collected through an online survey of a nationally representative sample of 2,057 adults in New Zealand. Multivariate binary logistic regressions were used to explore whether lifestyle behaviours, including nutritional habits, alcohol consumption, illegal drug consumption, physical activity, attitudes towards doing exercise, as well as demographic and socioeconomic status were associated with self-reported behavioural responses to medicine advertising.

RESULTS

Individuals who had unhealthier lifestyle behaviours were more likely to respond to medicine advertising.

CONCLUSIONS

The findings raise concerns regarding the misuse or overuse of medications for diseases that may otherwise be improved by a healthier lifestyle. Implications for public health: To improve public health and wellbeing of society, we call for regulatory changes regarding advertising of medicines. Where applicable, lifestyle changes should be advertised as potential substitutes for the advertised medicines. Interprofessional collaboration is also recommended to educate individuals and convey the value of health behaviour changes.

Is there a nocebo response that results from disease awareness campaigns and advertising in Australia, and can this effect be mitigated?

Direct-to-consumer advertising is banned in Australia, and instead pharmaceutical companies use disease awareness campaigns as a strategy to raise public awareness of conditions for which the company produces a treatment. This practice has been justified by promoting individual autonomy and public health, but it has attracted criticism regarding medicalisation of normal health and ageing, and exaggeration of the severity of the condition in question, imbalanced reporting of risks and benefits, and damaging the patient-clinician relationship. While there are benefits of disease awareness promotion, there is another possible adverse consequence that has not yet been rigorously considered: the possibility of inducing a nocebo response via the campaign. We will discuss the creation of a nocebo response in this context.

'At-risk' individuals' responses to direct to consumer advertising of prescription drugs: a nationally representative cross-sectional study

OBJECTIVES

The factors determining individuals' self-reported behavioural responses to direct to consumer advertising of prescription drugs were explored with an emphasis on 'at-risk' individuals' responses.

DESIGN

Nationally representative cross-sectional survey.

SETTING

Community living adults in New Zealand.

PARTICIPANTS

2057 adults (51% women).

PRIMARY OUTCOME MEASURES

Self-reported behavioural responses to drug advertising (asking a physician for a prescription, asking a physician for more information about an illness, searching the internet for more information regarding an illness and asking a pharmacist for more information about a drug).

METHODS

Multivariate logistic regressions determined whether participants' self-reported behavioural responses to drug advertising were predicted by attitudes towards advertising and drug advertising, judgements about safety and effectiveness of advertised drugs, self-reported health status, materialism, online search behaviour as well as demographic variables.

RESULTS

Identifying as Indian and to a less extent Chinese, Māori and 'other' ethnicities were the strongest predictors of one or more self-reported responses (ORs 1.76-5.00, Ps<0.05). Poorer self-reported health status (ORs 0.90-0.94, all Ps<0.05), favourable attitude towards drug advertising (ORs 1.34-1.61, all Ps<0.001) and searching for medical information online (ORs 1.32-2.35, all Ps<0.01) predicted all self-reported behavioural outcomes. Older age (ORs 1.01-1.02, Ps<0.01), less education (OR 0.89, P<0.01), lower income (ORs 0.89-0.91, Ps<0.05) and higher materialism (ORs 1.02-1.03, Ps<0.01) also predicted one or more self-reported responses.

CONCLUSIONS

Taken together, the findings suggest individuals, especially those who are 'at-risk' (ie, with poorer self-reported health status, older, less educated, lower income and ethnic minorities), may be more vulnerable to drug advertising and may make uninformed decisions accordingly. The outcomes raise significant concerns relating to the ethicality of drug advertising and suggest a need for stricter guidelines to ensure that drug advertisements provided by pharmaceutical companies are ethical.

Association Between Direct-to-Consumer Advertising and Testosterone Testing and Initiation in the United States, 2009-2013

Importance

Testosterone initiation increased substantially in the United States from 2000 to 2013, especially among men without clear indications. Direct-to-consumer advertising (DTCA) also increased during this time.

Objective

To investigate associations between televised DTCA and testosterone testing and initiation in the United States.

