By Mark Wamsley
Savvy marketers know that Smokey the Bear garners far more trust than men hawking Viagra ever could. With public trust and goodwill running in short supply, drug companies are borrowing a familiar page from the public relations handbook of non-profits and government agencies -- the use of public service announcements (PSA's) and other types of educational-style advertising. In the hands of the pharmaceutical industry, these normally genial message formats offer an aggressive and duplicitous technique for marketing prescription drugs; one that is touted as supporting the public good while simultaneously having its mechanisms obscured from public view. Stripped of product information and often a company name, "unbranded" pharmaceutical advertisements lure consumers with an educational label. Their omissions and posturing, however, belie the messages' true commercial intent, and their potential for public harm.
Ironically, the new trend of soft-selling prescription drugs began with the highly visible onslaught of direct to consumer (DTC) drug ads, and from the rising threat of government regulation that grew in its wake. Although DTC ads are possibly the most direct appeal ever to consumers by the pharmaceutical industry, many also integrate a pseudo-educational component that falls under the broader strategy of "disease awareness" or "disease marketing." Proffered as a means of helping the public recognize symptoms of serious but treatable illnesses, disease awareness functions as a stealthy marketing tool, building consumers' anxiety that they may be ill and in need of a particular drug.
This year the Pharmaceutical Research and Manufacturers of America (PhRMA) bowed to government pressure and enacted voluntary restrictions on certain DTC advertisements. Curtailed formats include "reminder" ads that simply state a drug's name and manufacturer without revealing the condition it treats, and some "product claim" ads that mention a drug's name, describes what it treats, and the risks and benefits of treatment. The restrictions are challenging the industry to find ways of scaling back overt public marketing without losing profits. To fill the gap, drug companies are placing their money and their creative zeal into "help seeking" DTC ads that specifically foster disease awareness, as well as other forms of educational PR. To the public, help seeking ads appear as free PSA's, produced by non-profit organizations with the silent financial backing of drug companies. Other PR formats include informational websites that do not display product information, and only occasionally reveal corporate affiliations, video news releases (VNR's) that mimic objective forms of journalism, and sponsored television magazine shows.
The gray area which these efforts occupy, somewhere between influencing individual views of health and advertising products, offer them a veneer of neutrality and legitimacy. The truth remains that educational PR, under the guise of disease awareness, is a profit-driven endeavor aimed at converting the public into patients, and hopefully customers. Any beneficial impact it might offer must be weighed against the prospective dangers of misdirecting public health concerns, increasing prescription drug consumption and health care costs, and using a trusted media format for a biased and selective introduction of information. By similarly packaging the divergent purposes of public education and marketing, drug companies are flying under the radar of public skepticism and government scrutiny. The approach sells manipulation as empowerment, and people appear to be swallowing it whole.
In their book, The Death of Advertising and the Rise of P.R., Al and Laura Ries state that the public takes advertising "for what it is—a biased message paid for by a company with a self-interest in what the consumer consumes." Those clear differences blurred with the modern development of DTC advertising in the 1980's and 90's. Beginning as print features, before expanding to television, radio, and websites, DTC ads informed consumers about a particular disorder, and then urged them to inquire about a prescription drug remedy with their physician. DTC ads were a marked change from traditional pharmaceutical advertisements that targeted physicians, not patients, in medical journals and via other professional channels.
The cost and impact of DTC ads has been astounding. According to statistics from IMS Health, a market data firm serving the pharmaceutical industry, money spent on DTC advertising rose over 500% between 1996 and 2004, from $791 million to over $4 billion. Proportionally, this represents nearly 30 percent of total advertising expenditures for the industry. Measured by changes in consumer behavior, the money has been well spent. A 2002 study by Prevention magazine revealed that one out of every three consumers who sees pharmaceutical ads on television or in magazines has spoken with a doctor about an advertised medication. Such interest translated into more than 53 million patients requesting, by brand name, a drug advertised on television and radio or in newspapers and magazines in a recent twelve-month period.
Other effects of DTC advertising raise questions and serious concerns. "Results of a survey published in the Journal of the American Medical Association found that 71% of physicians felt pressured to give their DTC ad-exposed patients medications they would not be inclined to prescribe otherwise." This type of scenario includes pressure to prescribe either inappropriate medications for a patient's condition, or high-cost brand name drugs when an older or generic variety may be equally or more effective. In addition, by defining almost every human physical condition in relation to a specific drug, there exists a real risk of patients becoming less inclined to accept doctors' recommendations of alternative, non-medical courses of action, such as increasing exercise and maintaining a proper diet.
