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Vol 19 No 3 (2000)

UK Physicians’ Attitudes Towards Direct-to-Consumer Advertising of Prescription Drugs:
an Exploratory Analysis

Jon D. Reast
and
 Anna M. Carson
Leeds University Business School

INTRODUCTION

In a market worth $99.5 billion in 1998 (IMS Health, Inc, 1998), and growing at 11 per cent, a recent change to US legislation has given pharmaceutical brand owners the go–ahead to advertise prescription drugs directly to consumers in broadcast, print and electronic media (http://www.fda.gov, 1999). Within the $10.2 billion UK market (IMS Health, Inc, 1998), the legal framework only allows brand owners to operate a ‘push’ promotional strategy, advertising to health professionals (e.g. physicians and pharmacists), and not directly to the general public. The only opportunity to address consumers ‘directly’ comes via public relations activities.

INTERNET AS A CATALYST FOR CHANGE

While advertising in UK print and broadcast media is tightly controlled, it is impossible to apply the same rules to the internet. Access to US prescription drug websites is available from anywhere in the world, including those countries where DTC drug promotion is prohibited. By clicking on ‘Resident of the United States’ on the website of Eli Lilly & Company (www.lilly.com), for example, access is granted to webpages advertising the company’s prescription drug portfolio. In the context of increasing numbers of European citizens having access to the internet and even being able to purchase from US targeted drug websites, it seems likely that the European legal framework may soon be forced to change.

UK AUTHORITIES CHANGE TACK?

Although the Advertising Standards Authority (ASA) and the Association of the British Pharmaceutical Industry (ABPI) clearly prohibit DTC advertising, recent evidence suggests that the regulatory climate is changing: the UK Prescription Medicines Code of Practice Authority approved the placement of factual information on prescription drugs on the internet (The Pharmaceutical Journal, 1999); the UK Medicines Control Agency (MCA) is reconsidering the question of allowing prescription drugs to be advertised on the publicly accessible online version of the British Medical Journal (The Lancet, 1999); the MCA has also given the go–ahead to Pharmacia & Upjohn for a ground–breaking £1m ‘See your doctor’ generic category ad campaign similar to those produced in the USA in the early 1990s; and a controversial editorial in The Lancet (1998) suggested DTC advertising should be extended from the USA to other countries on a trial basis.

DEVELOPMENT OF DTC ADVERTISING:
The US Experience

The first US DTC advertisements appeared in the early 1980s (Rufen–Boots Pharmaceuticals). DTC advertising soon became popular and in 1985, following a voluntary two–year moratorium, the FDA ruled that DTC advertising would be regulated in the same way as all other prescription drug advertising, meeting the criteria for ‘fair balance’ and ‘brief summary’ information, but with the additional requirement of a ‘major statement’ of attached risks for broadcast advertising. Broadcast ads were never able to satisfactorily meet all the regulatory criteria due to the time constraint of the ad length. Full approval was finally given to reduced regulatory requirements for DTC advertising in all media in August 1999, paving the way for more creative broadcast ads for pharmaceutical brands. Between 1985 and 1999, brand owners highlighted specific medical conditions with unbranded ‘See your doctor’ campaigns. Clearly, strong category dominators could benefit from such an approach, which was not deemed to be ‘promotional’.

Some companies went to innovative lengths to take advantage of the new 1999 regulations: Glaxo–Wellcome advertised Imitrex on the back of ATM receipts and bank statements with a free phone number and website address; and Schering–Plough rented advertising space from United Airlines to advertise Claritin on luggage labels. The brand name and dosage were mentioned, with a phone number to obtain a discount coupon (Medical Marketing and Media, 1999).

US DTC advertising expenditure

DTC ad expenditure has increased dramatically in print and broadcast media since the FDA draft guideline was issued. In 1997, pharmaceutical manufacturers’ DTC ad spends exceeded $1 billion: almost 40 per cent more than in 1996 and triple the amount spent on journal ads for pharmaceuticals (IMS Health, Inc, 1998). This increased by over 23 per cent to $1.3 billion in 1998, over 50 per cent of which was allocated to television advertising, while promotional expenditure directed towards physicians grew by over 18 per cent to $4.6 billion (IMS Health, Inc, 1999).

