C52: Please provide any comments on the advertising requirements and enforcement tools.
DTCA of psychotropic prescription medicines continues to be a contentious issue:
Impact of Advertising:
The pharmaceutical industry spends hundreds of millions of dollars each year for a return on profit margins and invest heavily in DTCA because they know consumers exert huge and effective pressure on prescribers. When prescribers feel pressured to support the patient’s choice, this may limit full disclosure about the best treatment options available e.g. a cheaper generic version of the advertiser’s product, or alternatives such as ‘prescribing’ a talking therapy approach. The risk to the patient is that they will be given medicines they don’t need at that time.
- Pharmaceutical advertisers’ interest is in promoting health worries or risks amongst the population, yet reluctant, for commercial reasons, to confront any misconceptions about their products yet promote presumptions about their products based on uncritical biases in the claims they make in their adverts.
- Commercially-driven advertisements employ the architecture of marketing strategies that carefully crafts the message to sell their products. This strategy can perpetuate false or misleading information in an advertisement, such as misrepresentation or misunderstandings about the origin and cause of mental distress/illness (i.e. depression is a chemical imbalance in the brain that can be corrected with drugs).
- Recently in New Zealand, a second-generation anti-psychotic medication in injectable form was advertised in the mainstream media e.g. television, non-medical journals and magazines, and at bus stops. The advertisements did not depict any additional or alternative therapy. These advertisements include on-screen endorsements by healthcare professionals. The life-size posters at bus stops made emotional depictions in their caption ‘When you have schizophrenia, people may nag you to take your pills and that can lead to conflict’. Risks and side effects required readers to go to a website of the pharmaceutical company.
Impact on the patient:
- As consumers we enjoy free-expression, choice and rely on openness about products available. However pharmaceutical products are different from food or clothing. Proper or improper use of pharmaceuticals can lead to harm and the safety of the patient therefore relies upon the strong relationship between patient and prescriber.
- With persuasion by adverts, people may seek access to the medication from other unreliable and risky sources e.g. order on the internet. Drugs acquired through alternate means raises concerns about whether the medication is what it is purported to be or a dangerous substitute; whether it is appropriate for the consumer even if it is as advertised (as there is no prescription involved); the dangers of injecting it incorrectly; the risk of overdose; polypharmacy; and where and how the person disposes their used needles. This increases a service user’s risk of harm exponentially.
Impact on the therapeutic relationship:
- Traditionally, health practitioners’ decisions about treatment were accepted by patients without question or discussion. The rise of the knowledgeable consumer-citizen and a democratisation of how information about medicines is available has resulted in patient’s expectations that they will be informed of uncertainties about products marketed in the media and what the alternatives may be. Further, both and/or prescriber and patient may believe that they will have to rely on psychotropic medication long-term (often in long acting injectable form). Also, individuals can become dependent on the medications as the only treatment alternative, have difficulty reducing or stopping the medication or are too daunted or defeated by the idea, usually due to the side effects themselves.
- The risks associated with DTCA (as above) are amplified when dealing with vulnerable populations, for example people with serious psychotic disorders such as schizophrenia and concerns for the overprescribing of this medication for Māori and Pacifica.
- Such direct marketing further relies on the health practitioner/prescribers to give a full account of all side effects etc. particularly psychotropics, whose side effects are toxic and known to reduce life expectancy. Therefore, in practice some prescribers are reluctant give a full disclosure of the risks and therefore informed consent is limited. However, when positive results have been the emphasis of the advertising it provides conflicting views that have the potential to rupture the therapeutic alliance between the patient and health practitioner in the face of the promises of good health outcomes by the commercial drug companies.
In summary, pharmaceutical advertising is strictly for profit: The argument for DTCA pharmaceutical advertising is that it provides helpful and empowering information to consumers, but the intent of any advertiser is to sell something, not to charitably educate their audience. For accurate, unbiased information on medication, consumers and physicians can turn to peer-reviewed literature and international clinical guidelines. If New Zealand is unable to repeal DTCA, we have made some suggestions to make it a fairer and safer process in section C53.
Bonaccorso, S., Sturchio, J., For and against: Direct consumer advertising is medicalizing normal human experience, BMJ, 2002; 324:910
Changing Minds. Direct to consumer advertising consultation: Nga Hau E Wha position statement. [Cited 2014 Feb 27]. Available from: email@example.com
Meehan, C. & Hamer, H. P. (unpublished paper) The Direct-to-Consumer Advertising of Anti-Psychotic Medication in New Zealand
Gilbody, S., Wilson, P., Watt, I., Benefits and harms of direct to consumer advertising: A systematic review, Quality, Safety and Healthcare, 2005; 14: 246-25
World Health Organisation [internet] Direct-to-consumer advertising under fire; c.2008 [cited 2018 Aug 30]. Available at: http://www.who.int/bulletin/volumes/87/8/09-040809/en/.
Ventola, C. L. Direct-to-consumer pharmaceutical advertising: therapeutic or toxic? Pharm Ther, 2011; 36(10), 669.
