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Healthy Skepticism International News

August 2003

Feedback about the AdWatch prototype


  Responses to the AdWatch prototype

  Correspondence with AstraZeneca staff

  Opportunity to comment

Responses to the AdWatch prototype

We posted the AdWatch prototype on our website on 20 June 2003. We received 57 responses up to 26 August of which 20 were received in the first 24 hours.

The AdWatch prototype asked 4 questions:

1) How helpful is the advertisement for Nexium?

  1 = extremely unhelpful
  2 = very unhelpful
  3 = somewhat unhelpful
  4 = neutral
  5 = somewhat helpful
  6 = very helpful
  7 = extremely helpful
  8 = No opinion
  9 = No answer to this question

Comment on the responses

  Of the 6 people who rated the advertisement as extremely helpful 5 also rated the AdWatch edition as extremely helpful so we suspect this question was misunderstood. Consequently we have re-written questions 1) and 2) for future AdWatch editions.

2) Any comments for us to send to the company responsible?

  Negative evaluations of the advertisement (n= 6 / 15 comments)

      “Ad is irrelevant if not comparing apples with apples.”

      “Packaging of Nexium is excessive and wasteful, and I threw a lot of it away before a trip, to save space. I personally found them no better than Acimax (omeprazole), by the way.”


      “Most medical practitioners don’t have access to medical literature like the AdWatch team and even the few who have access don’t have time to verify if your claims are accurate or not. So I think making such promotional claims is only aimed to mislead the medical profession and the profession should identify such companies and disregard their promotional material.”


      “The graph comparison of lansoprazole vs esomeprazole is not of any significance (3% difference). Important data to make a comparison is missing e.g. Equipotent dosing details, cost differences for dose adjustments if necessary to achieve the same endpoints.”

  Comments (n = 4 / 15)

      “I feel the marketing of esomeprazole to be another “evergreening” tactic. Patients will be converted from omeprazole to esomeprazole because it’s more “powerful” so that when a generic omeprazole is available, patients will remain on the more expensive esomeprazole.”

      “For a significant number of doctors, deceptive advertisement has the opposite effect than what the company wants. Doctors hate to be taken for a ride and opt to stay away from those new patent drugs of “Hoodwink’s Sarsaparilla” fame.”

      “Strengthens the case for academic detailing.”

      “The makers of Nexium are just doing their job: trying to make money. I have no quarrel with that. But I want doctors and scientists to do OUR job….which is to be critical so that we can safeguard the health and wallets of our patients.”

  Suggestions and Requests (n = 4 / 15)

      “Do I get a free pen with that?”

      “Please ask them to advertise truthfully.”

      “Please compare drugs appropriately and do not try to mislead doctors.”

      “Stop misleading us with your drug campaigns.”

Response from the AdWatch team

  Some of the responses are clearly addressed to the company. Others are not. We will send them all to the company and to the regulatory agencies.

2) How helpful is this Adwatch edition?

  1 = extremely unhelpful
  2 = very unhelpful
  3 = somewhat unhelpful
  4 = neutral
  5 = somewhat helpful
  6 = very helpful
  7 = extremely helpful
  8 = No opinion
  9 = No answer to this question

Comment on the responses

  This is a pleasing response for a prototype but shows that we need to make improvements.

4) Any comments for the AdWatch team?

  Negative evaluation of the AdWatch edition (n = 1 / 35 comments)

      “I am afraid that you display an unfortunate bias. While it may be true that there is not a great deal of difference in theory between 10 mg of s-omeprazole in Losec and 40 mg of s-omeprazole in Nexium, to suggest that there is no difference or that the difference is too trivial to be of concern is really stretching an argument beyond where it should go. If there were truly no difference between isomers, why do we bother to have l-thyroxine? We might as well just have d-l-thyroxine and give twice as much. Are AdWatch going to rile against the manufacturers/advertisers of l-thyroxine too?”

Response from the AdWatch team

  Bias is normal for humans so all scientists should use careful methods to minimise it. One of the methods we use is requesting and publishing feedback.  We also invite Healthy Skepticism members to join the AdWatch pre-publication quality control group. If you are interested in that or would like to help write AdWatch editions please contact: .(JavaScript must be enabled to view this email address) We want to expand our team including adding more people from outside Australia. We will be providing training via email feedback.

  The prototype stated that “40mg S-omeprazole in Nexium is more effective than the 10mg of S-omeprazole plus 10mg of R-omeprazole” so we are sorry about the misunderstanding. Perhaps the misunderstanding occurred because that statement was embedded in a complex paragraph.  We will aim for less complex paragraphs in future.

