Ratings

Participants’ ratings of AdWatch's appraisal of the Augmentin advertisement were:

Participants' ratings of our recommendations for Australia were:

Participant's ratings of the Augmentin advertisement were:

With few exceptions participants who rated our appraisal and/or our recommendations as misleading did not explain why.  One participant appears to have rated both as misleading because of personal experience of benefit from appropriate use of Augmentin plus perceiving AdWatch on Augmentin as an attack on the drug.  By contrast our intention is to defend Augmentin from inappropriate use so that it will remain effective when it is needed. We should have made that clearer.

Some participants ratings were contradicted by their comments. eg rating AdWatch as "misleading" but then praising it or rating the advertisement as "helpful" but suggesting that:

 "Commercially designed enticements pushing products to health professionals should be outlawed by governments."

Any suggestions for how to word our rating questions so as to reduce these misunderstandings would be appreciated.

Suggestions: 

(We will only receive your suggestion if you click on "Send comments to the AdWatch team at the bottom of this page.)

Comments

Of the 107 participants, 34 wrote no comments. The remaining 73 wrote 135 comments. I have classified the comments according to their main topic. My classification is somewhat arbitrary. 

All topics will be discussed below but not exactly in that order.

Comments about AdWatch

Praise for AdWatch

The praise included:

"Excellent. Very clear and important."

"Thought-provoking, useful"

"This is what GP's need - more of it thankyou!"

"A useful analysis of this product's advertising. Good to set it in the context of positive recommendations."

"Excellent. It gives me more insight into the subtleties of advertising and encourages me to stick to my guns." 

"Worthwhile issue as antibiotic overuse is a major issue in Australia. Agree that is carefully engineered to appeal to prescribers. Ad uses sex and would appeal to females as well as males."

"Thank you for another excellent piece of analysis -- I can feel my scepticism shaping up quite nicely."

"You have put a lot of effort into this. Thank you."

Response: We give more attention to criticism (below) but praise is just as important.  Praise helps us assess the criticism in a balanced context. That will help us avoid making too many changes to things that most participants like the way they are.  
Praise may help us win funding. 

Some participants wanted more doctors to read AdWatch.

"Very good! I hope more doctors get to read this! Please go on!!!"

Response: We too hope that more doctors will get to read this but we are having difficulties getting the word out.  Problems include our lack of funds and the fact that most channels of communication with doctors are influenced by drug company funding one way or another.

Some participants planed to tell others about AdWatch:

"Excellent. I have forwarded details of it to around 300 or so UK hospital Med Info pharmacists."

Response: Personal endorsement can be very effective so we are particularly grateful for such support.

Some participants mentioned that they they planed to use our material:

"I'm Clinical Pharmacologist, and plan to use these evaluations as examples to my students."

"Although Co-Amoxyclav is listed in the South African EDL [Essential Drugs List] for a specific condition (amoxycillin resistance in chronic and complicated sinusitis in children) the suspension is still freely available in State Institutions and is widely abused by prescribers who cannot produce evidence for their prescriptions when challenged. An article like this provides good evidence to back up pharmacist interventions. Thank you."

Response: We are very happy for our material to be used by others especially if we are acknowledged as the source. If people let us know that they are using our material that will help us win funding so we can do more.  We will establish AdWatch editions for other countries if we can find the resources (mostly people) required.

There was also praise for Therapeutic Guidelines Antibiotic which quoted:

I really like the plainly listed bullet points on the Therapeutic Guidelines Antibiotic (Oct 2003) This is clear, concise, and I wish this were more commonly presented in the US

Response: There would be a dramatic improvement in health care if all Australian health professionals moved from relying on drug companies for information to using the Australian Medicines Handbook, the National Prescribing Service including Australian Prescriber and the Therapeutic Guidelines.  Despite the fact that these organisations focus on the Australian context their products are often better than anything else available for health professionals in many other countries.