Every-Palmer, S. Duggal, R. & Menkes, D. Direct-to-Consumer Advertising of Prescription Medication in New Zealand, N Z Medical Journal, 2003; 127(1401): 102-110
Burton, B., Drug industry to fight New Zealand’s move to ban direct to consumer advertising, BMJ, 2004; 328: 1036.5
Menkes, D. [internet] Ad campaign for drug ‘will push up costs’; [cited 2015 Aug 30] Available from: URL: http://www.radionz.co.nz/news/national/136258/ad-campaign-for-drug-‘will-push-up-costs
Toop L, Richards D, Dowell T, Tilyard M, Fraser T, Aaroll B. Direct-to-Consumer Advertising of Prescription Drugs in New Zealand: For Health or for Profit. Report to the Minister of Health supporting the case for a ban on DTCA. University of Otago: Christchurch, 2003. https://www.otago.ac.nz/search/?q=Direct-to-Consumer+Advertising+of+Prescription+Drugs+in+New+Zealand&btnG= [cited 2015 Aug 30]
Aromaa, E., Tolvanen, A., Tuulari, J. & Wahlbeck, K. Predictors of stigmatizing attitudes towards people with mental disorders in a general population in Finland. Nord J Psychiatry, 2011; 65 (2), 125-132.
Peterson, D., Pere, L., Sheehan, N. & Surgenor, G. Experiences of mental health discrimination in New Zealand. Health Soc Care Community, 2007; 15 (1), 18-25.
MedSafe. [internet]. Clozapine: Fatal ‘constipation’ more common than fatal agranulocytosis. [cited 2015 Aug 30]. Available from: http://www.medsafe.govt.nz/profs/puarticles/clozgi.htm
De Hert, M., Detraux, J., van Winkel, R., Yu, W., & Correll, C. U. Metabolic and cardiovascular adverse effects associated with antipsychotic drugs. Nat Rev Endocrinol, 2011; 8(2), 114-126.
Wheeler, A., Humberstone, V. & Robinson, E. Ethnic comparisons of antipsychotic use in schizophrenia. Aust N Z J Psychiatry, 2008; 42 (10), 863-73.
Frances, A. Scandalous Off Label Use of Antipsychotics: Another Warning For DSM-5. [cited 2015 Aug 30]. Available from: http://chooseempowerment.com/docs/EI-Book-Club-DSM-Critique.pdf
The New Zealand Medical Journal 2014 – Direct-to-consumer advertising of prescription medication in New Zealand – https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2014/vol-127-no-1401/6278
Consumer NZ – 12 April 2019 “Time to ban drug ads – Medicine ads increase risk of drug misuse” – https://www.consumer.org.nz/articles/time-to-ban-drug-ads/take-action
Hood, Karen Michele, “Patients as Consumers: The Influence of DTCA and “Becoming Little Doctors.”. ” PhD diss., University ofTennessee, 2009. https://trace.tennessee.edu/utk_graddiss/38 (New Zealand Contect P.19)
Hoek, J., & Gendall, P. (2002). Direct-to-Consumer Advertising down Under: An Alternative Perspective and Regulatory Framework. Journal of Public Policy & Marketing, 21(2), 202–212. https://doi.org/10.1509/jppm.184.108.40.20686
Allan, T. “Advertising Psychiatric Drugs on TV” Mad in Aotearoa https://madinaotearoa.nz/2017/03/22/advertising-psychiatric-drugs-on-tv-taimi-allan/
The Royal New Zealand College of General Practitioners Position Statement. Prohibition of direct-to-consumer advertising of prescription medications https://oldgp16.rnzcgp.org.nz/assets/New-website/Advocacy/Position-Statements/2017.03-DTCAPositionStatement.pdf
C53 Do you have a view on whether direct-to-consumer advertising of prescription medicines should continue to be permitted? What are the reasons for your view?
“The power and sophistication of the pharmaceutical industry cannot be underestimated. Those who seek to counter it in the public interest need more than commitment and energy… In the absence of strong advocacy in the public interest, the pharmaceutical industry will continue to set the tone of public debate.” (Rt Hon Helen Clark, Minister of Health 1989 -1990)
The above warning about DTCA and Big Pharma is ever present – DTCA of prescription-only medication is permitted only in the United States and New Zealand. In 2008 the European Parliament opposed DTCA, in accordance with the ‘precautionary principle’ with most countries citing public safety as their rationale for banning the practice. The UK had previously prepared contingencies for the adoption of DTCA; we believe that New Zealand can take some lessons and recommendations from the UK rationale and build in the following safeguards for DTCA of selected items, specifically psychotropic medication:
- That New Zealand develop a non-partisan organisation that has no vested interest for or against DTCA of prescription medicines. This agency will have a neutral interest in promoting the honesty, reliability and transparency of claims that drug manufacturers make to people who are “ill… or who may be persuaded they are ill”.
- If we do not ban DTCA in New Zealand, then we can expect that the pharmaceutical companies will increase their opportunity to market their products even more aggressively and create more costly advertising that is persuasive and emotive. If so, a non-partisan agency can provide balanced information to allow patients and prescribers to make reasonable judgments and health decisions about the products advertised
- That all advertisements are vetted before distribution to the population such as the quality of the description of the product; that it includes an honest disclosure of adverse effects; provides information about the relative efficacy of the product and consideration of, and price evaluations for, alternative cost of generic products
- Adverts need to be explanatory rather than purely slogans, and linked to the NZ Clinical Guidelines/NICE guidelines (UK) to promote unbiased information on the prescribing of pharmaceutical products for both patients and prescribers
In summary, this submission supports the following recommendations by Toop, et al. (2003) Report to the Minister of Health supporting the case for a ban on DTCA –
- There is convincing evidence, supported by public and professional opinion, to justify a ban of direct-to-consumer advertising of prescription-only medicines in New Zealand.
- There is an urgent need for increased provision of comprehensive and readily accessible independent consumer information.
- Recommendations That the New Zealand government introduce regulations and /or legislation to prohibit the advertising of prescription medicines directly to the public, through print and broadcast media or any other means.
- That the Government establishes an independent medicine and health information service free of commercial interests