  L-thyroxine is used because there is a clinically important difference between the isomers of thyroxine. It would be in the manufacturer’s interests to produce evidence of a clinically important difference between the isomers of omeprazole but they have not done so. That fact plus the evidence that is available suggest that there is no such difference.

  AdWatch topics will be chosen at random from advertisements targeting Australian General Practitioners. Consequently, AdWatch topics will usually be advertisements for the new drugs that are profitable to advertise because of patent monopoly protection.

  Constructive criticism (n = 2 / 35 )

      ““There is no proven clinical significant difference between Nexium and equipotent doses of other proton pump inhibitors”
      This is a truism, the problem is to know what are equipotent inhibitors….
      Maybe it is better not to use the same publicity-style short language to describe recommendations.
      The company will exploit these weaknesses.
      “Prescribe which ever is the cheapest at the time in the lowest dose that controls the symptoms”
      Are you 100% sure that only short term symptom control is all there is to the clinical outcome?

      This is a very good piece of work (I particularly like the reference to non-PPI treatment of GORD, and the section on straw man comparators), but I think it could be even more explicit, and stronger. Firstly, it should be explained that the R-isomer is essentially inactive, so that esomeprazole is actually simply the active ingredient in omeprazole (at a substantially higher dose, and of course at an enormously higher price). Secondly, the conclusion should stress that it is not merely a case of “There is no proven clinical significant difference ...,” but rather that “available evidence strongly suggests no difference ....”

Response from the AdWatch team

  Our first statement is not quite a truism because doses of two drugs that are equally effective could have different adverse effect profiles. However we need to write more clearly in the future than we did in the prototype.

  We have a dilemma with writing AdWatch. On the one hand we want to explain all the important complex issues fully. On the other hand we need to keep AdWatch quick and easy to read so that we can reach a wider audience including very busy people. Feedback will help us know how well we manage to steer between the two horns of that dilemma.

  Because overconfidence is an major cause of error it is important to not be certain of anything. The originator of moderate skepticism, sixteen century theologian Sebastian Castellio, advocated aiming for reasonableness rather than certainty. The main impact of gastro-oesophageal reflux is symptoms. Consequently it is reasonable to treat symptom control as the main objective. It would be good to cover the issue of objectives in AdWatch. However it will be easier to introduce this issue with a clear example of promotion of the wrong objective.

  Positive evaluations of the AdWatch edition (n = 25 / 35)
  (Only a sample below)

      “Thanks for your thought provoking work.”

      “This is an excellent way of educating us. I guess the problem is, how do we get more prescribers to look at AdWatch?”

      “Great new development. I like this short form.”

      Thanks for your website. We patients never learn the truth about drugs we are given.

      “I enjoy having the ads analysed like this. Keep up the good work.”

      “Very clear comments on confusing advertising. I look forward to the next AdWatch.”

      “This type of work will definitely create more informed prescribers and ultimately patients will benefit a lot.”

      “AdWatch is fabulous - interesting to see deconstructionism at work in such a pragmatic context. Well done!”

      “GREAT WORK!!!! This is JUST what busy physicians need to be able to “counter-detail”. Thank you so much.”

      “This helps not only with this particular drug, but also equips me to better evaluate other drug company claims. Thanks.”

      “Would seem to be a useful way to point out tricks of the advertising trade to doctors and others. Also helpful when reading other ads with the same ploys. A good example of an ad that is truthful but misleading, just skirting the edge of legality.”

  Comments (n =  6 / 35)

      “They use the very same misleading claims “up here”, in Finland, too.”

      “I think Nexium was put on the market to capture the market share from Losec, which had lost its patent. Thank you for your interest, and good works!”

      “When such advertisements are being created as part of the ‘norm’ of pharmaceutical marketing, is there any hope for the health care industry in Australia?”

      “Excellent! There’s lots more, too. Schering and their efforts to overcome Claritin coming off patent etc. Do we need Bextra? Vioxx and Celebrex are bad enough.”

      “I like this approach because it clarifies the issues clearly. I often assume that “new” agents only come out because a patent has expired and the company wants to have sole ownership of an agent. A classic example would appear to be Allen and Hanbury dumping Becotide and promoting Flixotide. Nexium would appear to be in the same boat. I wonder if by arousing peoples cynicism in regards to Nexium if that will remind doctors that other new proton pump inhibitors also have very limited advantages. Some may say that if Nexium is not all it is cracked up to be then they will stick to Pariet as a new wonder drug!”

      “I feel that these ads work because the underlying pharmacokinetic and pharmacological principles of drug therapy are not well understood by many practitioners (or taught). Therefore, [they think] it’s not important to patient care. Drug companies know this and exploit this knowledge gap. In my experience medical students and residents have heard these terms like clearance, stereoisomers, bioavailability but cannot apply this understanding to the patient bedside, unless they use potent drugs on a regular basis (anaesthesia, ICU specialists, oncologists, etc etc). Just my $0.02 worth.”

