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UPFRONT provides a forum for airing opinions on prescribing issues. The opinions expressed in UPFRONT are those of the authors alone. They do not necessarily represent the views or opinions of bpacnz or its staff. In this issue Professor Les Toop and Dr Dee Mangin share their opinions about the effects of direct to consumer advertising of prescription medicines.

Direct to Consumer Advertising In New Zealand. Is the end in sight?

In recent years there have been few issues that match the advertising of prescription medicines directly to consumers (DTCA) in pitting the interests of public health against those of commercial gain. New Zealand and the U.S stand alone in the developed world in allowing the pharmaceutical industry to market their product ranges directly to consumers.

DTCA works by promoting messages that will increase commercial success (overstating benefits) and omitting messages likely to reduce commercial success (minimising harms). As spending on DTCA in both countries has increased from U.S $12 million in the mid 90s to U.S $4.1 billion in 2006 so consumer, health professional and political concern has grown. Internationally there have been many reviews of DTCA from health professional groups, academic institutions, governments and importantly many independent (non industry funded) consumer and patient groups. Without exception they have come to the same conclusion: the partial and potentially misleading information and the accompanying medicalisation caused by DTCA is of net public harm. The only reports and research supporting DTCA have been funded by the pharmaceutical industry, their marketing agents and others who benefit from their support.

All other jurisdictions have reaffirmed their commitment to prevent the introduction of DTCA. In 2002 European parliamentarians threw out a proposal to introduce limited DTCA by a vote of 14 to 1.

Its effectiveness is attested by the growth in expenditure on it, reportedly more than U.S $4 billion was spent on DTCA in the U.S in 2004 and tens of millions in New Zealand. Like the U.S DTCA was ‘allowed’ in New Zealand by default rather than by design.

DTCA is packaged and sold as ‘information’ with the pharmaceutical industry claiming to be acting in patients’ best interests. However advertising is about manipulation not information. Its sole purpose is to increase profits by convincing consumers they want or need a particular branded drug - to drive choice not to inform it.

Supporters of DTCA argue that consumers have a right to the information contained in prescription medicine advertising to facilitate autonomous choice. Does advertising fulfil this need? Within a bioethical framework, three forms of influence on decision making have been described. The first is persuasion, which is a rational process through which someone comes to believe something, through the merit of reasons another advances. Coercion is the second form of influence. The third is manipulation - swaying a person to do something by means other than coercion or persuasion.

‘In health care the key form of manipulation is information manipulation. This is a deliberate act of managing information that nonpersuasively alters a person’s understanding of a situation and thereby motivates him or her to do what the agent of influence intends’.

Information gaps are no excuse however to sanction deliberate misinformation. The presence of DTCA changes the balance of influence on decision making from persuasion to manipulation and masquerades as supporting autonomous choice when in reality it undermines it.

These issues were played out clearly for us as a case study in the recent revelations about Vioxx®, where the emergence of safety concerns occurred after large numbers of patients in many countries had been exposed, after vigorous promotion.

Physicians also have responsibilities to the community. Beneficence, which goes beyond non-maleficence (‘do no harm’), confers the moral obligation to prevent harm and promote benefit. This includes advocating for policy change that will protect from harm and promote benefit. In 2002 more than half of all New Zealand GPs responded within days to a letter from Academic General Practice, setting out their intention to lobby for a DTCA ban, and asking for colleagues to share their opinions and experiences. Four out of five GPs writing back felt negatively about DTCA. In this instance New Zealand general practice has let its voice be heard and has prompted all major professional prescribing groups to consider this issue and take a position opposing DTCA.

The combined weight of opinion of New Zealand GPs who responded along with the independent consumer groups, has put a ban of DTCA on the political agenda. In New Zealand we have just finished the second round of public consultation in five years which reaffirmed the unified health professional and independent consumer health organisation opposition to DTCA.

If we accept the need to regulate access to and advertising of prescription medicines because of the potential for harm, then the aim should not be balancing the interests of industry and consumers, but rather the protection of consumers. For industry there are major commercial benefits from DTCA but it is ultimately patients who take all the risks.

Hopefully New Zealand politicians and regulators will be able to put aside party politics for such an important public health issue and heed the calls of the majority of health professional and consumer groups to join the rest of the world (bar the U.S) and ban DTCA. Even better would be to replace it with useful, unbiased independent consumer health information.

An announcement from the Government has been promised.

Watch this space.

Dee Mangin

Les Toop