Drug ads were recently targeted by the American Medical Association as a health hazard. Food labels push the same emotional buttons to mislead the consumer. This blog helps filter out the spam and learn the facts about what we put into our bodies.
If you just want the practical stuff, skip to the last section of this blog (“Avoid Being Suckered…“).
We’ll start by discussing prescription drug ads, then move along to food. Drug ads are the more serious problem because the drugs themselves, if improperly used, can literally kill us. In addition, there’s a lot of money in the pharmaceutical business, so its marketing is more pervasive and more resistant to government regulation.
History of Drug Ads in the U.S.
The U.S. has a colorful history of drug advertising. Patent medicines claiming cures for every disease were heavily advertised in print media in the 19th century.
The modern history of drug ads begins with the 1938 Federal Food, Drug and Cosmetic Act (FDCA), which gave the Food and Drug Administration authority over drug labeling; however, drug advertising still came under the Federal Trade Commission. This divided command was resolved by moving all drug jurisdiction to the FDA with the 1962 Kefauver Harris amendment to the FDCA.
Both before and after this change, manufacturers promoted drugs and medical devices exclusively to physicians with the assistance of “detail men” who would deliver drug samples, branded office accessories and printed material. It was not until 1981 that the pharmaceutical industry first proposed direct to consumer (DTC) marketing of prescription drugs.
Drug Ads: The Inherent Contradiction
When you think about it, DTC drug ads make little sense.
Prescription drugs are products that can only be obtained from a licensed medical professional. The reason for this restriction is that it takes professional training to recognize when a person’s condition requires a particular treatment. Drugs can be dangerous unless administered at the right dosage for the diagnosed disease.
However, DTC drug ads are addressed to consumers who have little or no medical knowledge. Many of those consumers pester their doctors for a heavily advertised medication, and get angry if the doctor tries to explain that the drug in question carries unacceptable risks, or is not appropriate for their particular case. Truly in this case, “a little knowledge is a dangerous thing.” The Wilkes et al study of drug ads described below begins with an imagined dialogue between patient and physician that dramatizes the problem just described.
Drug ads are so effective at convincing the consumer to buy the product that doctors often find it easier to go along with the patient’s desire, so long as it will not harm them. For example, from 1998 to 1999 doctors wrote 34.2% more prescriptions for the 25 highest-selling drugs advertised direct-to-consumer, compared with only a 5.1% increase for all other prescription drugs. Wilkes states that these doctors are responding to the patient not as a medical professional, but rather “as a waiter in a restaurant: If it’s on the menu and you’re not allergic to it, you can have it.”
Before we condemn the doctor too much for acting like a waitron, we should note the conflicting factors that the doctor must consider. Medicine is partly an art, because it relies on the doctor’s judgment and experience as much as his or her training. Moreover, deciding to prescribe a particular drug is not a black-and-white decision: if the doctor prescribes a drug that the patient doesn’t want, the patient may not get well because of noncompliance, or as the result of a negative placebo effect. What’s worse, a persistent patient will simply shop around until they find a doctor who will give them the drug that has the most convincing TV commercial. Thus if the drug is not out-and-out harmful to the patient, a doctor may well decide that prescribing it is the only practical path that will help the patient toward health.
This contradiction was recognized when DTC drug ads were first proposed. The drug industry was quick to defend DTC ads as fulfilling a valuable function by educating the consumer. A typical 1999 pharma position paper was published in the Journal of the American Medical Association under the appropriate heading “Controversies.”
U.S. doctors were not persuaded by big pharma: in a survey taken around the same time, over four-fifths of physicians believed DTC ads were not a good idea, tending to increase costs and promote a “misleading, biased view” of advertised drugs.
Most countries in the world have looked at this situation and concluded that drug companies have no business targeting consumers with their advertising. Only the U.S., New Zealand and Brazil presently allow DTC prescription drug ads.
Drug Ads Today
After years of public hearings, in 1997 the FDA issued guidelines for DTC broadcast drug ads. Since that date, spending on prescription drug ads has grown rapidly. DTC drug ads totaled $3 billion in 2012 and grew to $4.5 billion in 2014.
This is a lot of money, but it’s only a portion of total drug marketing expense. Direct marketing to health care professionals dwarfs the DTC costs (eight times as much in 2012). The total expense of all kinds of drug marketing actually exceeds R&D as a cost item in nine of the largest ten pharma companies. Despite large promotional expenditures, pharma enjoys a startling 19% profit margin.