Criticism of AdWatch

Criticism of AdWatch mostly included constructive suggestions for improvement. eg advice about grammar and suggestions for improving the organisation of the material. It is good to know that we are building a community of people who read AdWatch carefully and are willing to help us to improve it. If you are interested in joining the AdWatch quality improvement group (who will get to see AdWatch issues before they are finalised), please contact jon@healthyskepticism.org 

Some felt that AdWatch on Augmentin was too long:

"Excellent contents; Could be a little shorter (got to go to work!)"

"A little too long and at times difficult to follow - particular the frequent use of the subheadings "Our reading", "Our opinion" "reasonable readings include" etc. Needs to be more succinct and hard hitting."

"I am afraid that your comments are too long, read mainly by people who already know, who already prescribe in the correct manner. There is an urgent need for even more easy-and-quick-to-read versions to move the case forward."

"...If I had to offer any critique it is that you've depicted all the various techniques deployed as of equal force - perhaps showing which is the most manipulative will highlight the pitfall more clearly."

Response. It is important that AdWatch do more than just preach to the converted. Often therapies (including interventions such as AdWatch) work better in smaller doses because less adverse effects makes it easier for people to persist longer.  We should keep AdWatch issues shorter in future. This will involve trying to pick and focus on the most important points rather than trying to cover all points. 

One participant felt that AdWatch on Augmentin was too short.

"...it's unfair to negatively critique an advertisement without criticising competitor product advertisements. For example, last issue's Nexium critique was quite negative. Indeed, this issue you posted percentages of practitioners who would decrease their prescribing of Nexium. What a boon for competitors of AstraZeneca! And yet, no doubt such competitors each have their own advertisements of similar integrity. Although the primary goal of Adwatch is to expose questionable marketing techniques, you must accept the prescribing influence you are having on practitioners. It would only be responsible (and fair to AstraZeneca & GSK) to include critiques of competitor advertising campaigns."

Response: I did critique all advertisements for a whole class of drugs for each edition of Healthy Scepticism New Zealand during 1998-2000. The reasons for not doing it that way now include the need to keep it short and simple discussed above and our lack of funding.  Ideally we would do one new topic a week and thus be able to cover all the drugs in a class.  Meanwhile we hope that we can influence drug use in the direction of our recommendations. If we are successful then the companies with the best products will gain sales. We are pro-patient, not anti-industry so as long as patients benefit we are happy for companies to benefit also. However we also hope that lessons learned from AdWatch about an advertisement for one drug will generalise to other advertisements so that if other companies are using misleading advertising then their sales may fall.

Some participants felt we were aiming at the wrong target but there was a range of views about who we were targeting:

"Interesting to read, but believe that your criticism is directed at the company and the industry rather than focussing on the drug and the published science surrounding the use of Augmentin."

"Not as great as the Nexium issue. ...  I'm not trying to defend my own prescribing;  but I do think that  picking on adverts which are fairly mild on the scale of things  runs the risk of  trivialising  the  message or making it look like  nit-picking.  The points about prescribing are all very well (and no I don't use antibiotics for bronchitis usually!  And certainly don't take it myself even during the  the rare & to me startling periods  I've found myself  febrile & coughing disgusting green stuff)  -  but it looks like you're not attacking the advertiser here as much as you are the prescribers.    Yes of course you blame the adverts for the prescribing - but the direct message seems to be as much about prescribing as advertising.   I am not sure that's deliberate -  I am possibly reading it differently to you,  but if I can, others will and  you  want to get docs on side!... Hadn't realised the ads were picked at random? Why not pick the worst?"

