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| Journal of the New Zealand Medical Association,
22-August-2003, Vol 116 No 1180
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New Zealand deserves better. Direct-to-consumer advertising
(DTCA) of prescription medicines in New Zealand: for health or for
profit?
Les Toop and Dee Richards
Direct-to-consumer advertising (DTCA) of prescription
medicines is legal only in the US and in New Zealand (by default). In both
countries the growth in this form of drug promotion has been spectacular. Why is
this, and does it matter? The answer to the first question is simple – it
is very effective both at increasing total market size and in encouraging
widespread switching to advertised brands, which are usually new and more
expensive.1 The answer to the second question
depends upon perspective. It clearly matters to many in the pharmaceutical,
advertising and print-media industries. The strength and nature of the response
by these groups to try to prevent a call from Academic General Practice to the
Minister of Health to reconsider banning DTCA2
shows how important a marketing strategy it has become. It should also matter to
us as health professionals, as it has important consequences for public
health.
All the evidence from studies in both countries suggests
that when patients ask for a particular drug more often than not they will
receive it, even when the prescribing doctor feels pressured and or
uncomfortable in so doing.3–6 It is naive
to suggest that doctors should simply resist the pressure to prescribe.
‘Inappropriate prescribing’ is not limited to the prescription of a
medicine that is completely unsuitable for the patient. It can also mean the
prescription of an equivalent yet more expensive medication than the one already
used, which the consumer has been misled into believing is superior, or
prescription of a new medication that is no more effective in treating the
condition than older medications, but for which less is known about long-term
unwanted effects. Clinicians, far from being paternalistic, struggle with the
tension of practising evidence-based medicine whilst remaining patient centred
and incorporating patient preferences in a shared decision about treatment
options. The use of patients as de facto salespeople for a particular brand-name
product is as effective as it is obvious.
Many of the reasons why DTCA is, on balance, harmful to the
public health are set out in a report submitted to the Minister of Health in
February (summarised in Table 1).7 The main
conclusions and recommendations of the report are shown in Table 2.
Table 1. Characteristics of direct-to-consumer
advertising (DTCA)7
Table 2. Conclusions and recommendations of report to
the Minister of Health7
There are two crucial issues that are at the heart of the
heated and often ill-tempered debate about the net worth of this form of
advertising. First, does (or indeed can) DTCA provide information that is
educational and of more use than harm? Second, is it possible to regulate DTCA
effectively to prevent the public from being misled?
Unfortunately, the advertising/marketing and the health
paradigms are so very far apart that dialogue and compromise are far from easy.
The language of the marketing and advertising arms of industry is characterised
by ‘bottom lines’, ‘market share’, ‘brand
loyalty’ and ‘disease
creation’.8,9 These are concepts foreign
to most health professionals, whose framework is the care of individuals in
patient-centred and evidence-based paradigms. Most clinicians are well aware of
their additional wider responsibility to use finite individual and public
resources wisely in a health system in which demand will always outstrip supply.
It is, therefore, understandable if disappointing that senior representatives of
the advertising and pharmaceutical industries have become frustrated and angry
at those who dare to suggest that the diet of misinformation that is advertising
is harmful to the public health and should be stopped.
Claims that DTCA provides useful and balanced information
are at odds with the industry’s lamentable track record both here in New
Zealand7 and in the
US.1 Many pharmaceutical companies have been
taken to task repeatedly for misleading the public and prescribers. Given the
purpose of brand advertising, it is perhaps not surprising that efficacy is
generally overemphasised, side effects and lack of long-term safety data are
minimised, and cost is rarely mentioned. There is usually no comparison with
other available treatments, which in many cases involve non-pharmaceutical
solutions. Studies that have systematically assessed the usefulness and
understandability of DTCA have uniformly found their educational value to range
from minimal to
misleading.10–13
Proponents of DTCA in New Zealand claim that advertisers
operating under a tighter regulatory framework and with appropriate penalties
would provide ‘fair balance’. However, this seems unlikely given the
profit-driven need for the industry to produce global blockbusters out of new
drugs, the vast majority of which offer little if any advantage over existing
products and are pseudo innovations.14–16
It is also hard to imagine what level of penalty would provide an
‘appropriate’ disincentive rather than being regarded simply as
another necessary business cost for a multibillion-dollar global corporation.