Science of Drug Ads
Because DTC drug ads rapidly became prominent (and an aggravation to family doctors), researchers have been studying their effects. When I looked at the literature, three articles stood out because they thoughtfully reviewed and analyzed large numbers of studies to look for findings that were widely confirmed. Here are some highlights of these articles, plus a newer article that provides still more valuable information:
Wilkes, Bell and Kravitz (2000):
– The authors analyzed 320 drug ads for 101 brands in 18 popular magazines from 1989 through 1998. DTC ads tended to play up the positive features of a drug and downplay the negative or unknown aspects. Side effects, for instance, were almost always discussed last. Headings and subheadings usually played up benefits; side effects were typically buried in the narrative. Thus DTC ads were strongly biased to sell the product, not to educate the consumer.
– Consumers were asked about their assumptions when they see drug ads. Here are four statements that are false but were widely believed: (1) 50% believed that DTC ads had to be submitted to the FDA for prior approval; (2) 43% believed that only “completely safe” drugs could be advertised to consumers; (3) 22% thought that only drugs without serious side effects could be advertised; and (4) 21% believed that only “extremely effective” drugs could be marketed directly to consumers. Thus many consumers are misled into believing that the Federal government has endorsed or approved the products they see in drug ads.
Frosch et al (2005):
– TV drug ads were found to be even worse than magazine ads in misrepresenting the product: (1) 95% of TV drug ads relied on emotional appeals, not logic; (2) No ads mentioned lifestyle change as an alternative to drug use, although 19% mentioned it as an adjunct to medication; (3) Ads often framed drug use in terms of losing (58%) or gaining control (85%) over some aspect of life; (4) 78% of ads promised social approval as a result of using the drug; and (5) 58% of ads described the product as a medical breakthrough, which tended to “distort and inflate” consumer expectations.
– The drug ads “show characters that have lost control over their social, emotional, or physical lives without the medication.”
– The ads were deemed to have little educational value and to oversell the benefits in drugs in a way that is incompatible with overall population health.
– This 2012 study looked at 13 additional studies and determined that the findings of 2005 had continued and deepened.
– DTC drug ads were found to have shifted prescriptions toward less appropriate drugs, more expensive drugs, and less cost-effective drugs.
– Drug manufacturer claims of improved patient adherence, improved treatment quality and earlier provision of needed medical care were not substantiated by independent studies.
“Blinded with Science” (2016): More recently, Tal and Wansink showed that drug descriptions that include graphs or a chemical formula are perceived as more convincing and trustworthy, even when the additions add no new information to the description. Moreover, people who believe more strongly in the validity of science are more likely to trust information when it has the appearance of being “scientific.” Not only are we easily deceived, but our personal values help us to deceive ourselves!
Food Labels: Psychological Distraction
Food marketers have been just as clever about labeling foods to promote more sales. Scientists have studied consumer response to food labels and advertising to tease out the factors that make them effective for the advertiser. The same tricks are used in drug ads, especially those appearing in print media.
A February 2016 article by Koenigstorfer and Baumgartner studied how people react to foods that are labeled as being good for “fitness” – that is, good health. Participants were offered either a trail mix labeled “trail mix” or a trail mix labeled “fitness trail mix” and showing a pair of running shoes on the label. People trying to lose weight actually ate more of the trail mix when it was called a “fitness” snack.
Similarly, when people had eaten the snack and were given the chance to use a stationary bike, those who had consumed the “fitness” trail mix exercised for a shorter time than those who had eaten the ordinary trail mix.
Thus in both cases, the fitness-branded food label allowed that snack to serve as a substitute for dieting or exercise. Consuming the food with fitness labeling gave people internal “permission” to cut corners on their diet or on their exercise activity.
Internal permission also helps explain another feature of consumer behavior. An article from July 2015 by Karmarkar and Bollinger studied supermarket shoppers who use reusable grocery bags. The researchers used scanner data from a California location of a major grocery chain and found one expected result, and one surprise. Reusable-bag shoppers purchased more organic foods than other shoppers, which was expected since bringing their own bags signaled a concern for the environment. However, these eco-friendly shoppers also bought more candy and chips, which the authors classed as “indulgent” foods. Using the reusable bag seemed to give shoppers free license to indulge by helping them “feel more deserving and less guilty about doing so.”
If drug ads seduce us into demanding prescriptions for heavily advertised drugs, food marketing helps us deceive ourselves. Merely labeling a food as healthy encourages us to eat too much of it and become couch potatoes. And the worthy act of bringing a reusable bag to the market gives us internal permission to negate our environmental friendliness by pigging out on chips and sweets!
The AMA Weighs In
It seems that today’s barely controlled drug ads serve big pharma at the expense of both consumers and medical doctors. Where, you ask, is the American Medical Association, which claims to speak for these doctors?