  Suggestions and Requests (n =  6 / 35)

      “Keep it up!! Please! How about a gallery!!”

      “Would like to see more. Please find a way for the general public to be more aware.”

      “More comparisons between older (and usually cheaper drugs) and newer drugs within the same class would be appreciated.”

      “I don’t know much about the subject. I am interested in seeing what you do. If you distribute this as a newsletter, please add me to our list.”

      “AdWatch should be included as a one page flyer in a commonly read GP journal such as Australian Family Physician. Get the message to the masses! Most GP’s don’t log on to this website.”

      “Particularly helpful to be reminded of cheaper alternatives. Being realistic, how else is a pharmaceutical company going to differentiate a product within a therapeutic group of similar effectiveness as pre-existent products, without some marketing hype. In other words, not only should such ads have included PI, but possibly also attached expert, objective commentary.”

Response from the AdWatch team

  We think we are on a winner! Thank you for the endorsements. We are using some of them in promotional material.

  Our main problem is how to expand and promote AdWatch so that more people will benefit. We have very little money and all the work is being done by a tiny team working without payment. We will have articles about AdWatch in several medical publications soon. You can help by informing all your contacts. Your personal endorsement in “word of mouth” email promotion can be very effective. We also invite all AdWatchers to become Paid Subscribers or Members of Healthy Skepticism because subscriptions are currently our only source of funding for AdWatch. Please see Your Options.

  We have included more comparisons including price comparisons in the first AdWatch edition.

Correspondence with AstraZeneca staff

Paul Woods, Global Promotional Consultant, AstraZeneca is a Healthy Skepticism Paid Subscriber so I asked him to comment on our AdWatch prototype. The correspondence that followed is presented below:

From: Paul Woods
Sent: 11 July 2003

  Dear Peter,

  Having returned from travelling I now have the chance to provide my observations on the new Adwatch item, as you requested.

  Firstly, as this is our first interaction, I should make a general point that AstraZeneca is committed to ethical advertising practices where ever in the world we operate. The AstraZeneca approach forms part of our company ‘Code of Conduct’ and our corporate responsibility policy. Further details can be found on the company website:

  We continue to devote attention to responsible marketing practices. You may be interested to know that my travel last week was to lead a meeting of our promotional regulatory ‘Nominated Signatories’ from all around the world to discuss how we can best perform our duties in the future. The doctors, pharmacists and others who make up the AstraZeneca ‘Nominated Signatories’ world wide network worked together to improve knowledge and understanding of ethical marketing practices and to share ‘best practice’. They are all absolutely committed to quality and compliance in our advertising and promotional activities and to working with marketing colleagues to nurture our company culture of marketing in a proper but also, of course, an effective manner.

  You asked for my comments on Adwatch. In my opinion, the approach whereby a guilty verdict on an advertisement is delivered and then the company asked for comments does not support continuously improving standards in pharmaceutical advertising - in fact, quite the opposite, since it does not encourage productive dialogue. I’m sure you are aware that the research based pharmaceutical industry has a global self regulatory code of marketing practices (The IFPMA code -, as well as national codes and national laws / regulations governing advertising. The IFPMA code states that companies must provide, on request, the scientific data to support claims. Why not put your concerns to the company first? Those in the company that have approved the ad would be able to explain their decision and provide the supporting evidence. You may well be satisfied with at least part, if not all, of the response you get.

  My second criticism of the Adwatch approach is that to present a highly critical appraisal of an ad, then to survey the readership on the ‘helpfulness’ of that ad will, of course, give entirely predictable results.

  Having criticised the Adwatch approach, I must stress that I fully support a constructive interaction on advertising between companies and their customers. If, after a professional dialogue, a healthcare professional’s concerns cannot be adequately answered by the company then resolution can come from objective review through regulatory and/or self regulatory complaint handling mechanisms.

  You have made some specific challenges to Nexium claims. I have been able to ascertain that the advertisement you cite was issued by our Australian subsidiary and I have I have therefore contacted both my Australian ‘Nominated Signatory’ and Sweden based global Nexium team colleagues. They are the relevant experts and I am hopeful that there will not be a long delay before a response to your challenges can be sent to you.

  Paul Woods
  Global Promotional Consultant

Response from the AdWatch team

  Often the first step to resolving a problem is to accept that there is a problem.

  In future we will send a draft of each AdWatch edition to the company concerned to provide an opportunity for concerns to be resolved prior to publication. The only difference with the prototype is that we made it available to our current subscribers at the same time. The official feedback from the AstraZeneca is “I have no objection to any part of Adwatch on Nexium.” (see below) By contrast some of our subscribers and our team have been able to suggest improvements.