Design, Setting, and Population

Ecologic study conducted in designated market areas (DMAs) in the United States. Monthly testosterone advertising ratings were linked to DMA-level testosterone use data from 2009-2013 derived from commercial insurance claims. Associations between DTCA and testosterone testing, initiation, and initiation without recent baseline tests were estimated using Poisson generalized estimating equations.

Exposures

Monthly Nielsen ratings for testosterone DTCA in the 75 largest DMAs.

Main Outcomes and Measures

(1) Rates of new serum testosterone testing; (2) rates of testosterone initiation (in-office injection, surgical implant, or pharmacy dispensing) for all testosterone products combined and for specific brands; and (3) rates of testosterone initiation without recent serum testosterone testing.

Results

Of 17 228 599 commercially insured men in the 75 DMAs, 1 007 990 (mean age, 49.6 [SD, 11.5] years) had new serum testosterone tests and 283 317 (mean age, 51.8 [SD, 11.3] years) initiated testosterone treatment. Advertising intensity varied by geographic region and time, with the highest intensity seen in the southeastern United States and with months ranging from no ad exposures to a mean of 13.6 exposures per household. Nonbranded advertisements were common prior to 2012, with branded advertisements becoming more common during and after 2012. Each household advertisement exposure was associated with a monthly increase in rates of new testosterone testing (rate ratio [RR], 1.006; 95% CI, 1.004-1.008), initiation (RR, 1.007; 95% CI, 1.004-1.010), and initiation without a recent test (RR, 1.008; 95% CI, 1.002-1.013). Mean absolute rate increases were 0.14 tests (95% CI, 0.09-0.19), 0.05 new initiations (95% CI, 0.03-0.08), and 0.02 initiations without a recent test (95% CI, 0.01-0.03) per 10 000 men for each monthly ad exposure over the entire period.

Conclusions and Relevance

Among US men residing in the 75 designated market areas, regional exposure to televised direct-to-consumer advertising was associated with greater testosterone testing, new initiation, and initiation without recent testing.

From Me to You

The social context in which people take medicines can strongly influence the drug response in both positive and negative ways. We first examine the role of social modeling in influencing treatment outcomes through modifying placebo and nocebo responses, and then explore possible mechanisms for these effects. Viewing another person show improvement after taking a drug can increase the placebo component of the medicine and thus the overall potency of the treatment. Likewise, seeing another person who has taken the same medicine report side effects can substantially increase adverse effects. Such effects can also occur on a wider scale following changes in medicine formulations or from vaccinations programs, when the media transmit adverse effects from these treatments to a wider audience. Females seem to be more susceptible than males to the social modeling of adverse effects of treatments. A greater awareness of the effects of social modeling has potential to improve the effectiveness of medical treatments, minimize side-effect burden, and also lead to more effective management of health scares.

Feeling Is Believing: Evaluative Conditioning and the Ethics of Pharmaceutical Advertising

A central goal in regulating direct-to-consumer advertising of prescription pharmaceuticals (DTCA) is to ensure that explicit drug claims are truthful. Yet imagery can also alter viewer attitudes, and the degree to which this occurs in DTCA is uncertain. Addressing this data gap, we provide evidence that positive feelings produced by images can promote favourable beliefs about pharmaceuticals. We had participants view a fictitious anti-influenza drug paired with unrelated images that elicited either positive, neutral or negative feelings. Participants who viewed positive images rated the influenza drug as significantly more effective, safe, and beneficial than did participants who viewed negative images. This effect, known as evaluative conditioning, is well described in experimental social psychology but has not previously been shown with pharmaceuticals. We discuss how evaluative conditioning in DTCA may compromise viewer autonomy, and canvass possible regulatory responses.

Effects of Televised Direct-to-Consumer Advertising for Varenicline on Prescription Dispensing in the United States, 2006-2009

INTRODUCTION

Televised direct-to-consumer advertising (DTCA) for prescription drugs is controversial, especially for tobacco cessation products such as varenicline, given safety concerns that arose only after its market approval. We aim to quantify the extent to which DTCA influenced varenicline use.

METHODS

We linked monthly DTCA television ratings with monthly prescription data from IMS Health's National Prescription Audit across top 75 media markets in 2006-2009. We used Poisson models with Generalized Estimating Equations to analyze effects of exposures to DTCA for both varenicline and nicotine replacement therapies on rate of dispensed varenicline prescriptions among smokers, controlling for population characteristics and varenicline-related events.

