Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters

Critical Test of the Beneficial Consequences of Lifting the Ban on Direct-to-Consumer Advertising for Prescription Drugs in Italy: Experimental Exposure and Questionnaire Study

BACKGROUND

There are only two countries in the world (the United States and New Zealand) that allow the pharmaceutical branch to advertise prescription medication directly to consumers. There is pressure on governments to allow direct-to-consumer advertising (DTCA) for prescription drugs elsewhere too. One argument the industry uses frequently is the claim that exposure to DCTA, through various methods and occasions, is supposed to improve customers' knowledge of a disease and treatment. This argument has been part of the health care community's wider discussion of whether DTCA of prescription drugs benefits the population's general interest or is only an attempt to increase the sales of the pharmaceutical branch. Belief in true learning by DTCA is rooted in concepts of empowered consumers and their autonomous and empowered decision-making.

OBJECTIVE

In this study, we tested the hypotheses that contact with DTCA increases recipients' literacy/knowledge, especially regarding the side effects of treatment (hypothesis 1), and empowerment (hypothesis 2). We further hypothesized that DTCA exposure would not increase depression knowledge (ie, about treatments, symptoms, and prevalence) (hypothesis 3).

METHODS

A snowball sample of 180 participants was randomly split into three experimental groups receiving (1) a traditional information sheet, (2) a DTCA video clip for an antidepressant prescription drug, or (3) both. The video was original material from the United States translated into Italian for the experiment. Dependent variables were measures of depression knowledge (regarding treatments, symptoms and prevalence, and antidepressant side effects), depression literacy, and empowerment.

RESULTS

None of the experimental groups differed significantly from the others in the empowerment measure (hypothesis 2 not confirmed). Partial confirmation of hypothesis 1 was obtained. Lower values on the depression literacy scale were obtained when participants had been given the video compared to the sheet condition. However, the general depression knowledge and its subscale on side effects reached higher scores when participants were exposed to the DTCA, alone or in combination with the information sheet. Finally, participants showed lower scores on knowledge about treatment and symptoms or prevalence after watching the video compared to the sheet condition (hypothesis 3 confirmed). Symptoms and prevalence knowledge increased only when the video was presented in combination with the sheet.

CONCLUSIONS

There is no evidence for an increase in empowerment following DTCA exposure. An increase in knowledge of the side effects of the medication was observed in the group exposed to the DTCA video. This was the only result that confirmed the hypothesis of the beneficial effect of DTCA videos on knowledge. Written information proved to be the most suitable way to convey knowledge on treatments and symptoms prevalence. Our findings support the necessity of studying health literacy and patient empowerment together and the consequences of such an increase in knowledge in terms of help-seeking behavior.

Detecting and Reporting Deceptive Prescription Drug Promotion: Differences Across Consumer and Physician Audiences and by Number and Type of Deceptive Claims and Tactics

The U.S. Food and Drug Administration's (FDA) Bad Ad program provides an avenue for healthcare providers to report false or misleading prescription drug promotion. Yet, whether healthcare providers can detect such promotion, and whether they believe it should be reported to FDA, remain open questions. Consumer audiences may also be capable of detecting such promotion and believe it should be reported, but even less is known about capability and belief in this population. Across two experiments using mock pharmaceutical websites, this research investigated capability to detect and inclination to report deceptive prescription drug promotion among a sample of primary care physicians and consumers. Study 1 varied the number of deceptive claims and tactics on a website for a chronic pain medication, operationalized as none, two, or five. Study 2 varied the type of deceptive content on a website for a weight loss medication, operationalized as none, implicit, or explicit. Findings reveal that, in line with expectations from FDA's Bad Ad program, physicians can detect deceptive promotion and tend to believe it should be reported. Consumers are also capable of detecting deceptive promotion and tend to believe it should be reported, but their capabilities and beliefs regarding reporting are generally lower.

