Breaking Down the Positive and Negative Aspects of Direct-to-Consumer Advertising

American consumers are exposed to 4,000 to 10,000 advertisements every day (Simpson J. Finding brand success in the digital world. Forbes. August 25, 2017). Ads come in all shapes and sizes, including print, TV, and radio ads, logos, billboards, and social media sponsored posts. According to the Consumer Healthcare Products Association, upper respiratory medications are by far the highest-selling segment of the over-the-counter (OTC) drug market, with 1.15 billion units sold in 2017.

The connection between these two figures isn’t accidental. Spending for prescription drugs for respiratory conditions is also off the charts. In September 2022 alone, Regeneron/Sanofi, Tarrytown, N.Y., spent the most ever ($29.4 million) on TV advertising for one drug—Dupixent (dupilumab)—in the United States (Adams B. AbbVie continues top TV drug ad spender reign and Pfizer’s Comirnaty makes new appearance, as overall spend jumps. Fierce Pharma. October 10, 2022). “Dupixent is FDA approved for multiple uses, but this spend is still quite high,” said Janelle Applequist, PhD, MA, an associate professor at the Zimmerman School of Advertising & Mass Communications at the University of South Florida in Tampa.

“Ads are all around us because they drive sales,” Dr. Applequist said. “When someone is in the market for a particular product, they’re more inclined to pay attention to an ad.”

Ads can be informational, where they attempt to help people avoid or solve problems, or transformational, where they offer something additional through sensory gratification, social approval, or the promise of a better life, Dr. Applequist said. Directto- consumer advertising (DTCA) is good at doing both—providing information about a product, but also using imagery that signifies a happier life just within reach.

Televised prescription drug ads often feature smiling patients stepping out into a brightly lit world surrounded by loved ones. This type of marketing often discusses potential harms as an afterthought in rushed voiceovers. —Vinay Rathi, MD, MBA

By pushing viewers to talk to their doctors about a certain drug, such as Dupixent, a branded drug has the already-worried, captive viewer in a false state of empowerment. “Consumers may not know that only the most expensive, newest drugs are currently advertised,” Dr. Applequist noted. “Patients may think that products will provide a quick fix for their ailments, but ads are designed to divert their attention in order to highlight a product’s benefits while still remaining legally compliant with FDA mandates, which require an equal presentation of drug benefits and risks to be present in DTCA.” What seems like a helpful act of suggesting a drug to their physician may not present an entirely accurate picture.

DTCA can lead patients to both overestimate a drug’s potential benefits and underestimate its risks. “It’s not hard to understand why,” said Vinay Rathi, MD, MBA, chief resident of otolaryngology–head and neck surgery, at Massachusetts Eye and Ear. “Televised prescription drug ads often feature smiling patients stepping out into a brightly lit world surrounded by loved ones. This type of marketing often discusses potential harms as an afterthought in rushed voiceovers.”

DTCA in Otolaryngology

DTCA can have both positive and negative aspects. Favorable outcomes include empowerment and promotion of autonomy among patients, avoidance of low-value clinical encounters, self-directed education, and decreased healthcare expenditures, said Edward McCoul, MD, MPH, professor and vice chair in the department of otorhinolaryngology at the Ochsner Clinic in New Orleans. This is balanced by potential concerns including the lack of rigorous regulation of OTC drugs, the burden of self-diagnosis, the risk of unsupervised use resulting in adverse effects or drug interactions, and redistributing pharmacy costs to consumers (Laryngoscope. 2020;130:2114–2119).

Douglas D. Reh, MD, director of clinical research at Centers for Advanced ENT Care, LLC, in Baltimore, said that DTCA can give the drugs that he prescribes credibility with patients. Considering the record amount of money spent on advertising Dupixent, he says it’s not surprising that Dupixent is the top drug that his patients ask about.

