Healthy Skepticism International News
November 2010
Public information as a marketing tool: Promotion of diseases and medicines
Gezonde scepsis is an initiative of the Dutch Institute for Rational Use of Medicine.
Gezonde scepsis is supported by the Netherlands Health Care Inspectorate (IGZ) and the
Ministry of Health (VWS). Gezonde scepsis is hosted by the Dutch Institute for Rational
Use of Medicine and Healthy Skepticism (International). The translation of this report has
been supported by Health Action International Europe.
The full report is available at: www.healthyskepticism.org/files/news_int/2010/gs_public_information_20100929.pdf
We present below the Summary, Introduction, Conclusions and Recommendations sections of the report.
Public information as a marketing tool - promotion of diseases and medicines
Summary
This report describes ways in which pharmaceutical companies provide
the public with information about diseases and conditions. It provides an
overview of the various methods used, and the impact that public
information campaigns can have. The aim of this report is to demonstrate
how companies use public information campaigns about diseases and
conditions as tools to market their medicines. In the research, we have
carried out three case studies to demonstrate how various methods are
applied and the parties are involved.
Symptom advertising
Pharmaceutical companies use various methods to communicate with the
public about diseases, conditions and medicines. They conduct public
information campaigns that focus on the symptoms of a disease or
condition, described as ‘symptom advertising’. In international literature,
this is also known as ‘disease mongering’: selling sickness so that the line
between healthy and sick becomes blurred and demand for medical
treatment increases.
Our research shows that the pharmaceutical industry makes use of the
leeway offered by current definitions of the term ‘information’ to market
their medicines through symptom advertising. Pharmaceutical companies
carry out campaigns to draw consumers’ attention to diseases or
conditions for which a medicinal solution is available. These campaigns
have a demonstrable effect on medicines use. One example is the
‘Schimpie’ campaign (the English version of cartoon figure Schimpie was
called ‘Digger’) that took place in The Netherlands in May 2000), which
drew attention to the risk of fungal nail infection (onychomycosis).
Elements of public information campaigns
The pharmaceutical industry has several ways to communicate with the
public: the Internet, radio and television broadcasting, market research
firms, patient organisations, (online) newspapers and magazines, and a
myriad of social media. For the recipients of this information, it is nearly
impossible to determine from the source of the information or who has
paid for the campaign.
Even before a medicine becomes available on the market, pre-marketing
activities begin as part of the public information campaign, also called
awareness campaigns. These disease awareness campaigns involve many
parties and are often designed in cooperation with a marketing agency.
They typically start with a press release about the introduction of a new
medicine, possibly in combination with research results that show the
severity of the disease burden. This press release is then taken up by
media, who often interview the medical specialists featured in the press
release.
Public information as a marketing tool - promotion of diseases and medicines 5
The marketing agency supports the press release with websites about the
ailment, television and radio commercials, newspaper adverts and paid
editorial content in magazines or on television programmes. Pharmacies
and GP surgeries offer brochures. Information screens in pharmacies refer
to the brochures on display. The brochures direct people to the product
website.
As part of this research, we examined campaigns around restless legs
syndrome (RLS), overactive bladder (OAB) and heartburn. These three case
studies demonstrate that elements of the public information are not in
accordance with the guidelines set by the Dutch General Practitioners
Society (NHG). For example, information about side effects and
information about when medicinal intervention is warranted.
In collaboration with the Dutch critical consumer programme Tros Radar, a
fake public information campaign around the issue of flatulence was
designed, in order to demonstrate the mechanisms typically used in these
campaigns and their effects on the public. We established a fictitious
company with its own website (www.hetluchtop.nl, itclearstheair.nl), and
commissioned TNS NIPO to carry out research into the disease burden.
Promotional materials were prepared and distributed to GP surgeries,
pharmacies and through the website. Based on the research conducted by
TNS NIPO, we sent out a press release and quickly obtained the desired
results: flatulence got a lot of attention in the media.