Analysis of Information About Medicines Available on Facebook

There are many anxieties have been shown and perceived by the experts for SMP of medicines. This procedure of DTCA can be reciprocated, and one of the reason is the platform is uncontrolled; the advantages of the medicines could be exaggerated compared to the disadvantages. Also, patients can share their own experience of using medicine on social networking sites. There is a high probability for the patients to be exposed to ambiguous, contradicting, and confusing information about medicines on social media. Our focal point is to inspect how drug pages in social media influencing the overall population or web-based media clients. We tried to investigate the data available on Facebook pages of popular drugs. Many social media users often go through the content posted on social networking sites. Patients and their family members are likely to be exposed to drug product claims while looking for information about medicines of a specific disease on social media.

Personalized Medicine in Gynecologic Cancer: Fact or Fiction?

Personalized medicine in gynecologic oncology is an evolving field. In recent years, tumor profiling and large databases such as TCGA and NCI-Match have provided us with enormous amounts of molecular data. Several therapies that capitalize on novel genetic and immune discoveries including VEGF inhibitors, PARP inhibitors, and cancer vaccinations are discussed in this article. Additionally, we have seen direct to consumer marketing play an important role in cancer care and prevention as patients have increased ability to access genetic testing. This presents a unique challenge to gynecologic oncology providers as we learn to navigate the world of personalized medicine.

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.

Experimental evidence of consumer and physician detection and rejection of misleading prescription drug website content

BACKGROUND

Consumers and primary care physicians (PCPs) sometimes encounter deceptive promotional claims about prescription drugs. Whether consumers and PCPs can detect deceptive claims or whether those claims negatively affect medical decision making, however, remain important, unanswered research questions.

OBJECTIVES

This article explores (1) the ability of consumers and PCPs to identify deceptive prescription drug promotion at various levels of deception, (2) the influence of such tactics on obstructing risk recognition, and (3) whether perceived deception mediates relationships between exposure to deceptive tactics and various outcomes (including false-claim acceptance, attitudes, information-seeking intentions, and interest toward the promoted drug).

METHODS

Two experiments-1 with consumers (N = 366) and 1 with PCPs (N = 378)-were conducted to determine whether participant exposure to deceptive prescription drug website content corresponds to detection and acceptance (or rejection) of claims and tactics. In each experiment, the number of deceptive claims and tactics on a consumer- or PCP-targeted website for a fictitious chronic pain medication were varied, in a 1 × 3 (none, fewer, more) between-subjects design.

RESULTS

Among consumers, exposure to more deceptive claims or tactics did not increase suspicion about the veracity of the website (relative to fewer claims and tactics) and actually had a limited positive direct effect on false-claim acceptance and attitudes toward the drug. Among PCPs, a mediation effect existed such that exposure to more deceptive claims and tactics resulted in higher perceived website deceptiveness relative to those in the fewer deceptive claims condition, which, in turn, resulted in lower acceptance of deceptive claims and tactics, lower perceived drug effectiveness, more negative attitudes toward the drug, and lower interest and intentions.

CONCLUSION

These experiments demonstrate potential differences between consumers and PCPs as well as implications for consumer and PCP vulnerability to website deception.

Access to innovative medicines by pharma companies: Sustainable initiatives for global health or useful advertisement?

Research & Development on new medicines plays an important role in life and well-being, making pharmaceutical companies important players in global health. Accessibility and financing new medicines, however, poses challenges for governments and patients around the world. Due to pricing and aggressive patent policy issues, pharma companies started to adopt access to medicines as a strategy to not only improve their public image but also to increase their economic performance. More than a useful institutional advertisement to attract new business, initiatives to improve access to medicines must be socially responsible and sustainable. Using content analysis methodology from CSR reports, the present study evaluated how 44 global companies are positioning themselves regarding access, whether these initiatives are aligned to existing access programmes and whether the actions disclosed on behalf of access are sustainable. We have identified 13 major access to medicines approaches that were classified into intrinsic, potentially sustainable and robust actions. We concluded that companies overvalue the term access to medicine. This can generate initiatives focused on advertisements rather than long-term actions and highlights the need for clear global criteria for companies and programmes that want to effectively publicise access to medicines as a social responsibility strategy.