  We are not able to predict responses to AdWatch. Drug companies have massive resources for persuasion. Our resources are very limited. Readers will have access to the company’s side of the story presented in the advertisement as well as our second opinion. Responses will depend on how misleading vs helpful readers judge the advertisement and our second opinion to be. We expect that readers will let us know if our concerns about any advertisement are not justified or not important.

From: Mike Bull
Sent:  24 July 2003

  Dear Dr Mansfield,

  With regard the Adwatch critique of a medical journal advertisement for Nexium, AstraZeneca stands by all the claims made in this advertisement. 

  Each of the claims made are clearly referenced to an appropriate publication and these references are fully cited within the body of the advertisement. 

  While this particular advertisement has not been used for some time, the claims made are accurate, balanced, and correct. 

  Your sincerely  

  Mike Bull
  Director, Sales and Marketing
  Primary Care
  AstraZeneca Pty Ltd

From: Peter Mansfield
Sent: 24 July 2003

  Mr Bull,
  Thank you for your concise message.

  Your message raises some questions.
  1. When was that particular advertisement last used?
  2. Why have you stopped using it?
  3. Are you aware that there are 2 advertisements containing some of the same claims in Medical Observer 25 July 2003 (dated for tomorrow but arrived here today)?
  4. Do you have any disagreement with any part of our AdWatch on Nexium?
  5. Would you like to see the feedback we have received about AdWatch on Nexium?
  6. Can you give us any reason for not reporting your current Nexium advertising to the Medicines Australia Code of Conduct Committee?
  7. What do you think of the following?
  Barlow J, Møller C. A complaint is a gift: Using customer feedback as a strategic tool. San Francisco: Berrett-Koehler Publishers. 1996
  The introduction to the first part of the book is as follows:
  “When customers feel dissatisfied with products and services, they have two options: they can say something or they can walk away. If they walk away, they give organizations virtually no opportunity to fix their dissatisfaction. Complaining customers are still talking with us, giving us an opportunity to return them to a state of satisfaction so they will be more likely to buy from us again. So as much as we might not like to receive negative feedback, customers who complain are giving us a gift.  If we shift our perspective in this way to see complaints as gifts, we can more readily use the information the complaints generate to grow our own businesses. Customer complaints are one of the most available and yet underutilized sources of consumer and market information; as such, they can become the foundation for a company’s quality and service recovery programs.  This is no small gift! In order to better understand complaining customers, Part 1 of this book examines the behavior and desires of dissatisfied customers. With understanding comes acceptance. We must welcome these complaining customers and make them want to come to us with their feedback.”

  Peter R Mansfield

From: Mike Bull
Sent:  30 July 2003

  Dear Dr Mansfield,
  Thank-you for your reply. I have outlined below responses to your questions.

  1) I believe that the stated advertisement was last placed in November 2002.
  2) The Nexium advertising campaign has migrated beyond the original launch phase. New executions of this campaign have been introduced post- November 2002.
  3) Yes, I am aware that current advertisements contain the same and similar claims to those made in the advertisement stated.
  4) No, I have no objection to any part of Adwatch on Nexium.
  5) I would be interested to see Adwatch feedback on Nexium advertising.
  6) As you will be aware, competitor dynamics in the pharma industry are always intense. This is particularly so at the time of launch of a new brand. The Nexium advertising campaign has already been reviewed twice by the full Code of Conduct Committee of Medicines Australia, including leading clinical and scientific experts in this area. As you know this process involves a critical examination of the stated claims and the supportive scientific documentation. These experts ensure also that the full regulatory status of the area is understood, as well as current ‘best practice’ in the nominated indication. The current Nexium claims, and those included in the stated advertisement, have been fully examined by experts and they have not been ruled in breach of the Code.
  7) I agree completely with the abstract from Barlow et al.

  Yours sincerely
  Mike Bull

Response from the AdWatch team

  We believe there are problems with the Nexium advertisement. Our concerns are supported by the feedback we have received. The difference between our reading of the advertisement and that of the Code of Conduct Committee may arise from different standards. We hope that AstraZeneca would agree that if doctors have developed incorrect impressions about a drug as a result of advertising then measures should be taken to correct those impressions. Therefore we would like to work with AstraZeneca to develop a new set of advertisements that would run until surveys of doctors show that any mistaken beliefs have been corrected.

  We hope that AstraZeneca will be willing to work with us to resolve our concerns. If not, we will submit a complaint of our own to the Code of Conduct system. If the Committee does not change its opinion on the advertisement and cannot convince us of the correctness of its position, then we will ask other regulatory agencies to act. If these agencies are unwilling or unable to act then we will express our concerns to medical journals, the general media and politicians.



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