1. Why Study This Topic Journal advertising is only a small percent of overall promotion: Journal advertising 2004 (US): $500 million Total promotion 2004 (US): $57.4 billion However, there are lots of ads Data sources 1.Othman et al. PLoS One 2009;4:e650 2.Ongoing systematic review of the effects of promotion on prescribing 3.Author’s personal files 4.Health Action International/World Health Organization database on drug promotion www.drugpromo.infowww.drugpromo.info 5.Healthy Skepticism database on drug promotion www.healthyskepticism.org Effects on prescribing Results Level of evidence* Joel Lexchin MSc, MD* School of Health Policy and Management, York University & Emergency Department, University Health Network *Conflicts of interest: Retained by Canadian federal government to provide expert advice in relation to a lawsuit regarding the legality of direct-to-consumer advertising in Canada Appeals to myths “Myth is often deployed in drug advertising to depict exaggerated therapeutic efficacy: armed with such drugs, the clinician can liberate patients from the oppression of disease and restore them to normality. With medicine as their alibi advertisers exploit the nude… Mythology transports the clinician into a wider sociocultural context than that of medicine alone. Viewing exotic or erotic scenes derived from “old masters,” the reader is relocated from office to gallery, obtaining visual relief from the clinical grind… Associations between diseases and drugs are made to seem natural unmotivated by commercial interest.” Scott et al BMJ 2004;329:1484-8 For further information Joel Lexchin jlexchin@yorku.ca. Drug Advertisements in Medical Journals: Education or Deception Journal advertising in Canada - 2000 ProductNumber of pages of ads Vioxx*1090 Celebrex613 Effexor974 Lipitor559 Baycol*361 *Removed from market for safety reasons OrganizationACCACPAMAATSIDSAMMS JournalJACCAnnalsJAMAAJRCCMCIDNEJM Revenue from ads per year (000,000) $4.67$6.00$18.63$0.717$0.715$14.31 Ad revenue as % total revenue 13.812.910.42.131.321.3 Ad revenue as % membership dues and assessments 93.0133.926.217.1125.4792.7 Journals make lots of money from ads Percent of doctors exposed to advertising about medications in past week Doctors don’t think that they are influenced by promotion Drug companies make money from ads: For every $1.00 spent there is a return of $2.43 StudyMeasurementChange in prescribing quality Becker - 1972Frequency of use of journal ads as a source of prescribing information and appropriateness of prescribing Infrequent use of ads was not associated with better prescribing StudyMeasurementChange in prescribing frequency Becker - 1972Frequency of use of journal ads as information source and number of chloramphenicol prescriptions Infrequent use of ads associated with lower number of chloramphenicol prescriptions Walton – 1980Journal ad recognition and number of prescriptions for medicationHigher ad recognition associated with larger volume of prescriptions Healthcare Communications - 1989 Journal ad recognition and market share of advertised medicationHigher ad recognition associated with higher market share Jones - 1999Use of journal ads and frequency of general practitioner prescribingNo association between use of ads and volume of prescribing Prosser - 2003Influence of journal ads and number of prescriptions writtenHigh volume prescribers more likely to cite ads as influential than low volume prescribers Charbit - 2003Use of journal ads and prescriptions for various antihypertensivesIncrease (decrease) in number of advertisements associated with increase (decrease) in number of prescriptions Hemminki - 2004Use of journal ads and prescriptions for HRTMore use of ads associated with more prescriptions StudyMeasurementChange in prescribing costs Watkins - 2003Frequency of reading of journal ads and cost of prescriptionsNo association between frequency of reading of ads and cost of prescriptions StudyLevel of evidence n (%) Systematic review or meta- analysis Randomized controlled trialOther evidence Smart - 19972/139 (1)41/139 (30)96/139 (69) Loke - 200299/855 (12)297/855 (35)75/855 (9) Villanueva - 2003--84/125 (67)18/125 (14) Lankinen - 20049/381 (2)33/381 (9)135/381 (36) StudyAdvertisements with n (%) Relative risk reductionAbsolute risk reductionNumber needed to treatOriginal data permitting calculation by readers Lexchin - 199929/130 (22)0 (0) 9/130 (7) Gutknecht - 2001Not reported 0 (0)Not reported Loke - 200213/174 (7)0 (0) 2/174 (1) Lankinen - 2004Not reported1/245 (0.4)0/245 (0)Not reported CountryUnambiguous clinical outcome n (%) Vague clinical outcome n (%) Emotive or immeasurable outcome n (%) Non-clinical outcome n (%) Australia (Loke – 2002)418/1504 (28)437/1504 (29)301 (20)346 (23) Finland (Lankinen – 2004) 81/883 (9)326/883 (37)270/883 (31)206/883 (23) How are benefits presented* Results Nature of claims made From: Othman et al. PLoS One 2009;4:e650 Images of women An analysis of advertisements for antidepressants in Scandinavian and American journals in 1995 showed that the Scandinavian advertisements tended to construct antidepressants as female gendered and Depression as detached from any social context. Both American and Swedish advertisements used images of couples and showed the drug as being key to maintaining the relationship, and the woman as the person needing the drug. (Lovdahl et al. Scan J Pub Hlth 1999;27:306-10) Although depression is diagnosed about twice as often in women than in men the ratio of females to males in ad- vertisements in the American Journal of Psychiatry was 5:1 and in the American Family Physician it was 10:0. (Hansen et al. Women & Therapy 1995;16:129-141) Conclusions Level of evidence cited in ads is generally poor Benefits are presented predominantly as relative risk reductions Most claims in ads are vague in nature Using ads as a source of information is associated with negative effects on prescribing Doctors use journal ads