It is increasingly important to understand the effects that drug promotion has on prescribing and the use of medication given the growing amounts of money companies are devoting to this activity. In 2002, almost US$21 billion was spent on promotion in the USA, including over US$2.6 billion on direct-to-consumer advertising (DCTA)i. These amounts are at least 30 times what national governments spend on drug information (for example, in Italy: US$4475/doctor by the pharmaceutical industry versus US$180/doctor by the government)ii. In Canada in 2000 there were over 3.4 million visits by sales representatives to doctors, leaving behind 21.5 million drug samplesiii and in the USA companies organized over 300 000 events for doctorsiv. Sales representatives are frequently the only source of information about medicines in developing countries where there may be as many as one representative for every five doctorsv.
i Canadian Medical Association Journal 2003;169:699.
ii Centro Studi Farmindustria, Indicatori farmaceutici, Farmindustria, Rome, 1998, p. 186.
iii CBC Disclosure, Targeting doctors. Graph: top 50 drugs by total promotional dollars. Available at: www.cbc.ca/disclosure/archives/0103_pharm/resources.html
iv Scott-Levin. Rx’s and RSVP’s: pharmaceutical companies holding more physician meetings and events. July 9, 2001. Available at:
v Lexchin J. Deception by design: pharmaceutical promotion in the third world. Penang: Consumers International, 1995.
Attempts to control promotion have largely relied on a combination of voluntary codes adopted by industry associations and medical organizations. On the surface, voluntary self-regulatory codes from the pharmaceutical industry may look like a sensible approach to controlling the promotional activities of companies; lacking government-industry adversariness, they have the potential to be a more flexible and cost-effective option. In a highly competitive industry, the desire of individual companies to prevent competitors from gaining an edge could be harnessed to serve the public interest through a regime of voluntary self-regulation run by a trade association. However, like many theories this one proves to be unsupported by the evidence. The mission of trade associations, such as Pharmaceutical Research and Manufacturers of America (PhRMA), is primarily to increase sales and profit. From the business perspective, self-regulation is mostly concerned with the control of anti-competitive practices. Therefore, when industrial associations draw up their codes of practice they deliberately make them vague or do not cover certain features of promotion to allow companies a wide latitude. Many misleading advertising tactics are good for business. As a result voluntary codes tend to be reactive, they lack transparency, they omit large areas of concern, and they lack effective sanctions.
Codes from medical associations may have stronger provisions but they are unenforceable and rely on moral suasion for their power. In the few countries where promotion is directly controlled by government, resource limitations mean that only a small fraction of activities can be monitoredvi.
vi Lexchin J, Kawachi I. Voluntary codes of pharmaceutical marketing: controlling promotion or licensing deception. In: Davis P ed. Contested ground: public purpose and private interest in the regulation of prescription drugs. New York: Oxford University Press, 1996:221-235.
If promotion leads to better prescribing, more rational use of medications or improved cost-effectiveness then there would be no concern. While the evidence is not conclusive, what there is all points in the direction of a strong association between reliance on promotion and less appropriate overall use of prescription drugsvii. Heavy promotion of new drugs leads to widespread prescribing and use before the safety profile of these products is fully understood. Newer, more expensive medicines displace older, less costly ones without any evidence of an improvement in therapeutic outcomesviii.
vii Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000;283:373-380.
viii Lexchin J. Should doctors prescribe new drugs? International Journal of Risk and Safety in Medicine 2002;15:213-22.