In the United States, direct-to-consumer advertising (DTCA) for prescription medications has become the norm. Pharmaceutical companies and proponents of DTCA would have us believe their motives are altruistic: empowering the consumer with information about diseases and pharmaceutical treatments, and improving diagnosis and treatment by encouraging informed discussions between patients and their medical providers.
However, DTCA seems to be more about the desire of the pharmaceutical industry to dominate the health market and make a profit.1,2,3 This is not unexpected; in fact, for several decades the pharmaceutical industry has had a hand in molding the field of health care in their favor. This is especially true in psychiatry, as described extensively in Whitaker & Cosgrove’s Psychiatry Under the Influence.4
I’ll begin with a brief review of the history which led to the development of DTCA, an assessment of its impact on consumer perception and empowerment, and a consideration of an alternative approach used in other countries. I’ll then establish a basis for arguing that the public deserves to receive health-related information and education through an independent and objective source, rather than pharmaceutical company advertising.
The History of DTCA
Prior to 1905, when seeking to obtain medication in the United States, there was little distinction between the doctor and the pharmacist. Essentially all medications could be obtained with or without a prescription.² The American Medical Association (AMA) perceived this ability to essentially self-prescribe as a threat to the medical profession. In response, they established the Council on Pharmacy and Chemistry (CPC) to establish and evaluate drug standards, as well as to advocate for doctor-prescribed drugs by both discouraging consumer directed advertising and encouraging physicians to only prescribe medications aimed specifically toward the medical profession.
Over the next several decades, pharmaceutical advertising was redirected toward the medical community. The US Food and Drug Administration (FDA) established advertising regulations to improve the accountability of pharmaceutical companies by requiring that drug information on packaging and in advertisements provide the name, dosing instructions, and drug composition—including the presence and quantity of harmful substances, as well as the risks and benefits of taking the medication. Exclusive access to this information enabled the medical profession to gain prestige and power, and it became common practice by the 1960s for doctors to withhold diagnostic and treatment information from patients.²
By the 1980s, pharmaceutical companies were essentially courting medical providers, providing them with free gifts and professional opportunities in the promotion of their products.² Meanwhile, to increase efficiency and reduce costs, managed healthcare was being developed to link patients through insurance to healthcare providers and medical facilities. By way of this initiative, patients acquired a greater voice in their medical care and consumer organizations began to demand that patients be informed of treatment and medicinal options.¹,²
Pharmaceutical companies, turning their attention toward the consumer once again, used the growing distrust in the medical community to promote the idea of a partnership with the patient to educate them about common diseases and available pharmaceutical interventions, and to facilitate informed conversations with medical providers.² They claimed this direct-to-consumer advertising would lead to earlier diagnosis, better compliance with treatment, and would enable equitable consumer access to health information.¹,³
However, spending on pharmaceutical advertising skyrocketed from $55 million in 1991 to $4.5 billion in 2014. Additionally, the loosening of advertising restrictions in 1997 allowed full drug information summaries to be replaced by brief statements of the main risks along with a reference as to where further information could be accessed—providing just enough information to influence the consumer to advocate for a particular drug, but not enough to enable fully informed healthcare decisions.5,²
In fact, not only do drug companies occasionally prime markets for the release of new drugs by promoting and exaggerating the prevalence of associated diseases or conditions in “public awareness campaigns,” but subsequent advertisements exploit the air of anxiety this produces to push their product.6
Impact on Consumer Perception
Television and internet advertising now dominate the market, enabling the use of visual images to persuade consumers. In pharmaceutical ads which typically feature healthy looking, but pained and unhappy people, generic symptomatology and minimal risk information is rapidly fired off as the viewer is distracted with images of the subject happily engaged in an ideal life (supposedly all due to the advertised medication). This leads the consumer to believe that their own potentially normal experiences are, in fact, pathological and that remedy through medication is quick and efficient.²,⁶,7
Contrary to what pharmaceutical companies would have us believe, these advertisements do not seek to educate and empower the consumer with accurate information regarding disease and potential treatment options, and there is no evidence that it improves health care.³ Nowhere do they accurately portray realistic symptomatology, particularly with regard to mental illnesses in ads for psychotropic medications; nowhere are lifestyle changes, holistic interventions, data regarding treatment efficacy, or older and less expensive medicinal choices emphasized.³
At times, ads do compare drugs to newly marketed competitors, though studies have shown these ads can affect the perception of benefit-risk balance by implying greater efficacy and minimising risk.⁷ These studies concluded that consumers make inferences when viewing this type of ad which cause them to misremember, thinking that what they inferred had actually been stated in the ad. In addition, an FDA survey showed that nearly a third of consumers nationwide believe that if a medication is advertised on television, it must be safe, thereby minimizing, or even dismissing, the message of the brief risk statement.³
These manipulations can serve to undermine the patient-doctor relationship in many ways: precious time can be misdirected away from discussing important and relevant healthcare; trust in the physician can be damaged when requested drugs are not prescribed, or through negative consequences resulting from unnecessary prescriptions; patients may consciously or unconsciously mimic symptoms, believing they are suffering from a disease they do not have; they can contribute to the overmedicalization of symptoms and dismiss the contribution of environmental factors; and can undermine doctor recommendations for alternative approaches to treatment.¹,²,⁶,⁷
Thus, under the guise of educating and empowering the consumer, DTCA serves to intentionally mislead the public in order to maintain dominance in the field and to turn a profit, a view that is supported by the fact that twice as much is spent on pharmaceutical marketing as on product research and development.8
Alternatives Across the Globe
The United States is not alone. New Zealand engages in DTCA as well, though other countries have banned DTCA due to regulation and ethical concerns similar to those of critics in the United States.¹,⁸ This does not deter the pharmaceutical industry from trying to expand their market via DTCA. In 2005, the United States attempted to include DTCA as part of the Australian-US Free Trade Agreement (AUSFTA), requiring Australia to allow pharmaceutical manufacturers to advertise via websites to health professionals and consumers.⁸ The small phrase, “as is permitted to be disseminated under the Party’s laws, regulations, and procedures,” provided the necessary loophole for Australia to accept the agreement without adopting DTCA. This phrase was noticeably omitted from the next trade agreement with South Korea.⁸
Apparently as a compromise, several other countries have adopted disease-awareness advertising (DAA) through which pharmaceutical companies provide general information about diseases and treatments, without naming specific drugs.¹ While seemingly better than DTCA, as it excludes specific drug marketing, DAA is not without its own ethical dilemmas. Critics argue that DAA encourages unnecessary, expensive, and/or intrusive medical testing and is still used to prime markets for product release when drug companies partner with disease support groups for publicity events. Furthermore, they argue that pharmaceutical companies merely circumvent bans on consumer directed marketing by using less obvious branding techniques, such as product placement and identifiable logos and “spokes-characters” to indicate company identity.¹
In the end, the effect is the same—pharmaceutical companies dominate and influence public access to health information and education, without really providing either. Instead of being empowered to advocate for better healthcare by being presented with neutral information and respected for the self-determination to evaluate it, it is through the duplicitous nature of marketing that people are deliberately manipulated via information management in order to sway their decision, with potentially life-altering consequences.³
As with any corporation in a capitalistic society, pharmaceutical companies have the right to advertise their products, but the job of educating the public on common medical conditions and the range, efficacy, benefits, and risks of potential treatment options should be undertaken by an independent and objective government health agency, not a for-profit, multi-billion dollar industry with a conflict of interest.
