Electronic letters to:

Research:
Barbara Mintzes, Morris L. Barer, Richard L. Kravitz, Ken Bassett, Joel Lexchin, Arminée Kazanjian, Robert G. Evans, Richard Pan, and Stephen A. Marion
How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA
CMAJ 2003; 169: 405-412 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read eLetter] Proprely define DTCA can benefit every one
Marc Lacroix   (28 October 2003)
[Read eLetter] DTCA Survey Leads to Different Conclusion
John R. Graham   (23 September 2003)

Proprely define DTCA can benefit every one 28 October 2003
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Marc Lacroix
Medical Marketing Association, Trans Canadian Advertising Agency Network, PMCQ

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Re: Proprely define DTCA can benefit every one

mlacroix{at}lxb.ca Marc Lacroix

October 23, 2003

Mr John Hoey, Editor CMAJ 1867 Alta Vista Drive Ottawa (Ontario K1G 3Y6

Dear Mr Hoey:

Further to a study published recently in your magazine, I wish to respond to the argument by Dr. Mintzes, who paints a negative picture in her study (CMAJ 2003: 169 (5): 405–412) of the arrival of DTCA in the United States and warns us of the danger of the probable deregulation of this type of advertising in Canada.

As an advertiser who has worked with the pharmaceutical industry for 15 years, I have been called upon in the past year to express my opinion on direct-to-consumer advertising (DTCA) of prescription medicines at a number of conferences. Obviously, my opinion differs from that of Dr. Mintzes and it was precisely for this reason that I was asked to voice my opinion.

Dr. Mintzes concludes in her study that if a patient brings up DTCA with a physician, it is highly likely that a prescription will result. This conclusion leads us therefore to believe that doctors feel pressured into prescribing medication without being certain about it. Other studies, however, have clearly demonstrated that this is not the case. In a study conducted in the United States and published in the British Medical Journal (Br Med J 1999; 319: 1321), Dr. Spurgeon reported that, when questioned about the impact of direct-to-consumer advertising on their prescription habits, doctors said they felt “little” or “very little” pressure from their patients. In fact, only 6% of the 200 general practitioners surveyed felt strongly pressured by their patients to prescribe medication they learned about through advertising. Despite this, all the doctors questioned who opted for the medication patients requested instead of their usual choices agreed that the treatments prescribed were totally acceptable for the diagnosed conditions.

In her study, Dr. Mintzes states that only 12.4% of doctors surveyed would “definitely” prescribe the same medication again instead of their usual choice if they encountered another patient with the same condition. She arbitrarily concludes that 50% of doctors would be ambivalent in choosing the same medication again. In a recent communication with Dr. Mintzes, I learned that, in fact, only 8% of the doctors would not have opted for the same medication again (information that was not revealed in the study). If, contrary to her method, the number of doctors who would “very likely” prescribe the same medication again was added to the number who said they would “possibly” do it again, as indicated in the study (and not with the number who would “possibly not” do so, as suggested by Dr Mintzes), 92% of physicians would have chosen again the advertised drug. This leads to quite a different conclusion!

DTCA has also been shown to be informative. A study (J Fam Phys 1997: 45: 495–499) involving 454 family doctors concluded that direct-to-consumer advertising encouraged patients to take an active role in managing their health and led them to seek advice about problems they would have otherwise ignored. When the results of Dr. Mintzes’ study are examined closely, they reveal that the patients most exposed to the advertising of prescription medicines are the ones doctors consider the best informed (71.4% versus 53.3%). It is unfortunate that this was not pointed out in the article.

Moreover, being better informed increases compliance with treatment. A study published in Drug Topics (Drug Topics 1999; 19 (4): 46–47) revealed that, according to patients themselves, the factor that influenced them the most to be compliant with their treatment was being better informed on their medical condition and the effects their treatment would have on them. This factor was even more important than having easy access to a healthcare professional (70% versus 60%). Knowing the effects that noncompliance with treatment has on the health of Canadians, it would have been worth raising the point.