On the downside, Amber Luong, MD, PhD, professor and vice chair for academic affairs in the department of otorhinolaryngology–head and neck surgery and Center of Immunology and Autoimmune Diseases at the Institute of Molecular Medicine, McGovern Medical School at UTHealth in Houston, said that DTCA may heighten patients’ expectations for a drug. “A lot of DTCA for respiratory drugs includes phrases such as ‘improves nasal congestion’ and ‘helps you breathe.’ Patients may not know how much improvement to expect,” she said.

Providers should educate patients on why they did or didn’t prescribe a drug initially or why it may or may not be the right treatment for them. —Marc G. Dubin, MD

DTCA is used for prescription drugs and much more. Regarding otolaryngology procedures, according to Medicare Part B national summary data files, there was a 468% increase from 2011 to 2017 in the number of balloon dilations performed annually in the United States. “It wouldn’t surprise me if this was at least partly a result of DTCA, given the increase in patient questions regarding balloon dilation at my practice,” said George A. Scangas, MD, an assistant professor of otolaryngology–head and neck surgery and a physician and surgeon at Massachusetts Eye and Ear.

Innumerable patients have asked Dr. McCoul about balloon sinuplasty, which they learned about through advertisements on TV or radio. “Oftentimes, however, their medical problem isn’t one that balloon sinuplasty is designed to treat,” he said. “So, these patients start their visit with an expectation that can’t be reasonably met. This typically leads to a discussion about why a balloon treatment is inappropriate, which could be time better spent in other ways (Int Forum Allergy Rhinol. July 16, 2022. doi:10.1002/ alr.23063).”

What the Studies Show

There are many misconceptions about DTCA, including the misconception that it’s tightly regulated. One study found that 43% of those surveyed thought that only “completely safe” prescription drugs could be marketed using DTCA, 21% thought that drugs had to be “extremely effective” to be advertised, and 22% thought that DTCA of drugs with serious side effects had already been banned (J Gen Intern Med. 1999;14:651–657).

In another study, Dr. Applequist and her co-author found that broadcast DTCA placed a greater emphasis on emotional appeals over informational appeals (Ann Fam Med. 2018;16:211– 216). “Essentially, ads are selling more lifestyle and less education,” she said. “If, however, the point of these ads is to spur conversations with one’s physician, then their content should be predominantly informational. This means that DTCA should tell viewers about a drug’s effectiveness, the population it treats, its side effects, and so forth. It shouldn’t be focused on a use of vivid imagery, characters, or a catchy song.”

Information is in the ads, but it’s buried, Dr. Applequist noted. Her 2018 study showed that 57% of ads portrayed main characters seeking social approval, which is up more than 17% compared to a previous study from 2007 (Ann Fam Med. 2007;5:6–13). Dr. Applequist’s study also found that ads were 30% longer than those featured in earlier studies, with her findings revealing that the information included about drugs was significantly lessened.

A study from 2020 found that most patients didn’t see a negative effect from DTCA (J Am Board Fam Med. 2020;33:279–283). The study found that about 76% of patients were more likely to ask their physician about a drug that was directly advertised to them, one-quarter had already asked their physician about an advertised drug, and 23% of patients said they would look for another provider if their physician wouldn’t prescribe a brand name drug they asked for, said Dr. Luong.

In addition, studies have shown that DTCA increases the frequency of physicians prescribing drugs that have been advertised (J Gen Intern Med. 2021;36:1390–1394; CMAJ. 2003;169:405–412). “DTCA is created to persuade,” Dr. Applequist said. “Patients sometimes prioritize their own suggestions for care on 60 to 90 seconds of advertising creativity over many years of professional medical training. Physicians may feel pressured to prescribe a certain drug, especially when patients create a dynamic in which they undermine a provider’s role in making healthcare decisions.”