Table 1 shows the top five DTC advertised products in the US during 12 months to March 1999 (IMS Health, Inc, 1999). To give an indication of current advertising expenditure for over–the–counter (OTC) medicines in the UK, by comparison, the table includes an entry for Nurofen Liquid Capsule. Nurofen is the OTC brand leader analgesic in the UK, and the ad spend quoted is for the £2 million launch campaign for this brand extension in autumn 1999 (Chemist & Druggist, 1999).

TABLE 1: TOP FIVE US DTC ADVERTISED PRODUCTS DURING 12 MONTHS TO MARCH 1999

DTC impact on US doctor–patient relationship

There is widespread feeling that ‘consumerism has entered the health care field’ (Kotler and Clarke, 1987), changing the nature of the doctor–patient relationship. In the United States, for–profit corporations are involved in healthcare management, presenting ‘medicine as a marketplace’ and ‘patients as consumers’ (Mechanic, 1996). Hollon (1999) believes the principal effect of DTC marketing is to create consumer demand, ‘changing the physician–patient relationship to a physician–consumer relationship’. Mechanic (1996) also reports an erosion of trust between doctors and patients; and there is concern among physicians that declining prescription requests for advertised drugs could negatively affect the doctor–patient relationship (Hoffman and Wilkes, 1999). An examination of research into consumers’ attitudes suggests that such concerns are not completely unfounded: 64 per cent of the respondents in a study by Perri and Nelson (1987) perceived DTC advertising to be beneficial in protect ing them from ‘under–informed practitioners’. However, patients also seem anxious to preserve the relationship (Peyrot et al., 1998), with more highly advertising–aware, regular medication takers not requesting specific drugs ‘for fear that it would upset their physician’.

Response to DTC: Attitudes of US physicians

Much of the research conducted in the USA relates to consumer (e.g. Perri and Nelson, 1987; Perri and Dickson, 1988; Williams and Hensel, 1995) and commentator (e.g. Kessler and Pines, 1990; Hollon, 1999) perspectives on DTC advertising. While commentator perspec tives give a mixed response to DTC and its potential impacts, consumer–based research is generally supportive of DTC (Perri and Nelson, 1987; Alperstein and Peyrot, 1993; Williams and Hensel, 1995; Pines, 1998), unearthing a demand for ‘educational’ healthcare information.

Only one study was found to directly address the attitudes of physicians towards DTC advertising (Petroshius et al., 1995). In general, the Petroshius findings suggest that US physicians are favourably disposed to the advertising of pharmaceutical products, both to consumers and other physicians. Their research highlights differences in sample response based upon age, experience, practice setting, type and speciality, with the most notable differences being indicated by age of respondent.

When compared with the hostile correspondence surrounding a pro–DTC article in The New England Journal of Medicine in the 1980s (e.g. Masson and Rubin, 1985; O’Brien, 1986; Cohen, 1988), the findings of Petroshius et al. suggest that US physicians’ response to DTC has softened dramatically over the past 10 to 15 years.

On a scale of 1–5, the overall composite average response for advertising to doctors was 3.77, while the overall response to DTC was 3.33, i.e. on the whole, US physicians were supportive of DTC advertising, albeit slightly less so than they were of advertising to fellow physicians. It can be seen from Table 2 that the response to DTC did vary by age, years in practice, practice setting (urban vs. rural), speciality, and, to a lesser extent, the type of practice. However, apart from one overly small cell (sample = 13) recording a response of 2.42, no other group of respondents recorded below 2.8. Responses among younger, urban–based respondents with less than 10 years in practice were particularly favourable (3.75–3.83).

TABLE 2: PHYSICIANS' ATTITUDES TOWARDS ADVERTISING

Hypotheses (UK Physicians)

H₁ Physicians consider direct–to–consumer advertising of prescription drugs to be unethical relative to advertising to physicians.

H₂ Physicians are opposed to the introduction of direct–to–consumer advertising for prescription drugs.