Medicines Information and the Regulation of the Promotion of Pharmaceuticals

Many factors contribute to the inappropriate use of medicines, including not only a lack of information but also inaccurate and misleading promotional information. This review examines how the promotion of pharmaceuticals directly affects the prescribing and use of medicines. We define promotion broadly as all actions taken directly by pharmaceutical companies with the aim of enhancing product sales. We look in greater detail at promotion techniques aimed at prescribers, such as sales representatives, pharmaceutical advertisements in medical journals and use of key opinion leaders, along with the quality of information provided and the effects thereof. We also discuss promotion to the public, through direct-to-consumer advertising, and its effects. Finally, we consider initiatives to regulate promotion that come from industry, government and nongovernmental organizations.

Actors in whitespace: Communicating risk information on pharmaceutical websites

This study examined the use of an actor to communicate prescription drug risks on pharmaceutical websites. Participants viewed risk information for a fictitious drug in one of several static visual formats or as a paragraph plus an animated actor; and with or without a signal directing them to the risk information text. The signal had little effect on outcomes. Format did not affect risk processing, but participants in the actor condition thought the website placed less emphasis on benefits. Actors communicating risk information on a pharmaceutical website do not appear to improve consumers' understanding of prescription drug information.

Personalized Medicine in Gynecologic Cancer: Fact or Fiction?

Personalized medicine in gynecologic oncology is an evolving field. In recent years, tumor profiling and large databases such as TCGA and NCI-Match have provided us with enormous amounts of molecular data. Several therapies that capitalize on novel genetic and immune discoveries including VEGF inhibitors, PARP inhibitors, and cancer vaccinations are discussed in this article. Additionally, we have seen direct to consumer marketing play an important role in cancer care and prevention as patients have increased ability to access genetic testing. This presents a unique challenge to gynecologic oncology providers as we learn to navigate the world of personalized medicine.

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.

Complaints addressed by regulatory authorities in drug advertising targeted at consumers: Cases across three, different countries

BACKGROUND

Misleading advertisements can affect behavior of both consumers and prescribers and may lead to inappropriate use of medications.

OBJECTIVE

To analyze the complaints upheld by regulatory authorities in the United Kingdom, Canada, and Australia regarding pharmaceutical advertising directed at consumers.

METHODS

Complaints addressed between January 2014 and June 2017 were retrieved from the websites of regulatory authorities. Complaints addressed by self-regulatory bodies were not included due to the poor availability of data.

RESULTS

Sixty complaints, 374 complaints, and 223 complaints from the United Kingdom, Canada, and Australia, respectively, were analyzed. In the United Kingdom, the most frequent type of violation was advertising of prescription drugs (70.5%); most of these violations involved botulinum toxin. In Canada, advertising on online media was more likely to be associated with prescription drugs than that on traditional media (P < 0.001). In Australia, advertising of prescription drugs accounted for less than 10% of complaints, but all were associated with online media.

CONCLUSIONS

In countries where direct-to-consumer advertising of prescription drugs is prohibited, regulatory authorities may need to devise further strategies to safeguard the public as this is an unresolved issue and is predicted to become more problematic with the increased use of online media.

A suggestion for evolution of Canada’s health regulatory system

Aspects of Canada’s health regulatory system are currently being reviewed. This is timely, as the regulation and definition of drugs, foods, and natural health products (NHPs) is in need of revision to facilitate greater transparency and less ambiguity. A number of studies have illustrated the importance of a nutritious diet to prevent and manage chronic disease. Therefore, legislation surrounding food health claims needs to be adjusted so that it is more informative for disease prevention and, in some cases, treatment. Canada is modernizing the regulation of self-care products, under which NHPs, including probiotic products, are listed. With the growing appreciation for the role that microbes play in human health and the recognition that many foods, including those containing probiotic organisms, can prevent or mitigate disease, this provides an opportunity to reassess regulatory categories.

"Dr. Google" and his predecessors

BACKGROUND

Contemporary medicine has expressed concern about lay incursions into the diagnostic process buttressed by commonly available medical information on line. Even while the world wide web is a new structure, there is a long historical precedent for this concern. With the emergence of scientific medicine in the late 19th century came a strong belief in the role of diagnosis, not only to explain disease symptoms but also to differentiate the physician from a range of other unreliable practitioners. Along with this focus on diagnosis came also a concern expressed by doctors about patients' inclination to self-diagnose, or to propose candidate diagnoses for the problems that ailed them.