Well, it takes time for a big organization to move. In November 2015, eighteen years after the FDA issued its rules for DTC drug ads over TV, the AMA issued a position paper. The title of their press release gives the bottom line: AMA Calls for Ban on Direct to Consumer Advertising of Prescription Drugs and Medical Devices. The statement itself makes some additional points: that the proliferation of DTC drug ads drives demand for expensive treatments despite the clinical effectiveness of less costly alternatives; and that drug company marketing costs contribute to escalating drug prices.
The New York Times weighed in by publishing an opinion piece less than a month later, advocating the banning of consumer drug advertising and reviewing the scientific data showing that drug ads lead to more prescribing and less appropriate treatments.
I found the Times article particularly interesting for its large number of passionate comments, almost unanimously endorsing the recommendation of the essay. Here are a few commenters and the nuggets that they contributed:
– Michele: “…marketing of drugs… introduces an interfering third party with a conflict of interest directly into the patient/physician therapeutic relationship.”
– Carol: “…my husband, an oncologist, often has patients who absolutely insist on drugs they have seen advertised or looked up on the internet. It often takes a time-consuming explanation as to why that drug is not in the best interest of the patient, but believe me, they can get angry if they don’t get their way!”
– Healing Resonance: “I consistently tell my clients to mute all drug commercials. We also need to realize as a society that what we see on television is not REAL life. Living is what we do when we’re not watching television.”
– Ed Blau: “As a retired physician I considered it a duty to know about the drugs I prescribed and to know if the newer drugs were any better than what I was currently prescribing. I never saw a drug detail person. If I did not know more than they did I should not be seeing patients. And if patients thought that I should prescribe a drug they saw advertised rather than the one I thought was best for them they were free to find another physician.”
– Rima Regas: “…the most harmful effect of direct drug ads has been the desensitization of the consumer to the most important part of the ad: the disclaimer. Most people shut that really fast part out, when it is about the only part they should intently listen to. The drugs’ side-effects should scare people away from asking to try them and the ads are having the opposite effect.”
With respect to this last point: the Wilkes study found that consumers are very selective about what they notice on TV: people who had been diagnosed with a disease paid much more attention to drug ads discussing treatments for that disease.
I will step out on a limb and make a prediction, which could be tested by further research. I predict that a careful study would reveal that these selective viewers, the people who should pay the most attention to the disclaimers and warnings, are more likely to absorb the emotional appeals built into the ad and shut out the disclaimers. I believe that their identification with the actor and their wish for a cure will cause them to gloss over and ignore the dire warnings of side effects of the drug. Moreover, their desperation for an easy fix will make them that much more insistent when they visit their physician.
Avoid Being Suckered by Drug Ads & Food Labels
The Times article commenters as well as thoughtful journalists expect that the rules concerning drug ads are not likely to be tightened up during our lifetimes. After all, a defective drug had to kill more than a hundred patients before Congress was willing to pass the FDCA law. Therefore misleading marketing is likely to continue, and increase.
Given this situation, how can we extract the educational information (if it exists) from drug ads and food labels without becoming victims to the cold-hearted marketing pitch that motivates the advertising expenditure?
In one word, awareness. We must be aware of the advertisers’ tricks, and of the tricks our own minds play on us. These two steps can help:
Drug Ads: Focus on the Side Effects. Try to block out the smiling, beautiful, improbably healthy models in televised and printed ads and focus your attention on the ominous description of side effects, the words that often include “may cause death.” Later, after the rosy glow of the ad has faded, ask yourself, has this drug been used long enough to reveal all the undesirable side effects? And are those side effects worth the benefit of the drug? Unless both these answers are “yes” you can dismiss that drug from consideration. If the answers are “unsure,” then at least you have desensitized yourself from the emotional pitch and can have a more rational discussion with your doctor about the drug.
Food Ads & Food Labels: Ignore “Health” Words and Pseudo-Science. Be aware of the signals in food ads and food labels that relax you and give you permission to misbehave in other ways. “Healthy,” “natural,” “organic,” and “fitness” labeling is a red flag that you should beware taking too much of that product. And any scientific-looking features in the advertising – graphs, chemical formulas, “improvement by” percentages – should also be red flags, unless you are expert at detecting marketing half-truths and exaggeration.
Have drug ads ever caused you to ask your doctor about a particular drug? Have food labels ever made you feel so virtuous that you ate more of the product?
– “Hand and Pills” by johnny_automatic on openclipart.org
– “Bonnore’s Electro Magnetic Bathing Fluid” label from Wikipedia
– “Prescription Bottle and Pills” by algotruneman on openclipart.org
– “Pie Graph” by jabernal on openclipart.org
– “Caduceus (Rod of Asclepius)” by global quiz on openclipart.org