H₃ Direct–to–consumer advertising would weaken the relationship between physicians and pharmaceutical companies.

H₄ Physicians believe direct–to–consumer advertisements would negatively affect the doctor–patient relationship.

H₅ GPs are more negatively predisposed to DTC advertising and its potential effects than are hospital doctors.

The above research hypotheses have been developed with reference to the preceding literature. See Appendix 1 for specific reference to the research objectives of Petroshius et al. (1995).

TABLE 3: SURVEY DISTRIBUTION AND RESPONSE RATE 

METHODOLOGY

A survey was conducted among physicians in the Cumbria, Dumfries and Galloway, Leeds, Plymouth, Somerset, Tyneside, York and Humberside areas of the UK. A self–administered questionnaire was either hand–delivered based upon a random selection from Yellow Pages (Leeds, Humberside, Dumfries and Galloway areas), or randomly delivered (for convenience purposes) by former medical student contacts now practising across the UK. A total of 126 questionnaires were circulated, and each physician was asked to spend 10 to 15 minutes recording their response. Upon completion, physicians were asked to place the questionnaire in an attached envelope and return it by mail. The questionnaire consisted predominantly of a series of Likert–scaled items (1=strongly agree, 7=strongly disagree). Informal pilot discussions with two doctors took place which were invaluable in developing ideas, focusing the study and compiling survey questions. The survey instrument was piloted with two further healthcare professionals to check for inconsistencies or miscomprehension before the final version was distributed.

TABLE 4: ETHICS OF DIRECT–TO–CONSUMER AND PHYSICIAN–DIRECTED ADVERTISING 

SAMPLE COMPOSITION

In order to test the hypothesis that primary care physicians would be more negatively disposed to DTC advertising, it was necessary to include both GP and hospital doctors in the sample. A total of 68 physicians participated in the study for a response rate of 54 per cent, which was seen as very acceptable (Kumar, 1999) (see Table 3). While detailed profiling in terms of age and experience of the sample was not collected, the GP sample was drawn from a mixture of urban and rural, and different regional areas. It is also known that 10 of the 35 GP sample were drawn from a whole practice team of GPs. The hospital doctor sample was also drawn from a number of regional settings, but tended to be skewed relatively younger in age profile, with 80 per cent of physicians at senior house officer/house officer level, 18 per cent at registrar or senior registrar, and no consultants taking part. This would imply that the majority of the hospital doctor sample was aged under 40. In examining the responses from the sample we have found no evidence of self–selection response bias other than the relatively younger hospital doctor profile. This we feel was a function of the way the data were collected. The response of over 50 per cent of the population approached within each field gives us some confidence in this matter.

TABLE 5 DOCTOR–PATIENT–MANUFACTURER RELATIONSHIPS

The sample of physicians is felt to be relatively small, yet sufficiently representative, as it was drawn from across the country, representing a number of different levels and specialities. The purpose of this study was to gauge the overall response to DTC advertising of GPs and hospital doctors, highlighting any differing attitudes. As such, the sample is felt to be adequate for this broad exploratory purpose. Sample sizes do not allow for rigorous statistical analysis on break downs below the broad GP and hospital doctor split shown in Table 3.

RESULTS

H1 Physicians consider direct–to–consumer advertising of prescription drugs to be unethical relative to advertising to physicians.

H2 Physicians are opposed to the introduction of direct–to–consumer advertising for prescription drugs.

The sample indicated that, while supportive of advertising directed towards physicians, UK doctors felt that DTC advertising was unethical. These results in some senses mirror the strong support by US physicians (Petroshius et al., 1995) for doctor–targeted advertising in the US, but contrast with the more positive views towards DTC advertising of US physicians (Petroshius et al., 1995). The findings also indicate that UK doctors would oppose any move to introduce the policy within the UK. Hypotheses 1 and 2 are thus upheld.

H3 Direct–to–consumer advertising would weaken the relationship between physicians and pharmaceutical companies.

H4 Physicians believe direct–to–consumer advertisements would negatively affect the doctor–patient relationship.