METHODS

This paper uses Zerubavel's social patterning method. Using material written by doctors from the late 19th until the mid-20th century, I explore comments about, and attitudes towards, self-diagnosis.

RESULTS

Three areas of concern about self-diagnosis are expressed by doctors. First, self-diagnosis produces anxiety in the patient. Second, it interferes with doctor-patient relationship. Finally self-diagnosis is commonly linked to commercial interests.

CONCLUSIONS

Contemporary concerns about self-diagnosis are part of an ongoing social pattern, which simultaneously promotes diagnosis as means for explaining disease but also protests when the diagnostic explanations originate with the patient.

Building pharmaceutical relationship marketing and social media impact

Purpose

The purpose of this paper is to identify key social medial channels which pharmaceutical firms need to consider when desiring to understand consumer behavior, build, maintain and proactively manage relationships. Also, it proposes the application of analytic hierarchy process (AHP) sensitivity analysis algorithm to test the stability or robustness of the priority ranking. Specifically, this paper leverages performance sensitivity analysis to evaluate how small changes (perturbation) in the major objectives of the pharmaceutical relationship marketing (PRM) tactics within the social media environment will influence the ranking of the alternative course of actions.

Design/methodology/approach

This paper used AHP-based questionnaire survey to evaluate the relative importance of factors accounting for PRM and the impact of social media channels. The major objectives and the alternative strategies used were from literature reviewed. Interviews with senior managers were insightful and helpful in the wording, content and format of the questionnaire.

Findings

Customer engagement is the most important PRM tactic, followed by communication and trust. The performance sensitivity analysis carried out on the PRM tactics showed that the ranking associated with social media channel options remained robust or insensitive to small perturbations.

Research limitations/implications

The data procured for this paper were based on one focal pharmaceutical firm. Convincing the same to grant an interview and late responding to the questionnaire was a great challenge.

Practical implications

Social media impact on pharmaceutical marketing relationship is important for pharmaceutical marketers. PRM bodes well with the social media environment. Pharmaceutical industry can build and maintain relationships with consumers through social media. Firms that leverage social media to enhance their PRM tactics will be viewed favorably in terms of trust, transparency, openness and honesty. The results provide pharmaceutical marketing managers with insightful and valuable information with respect to the role or social media impact on the PRM. The AHP model, objectives and their relative importance provide valuable information for managers on how to monitor the values that matters to customers the most.

Originality/value

This paper is one of the very few on the PRM and perhaps the first that examines social impact leveraging the AHP model. In addition, this paper contributes to the relationship marketing literature by leveraging a multi-criteria decision-making algorithm to prioritize the most important factors accounting for the PRM strategies.

Direct-to-Consumer Broadcast Advertisements for Pharmaceuticals: Off-Label Promotion and Adherence to FDA Guidelines

BACKGROUND

Direct-to-consumer (DTC) advertisements for prescription drugs in the United States are regulated by the Food and Drug Administration (FDA). Off-label promotion, or the advertisement of a drug for an indication not approved by the FDA, is prohibited. Our objective was to examine the presence of off-label promotion in broadcast DTC ads and to assess their adherence to FDA guidelines mandating fair balance in presentation of risks and benefits and prohibiting misleading advertisement claims.

METHODS

All English-language broadcast DTC ads for prescription drugs that aired in the United States from January 2015 to July 2016 were obtained from AdPharm, an online collection of healthcare advertisements. Ad length was measured and adherence to FDA guidelines was assessed for several categories: key regulatory items, indicators of false or misleading ads, and indicators of fair balance in presentation of risks and benefits.

RESULTS

Our sample included 97 unique DTC ads, representing 60 unique drugs and 67 unique drug-indication combinations. No ads described drug risks quantitatively, whereas drug efficacy was presented quantitatively in 25 (26%) ads. Thirteen (13%) ads, all for diabetes medications, suggested off-label uses for weight loss and blood pressure reduction. The most commonly advertised drugs were indicated for the treatment of inflammatory conditions (n = 12; 18%), diabetes or diabetic neuropathy (n = 11; 16%), bowel or bladder dysfunction (n = 6; 9%), and infections or allergic reaction (n = 6; 9%). More than three-quarters (n = 51; 76%) advertised drugs to treat chronic conditions.