Response: AdWatch aims to illuminate the techniques used in drug advertisements. We do not blame drug companies or doctors.  Drug companies are profit seeking companies and doctors are human.  Doctors and drug companies are often in a vicious cycle where misleading promotion leads to suboptimal prescribing and suboptimal prescribing rewards misleading promotion. It is common to blame the drug companies but Garai argued that companies just do what works to get sales. The system gives companies little choice but to do what works or be taken over by more "effective" competitors. What works depends on how doctors really make decisions. Consequently he put the onus on doctors to improve our decision making. (See: Garai's challenge: The 40th anniversary of the inspiration for Healthy Skepticism)  Where I part from Garai is that I believe that, because doctors have a range of normal human limitations, it is unreasonable to expect doctors to be able to always resist promotional techniques that are often effective for misleading humans.  Consequently we need multiple interventions to change the system and improve the performance of doctors and drug companies for the benefit of patients.  If we do a better job for patients then they may reward us so that we benefit also.  I hope that AdWatch will influence both doctors and drug companies but other interventions, such as redesigning the perverse incentives for drug companies and doctors, are needed also.  Both doctors and drug companies need support to grow out of rejecting criticisms because they feel hurt towards welcoming (and even seeking) criticisms as opportunities for improvements that can benefit all concerned. (See: A complaint is a gift)  Healthy Skepticism's value often arises from taking the role of the dissident who speaks out about the problems that most people prefer to ignore so as to feel comfortable. (See key points from Vital Lies Simple Truths. The psychology of self-deception.) Because we do not explicitly blame anyone many readers will think that we are blaming doctors or drug companies so we should add something about these issues to our Introduction to AdWatch webpage and invite new readers to read it before they read AdWatch editions. I will draft something after I get feedback about the above.
The feedback suggests that many doctors are more comfortable if our main focus is biological issues (as it was for AdWatch on Nexium) rather than psychological issues (as it was for AdWatch on Augmentin).  In future we will give biological issues more attention than we did for Augmentin. However the psychological issues are important and our aim is illumination rather than comfort.  The other cusp of the dilemma is that we don't want to put people off so we should discuss psychological issues (normal human limitations) with greater care in future.
I feel that the Augmentin advertisement is far worse than the Nexium advertisement.  In my opinion the marketing of Nexium will only kill people indirectly via opportunity costs whereas the over-promotion of Augmentin will kill larger number of people more directly via resistant serious infections within a decade or so. Augmentin is directly inferior to alternatives when over used because of more frequent adverse effects whereas Nexium is not medically inferior.  I also believe that the psychological techniques in the Augmentin ad are much more misleading than in the Nexium ad.
This disagreement illustrates why I believe we should not attempt to pick the worst ads.  An essential feature of being mislead is not knowing that you are mislead.  The most effective misleading advertisements leave more people convinced that they are not misleading.  Consequently it would be very difficult to judge properly which ads are the worst and even more difficult to reach agreement about such judgements.  This too should be explained on our Introduction to AdWatch webpage.

"Ok, but bit of a nitpick on no brainer issues. GPs don't need to be spoon-fed on issues such as 'sex sells' etc. Also, it would be unlikely for a fellow practitioner to rely on an advertisement for the approved indication - the schedule is used for that."

"The use of a young attractive woman is a fairly standard approach, and I wouldn't make much of it, though it is interesting that we can't have access to the relevant research."

Response: Whilst such views are rare amongst AdWatch participants they may be more common amongst the non-participants that we would like to make AdWatch useful for. The important and difficult challenge is how to make AdWatch more helpful for people with a wide range of different starting positions including those that make it difficult for people to understand the subtleties of what we are saying. 
Most people know that promotional techniques such as "sex sells" are effective for influencing other people. Many understand that some are more vulnerable than others. However many underestimate how effective these techniques are at influencing oneself.  This is called the illusion of unique invulnerability.  Rather than being a no-brainer I don't know how anyone could accurately judge their own of vulnerability because these techniques are often effective below the level of awareness. The world's best brains don't yet know how to protect people from being influenced by promotional techniques because the science of developing human capacity to discriminate between misleading and justified promotion is still in its infancy. (See: Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc Psychol. 2002 Sep;83(3):526-41. (abstract))
Promotion often uses a combination of methods that may seem silly when examined but are effective when given little attention.  We hope to break these spells by illuminating them. (See: Med J Aust December 2003 article explaining the ideas behind AdWatch)
My experience of listening to fellow GPs suggests that we are a very heterogenous group with a wide range of different needs.  However, many of us would prefer to have the right information available at the right time just like skilled surgical nurses "spoon-feed" surgeons with the correct instrument just as they need it.
The Australian Schedule of Pharmaceutical Benefits listing for Augmentin states the indications as: "Infections where resistance to amoxycillin is suspected, Infections where resistance to amoxycillin is proven." which is vague and ambiguous and thus useless. All the relevant studies we are aware of have found that doctors' reliance on drug company information varies greatly. More reliance is associated with worse prescribing.
Just because something is "standard" (or common) does not make it harmless or justified.

