Since the introduction of direct-to-consumer advertising of prescription medicines (DTCA) in the USA in the 1980s, there have been phenomenal increases in spending on it. One estimate was that in 1999, US$1.6 billion was spent on DTCA41.
Petroshius et al.42 describe the results of a questionnaire delivered to doctors (general practitioners, family practitioners, internists and dermatologists) by sales representatives as part of their normal visits. They found older doctors and internists to be less supportive of advertising of drugs and cosmetic drugs than other doctors. This was especially the case with DTCA. Those aged over 50 had a negative response to DTCA (mean response was 2.84 on a scale from 1 for strongly agree, to 5 for strongly disagree). The authors found that doctors’ attitudes towards DTCA were good predictors of whether they paid attention to such advertisements, and how they said they would respond to patient enquiries and requests for advertised drugs. This study obviously excluded doctors who do not receive sales representatives.
Cutrer and Pleil found largely negative attitudes towards DTCA of prescription medicines among the Texas doctors they surveyed43. However their response rate was very low (17%). Doctors felt that DTCA would increase the demand for drugs, and increase questioning by patients.
Lipsky and Taylor44 surveyed a 2% sample of active members of the American Academy of Family Physicians about their attitudes to DTCA. Doctors reported an average of 6.9 patients in the previous six months who requested a specific prescription drug, although the article is not explicit about whether doctors were asked specifically about requests that resulted from DTCA. Eighty per cent of those surveyed were opposed to print DTCA and 84% opposed to broadcast DTCA. While there was some agreement about possible positive outcomes of DTCA (56% agreed that it encourages patients to seek medical advice for conditions that may otherwise go untreated, and 73% that it alerts patients to new products), there was also consensus about possible negative outcomes (89% disagreed that DTCA enhances the doctor-patient relationship, 71% agreed that DTCA pressures doctors to use drugs they might not ordinarily use, and 72% felt DTCA discourages the use of generics).
CONCLUSION: Doctors are largely opposed to DTCA.
Lipton, a public relations executive from the USA, reports on a survey of consumers’ attitudes to DTCA45. The methodology of the study is not described. Half of the people thought that DTCA would provide them with more information about prescription drugs. Those who were better educated, younger, and those with higher incomes were less likely to feel that DTCA would increase their knowledge about specific drugs.
Bell, Kravitz and Wilkes46 surveyed 329 adults in Sacramento, California, about their awareness, knowledge and attitudes to DTCA. They asked whether people remembered advertisements for 10 different drugs, and found recognition varied between 8% and 72% for different drugs. Men reported seeing fewer advertisements than women. There was greater awareness of advertisements amongst sufferers of the conditions treated by the advertised medicines. More positive attitudes to DTCA were correlated with greater awareness of DTC advertisements. The authors found significant public misconceptions about the regulatory framework for DTCA. Fifty per cent of respondents believed that DTC advertisements had to be submitted to the government for prior approval, 43% thought that only completely safe prescription drugs could be advertised to consumers, 21% thought that only extremely effective drugs could be advertised to consumers, and 22% thought the advertising of prescription drugs with serious side-effects was banned. None of these beliefs are true. People from minority ethnic groups were more misinformed than whites. Positive attitudes towards DTCA were positively correlated with these misconceptions.
Prevention magazine carries out regular surveys which include consumers’ knowledge or and attitudes to DTCA. Telephone interviews with a representative sample of 1,222 adults in the USA were described in the 2000/2001 report41. Lower levels of awareness of DTCA advertising (i.e., reporting ever having seen a DTC advertisement) were found amongst ethnic minorities, low-income consumers, and those not taking prescription medicines. Ninety-one per cent of respondents reported having seen an advertisement for at least one of 10 highly advertised medicines (such as Claritin, Xenical). Fifty-seven per cent of consumers thought DTCA gave them the necessary information to ask their doctors about the risks of the medicines (62% for asking about benefits).