CONCLUSIONS

Few broadcast DTC ads were fully compliant with FDA guidelines. The overall quality of information provided in ads was low, and suggestions of off-label promotion were common for diabetes medications. The impact of current DTC ads and off-label marketing on patient and prescriber decisions merits further scrutiny.

Trade Agreements and Direct-to-Consumer Advertising of Pharmaceuticals

There is growing international concern about the risks posed by direct-to-consumer advertising (DTCA) of prescription pharmaceuticals, including via the internet. Recent trade agreements negotiated by the United States, however, incorporate provisions that may constrain national regulation of DTCA. Some provisions explicitly mention DTCA; others enable foreign investors to seek compensation if new regulations are seen to harm their investments. These provisions may thus prevent countries from restricting DTCA or put them at risk of expensive legal action from companies seeking damages due to restrictions on advertising. While the most recent example, the Trans-Pacific Partnership Agreement (TPP), collapsed following US withdrawal in January 2017, early indications of the Trump Administration’s trade policy agenda signal an even more aggressive approach on the part of the United States in negotiating advantages for American businesses. Furthermore, the eleven remaining TPP countries may decide to proceed with the agreement in the absence of the United States, with most of the original text (including the provisions relevant to DTCA) intact.

The Trans Pacific Partnership Agreement and Pharmaceutical Regulation in Canada and Australia

The Trans Pacific Partnership Agreement (TPP) is a large regional trade agreement involving 12 countries. It was signed in principle in February 2016 but has not yet been ratified in any of the participating countries. The TPP provisions place a range of constraints on how governments regulate the pharmaceutical sector and set prices for medicines. This article presents a prospective policy analysis of the possible effects of the TPP on these two points in Canada and Australia. Five chapters of relevance to pharmaceutical policy are analyzed: chapters on Technical Barriers to Trade (Chapter 8), Intellectual Property (Chapter 18), Investment (Chapter 9), Dispute Resolution (Chapter 28), and an annex of the chapter on Transparency and Anti-Corruption (Chapter 26, Annex 26-A). The article concludes that the TPP could have profound effects on the criteria these countries use to decide on drug safety and effectiveness, how new drugs are approved (or not) for marketing, post-market surveillance and inspection, the listing of drugs on public formularies, and how individual drugs are priced in the future. Furthermore, the TPP, if ratified and enforced, will reduce future policy flexibility to address the increasing challenge of rising drug prices.

How Affiliation Disclosure and Control Over User-Generated Comments Affects Consumer Health Knowledge and Behavior: A Randomized Controlled Experiment of Pharmaceutical Direct-to-Consumer Advertising on Social Media

Background

More people are seeking health information online than ever before and pharmaceutical companies are increasingly marketing their drugs through social media.

Objective

The aim was to examine two major concerns related to online direct-to-consumer pharmaceutical advertising: (1) how disclosing an affiliation with a pharmaceutical company affects how people respond to drug information produced by both health organizations and online commenters, and (2) how knowledge that health organizations control the display of user-generated comments affects consumer health knowledge and behavior.

Methods

We conducted a 2×2×2 between-subjects experiment (N=674). All participants viewed an infographic posted to Facebook by a health organization about a prescription allergy drug. Across conditions, the infographic varied in the degree to which the health organization and commenters appeared to be affiliated with a drug manufacturer, and the display of user-generated comments appeared to be controlled.