Another downside, Dr. Rathi added, is that patients may lose confidence in physicians when they suggest therapeutic alternatives to drugs seen on TV. “Patients may lose confidence in these alternatives, even when there is strong evidence supporting their safety and effectiveness and even if they are more cost-effective,” he said. “This could result in physicians feeling pressured to prescribe drugs that they don’t consider appropriate or are less comfortable managing.”

Problems can also occur when a physician doesn’t fully understand a new drug’s nuances. “In general, physicians prescribe drugs that they have a long history with and know how to manage,” said Marc G. Dubin, MD, president and CEO of The Centers for Advanced ENT Care, LLC, in Baltimore. “Many of the newer drugs don’t have as long of a follow-up because the post-marketing analysis hasn’t been completed.”

Handling Expectations

When a patient is interested in an advertised medication, Dr. Luong recommended asking them what they know or understand about it. “This helps patients to feel that they are being heard, while also helping me to determine how to respond,” she said.

Dr. Rathi noted that it’s important to understand what goals patients have for their health. “Marketing may help patients formulate or shape these goals, but it’s the physician’s responsibility to help them fill in any knowledge gaps about how advertised drugs may or may not help them achieve those goals,” he said. “Patients often appreciate learning about potential benefits with greater nuance or being alerted to important potential risks.”

DTCA can result in patients wanting the “latest and greatest treatment,” said Dr. Dubin. Physicians can use this opportunity to begin a beneficial dialogue. “Providers should educate patients on why they did or didn’t prescribe a drug initially or why it may or may not be the right treatment for them,” he said. “When a physician takes the time to do this and educates patients about the benefits of an alternative medication, it builds trust between them.

“Sometimes, patients bring up points that I hadn’t considered,” Dr. Dubin continued. “This keeps me on my toes and encourages me to make sure that I stay up to date with the most recently released drugs and procedures.”

When patients want additional information regarding an advertised product, providers can point them to various resources. “Oftentimes, the interaction between the patient and otolaryngologist can be too short for a patient to fully understand a complex disease like chronic rhinosinusitis. Rather than having patients Google for information, providing them with resources to learn more about a disease and potential treatments can help them understand why many advertised medications may or may not help their ailment,” said Dr. Luong.

Dr. Rathi advises patients to refer to FDA-approved patient package inserts, medication guides, and instructions for use that accompany prescribed drugs. “However, it’s important that clinicians such as otolaryngologists, collaborating physicians, and pharmacists help patients understand any technical information they may not understand or have questions about,” he said.

Dr. Luong points patients to the website of professional medical organizations, such as the American Rhinologic Society. Its website Sinus Health contains a wealth of information about diseases and treatment options. The American Academy of Otolaryngology–Head and Neck Surgery also has patient resources on its ENThealth site.

In private practice, there are pressures to keep patients happy so they return. “When a patient brings up a drug that you didn’t recommend, use it as an opportunity to educate them and demonstrate your depth of knowledge,” Dr. Dubin said.

If Dr. Reh recommends something different than what a patient asked for, he will explain why. “It’s rare to have a patient get upset if I suggest something else,” he said. “They’re thankful that I have their best interests in mind.”

A Final Word

Prescription drugs were first directly marketed to consumers in 1985. After 1985, most DTCA was relegated to print because advertisers were obligated to report all of the potential risks, Dr. McCoul said. Beginning in 1997, the rules changed, and companies neededto list only major risks as long as they referred consumers to a website or another source for full information.

“This made broadcast advertising a more practical option, and now it accounts for the majority of DTCA,” Dr. McCoul says. “Because TV and video are hotter media, it’s likely that the advertising message is more effective. This can be beneficial but can also be problematic when the notion of a particular treatment becomes fixed in a consumer’s mind.”

Despite the challenges that can result from DTCA, Dr. Applequist sees its value, particularly in a capitalist society. “Pharmaceutical products save lives every day and allow countless individuals to live improved lives,” she said. “But there are many ways that the marketing of these products could be improved.”

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Karen Appold is a freelance medical writer based in Lehigh Valley, PA.