DTC's rapid expansion and intrusion into doctor-patient relationships garnered the attention of government, public advocacy groups, and the medical profession alike, with Senate Majority Leader Bill Frist (R-Tenn) ultimately suggesting a moratorium on DTC advertising for new drugs entering the market. The resulting pressure led PhRMA to develop its "Guiding Principles on Direct-to-Consumer Advertising," which went into effect in January of 2006, and have been adopted by 27 of the organization's 34 member corporations. The guidelines effectively "turn down the volume" of DTC, according to Diane West of Pharmaceutical Executive magazine, by specifically curbing reminder and product claim ads. David Gascoigne, head of promotion management at IMS Management Consulting adds "Where DTC was once heavily skewed toward television and [branded] mass media campaigns, we're now seeing a greater emphasis on print advertising and a greater focus on disease education, medication adherence, and consistency. Mass media advertising brought consumers in, now marketers have to concentrate on keeping them."
In this respect, the shift in focus to disease awareness educational PR represents a change in business strategy more than a defeat for the pharmaceutical industry. The majority of DTC ads, although profitable, are not perfect marketing vehicles. In terms of providing information, Sue Ramspacher, senior vice president of GFK Market Measures, states "When asked where they get the most helpful information, people rate their doctors high. Advertisements are really down at the bottom." West concedes that DTC also fails at compliance marketing, stating "A funny thing happens on the way to the pharmacist, according to industry analysts: The prescription and the patient often don't get there." Whatever the future of DTC ads, the pharmaceutical industry is not retreating from drug marketing. In educational PR, drug companies see a means to advance their goals with more nuance, more precision, and less notoriety.
Drug company educational PR efforts seek the same outcome as other DTC advertisements -- increase the probability that consumers will meet with doctors and begin treatment with a prescription drug. Unlike branded DTC-ads, disease awareness PR campaigns leave the names of specific drugs and pharmaceutical companies inconspicuous, or omit them altogether. Whether structured as educational advertisements or as PSA's, the communications are then portrayed as sources of unbiased and invaluable information for public health, allowing drug companies to benefit from the credibility of message formats usually associated with non-profits and government agencies. When drug companies financially sponsor actual PSA's they gain additional legitimacy through teaming with respected not-for-profit organizations. The latter serve as the public face of the campaign, often adding the power of a celebrity spokesperson, while enabling ads to be broadcast free of charge. With the assistance of PR firms, drug companies also are employing video news releases (VNR's), or pre-packaged news reports that often announce medical breakthroughs related to their drugs, alongside paid, medically-based television magazine shows, and interactive websites and hotlines.
John Quick, Director of the New York Healthcare Group at communications firm Hill & Knowlton describes the ideal pharmaceutical PR process this way, "...we work with a third party, generally a disease-oriented nonprofit organization, to gain credibility. We educate the doctor before turning to the consumer, getting the professionals to support the program. Then we work with the media, laying a foundation of facts, both physical and psychological, to motivate the patient to seek treatment by seeing the doctor." Much of the effort occurs before a new drug is launched, to alert the public of the condition or disease and to make them aware that a treatment is available. In Product Management Today, Avelle Rickman writes that such campaigns are most valuable for targeting individuals who are not yet receiving treatment, as well as for those with diseases that are relatively unknown by the public, are difficult to detect, or are inherently embarrassing.
Simply providing information to consumers and doctors does not guarantee that one will seek out the other. Rich Levy, President of HealthSTAR Advertising explains that, "You have to give the consumer a reason to respond, as well as a vehicle for doing so. The ad provides the screening, urging those who think they might have the disease to call a toll-free number, visit a website, or see a physician. Once the consumer has done one of these things, it is up to the brand to follow through, either with a brochure or an interactive website." In one good example, Elizabeth Boehm, principal analyst at Forrester Research's Health Care and Science division cites, "When you see the 'Depression Hurts' TV commercial, they're talking about a Web site, not a medication. They're telling the viewer, 'Look, depression is a bigger problem than we can explain in a TV ad, so go to this Web site, where we have more of your time and attention.'"
Websites may prove to be the tool of the future for pharmaceutical disease awareness PR. Studies show that nearly 80 percent of web users have searched this largely unregulated arena for health care information, and drug companies have taken notice. Richard Campbell, partner of healthcare marketing agency Regan Campbell Ward (RCW) says, "Six or eight years ago you may have just done a web site with a little more information than your print or TV ad gave... People are doing a much better job of making information work for them as opposed to viewing web sites as something you just have to do." Diane West adds that many online offerings go "well beyond early invitations to simply 'Visit us at www dot . . .,' the Web offers chatrooms, blogs, listservs, message boards, groups, and instant messaging—many of which can be accessed from wireless hand-held devices." More dubious practices by drug companies include developing front websites that appear to have non-commercial sponsors. For example, sites for the Erectile Dysfunction Institute (EDI) (www.erectile-dysfunction-institute.org), and the Prostate Cancer Institute (PCI) (www.prostate.cc), are both part of the drug company Pfizer’s Viagra marketing campaign, and include links that direct potential consumers to their products. The false sense of control and access to free information on the Internet fosters the idea that consumers are experiencing "personalized medicine." They feel that they are being catered to and are empowered to make informed healthcare decisions. Of course the perception could not be further from the truth.