Results

Affiliation disclosure statements on a health organization’s Facebook post increased perceptions of an organization-drug manufacturer connection, which reduced trust in the organization (point estimate –0.45, 95% CI –0.69 to –0.24) and other users who posted comments about the drug (point estimate –0.44, 95% CI –0.68 to –0.22). Furthermore, increased perceptions of an organization-manufacturer connection reduced the likelihood that people would recommend the drug to important others (point estimate –0.35, 95% CI –0.59 to –0.15), and share the drug post with others on Facebook (point estimate –0.37, 95% CI –0.64 to –0.16). An affiliation cue next to the commenters' names increased perceptions that the commenters were affiliated with the drug manufacturer, which reduced trust in the comments (point estimate –0.81, 95% CI –1.04 to –0.59), the organization that made the post (point estimate –0.68, 95% CI –0.90 to –0.49), the likelihood of participants recommending the drug (point estimate –0.61, 95% CI –0.82 to –0.43), and sharing the post with others on Facebook (point estimate –0.63, 95% CI –0.87 to –0.43). Cues indicating that a health organization removed user-generated comments from a post increased perceptions that the drug manufacturer influenced the display of the comments, which negatively affected trust in the comments (point estimate –0.35, 95% CI –0.53 to –0.20), the organization (point estimate –0.31, 95% CI –0.47 to –0.17), the likelihood of recommending the drug (point estimate –0.26, 95% CI –0.41 to –0.14), and the likelihood of sharing the post with others on Facebook (point estimate –0.28, 95% CI –0.45 to –0.15). (All estimates are unstandardized indirect effects and 95% bias-corrected bootstrap confidence intervals.)

Conclusions

Concern over pharmaceutical companies hiding their affiliations and strategically controlling user-generated comments is well founded; these practices can greatly affect not only how viewers evaluate drug information online, but also how likely they are to propagate the information throughout their online and offline social networks.

The Conundrum of Online Prescription Drug Promotion Comment on "Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters"

This commentary discusses pertinent issues from Hyosun Kim's paper on online prescription drug promotion. The study is well-designed and the findings highlight some of the consequences of the Food and Drug Administration's (FDA's) decision to deregulate online advertising of prescription drugs. While Kim's findings confirm some of the early concerns, they also provide a perspective of implementation challenges in the ever-changing technological environment.

The Tip of the Iceberg of Misleading Online Advertising Comment on "Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters"

Kim's overview of Food and Drug Administration (FDA) regulatory actions from 2005 to 2014 is a comprehensive analysis of the US regulatory experience with online direct-to-consumer advertising (DTCA) of prescription medicines. This experience is of relevance internationally as online DTCA reaches the English-speaking public globally, despite the illegality of DTCA in most countries. The most common violations were omissions or minimizations of risk information, overstatements of efficacy, unsubstantiated claims, and promotion of unapproved ("off-label") use. Nearly one fourth of violations involved cancer drugs, raising additional concerns about patient vulnerability, limited treatment advance, and high costs. Based on content analyses of online DTCA, these cases likely reflect a small proportion of unbalanced and misleading promotional information available on the web. The FDA is only able to review a small proportion of promotional materials submitted to them, due to limited staffing, and the delay between first posting and regulatory action means that many people may be exposed to messages that are found to be inaccurate and misleading. The sheer volume of online DTCA, combined with the ability for content to shift continually, poses unique regulatory challenges.

Fair Balance and Adequate Provision in Direct-to-Consumer Prescription Drug Online Banner Advertisements: A Content Analysis

Background

The current direct-to-consumer advertising (DTCA) guidelines were developed with print, television, and radio media in mind, and there are no specific guidelines for online banner advertisements.

Objective

This study evaluates how well Internet banner ads comply with existing Food and Drug Administration (FDA) guidelines for DTCA in other media.

Methods

A content analysis was performed of 68 banner advertisements. A coding sheet was developed based on (1) FDA guidance documents for consumer-directed prescription drug advertisements and (2) previous DTCA content analyses. Specifically, the presence of a brief summary detailing the drug’s risks and side effects or of a “major statement” identifying the drug’s major risks, and the number and type of provisions made available to consumers for comprehensive information about the drug were coded. In addition, the criterion of “fair balance,” the FDA’s requirement that prescription drug ads balance information relating to the drug’s risks with information relating to its benefits, was measured by numbering the benefit and risk facts identified in the ads and by examining the presentation of risk and benefit information.