Magazine Publishers of America47 surveyed allergy sufferers in the USA. In their sample, 34% had seen advertisements for allergy medicines in magazines, while 36% had seen such advertisements on TV. Nineteen per cent were able to identify the brand for advertisements in each medium. Since less is spent on magazine advertising than TV advertising, the authors argue that advertising in magazines is more cost-effective. They also report that the perceived believability of advertisements for medicines has declined since restrictions on DTCA were relaxed in 1997.
Maddox and Katsanis48 surveyed consumers in a Canadian city that was exposed to DTCA advertising from the USA. They constructed two scenarios involving a fictitious drug. Patients who were given the scenario where they heard about the drug through DTCA, asked their doctor for it, and received a prescription, were more confident in their doctors than those whose scenario was that they heard about the medicine from their doctor first. This study had a rather low response rate, and the discussion and conclusions include assertions that do not appear to be justified by the findings.
Rockwell describes the attitudes of a sample of viewers of a US cable TV channel49. He is the president of this channel, which shows programmes intended for and advertised to health professionals. Advertisements for prescription drugs have been shown during these programmes since 1983. The programmes proved to be popular with the general public who subscribed to this channel. A survey of the non-professional viewers of these programmes found that 95% of them thought DTCA would make patients aware that useful treatments exist. Rockwell suggests that negative public attitudes to DTCA found in other studies are a result of fear of the unknown, but those who have been exposed to DTCA are positive towards it. However it seems untenable to assume that people who watch programmes intended for health professionals are representative of the general population.
Alperstein and Peyrot50 surveyed 440 people in Baltimore, USA. They found a moderate level of awareness of DTCA. Thirty-five per cent of people had heard of prescription drug advertising, and given a prompt, 42% were aware of advertisements for Seldane (an antihistamine). Most respondents felt that DTCA could help educate consumers (70%), while a minority agreed with possible objections to DTCA. Twenty-eight per cent felt it would confuse consumers, 21% that asking for an advertised product would upset a doctor, and 12% that DTCA would weaken the doctor-patient relationship. Respondents of higher socioeconomic status were more aware of DTCA advertising. Those who were more aware of the advertisements were less likely to believe that the doctor should be the sole source of information about drugs, that DTCA would confuse consumers, and that it would weaken the doctor-patient relationship.
CONCLUSION: Most of the available studies report mostly positive attitudes to DTCA amongst consumers. The apparent positive attitudes could have resulted from the ways the questions were framed or the population were sampled or who undertook the studies. Social and educational differences seem to influence acceptance of DTCA: the less educated may accept it more readily.
Mintzes and colleagues51 conducted a mail survey of experts in New Zealand, the USA and Canada, on their views of DTCA, and the evidence that supported these views. (DTCA is allowed in the USA and New Zealand, and Canadians are exposed to significant cross-border broadcast DTCA). The experts included people from health professional organizations, NGOs, government, the pharmaceutical industry, advertising and the media. Opinions about DTCA were divided by sector. Those from the pharmaceutical and advertising industries were overwhelmingly positive, patient representatives showed a lesser degree of support, and other experts had negative opinions of DTCA. Most respondents felt that the information DTCA provided about drug risks and benefits was poor. Respondents felt DTCA increased expenditure on medicines, but beliefs about the impact on doctor-patient communication varied according to sector.
In another study, most of the 97 Canadian Drug Directorate personnel surveyed52 believed that more prescription drug information was needed for consumers, but only a quarter of these thought advertising was an appropriate mechanism for this.
Amonkar and Lively53 mailed a survey to pharmacists in one Ohio county. Their study achieved a low response rate. Forty-two per cent of respondents did not think DTCA on television was beneficial to consumers. Although most (75%) thought that advertising may inform patients about available treatments, and some (32%) thought it may improve patient-pharmacist contact, most (90%) felt there should be prior review of advertisements by an independent panel, and most (87%) felt advertising would probably lead patients to pressure doctors to prescribe advertised drugs.
CONCLUSION: Surveys of experts’ beliefs about DTCA suggest that the beliefs expressed depend on what sector the expert belongs to, with industry experts expressing positive beliefs, patient advocates having mixed beliefs and medical experts having negative beliefs.