For example, how likely is it that the manufacturers of COX 2 inhibitors would
want to advertise the facts about their products in a fair and balanced way? Do
they advertise that their products, at several times the cost, are
at best no more effective than
traditional anti-inflammatories? That they may have marginally better
gastrointestinal tolerance but, for reasons that are unclear, a possible
pro-thrombotic effect, and increased rate of myocardial
infarction?17,18 No, instead these drugs have
huge marketing budgets funding advertising campaigns that have repeatedly been
found to be misleading and
unbalanced.1,7
The European Union Council of Health Ministers recently
reaffirmed last year’s decision by the combined European Parliament to
reject the proposal by the European Commission to allow DTCA to start in Europe.
The right to advertise in this manner has once again been overridden by the need
to protect the public health.
New Zealand has a self-regulatory system that clearly has
not prevented public exposure to misleading
advertisements.7,19 The US has a central
monitoring system that has no teeth and cannot
cope.1 Provision of centrally funded
comprehensive and independent consumer health information to replace DTCA would
represent a much more rational use of New Zealand’s scarce health
resources than setting up another expensive, central regulatory framework that
would almost certainly be ineffective at controlling DTCA.
In these very columns we have been reminded repeatedly over
the last few years that competitiveness, commercialism and marketing are not
compatible with a health system focused on the care of individuals and the wise
use of finite resources.
It is time that we recognised DTCA for what it is. It has
nothing to do with education and all to do with profit. New Zealand often leads
the world in social innovation. We have that opportunity to do so again by
legislating to replace this pernicious influence with world-class, independent
and comparative consumer health information that is free of commercial
influence.
Now is the time to make your views known to the
politicians.
Author information:
Les Toop, Professor of General Practice; Dee A Richards, Senior Lecturer,
Department of Public Health and General Practice, Christchurch School of
Medicine and Health Sciences, Christchurch
Correspondence:
Professor Les Toop, Department of Public Health and General Practice,
Christchurch School of Medicine and Health Sciences, P O Box 4345, Christchurch.
Fax: (03) 364 3637; email: les.toop@chmeds.ac.nz
References:
ResponseThe title of Professor Toop’s
article ‘For health or for profit’ accurately sums it up, but offers
a false proposition – that health and profit are inconsistent with each
other.
Manufacturers of medicines, along with suppliers of
high-tech medical equipment are part of a market economy, which, along with good
government, has delivered major improvements to public health over the past 200
years. These include clean water, modern sewerage systems, and more efficient
food production methods, as well as the new medicines and medical technology
that have all helped make our lives longer, healthier and more
interesting.
Making profit is an essential element in the mix. It is the
prospect of making better than average profits that stimulates pharmaceutical
manufacturers to spend hundreds of millions of dollars on researching possible
new and better products. Sometimes the expenditure yields nothing of real value
– that is the risk the companies must take.
The fact that pharmaceutical companies may be driven
substantially by profit in no way diminishes the magnificent contribution they
make to the health of our society. The fact that, through DTCA, they also hope
to sell more of their products should not be seen as negative. There are enough
checks and balances in the system to ensure no damage is done to the health
budget or consumers.
First, a prescription is necessary and I am not inclined to
believe GPs are so weak they will yield to any pressure from their patients. If
that were the case we would have to be concerned about their response to
non-DTCA-created requests also. Second, through its various programmes and iron
grip over the availability of medicines, PHARMAC has effective control over the
cost of their usage.
Professor Toop labours the point about the pharmaceutical
companies’ profit motive, but seems oblivious to the fact that doctors,
specialists and even medical academics all in their own way have vested
interests as well, and have been effective lobbyists for their interests over
the years.
However, the group that is most important, the consumers,
receive little attention in his report to the Minister and the article above.
Consumers are not demanding a ban on DTCA and many appreciate the information
and stimulus DTCA gives them to seek medical advice.
The advertisements are often criticised because they do not
contain all the information that is necessary to make an informed decision. This
criticism can be made of most advertisements, particularly those on television.
As a consequence, consumers have become discerning about claims made by any
advertiser. However, there is scope for pharmaceutical companies to improve the
quality of information made available in their advertisements, and this issue
could be addressed by the industry voluntarily upgrading its codes of practice,
which it has been doing, or through a revision of the existing government
regulations.
In summary, the Government plays a key role in ensuring that
safe medicines are available to New Zealanders, that only qualified people can
permit access to them, and that subsidies are available to ensure that no one is
deprived of medicines through lack of income.
The real health issues are obesity, lack of exercise, and
other lifestyle-created medical problems. None of these are susceptible to a
quick fix, but they deserve far more attention than a non-problem like
DTCA.
Barrie Saunders
Public Policy Consultant Saunders Unsworth Limited, Wellington |
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