Finally, if Dr. Mintzes is afraid that patients will shop around for a new doctor if the medication they request was refused, a published study including 329 patients (J Fam Pract 1999; 48 (6): 446–452) proves the contrary. Faced with a refusal, 92% of patients said they would be “not disappointed” or “not very disappointed,” while 4% would try to change their doctor’s mind and only 3% would be inclined to change doctors.

The literature indicates that opponents of direct-to-consumer advertising have never succeeded in demonstrating that the costs generated by the increase in patients who obtain prescriptions for a promoted drug are higher than the savings obtained by reducing inherent health service fees (hospital costs, for example). Just think of the drastic reduction in gastroscopies since proton pump inhibitors came on the market (Prevacid, for example).

Direct-to-consumer advertising of prescription medicines is already a reality in Canada. The 1996 census revealed that 70% of families had cable. Imagine what it’s like today with the advent of satellite TV and Internet access.

What we have to realize is that, whether we like it or not, Canada is open to global influence. Updating and clarifying regulations in a way that takes this reality into account and gives it direction is not only necessary, but also urgent. Properly defined, regulations can benefit everyone: - The people at Health Canada, who would have a clearer basis to work from that would also be easier to enforce - The industry, which would know where it stood instead of writing the book on regulations and pushing the limits as it is currently encouraged to do - The public, which would not only have more information— something it wants, incidentally—but would also know where the information came from (Advertising always wear the signature of the advertiser but there is no regulation in Canada about public relations) - The medical community, which the industry would help to prevent certain pathologies and promote compliance with treatment, thereby reducing the long term pressure on the health care system - The entire community, which would see Canadian-produced advertising realistically framed by Canadian policies to counterbalance foreign sources it can’t control.

Sincerely,

Marc Lacroix President and CEO LXB Communication Marketing

Conflict of Interest:

president of an advertising agency
DTCA Survey Leads to Different Conclusion 23 September 2003
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John R. Graham
The Fraser Institute

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Re: DTCA Survey Leads to Different Conclusion

johng{at}fraserinstitute.ca John R. Graham

Mintzes and colleagues(1) likely show net benefits of DTCA. Patients who requested advertised drugs received them in 86% of cases, whereas patients who did not request received prescriptions in 26% of cases. However, patients who requested non-advertised drugs received prescriptions in 74% of cases. While DTCA caused some increase in requests, it was minor relative to other, unexplained, reasons why patients requested prescriptions.

For non-requested prescriptions, physicians considered 12% “possibly” or “unlikely” to be appropriate. For requested, advertised drugs, the share was 50%. For requested, non-advertised drugs it was 39%, so we have the same issue as above.

Of prescriptions related to advertisements, half were unambiguous, and not all ambiguous prescriptions had negative outcomes. I show elsewhere(2) that if less than 42% of the ambiguous prescriptions caused negative outcomes, DTCA is net positive. The actual share is likely less. The US FDA’s survey(3) of American physicians reported that in 91% of cases, patients did not try to influence the treatment harmfully.

References

1. Mintzes B, Barer ML, Kravitz RL, Bassett K, Lexchin J, Kazanjian A, Evans RG, Pan R, Marion SA. How Does Direct-To-Consumer Advertising (DTCA) Affect Prescribing? A Survey in Primary Care Environments With And Without Legal DTCA. CMAJ 2003;169(5):405-412.

2. Graham JR. Who’s Afraid of Prescription Drug Advertising? CANSTATS Bulletin. 2003: Sep 8. Available: http://www.canstats.org/readdetail.asp?id=574 (accessed 2003 September 18).

3. Aikin KJ. Direct-to-Consumer Advertising of Prescription Drugs: Physician Survey Preliminary Results. PowerPoint ® presentation. Rockville (MD): United States Food and Drug Administration: 2003; Jan 13: 21.

Conflict of Interest:

The author's employer has received donations from research-based drug makers. The author has received speaking fees from research-based drug makers.