Comments about the Augmentin advertisement

Praise for the advertisement

The only praise for the advertisement was:

"In comparison to what pharma companies used to put in medical journals, this is very tame. The advertisement complies with the Code of Conduct."

Response: The advertisement is more subtle than many in the past but maybe not less harmful. Most participants rated it as "misleading" which suggests that it is in breach of the Medicines Australia Code.  If GSK don't agree to provide adequate corrective advertising then we will report the advertisement to the Medicines Australia Code of Conduct Committee.

Criticism of the advertisement

"Promoting the over use of a very useful antibiotic whose restricted use would better serve the public in the long term."

"This is an effective and well designed ad., which is clearly misleading."

"Gross distortion of benefits."

GSK is careful about their wording, so plays it up with the picture

There are only a few indications where Augmentin should be used first-line. This is not the message of the ad.

The fact that the indication for Augmentin prescribing is not given (in large enough font) with the emphasis on 'time' suggesting rapid cure, no failures make the advertisement misleading to me.

I agree with the Adwatch points. The side effects in the small print are muffled by use of vague words, like 'gastrointestinal reactions'. That's bad!

"You've chosen a very widely used product - not only in Australia, but also here in South Africa. The key message to my mind is that of "Augmentin delivers first time". Prescribers often feel unease in relation to empiric antibiotic selection - this purports to alleviate that unease, particularly in patients with perceived higher social value (busy executives - "time is money" types). 

I'm not fussed about the overall subconscious appeal of the advertisement - after all we live in a society crammed with advertisements, so get used to it. However the PBS misquote is, in my opinion a severe breach of honesty.

The content of this advertisement does not help doctors who must make appropriate prescribing decisions. It would be more helpful for the guidelines for current use to be quoted.

I'm not a medic but I understand the dynamics of coercive advertising and this ad uses the same commercial wool-gathering techniques as those pushing any other product in the marketplace. Shame on them.

Sue is an aggressive person who might sue you if she gets worse, is another potential overtone (undertone) of the advertisement.

Sue also doesn't want to get drug induced hepatitis. Why didn't GSK mention that?!

They are continuing their long standing pattern of playing to their perceived strengths of broad spectrum A/B by using doctors desire for more certainty

Undoubtedly encourages the idea that antibiotics provide quicker recovery. Sue doesn't look ill. I agree that it appeals to the worst indications for prescription of antibiotic - pleasing a pt and meeting pt expectation.

We will ask GSK to respond to all the criticisms.

Other comments

Criticism of GSK and/or other companies

"It is very slick, but of course they are trying to make a living. Their replies to Dr. Mansfield's letters are most revealing."

"Of course SKB are not going to agree with you (or Cochrane, or anybody else). Their job is to sell their product. They are more or less restrained from out-and-out lying, but "truth" is awfully difficult to define, and it is awfully naïf to believe that an advertiser is going to promote the whole truth and nothing but (or even like) the truth."

Response: Companies are expected to focus on profits but many company staff would prefer to be providing a benefit for society at the same time. We need to redesign the incentives towards paying companies more for doing the right thing than for doing the wrong thing.

 

Praise for Augmentin

I have seen it [the ad] and possibly been influenced by its message- Augmentin is often a good alternative for me because of ease of administration, and also because it I believe it is more likely to achieve results in cases of sinusitis, where I believe antibiotic penetrance may be a problem

Response: Augmentin does more harm than good for sinusitis but it is effective at causing diarrhoea. (Bucher HC, Tschudi P, Young J, Periat P, Welge-Luussen A, Zust H, Schindler C; BASINUS (Basel Sinusitis Study) Investigators. Effect of amoxicillin-clavulanate in clinically diagnosed acute rhinosinusitis: a placebo-controlled, double-blind, randomized trial in general practice. Arch Intern Med. 2003 Aug 11-25;163(15):1793-8. (abstract))

Where resistance is suspected or proven, with Amoxycillin alone, what are the current resistance rates (yeah I know its in vitro) but my understanding is that Otitis media (non haemophilus) is something like 80%+ resistant in a trial in Sydney (this was a talk I attended in 2002 so I don't recall the references) - so what are the 1st line indications for amoxycillin, and the resistance rates, are they lower than I think? That's where I would tend to err toward amoxycillin/clavulinate combo, also hasn't BD dosing been seen to effect greater compliance than TDS that QID dosing?

