In most of the world, this is a strange sight.
It’s a TV commercial for a prescription drug.
These ads are illegal in most countries.
but in the US, they’re everywhere.
On average, 80 of them air every hour on American television.
"Ask your doctor."
"...my doctor told me..."
"Ask your doctor."
The American Medical Association, a major group of doctors, has called for a
ban on these direct-to-consumer ads.
But there’s a case to be made for them too.
So today we’ll take a look at both sides.
First, a little background.
Before the 1980s, prescription drug commercials were unheard of in the US.
Drug companies focused their marketing solely on doctors, and they didn’t want to hurt
those relationships.
When asked by Congress in 1984, if direct-to-consumer advertising should be allowed, one pharmaceutical
executive said:
And an executive at Schering-Plough, which is now part of Merck, said:
Needless to say, they changed their minds.
At the time there was a larger cultural shift in health care toward empowering patients
to make decisions rather than just listening to their doctors.
And advertisements fit with that trend.
Drug Ads started appearing in print publications, but there was still another thing keeping them off TV,
and that was FDA’s regulations at the time.
They were interpreted as requiring ads to include all of the information about the drug’s
risks and side effects, which simply wasn’t feasible to do in
a tv or radio commercial the way it was in a magazine.
There was a bizarre loophole though: The ads didn’t have to mention the drug’s risks,
if they also didn’t mention the disease or condition that the drug was supposed to treat.
Here’s what that looked like — in an ad for Claritin back before it was available
over the counter: "It’s time."
"It’s time!"
"Don’t wait another minute with Claritin."
"Claritin."
"I’ll ask my doctor!"
"It’s time to see your doctor."
"Mr. Wilkin, the doctor will see you now."
"At last, a clear day is here."
Confused?
Yeah, everyone was.
So in 1997, the FDA clarified that the industry could run the full drug ads and wouldn’t
have to give ALL the risk information from the label, as long as they included the major
side effects and referred viewers to another source for the rest.
That’s why the commercials direct us to phone numbers or print ads.
Come for the pharmaceutical fine print — stay for “the secret to crisp contact in soggy conditions”
That new FDA guidance removed the main barrier
keeping drugs off of television.
and you can guess what happened next...
spending on ads quadrupled by 2004. And now, we know the names of prescription drugs like
we know the names of cars and clothing brands.
"Lunesta, Xanax, Celebrex, Flomax, and HGH."
"And as of Thursday, Lipitor."
"Oh and if you have trouble sleeping, Marla has Ambien. I prefer Lunesta."
"Lipitor, Baby Aspirin... Flomax."
"Flomax?"
"…and some Cialis!
I’m just assuming."
So that’s how we got here.
Drug ads are now the most frequent form of health communication that most Americans see.
So what does that mean for public health?
Are those prescriptions going to the right people?
Or are they going to people who probably won’t benefit from the drug — people for whom the potential
risks outweigh the potential benefits?
Well, the answer seems to be: both.
A clever experiment in 2005 tested this by sending actors to real primary care doctors.
Dr. Richard Kravitz: We helped them make appointments.
In half of the visits, the actors reported symptoms of depression.
In the other half of the visits, the actors said they were feeling down
after becoming unemployed.
The study authors called this an “adjustment disorder.”
In some visits, the actors mentioned seeing an advertisement for Paxil on TV,
that's an antidepressant.
In others, they didn’t bring up medication at all.
And the doctors seemed to take patients more seriously if they mentioned seeing the Paxil commercial.
They were more likely to refer patients to a mental health consultation,
And much more likely to prescribe an antidepressant.
That may be a good thing for those with major depression, who might benefit from an medication.
But it’s more questionable for those with a more temporary condition.
This study, and others, have shown that doctors can be persuaded to broaden the scope of who
gets treated with drugs.
And advertisements often seem designed to encourage that.
Take Androgel — it was approved to treat men with hypogonadism: that’s extremely low
testosterone levels due to injury or disease.
But here’s how it was promoted by Abbott: "Millions of men 45 and older just don’t
feel like they used to.
Are you one of them?
Remember when you had more energy for 18 holes with your buddies?
More passion for the one you love."
Some middle aged men don’t feel like they used to?
You don’t say.
A study looking back at 10 years of testosterone prescriptions found that only half had been
diagnosed with hypogonadism in the previous year.
Drug ads give the industry an incentive to make healthy people feel unhealthy.
“Latisse is the only FDA approved prescription treatment for inadequate, or not enough lashes.”
And they contribute to unrealistic expectations about what pharmaceuticals can do.
So what’s wrong with that?
Well, every single drug comes with risks.
Big ad campaigns are usually for newer drugs, for which not all the risks may be known yet.
In the case of the painkiller Vioxx, a massive ad campaign led millions of people with arthritis
to switch to Vioxx instead of sticking with older drugs like Ibuprofen.
“It’s a beautiful morning…ask your doctor today about Vioxx, and find out what Vioxx
can do for you."
Vioxx was more expensive and not actually
more effective, and...
“The manufacturer of Vioxx have just recently pulled this popular arthritis drug from the
market over health concerns."
Merck withdrew the drug after it became clear
that it increased the risk of heart attacks and stroke.
A Kaiser Permanente study later confirmed that ad exposure was linked to inappropriate
prescribing of Vioxx and a similar drug called Celebrex.
So that’s a worst case scenario.
But there is also an argument that these ads can be good for public health.
Sidney Taurel: “There are many diseases for which people don’t seek treatment.
So if you can educate through direct-to-consumer about the fact that this can be treated, you
will get a better outcome for everyone.”
In their view, more communication with your
doctor is always a good thing.
And it’s up to the doctor to make the right prescribing decisions.
Surveys of the public have confirmed that drug ads prompt people to visit their doctor,
in some cases for diabetes, hypertension, depression — these are conditions that are thought to
be under treated.
In the case of the HPV vaccine, that's now recommended for all pre-teens to prevent cervical and
other cancers, Merck’s ad blitz for Gardasil probably reached more people than a government
communications effort could.
And whatever you think of erectile dysfunction drugs, they got men to see their doctors and
undergo the required heart screening, potentially catching problems not yet treated.
But the strongest argument in favor of drug ads may be the legal one.
The Supreme Court ruled in favor of prescription drug advertising back in the 1970s, when the
state of Virginia tried to prohibit pharmacists from advertising their prices.
Harry Blackmun: “We further hold that so called commercial speech is not wholly outside the protection
of the 1st and 14th amendments.
The individual consumer and society in general may have strong interests in the free flow
of commercial information.”
It was the first time that the Court said advertisements were entitled to
free speech protections.
There was only one dissenting Justice at the time: William Rehnquist — who Ronald Reagan
would later appoint Chief Justice — In his dissent, Rehnquist wrote a kind of
uncanny prediction of the type of commercials that would come decades later:
"Don't spend another sleepless night.
Ask your doctor to prescribe Seconal without delay."
Rehnquist worried that ads would “generate patient pressure on physicians to prescribe”
drugs; and that they’d end up being “advertised on television.”
And as we know now, for better or for worse, that’s exactly what happened.