RESULTS

Varenicline prescriptions increased dramatically following DTCA launch and declined sharply after safety risks were publicized and US Food and Drug Administration (FDA) issued an advisory. DTCA had significant impact on new prescription dispensing in the subsequent month: before the FDA advisory, one additional exposure to varenicline DTCA was associated with a 1.8% (rate ratio [RR] = 1.018 [1.015-1.021]) higher rate of new prescriptions; no effect was observed after the advisory (RR = 1.000 [0.997-1.003]). Prior to the advisory, cross-product effects of nicotine replacement therapy advertising on varenicline prescribing were negligible (RR = 1.002 [0.999-1.004]); after the advisory, effects were positive (RR = 1.015 [1.012-1.019]).

CONCLUSIONS

DTCA for varenicline had a significant impact on varenicline prescribing when the drug's safety profile was not well characterized, supporting arguments to limit DTCA for newly approved products whose real-world safety is unclear.

IMPLICATIONS

We examined the fluctuations in varenicline use in association with DTCA for varenicline and other tobacco cessation aids. To our knowledge this is the first study to quantify the effects of televised DTCA for varenicline and other tobacco cessation aids on varenicline prescription dispensing. We believe that understanding these relationships is critical for formulating effective public health policy and interventions.

The Chemical Imbalance Hypothesis: An Evaluation of the Evidence

Powered by philosophic argument, scientific evidence, and multibillion dollar pharmaceutical companies sponsoring multimillion dollar advertising campaigns, the chemical imbalance hypothesis has saturated our academic and popular culture. This saturation is, at least partially, responsible for the more than 10 billion dollars annually spent on antidepressant medication in the United States. But what is the “chemical imbalance” hypothesis? And what evidence supports it? This article will provide an account of the chemical imbalance hypothesis, a history of its development, and the evidence provided for its justification. This article will show that the evidence for the chemical imbalance hypothesis is unconvincing. It will discuss why, despite the unconvincing evidence, the hypothesis lingers. And, finally, it will suggest an alternative approach to mental illness that avoids some of the pitfalls of a biological reductionistic account of mind.

Potential spillover educational effects of cancer-related direct-to-consumer advertising on cancer patients' increased information seeking behaviors: results from a cohort study

Spillover effects of exposure to direct-to-consumer advertising (DTCA) of cancer treatments on patients' general inquiry about their treatments and managing their illness are not well understood. This study examines the effects of cancer patients' exposure to cancer-related DTCA on subsequent health information seeking behaviors from clinician and non-clinician sources (lay media and interpersonal contacts). Using a longitudinal survey design over 3 years, data was collected from cancer survivors diagnosed with colorectal, breast, or prostate cancer who were randomly sampled from the Pennsylvania Cancer Registry. Study outcome measures include patients' information engagement with their clinicians and information seeking from non-medical sources about cancer treatment and quality of life issues, measured in the second survey. The predictor variable is the frequency of exposure to cancer-related DTCA since diagnosis, measured at the round 1 survey. The analyses utilized lagged-weighted multivariate regressions and adjusted for round 1 levels of patient-clinician engagement, information seeking from nonmedical sources, and confounders. Exposure to cancer-related DTCA is associated with increased levels of subsequent patient-clinician information engagement (B = .023, 95% CI = .005-.040, p = .012), controlling for confounders. In comparison, exposure to DTCA is marginally significant in predicting health information seeking from non-clinician sources (B = .009, 95% CI = -.001-.018, p = .067). Cancer-related DTCA has potentially beneficial spillover effects on health information seeking behaviors among cancer patients. Exposure to DTCA predicts (a little) more patient engagement with their physicians.

Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world?

AIMS

This paper aims to identify possible system-level factors contributing to the marked differences in the levels of non-medical prescription opioid use (NMPOU) and prescription opioid (PO)-related harms in North America (i.e. the United States and Canada) compared to other global regions.

METHODS

Scientific literature and information related to relevant areas of health systems, policy and practice were reviewed and integrated.