Response: Otitis media is rare in young adults like Sue in the advertisement so we did not mention it. 
In general BD doses are easier to take than more frequent doses so BD doses can lead to more benefit and/or more harm. In otitis media if there is no pain to act as a reminder then almost all patients will be better off if they do not "comply".
Resistance rates vary from time to time and place to place. You could ask your friendly local microbiologists but they are unlikely to be able to provide reliable estimates specifically for otitis media because it is unusual in general practice to take microbiology specimens from the middle ear.  More importantly in vitro susceptibility does provide useful information about antibiotic treatment responses in otitis media.   

What anyone treating otitis media needs to know

 

Criticism of doctors

Almost all the criticism of doctors was made by doctors.

Doctors like to be right first time and tend to prescribe "just in case"

The other reason I can think of that might lead to "inappropriate antibiotic prescribing" is a doctor's desire to reduce the chance of a re-visit by the patient: not a good motive but one that I think occurs in the managed care area and in busy practices and even possibly a well intentioned doctor's desire to reduce the inconvenience and time lost from work for a patient who has to return if they fail first line treatment. Not a valid reason to use inappropriate medication but I do think this occurs

I often find it hard to believe how many doctors are sucked in by drug reps and advertising and believe the best option is to convince the government to ban reps giving out samples but fear the doctors, government and drug companies are so interwoven this is not likely to happen. I actually find most patients are relieved when I tell them antibiotics are not required so perhaps educating the general public to be sceptical about doctors prescribing habits and to always ask the doctor if an antibiotic is really necessary and to please prescribe the cheapedt one with the fewest side effects is the way to go.

Response: Doctors have human limitations.  We have to accept that.  The way forward is to design systems that will support humans to make good decisions.

 

Are doctors influenced by drug promotion?

I tend not to look at adverts and cannot think of an instance when one has altered my prescribing habits!

"My scepticism is fairly strong already!"

"Doctors are no more immune to seductive and misleading advertising than anybody else."

"I hate hate hate ads which use young/beautiful women to sell anything - so immediately would have turned the page on this one anyway."

Response: The best available evidence suggests that on average doctors are influenced but some are more influenced than others. (See list of studies) Avoiding exposure eg "turning the page" may be protective but there have not been any intervention studies yet so we don't know.
If you think you are not influenced, you may be right but, you may be a normal human with a normal human belief: the illusion of unique invulnerability. That illusion increases vulnerability to misleading influence. Misleading promotion can be more effective if we are not aware of it.  (See: Sagarin BJ, Cialdini RB, Rice WE, Serna SB. Dispelling the illusion of invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc Psychol. 2002 Sep;83(3):526-41. (abstract) and Med J Aust December 2003 article explaining the ideas behind AdWatch)

Government regulation

An excellent critique which highlights a basic problem with current promotional standards, that is, advertisements making claims that comply with Medicines Australia Code of Conduct by being in accord with TGA [Australian Therapeutic Goods Administration] approved indications (which assess safety & efficacy only) often do not comply with best-practice guidelines (which take into account cost-effectiveness). In addition, some PBS [Pharmaceutical Benefits Scheme] guidelines, as in this case, are not very helpful clinically, “Infections where resistance to amoxycillin is suspected or proven" needs to be better defined and also infections where Augmentin is contraindicated, such as tonsillitis, bronchitis, etc. need to be specifically mentioned (as Therapeutic Guidelines often does).
Promotional claims should be linked to best-practice recommendations, not TGA approved indications and PBS guidelines should also be tightened up similarly.

Response:  These are good suggestions.  The challenge is to build up the political support to make such improvements happen.  I hope that AdWatch can help with that.  We will write to TGA and the PBS later.