Results

Every ad in the sample included a brief summary of risk information and at least one form of adequate provision as required by the FDA for broadcast ads that do not give audiences a brief summary of a drug’s risks. No ads included a major statement. There were approximately 7.18 risk facts for every benefit fact. Most of the risks (98.85%, 1292/1307) were presented in the scroll portion of the ad, whereas most of the benefits (66.5%, 121/182) were presented in the main part of the ad. Out of 1307 risk facts, 1292 were qualitative and 15 were quantitative. Out of 182 benefit facts, 181 were qualitative and 1 was quantitative. The majority of ads showed neutral images during the disclosure of benefit and risk facts. Only 9% (6/68) of the ads displayed positive images and none displayed negative images when presenting risks facts. When benefit facts were being presented, 7% (5/68) showed only positive images. No ads showed negative images when the benefit facts were being presented.

Conclusions

In the face of ambiguous regulatory guidelines for online banner promotion, drug companies appear to make an attempt to adapt to regulatory guidelines designed for traditional media. However, banner ads use various techniques of presentation to present the advertised drug in the best possible light. The FDA should formalize requirements that drug companies provide a brief summary and include multiple forms of adequate provision in banner ads.

Still the Great Debate - "Fair Balance" in Direct-to-Consumer Prescription Drug Advertising Comment on "Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters"

The above titled paper examined the Food and Drug Administration's (FDA's) warning letters and notice of violations (NOV) over a 10-year period. Findings from this content analysis reinforced what has been the primary issue for prescription direct-to-consumer advertising (DTCA) since its beginning, the fair balance of risk and benefit information. As opposed to another analysis in 2026 about this still being an issue, is there anything that can be done to prevent this problem from continuing?

Considering the Future of Pharmaceutical Promotions in Social Media Comment on "Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters"

This commentary explores the implications of increased social media marketing by drug manufacturers, based on findings in Hyosun Kim's article of the major themes in recent Food and Drug Administration (FDA) warning letters and notices of violation regarding online direct-to-consumer promotions of pharmaceuticals. Kim's rigorous analysis of FDA letters over a 10-year span highlights a relative abundance of regulatory action toward marketer-controlled websites and sponsored advertisements, compared to branded and unbranded social media messaging. However, social media marketing efforts are increasing, as is FDA attention to these efforts. This commentary explores recent developments and continuing challenges in the FDA's attempts to provide guidance and define pharmaceutical company accountability in marketer-controlled and -uncontrolled claims disseminated through social media.

Digital Direct-to-Consumer Advertising: A Perfect Storm of Rapid Evolution and Stagnant Regulation Comment on "Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters"

The adoption and use of digital forms of direct-to-consumer advertising (also known as "eDTCA") is on the rise. At the same time, the universe of eDTCA is expanding, as technology on Internet-based platforms continues to evolve, from static websites, to social media, and nearly ubiquitous use of mobile devices. However, little is known about how this unique form of pharmaceutical marketing impacts consumer behavior, public health, and overall healthcare utilization. The study by Kim analyzing US Food and Drug Administration (FDA) notices of violations (NOVs) and warning letters regarding online promotional activities takes us in the right direction, but study results raise as many questions as it does answers. Chief among these are unanswered concerns about the unique regulatory challenges posed by the "disruptive" qualities of eDTCA, and whether regulators have sufficient resources and oversight powers to proactively address potential violations. Further, the globalization of eDTCA via borderless Internet-based technologies raises larger concerns about the potential global impact of this form of health marketing unique to only the United States and New Zealand. Collectively, these challenges make it unlikely that regulatory science will be able to keep apace with the continued rapid evolution of eDTCA unless more creative policy solutions are explored.

Future Challenges and Opportunities in Online Prescription Drug Promotion Research Comment on "Trouble Spots in Online Direct-to-Consumer Prescription Drug Promotion: A Content Analysis of FDA Warning Letters"

Despite increased availability of online promotional tools for prescription drug marketers, evidence on online prescription drug promotion is far from settled or conclusive. We highlight ways in which online prescription drug promotion is similar to conventional broadcast and print advertising and ways in which it differs. We also highlight five key areas for future research: branded drug website influence on consumer knowledge and behavior, interactive features on branded drug websites, mobile viewing of branded websites and mobile advertisements, online promotion and non-US audiences, and social media and medication decisions.