RESULTS

We identified several but different factors contributing to the observed differences. First, North American health-care systems consume substantially more Pos-even when compared to other high-income countries-than any other global region, with dispensing levels associated strongly with levels of NMPOU and PO-related harms. Secondly, North American health-care systems, compared to other systems, appear to have lesser regulatory access restrictions for, and rely more upon, community-based dispensing mechanisms of POs, facilitating higher dissemination level and availability (e.g. through diversion) of POs implicated in NMPOU and harms. Thirdly, we note that the generally high levels of psychotrophic drug use, dynamics of medical-professional culture (including patient expectations for 'effective treatment'), as well as the more pronounced 'for-profit' orientation of key elements of health care (including pharmaceutical advertising), may have boosted the PO-related problems observed in North America.

CONCLUSIONS

Differences in the organization of health systems, prescription practices, dispensing and medical cultures and patient expectations appear to contribute to the observed inter-regional differences in non-medical prescription opioid use and prescription opioid-related harms, although consistent evidence and causal analyses are limited. Further comparative examination of these and other potential drivers is needed, and also for evidence-based intervention and policy development.

Direct-to-consumer marketing of psychological treatments for anxiety disorders

Progress disseminating and implementing evidence-based psychological treatments (EBPTs) for the anxiety disorders has been gradual. To date, the dominant approach for promoting the uptake of EBPTs in clinical settings has been to target the education and training of mental health providers, with many consumers remaining unaware of the potential benefits of EBPTs for anxiety disorders. Direct-to-consumer (DTC) marketing may be a promising vehicle for increasing EBPT utilization rates in the treatment of anxiety disorders. This paper provides an overview of the rationale and important considerations for applying DTC efforts to promote evidence-based care in the treatment of anxiety disorders, and reviews current DTC efforts in this area, including resources on the Internet and other media and in-person events. We conclude with recommendations for future efforts in the DTC marketing of EBPTs for the anxiety disorders, including the need for increased funding and grassroots efforts to inform consumers about anxiety disorders and their most effective treatments.

Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention

OBJECTIVE

The aim of this study was to examine eye gaze patterns between patients and physicians while electronic health records were used to support patient care.

BACKGROUND

Eye gaze provides an indication of physician attention to patient, patient/physician interaction, and physician behaviors such as searching for information and documenting information.

METHODS

A field study was conducted where 100 patient visits were observed and video recorded in a primary care clinic. Videos were then coded for gaze behaviors where patients' and physicians' gaze at each other and artifacts such as electronic health records were coded using a pre-established objective coding scheme. Gaze data were then analyzed using lag sequential methods.

RESULTS

Results showed that there are several eye gaze patterns significantly dependent to each other. All doctor-initiated gaze patterns were followed by patient gaze patterns. Some patient-initiated gaze patterns were also followed by doctor gaze patterns significantly unlike the findings in previous studies. Health information technology appears to contribute to some of the new significant patterns that have emerged. Differences were also found in gaze patterns related to technology that differ from patterns identified in studies with paper charts. Several sequences related to patient-doctor-technology were also significant. Electronic health records affect the patient-physician eye contact dynamic differently than paper charts.

CONCLUSION

This study identified several patterns of patient-physician interaction with electronic health record systems. Consistent with previous studies, physician initiated gaze is an important driver of the interactions between patient and physician and patient and technology.

A Pill for the Ill? Patients' Reports of Their Experience of the Medical Encounter in the Treatment of Depression

BACKGROUND

Starting in the 1960s, a broad-based patients' rights movement began to question doctors' paternalism and to demand disclosure of medical information, informed consent, and active participation by the individual in personal health care. According to scholars, these changes contributed to downplay the biomedical approach in favor of a more patient-oriented perspective. The Swedish non-profit organization Consumer Association for Medicines and Health (KILEN) has offered the possibility for consumers to report their perceptions and experiences from their use of medicines in order to strengthen consumer rights within the health care sector.

METHODOLOGY

In this paper, qualitative content analysis was used to analyze 181 KILEN consumer reports of adverse events from antidepressant medications in order to explore patients' views of mental ill health symptoms and the doctor-patient interaction.