Requests

Great job. Is there a facility whereby when a rep is to see me (I see 2 a week), I can plug in the company name and any relevant/recent AdWatch data will come up?

Response. Visit www.healthyskepticism.org and click on "Search" in the left margin. On average your patients will be better off and you will save time it you do not see drug reps. (See list of studies) 

I survived massive doses of Augmentin, probably correctly prescribed for a serious case of cellulitis, but almost didn't survive the multiple, severe adverse reactions to CIPRO. I don't know what CIPRO is called in AU. Can you/will you look into CIPRO?

Response:   Cipro is ciprofloxacin. The first tradename for ciprofloxacin in Australia is Ciproxin. We had some dialogue with Bayer about misleading promotion of Ciproxin in 1995. It is now rarely promoted or used in Australia. This is in part because it is only subsidised for limited indications by the PBS. (See PBS listing for ciprofloxacin)  If we can get the resources then we will start AdWatch editions for other countries including the USA.

Just wanted to submit an idea for a future AdWatch - Sanofi are running a very aggressive campaign against generic substitution. They have a "do not substitute - tick the box" logo in the corner of all advertising material for Epilim, and one of their references (for Epilim) was very dodgy - they used it to claim that 29% of patients suffered problems when epilepsy scripts were switched - the reference included lots of different epilepsy drugs, not just Epilim and concluded that there were benefits from generic substitution! Our drug committee is going to ask them not to use the advertising inside the hospital and considering a letter to Medicines Australia also.

Response: We choose topics for AdWatch at random for the reasons given above. We are inundated with many more requests to do something about specific promotional problems than we currently have the resources to cope with. Our resources are now growing so there is hope for the future. Meanwhile, please do write to Medicines Australia and let us know how they respond.   

Generics

In The Netherlands usually drugs are not prescribed on brand-name.

According to the latest MIMS, Augmentin Duo Forte [10] PBS $18.27
Clavulin Duo Forte, Curam, Clamohexal [10] 16.97
So I would tend toward the generic anyway

Response: The indirect economic harm is less but the biological issues are the same.

Miscellaneous

Other comments included information from specialists about their type of speciality and their use of Augmentin. There were reports that the problems are similar in Turkey but worse in Spain.  A member of the public wrote:

 "Will be very careful if any GP offers Augmentin!"

Plans

Before participants read AdWatch on Augmentin 

Augmentin

(Two participants asked us to add a "rarely" option in future. We will.)

Having read AdWatch on Augmentin, participants planed to prescribe, take or recommend Augmentin

Of the 4 participants who prescribed Augmentin often before reading AdWatch on Augmentin, 3 planed to prescribe it less often and 1 as often.

Of the 48 participants who prescribed Augmentin sometimes before reading AdWatch on Augmentin, 20 planed to prescribe it less often and 28 as often.

Comments on plans included:

"I won't change my Augmentin prescribing, because I don't prescribe it very often, anyway. I agree with the AdWatch analysis and recommendations."

Response: Perhaps one of the values of AdWatch is reinforcing good prescribing.

Dialogue

38 participants wanted their name to be sent with their feedback to pharmaceutical companies and regulatory agencies.  We believe that will give the feedback more credibility.  We also understand that many people have compelling reasons for keeping their participation in AdWatch confidential.  All participants’ feedback will be kept confidential unless permission is given for disclosure.

We will write to GSK soon.  If there is no progress then we will write to Medicines Australia.

Opportunity for further comment

Comments and suggestions are welcome:

I am a . doctor journalist medical student member of the public other health professional pharmaceutical industry employee pharmacist pharmacy student other

It would help AdWatch if you give us your name and address to give us the opportunity when needed to clarify your comments or check that we have resolved your concerns. Your name and email address will not be given to any other organisation without your specific permission. Please check that your email address is correct and notify adwatch@healthyskepticism.org if your email address changes or if you don't hear from us within one month. 

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Please . do do not add my email address to the list to be notified about  new AdWatch issues once a month.

I . do not do give permission for my feedback, without identifying information, to be included in data for research reports.