1. International Seminar on Drug Advertising Canadian Experience Brazilian Health Surveillance Agency and Pan American Health Organization Brasilia, Brazil April, 2005 Erwin Friesen, Pharm.D, FCSHP efriesen@cha.ab.ca

2. Presentation Outline Overview of Canada and Health Care System Arguments to Allow and Prohibit Direct to Consumer (DTC) advertising of prescription drugs Current status of DTC advertising in Canada Reasons for Canadian decision Canadian challenges with advertising Difference in impact of advertising in Canada/US Questions

4. Canada Health Overview Life expectancy 2004 (Source - WHO) –Canada 79.8 years –USA 77.3 years All citizens are covered by the government for a wide range of services (e.g. hospitals, physicians) regardless of financial status People have access to health care regardless where you happen to be or live in Canada. Health care system is publicly administered through tax revenues not by private business Provinces and territories administer their own publicly funded drug programs

5. Clinical Arguments to Allow DTC Advertising of Prescription Drugs Lead to better health because public becomes educated Under diagnosed e.g. high cholesterol Under treated e.g. erectile dysfunction (impotence) Increase discussion between patient and health care workers about drugs and medical conditions Better patient compliance with prescription drug treatment regimens New and better medications

6. Economic Argument to Allow DTC Advertising of Prescription Drugs Earlier management of more serious, costly conditions that consumers typically ignore, or chose not to treat when symptoms appear to be minor or non-acute

7. Clinical Arguments to Prohibit DTC Advertising of Prescription Drugs  DTC has emotional rather than educational content  Negative effect on relationships by creating conflicts between the patient's desire and the caregivers more informed judgement  No discussion of “non drug” or non prescription treatments  Lead to “medicalisation” of normal human experiences in healthy patient populations  No evidence of improvement in choices by physicians, patients or public health

8. Economic Arguments to Prohibit DTC Advertising of Prescription Drugs  Increases prescription expenditures  Usually only advertise new drugs which are more expensive than older drugs  No good evidence of value for money

9. 2004 Canadian Parliamentary Inquiry Recommended against Direct to Consumer Advertising for Prescription Drugs Reason 1 “DTC” advertising of prescription drugs could contribute to increased or inappropriate drug consumption.

10. Total Expenditure on Drugs and Health OECD 2001

11. Top 10 Pharmaceutical Markets in the world in current US$ billion Source: IMS Midas Customized Insights (October 2001)

12. Change in U.S Health Expenditures 1970 - 2002

13. Drug Expenditure - International Comparisons

14. 2004 Canadian Parliamentary Inquiry Recommended against Direct to Consumer Advertising for Prescription Drugs Reason 2 “Drug advertisements could endanger rather than empower consumers by minimizing risk information and exaggerating benefits”

15. *Represents cost in millions of advertising Source IMS Health 2002-2003 Leading 10 US Products in Dollars Spent on Advertising - 2002

16. However - Canada is not insulated against advertising!!! “Spillover” from American media –Television –Newsprint, magazines Canadian government has allowed two types of indirect advertising –Reminder advertisements –Help seeking advertisements

17. Three Forms of DTC Advertising to Public 1. Product-disease advertising that includes both the product name and specific therapeutic claims; 2. “Reminder” advertisements that provide the name of a product without stating its use; 3. “Help-seeking” advertisements, which tell consumers about a new but unspecified treatment option.

18. “Reminder” Advertising Birth control product that is now mainly indicated for treatment of severe acne Banned in several countries due to liver toxicity and possibly blood clots Why is second line second line drug in bus shelters?

19. “Help Seeking” Advertising

20. Comparison of DTC Advertising Effect in USA/Canada Canadian Medical Association Journal 2003;169(5):405-12

21. Possible reasons that Canadians ask and spend less often for advertised drugs USA public has “constant” advertising Canadian “reminder” and “help seeking” advertising is not as effective as product - disease advertising Payment expenditure increases hampered by public funding mechanisms and public/government is more “cost conscious” Canadians less inclined to see drug therapy as another marketplace commodity

22. Closing Currently Canada’s view is that direct to consumer advertising for prescription drugs is not in the best interest of the patient or society However due to television, press and internet -- Canadian society is not isolated from US advertising