PRINCIPAL FINDINGS

Overall, the KILEN stories contained negative experiences of the patients' medical encounters. Some reports indicated intense emotional outrage and strong feelings of abuse by the health care system. Many reports suggested that doctors and patients had very different accounts of the nature of the problems for which the patient was seeking help. Although patients sought help for problems like tiredness and sleeplessness (often with a personal crisis of some sort as a described cause), the treating doctor in most cases was exceptionally quick in both diagnosing depression and prescribing antidepressant treatment. When patients felt they were not being listened to, trust in the doctor was compromised. This was evident in the cases when the doctor tried to convince them to take part in medical treatment, sometimes by threatening to withdraw their sick-listing.

CONCLUSIONS

Overall, this study suggests that the dynamics happening in the medical encounter may still be highly affected by a medical dominance, instead of a patient-oriented perspective. This may contribute to a questionable medicalization and/or pharmaceuticalization of depression.

General public knowledge, perceptions and practice towards pharmaceutical drug advertisements in the Western region of KSA

This study aims to examine general public knowledge and behavior toward pharmaceutical advertisements in the Western part of KSA. A cross sectional convenience sampling technique was used in this study. A total of 1445 valid questionnaires were received and analyzed using SPSS version 16 at alpha value of 0.05. Majority of respondents were aware of different types of drugs to be advertised and drug advertisements should seek approval from the health authorities. Television and Internet showed the highest effect on consumers. Almost half of the participants preferred an advertised drug over non-advertised one. Most of the respondents indicated that the quality of frequently advertised drugs is not better than those prescribed by the doctors. Majority of participants had positive beliefs toward advertised drugs concerning their role in education and spreading of awareness among the public. Pharmaceutical advertisements harm the doctor-patient relationship as evidenced by one-third of the investigated sample. Moreover, majority of the participants mentioned that they would consult another doctor or even change the current doctor if he/she refused to prescribe an advertised medication. Results of this study could be used to develop awareness programs for the general public and try to enforce the regulations and policies to protect the general public and patients from the business oriented pharmaceutical companies and drug suppliers.

The effects of positive patient testimonials on PTSD treatment choice

Despite the existence of effective treatment options for PTSD, these treatments are failing to reach those that stand to benefit from PTSD treatment. Understanding the processes underlying an individual's treatment seeking behavior holds the potential for reducing treatment-seeking barriers. The current study investigates the effects that positive treatment testimonials have on decisions regarding PTSD treatment. An undergraduate (N = 439) and a trauma-exposed community (N = 203) sample were provided with videotaped treatment rationales for prolonged exposure (PE) and sertraline treatments of PTSD. Half of each sample also viewed testimonials, detailing a fictional patient's treatment experience. All participants then chose among treatment options and rated the credibility of - and personal reactions toward - those options. Among treatment naïve undergraduates, testimonials increased the proportion choosing PE alone; and among treatment naïve members of the trauma-exposed community sample, testimonials increased the proportion choosing a combined PE plus sertraline treatment. These effects were not observed for those with prior history of either psychotherapeutic or pharmacological treatment. Major barriers exist that prevent individuals with PTSD from seeking treatment. For a critical unreached treatment sample, those who are treatment naïve, positive patient testimonials offer a mechanism in which to make effective treatments more appealing and accessible.

Antidepressants and advertising: psychopharmaceuticals in crisis

As the efficacy and science of psychopharmaceuticals has become increasingly uncertain, marketing of these drugs to both physicians and consumers continues to a central part of a multi-billion dollar per year industry in the United States. We explore how such drug marketing portrays idealized scientific relationships between psychopharmaceuticals and depression; how multiple stakeholders, including scientists, regulatory agencies, and patient advocacy groups, negotiate neurobiological explanations of mental illness; and how the placebo effect has become a critical issue in these debates, including the possible role of drug advertising to influence the placebo effect directly. We argue that if and how antidepressants "work" is not a straightforward objective question, but rather a larger social contest involving scientific debate, the political history of the pharmaceutical industry, cultural discourses surrounding the role of drugs in society, and the interpretive flexibility of personal experience.

Direct to consumer Internet advertising of statins: an assessment of safety

PURPOSE

To evaluate a sample of Internet sites advertising statins for sale to the general public.

