Healthy Skepticism Library item: 16922

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: Journal Article

Mintzes B, Mangin D
Opinion: Direct-to-consumer advertising of prescription medicines: a counter argument
Future Medicinal Chemistry 2009 Dec; 1:(9):1555-1560
www.future-science.com/doi/full/10.4155/fmc.09.136

Abstract:

Direct-to-consumer advertising of prescription-only medicines is currently only permitted in the USA and New Zealand. Barbara Mintzes and Dee Mangin provide their case against direct-to-consumer advertising of prescription medicines, arguing that its wider introduction would lead to a ‘Pharma-knows-best’ culture.

Should direct-to-consumer advertising (DTCA) of prescription drugs be allowed in jurisdictions where it is currently banned? In his article ‘The case for advertising pharmaceuticals direct to consumers’, published in Future Medicinal Chemistry, Frank Auton argues that DTCA leads to improved diagnosis and treatment, better doctor–patient relationships, a more educated and informed public and that DTCA represents an inevitable wave of the future in an era in which paternalistic ‘doctor-knows-best’ attitudes are no longer relevant [1].

These arguments are timely. The EU is once again considering proposed reforms to pharmaceutical legislation, including a highly controversial ‘patient information’ initiative involving some forms of DTCA [2]. Recently, Canada’s largest media company, CanWest, mounted a charter-of-rights challenge of the ban on DTCA, arguing that the law infringed its freedom of expression. The case was adjourned ‘at the 11th hour’ in June 2009, due to financial insolvency [3].

The rationale for the prohibition of DTCA is health protection. Medicines have prescription-only status because they are more toxic than over-the-counter drugs. They often treat more serious conditions, for which both diagnosis and treatment are complex, and require a physician’s assistance. In an aging population, multiple comorbid conditions are the norm and there is great potential for drug–drug and drug–disease interactions. People with serious diseases are vulnerable to messages of hope in misleading advertising in a way that someone buying a new pair of jeans is not. Individuals have limited means to evaluate the scientific evidence underpinning advertising claims for medicines. The choice of a medicine should be based on the greatest benefit to overall quality of life rather than the most powerful advertising message.

There is no public health rationale for the introduction of DTCA, no reliable evidence that it leads to better care, public or patient empowerment or to the type of information needed for shared informed treatment choices. DTCA does lead to more frequent medicine use and to substitution of expensive new brands for equally effective, less-costly alternatives [4]. It has led to the use of unnecessarily harmful medicines and can expand the market for drug classes to those unlikely to benefit and encourage treatment of milder health problems for which nondrug solutions are often more appropriate. All medicine use is a balancing act, weighing up potential benefits and harms. As the problem treated becomes milder, benefit shrinks and the potential for harm can outweigh benefit.

Auton presents a highly selected subset of the research evidence on DTCA, much of it produced by, or on behalf of, pharmaceutical manufacturers. As is discussed below, many of the claimed benefits for DTCA do not stand up to scrutiny and evidence on harm is largely omitted.

We agree with Auton that the quality of medicine use could be improved and that the public can benefit from better access to health and treatment information, but we would suggest different means, including a ban on DTCA as one important aspect. Information can influence healthcare choices in different ways. An individual may come to a decision based on an assessment of the available evidence presented neutrally. This is the basis of shared informed decision making and is fundamental to respect for autonomy. By contrast, information manipulation is a deliberate act of managing information that alters a person’s understanding of a situation in order to motivate him or her to do what the agent of influence intends. This is precisely how advertising acts: by definition, it seeks to drive decisions in favor of the advertised medicine. This is not shared informed decision making or consumer empowerment. In an era that values respect for autonomy, DTCA is unsustainable.

Improving provision and access to independent information for consumers and physicians would help make shared informed treatment choices more of a reality [101] and likely be cost-effective, as would better regulation of drug promotions targeting physicians. Recent US court cases have uncovered a range of promotional practices of grave concern, such as widespread promotion for unapproved uses without evidence of effectiveness, use of physician ‘key opinion leaders’, sponsored continuing medical education to promote sales [5] and ghostwriting of scientific articles [6,102].