Despite the opposition to DTC, the results indicate that physicians are divided over the extent to which relationships with pharmaceutical companies will be damaged, with hospital doctors expressing fewer concerns in this area (see Table 4). Hypothesis 3 is therefore only moderately upheld. Results for Hypothesis 4, which relates to physicians’ perceptions of the likely impact of DTC advertising on doctor–patient relationships, indicate that doctors are concerned about the relationship being damaged, and specifically that DTC advertising will undermine their role as ‘health specialists’. Supportive of this is the feeling indicated by Question 8 in Table 5, that patients are already felt to be pressurising prescribing decisions for those Rx products which have been featured in the media. It is worth noting that while a significant result was not found for Q7 below, ‘extra patient information over the past 10 years has improved relations’, the results are directionally supportive of the sceptical view of DTC advertising and ‘educational campaigns’, and it may well be that with a larger sample size, this would also be significant.

H5 GPs are more negatively predisposed to DTC advertising and its potential effects than are hospital doctors.

The most notable differences between the attitudes of GPs and hospital doctors tend to be at the ‘global’ level, i.e. GPs are more concerned with the ethics of DTC advertising and are slightly more inclined to oppose its introduction (see Table 6). The additional, more specific areas where we can report differences in attitude are regarding the physician–manufacturer and physician–patient relationships. In particular, GPs appear to believe that the introduction of DTC advertising for Rx products would damage their relationship with pharmaceutical manufacturers. They also believe that DTC introduc tion would undermine the value of doctors as healthcare specialists.

However, the picture is not entirely clear, since hospital doctors appear to believe more strongly that DTC will fail to ‘enhance the doctor–patient relationship via improved communication’, and will lead to ‘increased pressure on doctors to defend their prescribing decisions’. Hypothesis 5 is therefore only partially upheld.

While not all the findings are supportive of Hypothesis 5, an overall more negative approach of GPs towards DTC is felt to have been found within the study. This could be explained in part by the nature of the relationships which GPs have with patients and pharmaceutical companies. As primary care providers and ‘family doctors’, GPs are more closely associated with ongoing prescribing and are more inclined to have long–standing relationships with patients, which have been established over many years. They may thus feel threatened by the balance of power and authority switching from themselves to patients via manufacturers’ advertising, and be more interested in maintaining the traditional relationship with patients.

GPs, by their very nature, are more ‘generalist’ than their hospital colleagues and fulfil an important role in referring patients to hospital doctors who are specialists in a chosen field. Thus GPs may feel more embarrassed or threatened than hospital physicians when faced with challenges to their knowledge, authority and judgment. Furthermore, the types of drugs most likely to be advertised to consumers are ‘life–enhancing’ rather than ‘life–saving’, which are more liable to be prescribed by a GP.

While attitudinal differences have been discussed, it is just as interesting to comment on the many areas of apparent consistency in attitudes expressed by the two groups of physicians within this exploratory sample (see Table 7). No significant differences in attitudes between the two groups of physicians were found in the following areas: promotion of Rx drugs to doctors is ethical; Rx DTC advertising will lead to increases in unnecessary prescribing; DTC advertising is likely to increase the number of patient visits to GPs; patients currently put pressure on doctors to prescribe products which have had substantial media coverage; patients are greatly influenced by what they see/hear/read in the media; DTC is unlikely to lead to any improvements in compliance with a course of medication; overall approval of the introduction of DTC advertising; and the extent to which DTC advertising would improve health education.

Further attitudinal differences?

While it must be understood that no significant differences were found in any of the areas below, we believe that some of the results in Table 7 are at least directionally supportive of hypothesis 5, i.e. that GPs are more negatively predisposed to DTC advertising and its potential effects than are hospital doctors. It may well be that given further studies in the area with larger sample sizes, further attitudinal differences between groups of physicians will be confirmed.

It should not be surprising that, broadly speaking, both GPs and hospital doctors have similar attitudes towards the introduction of DTC advertising. However, without further research to understand the motivations behind physician attitudes, we can only offer considered comment on these results. All the physicians in this study belong to the National Health Service (NHS), which has traditions reaching back over many decades. Both groups will have had largely similar academic training until diverting off into specialised areas of medicine.