Recommendations to reduce unwanted effects of public information campaigns
* restricted use of public information campaigns that focus on symptoms,
if these campaigns are found to stimulate GP consultation or medicines
use;
* a more precise explanation of the difference between information and
advertising in the CGR and KOAG/KAG codes of conduct (Dutch national
self-regulatory codes) (see ‘Conclusions’). Establish a separate code for
public information campaigns on disease and health;
* more opportunity for preventive assessment and monitoring of public
information campaigns by the self-regulatory agencies;
* stringent supervision by the Dutch Public Health Inspectorate (IGZ);
* pharmaceutical companies and parties that offer a platform for public
information campaigns should establish or sharpen internal procedures
for their participation in such campaigns, in order to prevent public
advertising or irrational use of medicines;
* professional organisations and patient organisations should be aware of
their role in public information campaigns and ensure that their policies
are geared toward promoting accurate and balanced public information.
Introduction
This report describes how pharmaceutical companies communicate
information about diseases and conditions to the public. It provides an
overview of the various methods used, and the impact that public
information campaigns have. Gezonde Scepsis (Healthy Scepticism)
prepared this report at the request of the IGZ, the Dutch Public Health
Inspectorate. The aim is to demonstrate how pharmaceutical companies
use public information campaigns around diseases and conditions as a
tool to market their medicines, and the effect that this has on the use of
medicines. To describe how the various methods are practised and which
parties are involved in the process, several case studies have been used as
examples: restless legs syndrome, heartburn, overactive bladder and
flatulence. Additionally, a literature review has been conducted with
regard to relevant laws and regulations, and the effects of public
information campaigns.
Good public information about diseases and medicines is necessary. In
order to safeguard the quality of this information, the public needs to be
provided with balanced data that is consistent with the medical-scientific
information and that takes all treatment options into account, including
non-medicinal ones. Pharmaceutical companies can inform the public
about health and diseases, but the question is whether their public
information campaigns deliver a positive contribution when they are being
used to focus on a disease and the corresponding symptoms, i.e. symptom
advertising.
Dutch law prohibits public advertising of prescription medicines. Informing
the public about diseases and health is permitted. Where there are no
direct or indirect references to a medicine, current legislation and
regulation regards a campaign as informative. Though, as a rule, ‘any
form of influence with the apparent purpose of promoting the prescription,
supply or use of a medicine, or instigation of the same’ constitutes
advertising.
In 2000, Novartis launched the ‘Schimpie’-campaign to promote
terbinafine (Lamisil) against fungal nail infection. The campaign started
with television adverts in which a doctor told the viewers: “fungal nails.
Don’t transmit them to others. Consult your GP”..People with fungal nails
then reported en masse to their GP, who had received glossy Lamisil
leaflets from the manufacturer. ‘Schimpie’ turns out not to be an isolated
case. Pharmaceutical companies have also elevated other everyday
inconveniences to diseases that require treatment. Companies seem to
continually push the boundaries of what can be considered ‘patient
information’. In an August 2009 judgment for example, the Dutch
Advertising Code Committee’s Board of Appeal ruled that the website
www.erectiestoornis.nl (erectiledysfunction.nl) was in violation of article
85.a of the Dutch Medicines Act.
Before starting this research, we first consulted the relevant literature for a
description of the term ‘symptom advertising’. For more information, go to
chapter 3. In chapter 4, we describe the effects of information campaigns
and in chapter 5 an explanation of the relevant legislation and regulation
is provided. In chapter 6, we then present an overview of the marketing
methods that pharmaceutical companies use in their campaigns, and the
various parties that are involved in those campaigns. In chapters 7 through
9, we describe three real-life case studies to explain the mechanisms of
symptom advertising: restless leg syndrome, heartburn and overactive
bladder. In 2009, the Dutch consumer television programme Tros Radar
joined forces with Gezonde Scepsis to establish flatulence as a ‘disease’. On
the programme, we explained how disease creation works and how various
parties play a role in drawing attention to a disease. In chapter 10, we will
demonstrate how the symptom ‘flatulence’ was established as a medical
condition on the market. Chapter 11 describes the methods used during
this research.
Conclusions
This research into the provision of public information shows that
pharmaceutical companies communicate with the public in various ways
about diseases, conditions and medicines. They organise information
campaigns to draw attention to medical conditions and by doing so, focus
on the symptoms, rather than the medicinal product.
Three case studies are described in this research: restless leg syndrome,
heartburn and overactive bladder. All three case studies demonstrate how
members of the public are motivated to visit their GP, either through the
direct message ‘go to your GP’ or through a self-test. In the cases of
restless leg syndrome and overactive bladder, the name of the medicine
manufactured by the pharmaceutical company organising the campaign
is mentioned, starting with the press release.