The pharmaceutical industry asserts that its educational PR and DTC advertisements contain valuable information for the public, and that they are necessary to sustain the research and development process for life-saving drugs in the face of stiff challenges from competitors. Dr. Dorothy L. Smith, president of Consumer Health Information Corporation which specializes in strategic planning for DTC campaigns, states "...given that no one has a doctor on hand at all times to offer advice, consumers have no choice but to make certain decisions about medicines on their own. That process can be made more effective or less effective depending on the amount and quality of the information available.... If the DTC ad provides consumers with 'information' -- which is different from 'advertising' -- the pharmaceutical company will be providing a worthwhile service to consumers. It will also reap the benefits of improved consumer awareness and patient compliance."
Critics, however, contend that mixing marketing and educational strategies creates confusion and potentially dangerous situations. A New England Journal of Medicine article from 2002 held that "patients have dangerous misconceptions about DTC advertising, believing, for example, that only the safest and most effective drugs and medical services can be advertised directly to consumers." Further, "they believe that the FDA requires these advertisements to be under strict review and scrutiny before being published or aired on television. On the contrary, the FDA has not approved and, in fact, opposes some medical services directly offered to consumers." Another source of public confusion arises from laypeople trying to sort through the complex benefits and side effects of a particular drug advertised in a 30 to 60-second television spot, information that is normally interpreted by highly trained doctors.
Beyond creating public confusion, the information offered in educational advertisements, sponsored PSA ads, and informational websites often is not neutral. In a study published in the Journal of Advertising, Macias and Lewis found that the appeals used in nearly 70 percent of prescription drug websites targeted visitors' emotions, often their fears. Admittedly, fear is also a common element in many traditional PSA's, but drug makers direct this fear into public behaviors that benefit their own self-interest. Pharmaceutical sponsors can also control the type and range of illnesses for which the public receives information. Their choices often have little to do with the relative severity, extent, or preventability of a particular condition. Instead, the diseases "marketed" fit with the business needs of the particular corporation. In this sense, health information that the public receives may be completely out of synch with the priorities of agencies actually entrusted with protecting the public health.
Similarly, one of the more troubling risks associated with the use of PR and PSA-style formats for marketing are the impacts that these practices may have on legitimately neutral sources of public information. People have come to trust public service announcements by reputable groups like the Ad Council as a means of receiving objective, non-commercial information intended to promote their health and safety. In this role, advertisements initiated by government agencies and by non-profit groups or associations have produced remarkable results. Among other accomplishments, early PSA's are credited with helping to eradicate polio (the March of Dimes), launch the environmental movement (Keep America Beautiful), and support hurricane relief (American Red Cross). Recent PSA’s have proven highly effective in influencing public behavior toward colon cancer, heart disease, diabetes, AIDS prevention, and drunk driving. An analysis conducted by the Advertising Research Foundation (ARF) concluded that "in one of the toughest and most challenging areas for advertising today -- that of changing attitudes and behavior for health-related issues -- the use of public service advertising alone not only increased awareness, but also reinforced people's belief, fostered their intent to act and inspired potentially life-saving action."
Legitimate sources delivering impartial information build public trust. Unfortunately, in the information free-for-all that characterizes today's media, it is becoming easier to hide motives and obscure relationships. Ivette Achong, Director of PSA Services at WestGlen communications says that she has been intrigued by "the upswing in... corporations turning to PSA's to promote causes and programs that align with their business interests." The trend makes sense for the pharmaceutical industry. A worldwide survey printed in Ad Age International, a leading publication for advertising professionals, found that the vast majority of consumers believe marketers exaggerate the health benefits of their products. The questions remain, will pseudo-educational drug marketing campaigns counter this skepticism and pass as legitimate, unbiased sources of public information? Or, will they ultimately contribute to public cynicism toward the media in general? Given the undeniable importance of true, non-commercial information for public health and safety, it seems unacceptable to risk tainting these trusted formats for communication any further. Practical changes may lie in increased sponsorship by public institutions, or in increased transparency of funders and their interests. As of now, the public remains perilously close to becoming isolated, and drifting away in what they perceive as a sea of untrustworthy information.