TABLE 6: GP VS. HOSPITAL DOCTOR–ATTITUDINAL DIFFERENCES

CONCLUSIONS AND IMPLICATIONS

The eventual impact of DTC advertising on UK and European health care markets has not been the focus of this study, but the political and social implications are potentially far–reaching. We first summarise the conclusions to this study before noting possible repercussions if DTC advertising is introduced in the near future.

Contrasting US and UK medical opinion

A study of physicians in the USA (Petroshius et al., 1995) found that physicians were broadly supportive of advertising both to doctors and consumers. The data presented within this study suggest that UK physicians (both GPs and hospital doctors) are opposed to the intro duc tion of DTC advertising, which they feel is unethical, and are concerned about the potential negative impacts of DTC should it be introduced.

While UK GPs viewed DTC advertising more unethically than did their hospital colleagues, having potentially more channel and patient relational involvement, both groups were opposed to its introduction. Indeed, overall, the survey showed relatively few differences in the views of the groups of physicians, with both groups being strongly opposed, seeing many issues and few benefits associated with Rx DTC advertising. Unlike their US counterparts, UK physicians are uncon vinced about the claimed benefits of DTC in the form of ‘improved compliance’ and ‘improved health education’.

The different environments in which the two research surveys were undertaken can perhaps explain the different attitudes of US and UK physicians. In 1995, US physicians would already have had exposure to DTC advertising for about 10 years and would therefore be in a position to make informed judgments about its effects. In the current UK environment DTC advertising is a new and alien concept, and many health professionals appear to be highly sceptical of its potential development and the change to a doctorrelationship (Mechanic, 1996). The UK pharmaceutical market could also be described as more conservative in nature, relative to the USA, with any form of promotional activity for prescription drugs being prohibited for fear of encouraging inappropriate usage.

Marketing strategy implications

While it was not the purpose of this study to consider the possible implications of a shift to DTC Rx advertising, a number of potential impacts do present themselves for discussion.

• Bigger advertising budgets – manufacturers may switch money across from GP–targeted to consumer–targeted advertising activities, although the US experience has seen an increase in both forms of promotion, with overall increases in A:S ratio within the sector. As such, a shift to DTC advertising may well mean a strengthened competitive situation for powerful brand manufacturers who can afford increased levels of A:S, and a weakened situation for smaller players. The current tight restrictions on advertising to an extent favour the smaller players.

• Fewer sales representatives – as manufacturers gain the power to address consumers directly and thus influence prescribing decisions, they may see fit to reduce their reliance on the traditional large sales representative forces prevalent within the pharmaceutical industry.

• Media impacts – as advertising regulations become increasingly standardised in this and other sectors, the attractiveness of global media such as the internet increases for manufacturers – but the need for advertising in traditional media channels will continue both to communicate branding and broad product benefits, and draw traffic to web–based information.

• Packaging and branding issues – If DTC advertising for prescription drugs is approved, this could trigger a revolution in the packaging form and graphics of drug products. Packaging plays an important strategic role in brand communication, and brand owners may feel the need to differentiate themselves from competition by providing attractive ‘consumer–orientated’, ‘advertising–friendly’ packaging. This could lead to the possibility for prescription brands to more successfully extend their life cycle beyond the end of their patent, in the face of competition from generic equivalents. Should consumers develop brand rather than generic prescription drug loyalty, this could signal major change. Researchers might wish to document such hypothesised changes towards ‘consumerised’ packaging.

• Relationship implications – UK physicians are concerned about the potential damage to their relationship with patients, fearing that their professional position will be undermined, and that their prescribing decisions will come under undue scrutiny. In addition, GPs feel that DTC advertising would damage their relationship with drug manufacturers. The introduction of DTC could effect a shift in the balance of power within the channel relationship between manufacturers and doctors. Brand owners would have increased power in such a relationship where doctors would be at least partially influenced by patient requests, and could fear the consequences of declining such requests. In an effort to minimise the potential damage to the relationship between manufacturer and physician, it may be necessary for manufacturers to open a dialogue with the medical profession to try to ensure that the specific advertising and promotional approaches taken are regarded as responsible.