Little research has been done with regard to the effects of public
information campaigns. The research that is available, however, shows
that public information is effective; that it prompts more people to go to
their GP; and that GPs more often prescribe medicines for the condition
that is the target of the campaign. This can lead to overburdened GPs and
have a negative impact on the rational use of medicines.
When no medicine is mentioned by name, the relevant Dutch legislation
and regulation deem a campaign to be ‘informative’. The industry
guidelines established by the Code of Conduct for Pharmaceutical
Advertising (CGR) and the Inspection Boards for the Public Commendation
of Registered Medicines and the Commendation of Health Products
(KOAG/KAG) leave room for different interpretations of the distinction
between information and advertising. The situation is complicated further
by the fact that there is no code of conduct with regard to information
campaigns that do not mention a medicine. The Medicines Act states that
‘any form of influence with the apparent purpose of promoting the
prescription, supply or use of a medicine, or instigation of the same’
constitutes advertising. Because of its effects, it would appear that
symptom advertising is in contravention of the Medicines Act.
Various parties provide channels that pharmaceutical companies can use
to reach the public:
* on the Internet, information about diseases and conditions is provided
through websites that are sponsored or owned by pharmaceutical
companies. These websites encourage people to visit their GP through
the provision of self-tests and information;
* commercial networks broadcast health programmes that are sponsored
by pharmaceutical companies through non-spot advertising;
* marketing agencies are hired by the pharmaceutical industry to utilise
the leeway provided by current legislation and regulation, in order to
produce the desired marketing effect for a new medicine;
* market research agencies are hired to conduct research that will
demonstrate the so-called health complaint to be problematic. This
research is then transformed into a press release that is distributed and
– because a market research firm such as TNS NIPO is generally
regarded as independent –taken up by news media;
* magazines publish editorial content paid for by pharmaceutical
companies;
* patient organisations are involved in marketing campaigns that
constitute symptom advertising. They organise meetings, appear in the
media, provide patient experts and organise information sessions. Our
research shows that a marketing agency handling the campaign may
also work for a patient organisation, which was the case with a
marketing firm that worked on the restless leg campaign;
* editors of news items on television, radio, the Internet and in
newspapers publish press releases without necessarily checking the
original source.
Recommendations
Because public information campaigns, as described in the case studies,
can directly or indirectly promote a medicine, encourage GP consultations
and increase medicines use, we recommend that the pharmaceutical
industry exercise restraint.
Currently, there is too much room for interpretation of the key concepts
‘information’ and ‘advertising’. The CGR and KOAG/KAG codes need to be
rewritten into clearer, more precise language that eliminate the grey area.
Pharmaceutical companies can draw up new, or sharpen existing, internal
procedures to ensure that their efforts to provide the public with
information do not constitute public advertising of prescription medicines,
nor promote the use of medicines.
Information about diseases and health should in no way stimulate
unnecessary GP consultations or medicines use. Therefore, we recommend
further development of the CGR and KOAG/KAG codes regarding
information about diseases and health. As long as no medicine is
mentioned, the current code defines a campaign as strictly informative.
The current code therefore does not serve as a monitoring tool for the
substance of that information. This gap needs to be closed.
We also recommend that existing self-regulatory agencies such as the
CGR and KOAG/KAG start playing a bigger role in preventive testing and
monitoring. The parties concerned need to reassess whether or not the
current working arrangements between the IGZ and CGR and KOAG/KAG
will accommodate such increased responsibility.
Because of its effects, symptom advertising appears to be at odds with the
Medicines Act. This is why stringent supervision by the IGZ is needed to
prevent public advertising in the form of public information campaigns.
The case studies described in this report provide a basis for doing so.
Various parties offer channels for pharmaceutical companies to reach the
public with their messages. These parties should also adhere to the CGR
guidelines. For instance, establishing internal procedures for contact with
sponsors, advertisers and other sources of information. All parties involved
have a responsibility in this matter: marketing firms, opinion pollsters,
patient organisations, doctors, journalists and television programme
makers.
We recommend that professional associations and patient organisations
strive for greater awareness of their role in public information campaigns –
especially in the form of symptom advertising – and make this endeavour
a priority. A focus on the role doctors play in information campaigns
should also be part of the effort.
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