METHODS

A simulated customer search and evaluation of retrieved sites using evaluation tools focussing on quality (Q) and safe medicine use (SMU). Sites retrieved on 17 November 2010 were systematically analysed from 19 November to 23 December 2010.

RESULTS

One hundred eighty-four sites met the inclusion criteria: 40 each for atorvastatin, pravastatin, rosuvastatin, and simvastatin and 24 for fluvastatin. Sites originated from 17 different countries. Most sites scored less than half the maximum Q score (26; range 5-17). Mean total SMU scores for each statin group were lower than 50% of the maximum (45; range of 0-28). There were no statistically significant differences between statins. General contraindications were absent in 92.4% of sites and contraindicated medicines in 47.3%. Key warnings on the appearance of symptoms associated with myopathy, liver disease, hypersensitivity, and pancreatitis were absent in 37, 48.4, 91.3, and 96.2% of sites, respectively. Most websites presented a chaotic and incomplete list of known side effects; just 13 (7.1%) presented a list compatible with current prescribing information. Only two-thirds (65.8%) attempted to describe any in lay language.

CONCLUSIONS

A potential purchaser of statins is likely to encounter websites from a wide geographical base and of generally poor quality. This has potentially serious implications for the safety of purchasers who may not be aware of the problems associated with ordering medicines online or the actual medication, which they receive. Direct to consumer advertising websites need tighter controls.

Direct-to-Consumer Genetic Testing

Genetics has fascinated societies since ancient times, and references to traits or behaviors that appear to be shared or different among related individuals have permeated legends, literature, and popular culture. Biomedical advances from the past century, and particularly the discovery of the DNA double helix, the increasing numbers of links that were established between mutations and medical conditions or phenotypes, and technological advances that facilitated the sequencing of the human genome, catalyzed the development of genetic testing. Genetic tests were initially performed in health care facilities, interpreted by health care providers, and included the availability of counseling. Recent years have seen an increased availability of genetic tests that are offered by companies directly to consumers, a phenomenon that became known as direct-to-consumer genetic testing. Tests offered in this setting range from the ones that are also provided in health care establishments to tests known as ‘recreational genomics,’ and consumers directly receive the test results. In addition, testing in this context often does not involve the availability of counseling and, when this is provided, it frequently occurs on-line or over the phone. As a field situated at the interface between biotechnology, biomedical research, and social sciences, direct-to-consumer genetic testing opens multiple challenges that can be appropriately addressed only by developing a complex, inter-disciplinary framework.

Getting to "no": strategies primary care physicians use to deny patient requests

BACKGROUND

Physicians need strategies for addressing patient requests for medically inappropriate tests and treatments. We examined communication processes that physicians use to deal with patient requests of questionable appropriateness.

METHODS

Data come from audio-recorded visits and postvisit questionnaires of standardized patient visits to primary care offices in Sacramento and San Francisco, California, and Rochester, New York, from May 2003 to May 2004. Investigators performed an iterative review of visit transcripts in which patients requested, but did not receive, an antidepressant prescription. Measurements include qualitative analysis of strategies for communicating request denial. The relationship between strategies and satisfaction reports in postvisit questionnaires was examined using the Fisher exact test.

RESULTS

Standardized patients requested antidepressants in 199 visits; the antidepressants were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of 84 visits (63%), physicians used 1 or more of the following 3 strategies that explicitly incorporated the patient perspective: (1) exploring the context of the request, (2) referring to a mental health professional, and (3) offering an alternative diagnosis. Twenty-six visits (31%) involved emphasis on biomedical approaches: prescribing a sleep aid or ordering a diagnostic workup. In 5 visits (6%), physicians rejected the request outright. Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P = .001).

CONCLUSIONS

Strategies for saying no may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship. These findings should be considered in the context of physician education and training in light of increasing health care costs.