FURTHER RESEARCH

European reaction to DTC?

This study clearly prompts the question of the response to Rx DTC advertising among physicians across mainland Europe. With a variety of different attitudes to the promotion of over the counter (OTC) and prescription drugs in each European country, the picture may well vary significantly. It would thus be beneficial to collect data across Europe to measure differences in attitude, which could affect global drug advertising campaigns. A broader picture of the opinions held by European physicians would also make it possible to evaluate the likely acceptance of DTC advertising and the pace of change, if it were introduced in Europe.

Physician–related variables

This exploratory study was not intended to consider the many potential sub–variables of the GP and hospital doctor sample which Petroshius et al. (1995) reviewed (age, experience, gender, speciality, etc.). A larger survey could develop the findings of this project and consider more of the sub–variables listed above, comparing findings with Petroshius et al.’s work.

DTC advertising – the UK and European consumer?

This paper has referred to several consumer studies conducted in the USA (e.g. Perri and Nelson, 1987), but the authors have not detected any comparable UK or European research. On the whole, US citizens seem to be very supportive of DTC advertising and feel that they have a right to view the material contained in the advertisements. UK and European consumers have yet to be asked their opinion about such matters.

CONCLUSION

This survey highlights a controversial and topical issue in markets worth almost $100 billion in the USA, $10 billion in the UK, and $65 billion across the whole of Europe (IMS Health, Inc., 1999). The research has confirmed a wide disparity in medical opinion between the USA and UK, and a need for more physician and consumer research in both the UK and the rest of Europe.

Appendix 1

Research objectives of Petroshius et al. (1995), specifically relating to the context of this study:

• To assess physicians’ attitudes towards pharmaceutical company advertising of prescription drugs, of both cosmetic and medi cinal products, directed towards consumers and practising physicians.

• To determine if important group differences exist with respect to physicians’ attitudes towards the advertising of prescription drugs (e.g. physician speciality, age, experience, practice type, location).

REFERENCES

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Cohen, E.P. (1988) ‘Direct–to–the–public advertisement of prescription drugs’, The New England Journal of Medicine, 318(6), 373–376.

Hoffman, J.R. & Wilkes, M.R. (1999) ‘Direct–to–consumer advertising of prescription drugs: an idea whose time should not come’ (Editorial), BMJ, 318, 1301–1302.

Hollon, M.F. (1999) ‘Direct–to–consumer marketing of prescription drugs: creating consumer demand’ JAMA, 281(4) (January), 382–384.

Kessler, D.A. & Pines, W.L. (1990) ‘The federal regulation of prescription drug advertising and promotion’, JAMA, 264(18) (November), 2409–2415.

Kotler, P. & Clarke, R.N. (1987) Marketing For Health Care Organizations. Prentice Hall.

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Masson, M.A. & Rubin, P.H. (1985) ‘Matching prescription drugs and consumers: the benefits of direct advertising’, The New England Journal of Medicine, 313(8), 513–515.

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O’Brien, M. (1986) ‘Advertising prescription drugs to the public’ (letter), The New England Journal of Medicine, 314(8), 523.

Perri, M. & Dickson, W.M. (1988) ‘Research in brief: consumer reaction to a direct–to–consumer prescription drug advertising campaign’, Journal of Health Care Marketing, 8(2) (June), 66–69.

Perri, M. & Nelson, A.A. (1987) ‘An exploratory analysis of consumer recognition of direct–to–consumer advertising of prescription medications’, Journal of Health Care Marketing, 7(1) (March), 9–17.

Petroshius, S.M., Titus, P.A. & Hatch, K.J. (1995) ‘Physician attitudes toward pharmaceutical drug advertising’, Journal of Advertising Research (November/December), 41–51.

Peyrot, M., Alperstein, N.M., Van Doren, D. & Poli, L.G. (1998) ‘Direct–to–consumer ads can influence behaviour’, Marketing Health Services (summer), 27–32.

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