Self-reported responsiveness to direct-to-consumer drug advertising and medication use: results of a national survey

Considerable controversy surrounds the practice of direct-to-consumer (DTC) marketing of pharmaceuticals. While some argue that DTC advertising serves as an educational resource for patients,[1] others say that DTC advertising contributes to the medicalization of trivial ailments, and leads to overuse and misuse of pharmaceuticals[2]. Since initially allowed by the Food and Drug Administration in 1985,[3] spending on DTC advertising grew steadily over the following decade. DTC advertising spending accelerated rapidly after 1997, when the Food and Drug Administration provided draft guidance which described how sponsors could disseminate information on drugs and biological products using radio and television [4, 5]. Pharmaceutical industry expenditures for DTC advertising increased 330% between 1996 and 2005. In 2005, $4.2 billion was spent on DTC advertising, which accounted for 14% of all promotional spending for prescription drugs[6]. Expenditures have decreased (in absolute terms) since 2007 following a peak of $5.4 billion in 2006 [7].

Although it is difficult to find data on the effectiveness of DTC advertising for individual drugs, 10-35% of survey respondents say they have discussed medical conditions or medications with their physicians as a result of DTC advertising[8–10]. Furthermore, patients who specifically request medications during an office visit are much more likely to receive them than those who do not[9, 11–13].

While much has been written regarding consumer and physician attitudes toward DTC advertising, less is known relating patient characteristics, notably medication use, and responsiveness to DTC advertising. One survey found that responders to DTC advertising were more likely to be nonwhite, have lower educational attainment and lower income,[10] whereas Bell found that women, as well as persons with a positive attitude towards DTC advertising, in poorer self-reported health, and with better self-reported insurance coverage of medications were more likely to respond to DTC advertising[9]. This survey also found that persons using prescription drugs at the time of the interview were more likely to be influenced by DTC advertising. To further investigate the relationship between self-reported medication use and responsiveness to DTC advertising, we conducted a secondary analysis of data obtained in an FDA survey of exposure to, perceptions of, and attitudes toward DTC advertising.

Our data indicate that a cross-sectional relationship exists between number of prescription drugs used and "responsiveness" to DTC advertising. This strong linear relationship remains even when controlling for demographic and socioeconomic variables and self-reported health. Overall, 25.3% of respondents were motivated by DTC advertising to initiate discussion regarding new health problems. Among respondents taking no prescription medications, fewer than 10% were motivated by DTC advertising. Conversely, among respondents taking five or more prescription medicines, nearly 40% were motivated.

In 2002, the Government Accountability Office has identified 13 surveys, primarily for lay publications, which attempted to assess consumer behavior related DTC advertising[8]. Since that time several additional surveys have been published in the medical and scientific literature[10, 14–16]. In these studies, the proportion of respondents who reported being influenced by DTC advertising to seek medical care ranged from 10.5 to 35%. Although there is some variation in how each survey defines responsiveness to DTC advertising, our finding that 25% of respondents had discussed a new medical condition with a physician based on DTC advertising is generally consistent with others.

Our results confirm those of previous studies, [10, 17] which identify older age, lower educational attainment and a positive attitude towards DTC advertising as factors associated with responsiveness to DTC advertising[9, 10]. In contrast to other studies, [14, 18] we did not find an association between ethnicity, income or self-reported health status and DTCA.

We found that a cross-sectional relationship exists between responsiveness to DTC and self-reported use of prescription, but not OTC, drugs. Because there was a trend towards poorer self-reported health and responsiveness to DTC, is plausible that users of prescription medications represent a sicker population, and one that may be more attuned to the messages conveyed in DTC advertising. Alternatively, because DTC advertising largely focuses on prescription medications, persons who are responsive to DTC may have approached their prescribers based on information in DTC, resulting in more prescription, rather than OTC, use. Bell and colleagues found that current users of prescription drugs were more likely to be influenced by DTC advertising,[9] but did not quantify the number of prescriptions, and limited their sample to one county in California.

Our investigation confirms results of a smaller study of Minnesotans by Schommer et al. [15] that found prescription medication use to be statistically greater in respondents who were responsive to DTC advertising than those who were not. Similar to our results, no significant difference was found in the number of OTC medications used by responsive versus unresponsive patients.

The main strength of our study is that the source of data comes from a large nationally representative sample with a high response rate. Furthermore, unlike some other studies, OTC as well as prescription drug use was ascertained. Our study has several limitations. First, these data were collected in 1999. Penetration and awareness of DTC advertising, as well as types of media outlets (e.g. internet), have increased considerably in subsequent years. Despite this, however, we are encouraged by similarities in regard to attitudinal, socioeconomic and demographic predictors of susceptibility to DTC advertising demonstrated in more recent surveys, [14, 15] and likewise feel that the relationship between number of prescription drugs used and susceptibility to DTC advertising should be no less true today. Second, this is a secondary analysis of FDA data originally collected to investigate attitudinal and demographic effects toward DTC advertising; thus, rigorous ascertainment of medication use was not included. Although the self-reported medication use measure is a limitation, it has been used in a previous survey of DTC advertising,[15] and has been found to be congruent with pharmacy prescription data[19, 20].

The cross-sectional nature of this study does not allow for unequivocal statements regarding the direction of causality. Although this relationship could be explained by physician compliance with patient requests for medications, it is also plausible that DTC advertisements have a particular appeal to patients prone to taking multiple medications. Finally, the main measure in this study specifically asks about initiating discussion with a physician about a new medical problem and thus may not have captured those patients who use DTC advertisements to prompt discussion of previously discussed problems, or those patients who may have discontinued a medication due to information contained in DTC advertisements.

There is a strong cross-sectional relationship between the number of prescription, but not OTC, drugs used and responsiveness to DTC advertising. Although this relationship could be explained by physician compliance with patient requests for medications, it is also plausible that DTC advertisements have a particular appeal to patients prone to taking multiple medications. Outpatients motivated to discuss medical conditions based on their exposure to DTC advertising may require a careful medication history to evaluate for therapeutic duplication or overmedication.

Further research needs to be performed to understand this population's eagerness to utilize prescription drugs and to determine if this eagerness transcends to utilization of other health care resources. Clearly, these DTC advertisements are powerful motivators. Perhaps they could be used to enhance evidence-based prescribing and advance public health.