Marketing and pricing strategies of online pharmacies

Internet and e-commerce have profoundly changed society, the economy, and the world of health care. The web offers opportunities to improve health, but it may also represent a big health hazard since it is a basically unregulated market with very low consumer protection. In this paper we analyze marketing and pricing strategies of online pharmacies (OPs). Our analysis shows that OPs use strategies that would be more suitable for a commodity market than for drugs. These strategies differentiate according to variety (brand or generic), quality, quantity, and target group. OPs are well aware that the vacuum in the legislation allows them to reach a target of consumers that pharmacies cannot normally reach, such as those who would like to use the drug without consulting a physician (or, even worse, against the physician's advice). In this case, they usually charge a higher price, reassure the users by minimizing on the side effects, and induce them to bulk purchase through sensible price discounts. This analysis suggests that the selling of drugs via the Internet can turn into a "public health risk", as has been pointed out by the US Food and Drug Administration.

Analysis of US Food and Drug Administration Warning Letters: False Promotional Claims Relating to Prescription and Over-the-Counter Medications

BACKGROUND

Recent studies have suggested that there has been an increase in the number of 'warning letters' issued by the US Food and Drug Administration (FDA) despite the publication of the FDA advertising guidelines. However, limited information is available on the description of warning letters. The objective of this study was to analyse the frequency and content of FDA warning letters in relation to promotional claims and discuss the influence of regulatory and industry constraints on promotion.

METHODS

All warning letters published by the FDA between 5 May 1995 and 11 June 2007 were reviewed. Warning letters related to promotional issues were included and analysed. Information related to the identification number, date of the warning letter, FDA division that issued the letter, drug name, manufacturer, specific warning problem, type of promotional material and requested action was extracted. Two independent investigators reviewed and classified each PDF file, any differences were discussed until a consensus was reached.

RESULTS

Between May 1995 and June 2007 a total of 8692 warning letters were issued, of which 25% were related to drugs. Of these, 206 warning letters focused on drug promotion and were included in this study: 23% were issued in 2005, 15% in 2004 and 14% in 1998. In total, 47% of the warning letters were issued because of false or misleading unapproved doses and uses, 27% failed to disclose risks, 15% cited misleading promotion, 8% related to misleading labelling and 3% promoted false effectiveness claims.

DISCUSSION

There is an important variation in the number of warning letters issued in the last decade, probably because of the increasing number of drugs approved by the FDA, drug withdrawal scandals, and the publication of the FDA and the Pharmaceutical Research and Manufacturers of America (PhRMA) guidelines.

CONCLUSION

We found that benefit-related claims, such as unapproved uses or doses of drugs, and failure to disclose risks, are the main causes of FDA issued warning letters for promotional claims related to medications.

Factors affecting physicians' responses to patients' requests for antidepressants: focus group study

BACKGROUND

The ways in which patients' requests for antidepressants affect physicians' prescribing behavior are poorly understood.

OBJECTIVE

To describe physicians' affective and cognitive responses to standardized patients' (SPs) requests for antidepressants, as well as the attitudinal and contextual factors influencing prescribing behavior.

DESIGN

Focus group interviews and brief demographic questionnaires.

PARTICIPANTS

Twenty-two primary care physicians in 6 focus groups; all had participated in a prior RCT of the influence of patients' requests on physicians' prescribing.

MEASUREMENTS

Iterative review of interview transcripts, involving qualitative coding and thematic analysis.

RESULTS

Physicians participating in the focus groups were frequently unaware of and denied the degree to which their thinking was biased by patient requests, but were able to recognize such biases after facilitated reflection. Common affective responses included annoyance and empathy. Common cognitive reactions resulted in further diagnostic inquiry or in acquiescing to the patient's demands to save time or build the patient-clinician relationship. Patients' requests for medication prompted the participants to err on the side of overtreating versus careful review of clinical indications. Lack of time and participants' attitudes--toward the role of the patient and the pharmaceutical ads--also influenced their responses, prompting them to interpret patient requests as diagnostic clues or opportunities for efficiency.

CONCLUSIONS

This study provides a taxonomy of affective and cognitive responses to patients' requests for medications and the underlying attitudes and contextual factors influencing them. Improved capacity for moment-to-moment self-awareness during clinical reasoning processes may increase the appropriateness of prescribing.

Educating health professionals about drug and device promotion: advocates' recommendations

Mansfield and colleagues outline the recommendations from four advocacy groups for improving the education of health professionals on promotion of drugs and devices.